J. Peter Rothe

Alberta Centre for Injury Control and Research

School of Public Health

 

 

            Injury prevention strategies typically pay tribute to the thought that the social, economic, political, cultural, educational and environmental conditions must be in place for injury prevention to become a reality. It means making positive choices about minimizing risk at all levels of society while maintaining healthy, active and safe communities and lifestyles (CCCIPC, 2003). Couched within this viewpoint is that injury is not only the consequence of individual behavior, but a product of community structure, social context and local history. In conflict-affected settings like First Nations communities in northern Canada, people have long been witnesses to community breakdown, social disruption, poverty, violent death, and hopelessness. This is a result of former political and religious repression and educational colonialization under former governments.  First Nations people were approximately 6.5 times more likely to die of injury than the Canadian average(First Nations and Inuit Health, 2005). As is widely acknowledged, First Nations people are highest at risk for injury and they have the highest potential years of life lost (PYLL). In a major research project with thirteen Alberta rural, small city and metropolitan communities, when interviewed in focus groups, the majority of respondents were critical of their neighborhood communities. There was a noticeable level of dissatisfaction with the towns and cities in which they resided. Some of the descriptors were urban blight, scary place, dangerous, place that sucks, dirty, unfriendly and place of drugs and alcohol (Rothe, 2005: 22-24). The feelings offered by average community residents are a warning that there is a broaderand more embedded problem in injury, the decline of community.   

 

 

            Writings are replete with descriptions of community that are interchangeable as, for example, small rural towns; medium-sized towns, cities, neighborhoods, collection of people with similar organizational affiliations, ethnicity, life interests or forms of livelihood among others.   The span of definition is evident in Canada’s officially declared Safe Communities that include communities ranging from large cities like Calgary, Alberta where citizens on the whole have limited interaction, small cities like Fort McMurray, Alberta to small towns like Rainy River, Ontario where residents have intimate contact. Despite their different populations, geographic area and industry, they are equally encouraged to motivate members of all sectors in their communities to work together in a coordinated and collaborative way at a local level to reduce injuries and increase the safety of its members .  

            Some health professionals assume that people’s health and safety-related knowledge, attitudes, behaviors and skills reflect their experiences with institutions, cultural forces and social relations in a community (McGee, 1996). It is here where people gain an accurate understanding of safety and injury. Neighborhoods that are safe for walking, biking and driving and which promote social interaction are healthy places to live for seniors, children, women and other vulnerable members (Frumkin, Frank & Jackson, 2004: Berke, et al: 2007). Good neighborly interactions are thought to help reduce local crime and poverty, increase personal security and provide members greater safety while being outdoors or participating in social activities (Lucy and Phillips, 2006; Hillier and Sahbaz, 2006: Bray, Vakil and Elliott, 2005:). On a similar note interactions between community members can have a role in reducing depression, suicide and illness (Yates, 2004). 

 

            North American communities are undergoing significant social change. Systemic socio economic, cultural, familial, government, business, labor and technological changes have placed traditional communities on a social and moral decline. Many of these communities no longer adhere to previously unaccepted iniquitous moral behavior. Their new socio economic and/or cultural mix is more likely to reflect diversity of values and ethical behavior. Accompanying major social changes is an accelerated lapse or breakdown of traditional community social support systems (Hirschman, 1970). Hospitals may become overcrowded, which significantly increases waiting times in the emergency departments; police department budgets are taxed to the limit in their attempts to fight major crime, which necessitates sidestepping minor ones; schools begin to perceive racial violence or gang activity as the norm; and some urban communities find themselves in a state of disrepair, commonly called urban decay. In the rural areas, rail transport to small farming villages is cancelled due to rationalized agricultural planning; neighborhoods lose essential services like banking to more centralized locations; schools and hospitals are closed; young people migrate to other centers thus depopulating small communities; and aging farmers are required to work the land with unsafe equipment and without adequate affordable labor. Whereas new pre fabricated neighborhoods spring up as land developers bundle houses and sell a lifestyle, many older or more traditional communities increasingly experience abandoned properties, high unemployment, fragmented families, political disenfranchisement, increased crime, and more desolate and unfriendly landscapes. Some of the decline is a direct reflection of government policies in economic matters (e.g. land development, industrial expansion), transportation infrastructure (e.g. major freeway or road development), health policies (e.g. hospital closures), immigration (e.g. foreign workers), agriculture (e.g. decreasing farm support and closing markets), and education (e.g., school construction or closures).  

            When neighborhood communities become destabilized they no longer have a group feel (Rosenberg and Lewis, 1993). Individuals act on their individual desires and wishes instead of reflecting on the needs, obligations and rights of the group or community thereby creating feelings of fragmentation of local social life. It may be a matter of personal survival, minding one’s own business or isolation from others. And often the bases for such feelings are unemployment, underemployment, wage disparity and poverty. 

 

A large part of people’s lives revolves around earning sufficient money to fulfill our need to buy goods. Economics is the locomotive that allows North Americans to live the way they do. Hence it is no surprise that economic inequalities like low earning capacity, limited or non existing higher wage opportunities and unemployment contribute to property and violent crimes (Hagan and Peterson, 1995). Widespread and chronic unemployment and disparity between comfortable income and minimum wages within a community fosters social contexts that could best be described as a “culture of unemployment or “the culture of underemployment.”  People routinely experience low self esteem and motivation, have normalized poverty as status quo to the point and where unemployment or underemployment is easily inherited by the next generation. Research has shown that people living in poverty for an extended period of time are more likely to be isolationists and victims of or witnesses to intentional violence (Cohen et al, 2003).

Of special significance is poverty in women. Although poverty affects millions of Americans and Canadians, women suffer disproportionately from its difficult and often lasting hardships. According to the New Legal Defense and Education Fund, the 2002 U.S. Census put the poverty rate for adult women at 12.3 percent, whereas for men it was 8.7 percent. Moreover, the rate of poverty among single mothers was 33.7 percent, and two-thirds of the nation's poor children were in single-parent homes. Single parenthood, or more specifically, single motherhood, is a leading cause of poverty, which in turn contributes to subsequent violent behavior by older children (Harvard Political Review, 2004). 

Poverty erodes hope and opportunity. The poor are disempowered from making important social and economic decisions that affect their lives. Individuals who are relegated to marginal social groups and who are consistently denied privilege and power, often internalize their disempowerment, accepting an "I am less worthy" attitude.   They have become an institutionalized class of people ‘different’ from the well to do. They develop their own perspectives, pursue goals, encounter problems, hold to important life events and embrace ideas in ways that differ from those of socio economically privileged people (Anastasi, 1966). 

The 2003 Census data showed that many families in the lowest

income groups are recent immigrants, visible minorities, Aboriginal

people, single parent families headed by women, and/or people with

disabilities (Canadian Council on Social Development, 2006). They

continue to be the highest at-risk groups for whom the traditional

community often provides limited or no support. They have not shared

in the economic prosperity that many Canadians experienced. For example, according to the Canada Council of Social Development’s (2001) review of Statistics Canada numbers:

 

 

      There are more poorly paying jobs than before, and overall falling relative  incomes. People in poverty often experience higher rates of illness, stress, food insecurity, inadequate housing and difficulty accessing community services. They also have the highest rate of potential years of life lost due to injury (Statistics Canada, 2003). Furthermore people living in poverty  are less likely to purchase safety devices like bicycle helmets, life jackets and in-home products like smoke detectors, engage in home repairs that help prevent falls and properly maintain their vehicles. 

Children from impoverished families are more likely to be in harm’s way on public roadway and become fatalities than children with greater economic resources. As stated in the National Safe Kids literature: 

Despite an overall decline in injury-related death, death rates for children of low-income families continue to increase.  This phenomenon may be explained by the higher incidence of the most severe types of injuries, such as firearm and pedestrian (motor vehicle) injuries, among low-income children. (National Safe Kids, 2004: p.2)

 

…Injuries to poor children also result in more fatalities than injuries to children with greater economic resources. Children from low-income families are twice as likely to die in a motor vehicle crash, four times more likely to drown and five times more likely to die in a fire. (p.1)

 

 

Homelessness is but another substantial issue that places pressure on community services and contributes to unsafe lives.  

 

Social inclusion refers to people’s ability to participate adequately in a community’s education, employment, public services, social and recreational activities. Conversely, social exclusion refers to the presence of constraints to adequate participation.   It plays a significant role in community decay as it reflects increasing numbers of single parent families (which can lead to poverty) and/or specific geographical segregation that is akin to ghettos (e.g. Aboriginal people’s reservations), changes in government policies (e.g. changes in standard of housing, land use and development and/or immigration policies), local economics (e.g. job insecurity and opportunity), and/or naturally changing demographics like aging (Shaw, Dorling & Smith, 1999). 

            Nowhere is exclusion more apparent than with the First Nations people of Canada and the United States. Health Canada (2004) reported that the cultural and material losses that Aboriginal people have suffered, and their place of relative powerlessness in Canadian society, have contributed to anger that has harmful outlet, grief that does not ease, damaged self-esteem, and a profound sense of hopelessness about the future of Aboriginal people in general and individuals in particular. These factors contribute in many subtle and not so subtle ways to the incidence of injury (Hurley and Wherrett, 1996).
          First Nations people are gravely economically underprivileged. They live in substandard housing which increases the chance of fire or injury due to falls. Canada’s First Nations people have one of the lowest literacy rates in North America, which contributes to them having the highest poisoning rates through inability to read warning labels. Reckless and potentially self-destructive behaviour, such as operating motor vehicles (car, truck, snowmobile or boat) while under the influence of alcohol, may be caused or triggered by the powerful emotions of grief, anger and hopelessness (Hurley and Wherrett, 1996). Alcohol addiction, which is fueled by this anger and hopelessness, often results in violence and/or family breakdown, which in turn increases the social exclusion. 

          The vicious cycle of social exclusion of First Nations people has become a generational issue whereby members of this culture have internalized the stigma. The issue was featured in a recent study of impaired driving, when First Nations people consistently said that no one cares about them (Rothe and Elgert, 2004). Many Canadians have characterized First Nations people as being impoverished and deviant, living a high-risk lifestyle. It has taken on the meaning of fact, something that is beyond the need for immediate attention. Hence the extraordinary high injury rates amongst First Nations people is often assumed to be a natural consequence of a troubled people, to which Canadians and Americans assign minimal meaningful attention, other than band aid interventions and finances.. 

            Another demographic who is vulnerable to social exclusion is the elderly. Senior citizens live in communities which in large part are controlled, maintained and organized for the young. Recreational facilities, educational institutions, employment opportunities, transportation systems and street designs are designed and structured according to the norms, interests and abilities of the young and middle-aged. In many cases seniors are given little voice for their needs and they often experience difficulties negotiating the community infrastructure. Furthermore senior citizens typically experience a denial of economic and political opportunities; denial of self-esteem; denial of opportunities to influence the terms of their participation in the community; and the regulation of their affairs and interests by representatives or agencies of the larger community (Forcese and Richer, 1982). 

Senior citizens are major contributors to national injury statistics. More than one-third of adults ages 65 years and older fall each year (Hornbrook et al,1994; Hausdorff 2001). Among older adults, falls are the leading cause of injury deaths (Murphy 2000) and the most common cause of nonfatal injuries and hospital admissions for trauma (Alexander et al. 1992). Miceli et al. (1994) posit that major socio-psychological variables such as feelings of hopelessness and helplessness contribute to seniors’ falls, and in fact, fall rates are noticeably high among institutionalized seniors - those with the least control over their lives (Speechley and Tinetti, 1990). Furthermore, because of their economic status and age, some seniors disengage from local support people and neighbors, and use detachment and withdrawal as a way of life. They become isolates outside of the community attention zone. As Klinenberg (2000) so aptly described, without assistance, they become prime candidate for injury.

            Finally, social exclusion contributes to problems such as crime, alcoholism and drug addiction. This reduces economic productivity directly by reducing employment, and indirectly by increasing demands on social, health and security services. Social exclusion  can nurture or create hate and violence. It can also lead to discriminatory policies and practices that result in unsafe environments or less protection for excluded groups as for example, the inconsistent laws regarding gender and the workplace. To be excluded can also mean to be offered segregated housing, or inadequate living conditions or, as detailed earlier, homelessness, on the basis of issues like race, mental health, ethnicity, kind of family, previous family violence, etc. 

            A strong and complex relationship has been reported between homelessness and adverse health status (Hwang, 2001; Frankish, Hwang, Quantz, 2005). For example, substance abuse, poverty, mental illness, unemployment, have all been associated with negative health implications and have been reported to be highly prevalent among the homeless (Hwang, 2001). Homeless individuals have high incidence of injury (Gaetz, 2004) and they may face barriers to health care access when they are injured. Finally they are less likely than others to follow medical compliance after having their injuries diagnosed (Hwang, & Gottlieb, 1999). 

            Unintentional injuries are common among the homeless population. Unintentional injuries may arise as a consequence from a fall or being hit by a car; these are leading causes of morbidity among homeless males. In addition, unintentional drug overdoses are common (Hwang, 2000).   Essentially, any human being will have an unintentional injury during their lifetime. However, for homeless individuals, access to treatment and prevention strategies may not be as widely available. Furthermore Lacerations, wounds, sprains, bruises and fractures are common traumatic injuries. Homeless individuals are at increased risk for such injuries because they are often victims of violence and abuse, and/or live in areas where crime rates are high (Hwang, 2000). Mortality rates among the homeless have been reported to be significantly higher than the general population (Hwang, 2000; Hwang, 2001). For example, mortality rates among this population of men were 8.3 times higher that the general population for men aged 18-24 years, 3.7 times higher for men between the ages of 25 and 44 years, and 2.3 times higher for men 45 – 64 years (Hwang, 2000). Because of Canada’s universal health care system that the United States does not have, the mortality rates in Canada are still lower than those of the United States. When or if housing for people considered to be excluded is sought, individualism, self-interest and lack of community cohesion become apparent when neighbors proclaim the NYMBY rule – “Not in My Back Yard.” ]Hence the homeless are often destined to find park benches, tents, community shelters, or dilapidated houses.  And the number of homeless increases yearly in magnitude and complexity as for example in Calgary where, the city’s homeless population has increased by 23.3% between 2002 and 2004 (City of Calgary, 2004: Edmonton Joint Planning Committee on Housing, 2004). This trend will surely increase the pressure on neighborhood communities to cope and maintain a semblance of cohesion beyond implementing stopgap measures like emergency shelters, transitional housing, voucher distribution for housing, food pantries, soup kitchens and meal distribution programs, mobile food programs, physical and mental health, alcohol and/or drug, HIV/AIDS, and outreach programs and drop-in centers.

            The World Health Organization reported that mental disorders are the third leading cause of disability worldwide, behind infectious diseases and injuries. Depression is expected to be the second largest contributor, after heart disease, to the world disease burden by 2020 World Health Organization, 2002).  Interest in mental health came to the forefront in Canada with the release of the 2006 Kirby Commission’s Standing Senate Committee on Social Affairs, Science and Technology final report where the task force members outlined the problem of mental health and its effects (Kirby, 2006). ). In the next two sections of this paper, I will discuss how mental health problems (specifically, from the perspective of fear and social stress) have contributed to community breakdown and are a growing health problem linked to injury. 

 

            Each day a barrage of media messages bombards us. We read tabloid headlines that announce gang fights. Each morning, talk shows feature yet another victim of sexual abuse. On the car radio we hear the details of what seems to be the latest in a string of serious youth crimes. Television newscasts spend months discussing war and terrorist victims. Politicians remind us daily that a terrorist could blow us up at any time. And, on a day-to-day basis, we look over our shoulders wondering whether the next meeting with the boss means loss of income and our way of life. We are living in a time of collective fear - fear of terrorism and of war, but also fear of crime, of disease, of economic instability and family dissonance. We have lost a sense of ontological security, or the sense of continuity and order (Bilton, 1996). It makes us fearful of the loss of familiarity, home and basic safety

            Many people’s everyday experiences contribute to a culture of fear – fear of failure, rejection, the unknown, death, isolation, loss of dominance. Klinenberg (2000) describes it in his portrayal of senior citizens who died in isolation during the Chicago heat wave, because of their feelings of vulnerability if they stepped outside of their domiciles. A culture of fear has materialized among seniors that had its roots in neighborhood violence. Fear of becoming victimized has left many senior citizens isolated. It has contributed to the reality whereby one out of every two American aged 80 years or older lived alone in the 1980’s and 1990’s, a  proportion that has  increased in the 21st century (Klinenberg, 2000). Seniors, who live alone because of fear of violence, and lack of nearby family or neighborhood friends are generally impoverished and they are less likely to report poor health and more likely to be limited in their basic hygiene and daily tasks (Klinenberg, 2000). They are more likely to experience injury and, when injured, are less likely to receive timely help because of their isolation. In 1994, those 71 years of age or older accounted for over 27% of all unintentional injuries resulting in hospitalization and 34% of the deaths resulting from unintentional injury. Of all the causes of seniors’ injuries, falls are by far the biggest problem, accounting for over 87% of unintentional injuries resulting in hospitalization for those 71 years of age or over, and 75% of the deaths resulting from injury. (Public Health Agency of Canada, 2005. 

However, fear is not only a problem for the elderly. Perhaps the most intrusive fear is that of losing a job and the resultant economic insecurity. Catalano (1998: 168) described the findings of a 1996 USA survey in which researchers found that as many as 37% of American households felt “economically insecure”; and 43% of households with an annual income of more than $50,000.00 feared that one of their members would be laid off in the next three years.

Fear and distrust of strangers also has implications for community cohesiveness. American and Canadian communities continue to experience significant changes in terms of their racial, socio economic, industrial and geo political make-up Many continue to deteriorate, which brings about increasing concern of crime and personal safety. It motivates people to turn strangers away at the door as part of their survival strategy. Overpowering feelings of fear breed distrust of others, causing some community institutions and social control to disintegrate (Maser, 2004). Furthermore it decreases community interaction and makes people less inclined to seek help when they are hurt or when they experience personal difficulties.

Especially noteworthy is prolonged fear which, psychologists say can turn into anger and often depression (reference?). The issue becomes the release of pent up anger, which often leads to injury, as for example hostile actions in organized sports, bars, cars or public spaces. The anger may be an expression of fear due to uncontrollable factors like employer neglect, industrial power, government policies, anonymous institutions or intransient bureaucracies.   Some people lash out at strangers – for example, automobile drivers. Anger can become a destructive force in the community whereby individuals in one group come into conflict with other groups, breaking up the community’s social fabric. For example, a northern Alberta village is in the throes of social destruction because three young males, frustrated with their lot in life and belonging to one extended family, killed an older male, thought to be a drug seller from another prominent family. The conflict has become a dominant feature in the implementation of traffic safety programs. Both families are unwilling to participate, rendering a potential prevention program impotent. 

            Some call it emotional stress, others refer to it as dealing with daily pressures, others still suggest that it is the result of physical or emotional demands that we can’t handle (references?). Social demands like those of marriage and family often exceed our adaptive capacity to deal with them. Research evidence has shown that hostile behavior during marital troubles seriously damages combatants’coping skills and mental health (Amato, 2000). It is no surprise, therefore that divorce - which has become so common - has also become a dominant stressor in our society. As a culture we have tried to dismiss the devastation of divorce, minimizing its effects as "a squall in the ocean of life, intense but short lasting. We take solace in the view that divorced partners live to love again, to find happiness with a new partner. But it is not that simple. The National Institute for Health Care Research (1998) suggested that a significant number of divorcees’ and their children experience psychological tremors throughout their lives, showing up in increased emotional trauma physical risk and destructive behaviors. Taken on a large scale this syndrome affects communities in major ways. 

When husbands and wives divorce, they likely split the family, severely altering the relationships children have with their fathers and mothers. Children can easily lose their sense of family, security and attachment; they fear abandonment; and experience first hand the hostility between parents. They often become frightened and confused by the threat to their security, becoming vulnerable to physical and mental illness (American Academy of Child and Adolescent Psychiatry, 2004).   Furthermore children may hold anger within them, become more accident prone, and increasingly aggressive, which can lead to personal harm. Peak times for this emotional turmoil are teen-age years where children of broken homes become increasingly resentful and angry, becoming involved in extreme high-risk and violent behaviors that stretch the community’s ability to cope (DeBord, 2004). 

Social stress is also the consequence of other community-destroying forces like unemployment, job security, social exclusion, financial challenges, indifferent bureaucracies, family death and deteriorating health problems due to lack of finances for cures. Chicago sociologists have long suggested that cities are inherently stressful because the high density of settlement causes much anxiety and tension that cumulates into social stress (Berger & Berger, 1975). Too many people living within confined areas with limited access to essential services like garbage collection and pest control, or safety installations like adequate street lighting, creates conflict within and amongst individuals and unsafe environments. 

Social stress often exhibits itself as fear, anxiety, anger and aggression amongst children and adults (Carrère, et al, 2005: Lam, 1999). The causes are readily apparent intraffic. For example, after Selzer et al (1968) engaged a hallmark study on anger and driving they concluded that a motorist's inability to deal effectively with anger seriously degrades driving performance. People increased their risk of road rage or aggressive driving after they had recent experiences that left them uncertain and anxious. After completing a statistical analysis of fatal collisions, the researchers reported that 20% of the cases studied involved drivers who had been in aggressive altercations within a six-hour period before their deaths. More recently Roberts (2005) concluded that social stress, caused by increased economic/workplace and social uncertainty and insecurity contributes to greater probability of drivers becoming involved in aggressive and high risk driving behaviors. 

One coping mechanism against social stress is alcohol (Cappell and Greeley (1987: Krause, 1991). Sstressful life events are correlatedwith alcohol dependence that eventually results in health problems, one of which is aggression and the propensity to become violent with a vehicle. (Johnson & Pandina, 1993: Welte &Mirand, 1995). As social stress increases in a community so does abuse of alcohol and drugs, family violence, self harm like suicide and vehicular violence (Rothe, forthcoming).

 

Family well being and community health seem to go hand in hand. But North American communities are still reacting to the decade of rapid change involving the family. The family and related factors like housing, child rearing practices and nutrition has become a lightening rod for injury. As a society we tend to reify families as special social entities that have a special status. We easily accept the principle that our families nurture children so that they are more likely to do well in school, form healthy relationships, and create better lives for themselves. Research from multiple fields confirms the importance of the family unit as the provider of safe, stable, and nurturing environments for children. Unfortunately the principle is a myth. The traditional family is changing, and from an community stability and injury perspective, not necessarily for the better. 

Today’s families face greater challenges than those of earlier times. Today’s families have less extended family support. They are more isolated from their parents and siblings, who were available to help with the children. Parents are less likely to know their neighbours and they are more likely to feel alone in the community. Today’s parents have more ambiguity as to their role definitions. They are more likely to experience stagnating incomes and have difficulty attaining suitable homes. They work longer hours on the job and their jobs have become less secure (Cowan and Cowan, 1998). Such forces lead to increased anxiety and stress with which families must deal. They have slowly become  immunodeficient – the loss of ability to fight off and survive pressures (Landa, 2005).

The disruption or increasing destabilization of families with children in recent decades has been accompanied by substantial changes. We are more likely to continue a dysfunctional family culture comprised of poverty, alcohol abuse, depression, domestic insecurity or violence, all of which have deleterious effects on both parents and children. We can no longer assume that the family helps protect us from ourselves. 

As a culture we’ve tried to dismiss the devastation of divorce, minimizing its effects as "a squall in the sea of life, intense but soon over.” But for some, especially children, divorce carries tremors felt throughout their lives, showing up in increased emotional and physical risk and destructive acting out behaviors (National Institute for Health Care Research, 1998). For 30 years there has been one divorce for every two marriages in America. This 50% divorce rate is generally consistent in both the United States and Canada with its “no fault divorce” policy. 

One of the results of divorce is increased child anxiety and stress. Children often lose their meaning of family and attachment, fear abandonment and experience hostility between parents. Furthermore young children may hold anger inside, may be accident prone, and may become aggressive and angry, responses that contribute to personal harm as falls or being hit by an object. Once the children hit the teenage years, they may display negative emotions through involvement in high-risk behaviors (DeBord, 2004). 

Parents are a child’s first teachers. They model what they themselves learned and experienced and how they react to different situations. They pass on their views and behavior regarding risk taking, dealing with stress, practicing personal justice and making do in competitive situations (Rothe, 1984). For example, many parents drink and drive, willfully break traffic laws, demand their children to be violent in sports, take risks around the house to save money and celebrate successful risk taking. What young people believe about prevailing norms is also influenced by what their parents do on the road. Research has shown that drivers who are exposed to unpunished aggressive driving behaviour are likely to decrease their inhibition to drive this way in the future (Novaco, 1998). If children routinely see their parents vent anger, gesture obscenely or violate traffic laws by following too closely, exceed the speed limit, pass on the right at high speed or weave in traffic, then they grow up thinking that these behaviours are normal or acceptable.

As children become adolescents they look to their parents for advice and observe their behavior as models. They watch and imitate. Two examples come to mind. We determined that when fathers teach their sons to drive, the boys interpreted the training as little more than practicing the driving actions they had already learnt by watching their parents drive (Stoddart, 1991). They saw their fathers speed, try to beat the red light, go through stop signs, ignore pedestrian rights, drive without seat belts, use their vehicles for revenge, and drive under the influence of alcohol (Stoddart, 1991: 149). In a more recent study we established that the majority of drivers started consuming alcohol around 13-14 years old. Family members either directly or indirectly facilitated their initiation into alcohol consumption (Rothe and Elgert, 2002). 

 

 

Chicago sociologists, Parks and Burgess (1925), theorized that social life consists of competition, too much of which can contribute to the structural breakdown of communities. Social institutions, values and norms have changed over the years, resulting in increased competition amongst citizens for a university education, professional employment, gender equality and child discipline among other areas of life. People compete for wealth, power, luxuries and social standing. Our educational system is based students competing against another for the highest marks. Furthermore, people from different backgrounds compete against one another to gain favor with the government and to successfully lobby their needs. Consumers are always looking for the best deals - quality product at the lowest possible price. They tend to share a view that “If I don’t get all I want now, someone else will get it, which means there will be less for me.” And that tends to translates into people taking additional risks at work, home or on public streets. It is part of a consumerist ideology that has found a place in people’s souls. 

            Community planners attend to this competition by developing roadways and intersections that decrease the potential for competition and maximize the flow of efficient traffic. The construction of freeways and multi lane intersections limits increases traffic volume but it also decreases opportunities for community interactions. Traffic planners and highway engineers design lanes, roadways and intersections for convenience of the driver by limiting competition and inducing consensus. Unfortunately these actions create higher traffic flow, which increases the probability of crashes. Furthermore they establish automobile dependent communities (Surface Transportation Policy Project, 1998). Driving becomes more of a necessity, due to the dispersion of destinations, poor travel options for non-drivers, and because alternative modes (walking, cycling and public transit) are assigned lower priority.  In such communities, non-drivers tend to be excluded from the transport equation, being offered fewer alternatives at higher costs. Furthermore the cumulative effect of streamlining traffic leads to land use patterns that reduce transport alternatives, damaging a “sense of community”.  

            Many current planning practices stimulate automobile-oriented sprawl, reducing mobility options for non-drivers and increasing social segregation. These include generous minimum parking requirements, building setback requirements, constructing vehicle only accessible suburban shopping centers and restricting land for vehicles. Infrastructure funding and pricing practices tend to favor urban expansion over quality of life development (Litman, 2005). Although individually introducing car-friendly infrastructure may seem modest and justified, its effects are cumulative, particularly over the long-term. The result is a significant increase in automobile dependency and sprawl, reduced opportunity for non-drivers, degraded urban environments, and reduced community cohesion (Litman, 2003), factors that limit the community as a focal point for health and traffic safety.

 

The decline of many central-city neighborhoods has been facilitated significantly by individual migration patterns and government policies on public housing that concentrate the poor. Tax breaks are given to land developers, who create suburban sprawl, roadway construction, economic disinvestment in central parts of cities, and haphazard zoning on land use as part of an economic ideology. Community safety is usually factored out, as for example, developing parks and recreation areas that provide citizens opportunities for safe exercise and play. Revenue oriented land use or high density housing are typically preferred by municipal planners, land developers and commercial realtors. 

Over the years municipal officials have become increasingly interested in planning communities on the basis of taxation revenue and land value. Such planning demands the invisibility of the poor. They threaten its legitimacy (Knox, 1993). Hence certain groups find it increasingly difficult to exercise their citizenship. The community of the ghetto, the aged, the immigrant, the poor, the transient Aboriginal, and the young and homeless has a limited or no role in the restructured city. They become marginalized, dispossessed and largely invisible.

The collective elements of the community, such as norms, values, shared attitudes and beliefs, and structural elements like roles, rules, precedents and personal histories, play a fundamental role in the prevention, maintenance and development of ordered forms of social behavior that may result in or negate injury. Anything that limits the availability of social capital for community members can have a negative effect on the health and well being of its the members, which in turn can effect the community as a whole. Voting is a suitable example. Communities with lower social capital are less inclined to vote in elections, which may result in elected officials who offer a platform of industrial ambition and have limited interest in community structures that enhance safety or reduce injury. 

Kawachi et. al. (1997) assessed the relationship between measures of social capital, income inequality and mortality in 39 States across the United States. The research showed that income inequality was strongly associated with lack of social trust. The states with high levels of social mistrust had higher age adjusted mortality rates from a range of conditions including unintentional injury. According to the research team, the growing gap between the rich and the poor affects the social organization of communities and that the resulting damage to the social fabric has profound implications for injury (Kawachi et. al., 1997). As the communities’ social capital is reduced, the chances of injury are increased (Coleman, 1988; Barber & Olsen, 1997).

Issues of community breakdown have been linked with many types of injury and social problems that lead to injury. Socially disorganized communities increasingly resort to social isolation as a means of protecting themselves against risk. A community can bear great amounts of stress when strong social organization is in place, but once this organization is eroded and fragmented, it is less likely to deal with social stressors effectively and constructively. For example, a cohesive community exerts its influence on the risk of injury to 2 – 3 year old children by offering a collective socialization on safe behavior (Platt & Pharoah, 1996). The more unstable the community, the less likely there is a normative social control over individual actions. 

There is a connection between mental health issues, lack of self esteem, unemployment, poor housing conditions and increased rates of injury. Living in dilapidated houses, tents or under bridges creates high risk of injury, and it contributes to mental health problems that lead to self harm, violence or poisoning. Children in low-income neighborhoods are at greater risk of sustaining major injuries and most of the injuries happen near the home. Differences in parenting practices help explain differences in childhood injuries (Aagran et al, 1998).  Social stress and fear is often the trigger for self injury, herby defined as deliberate acts that cause harm to one’s body.

Risk for injury continues to dominate. Residents living in certain communities do not have extended health care insurance, cannot afford the fee for an ambulance, fear outside investigative involvement in their family’s life, or they hesitate to get medical help because they do not know the serious nature of an injury or they cannot afford appropriate medical attention. Physical deterioration of neighborhoods caused by political neglect and social change creates greater opportunities for falls, motor-vehicle crashes and drowning among other related injuries. Criminal elements and transients may take residence in poor neighborhoods, creating within those still living there a sense of isolation, which increases the risk of injury and severity of injury due to lack of timely help among seniors and other vulnerable populations. Local politicians, who prize the ideology of land value rather than social capital, impose planning standards that create efficient and profitable residential, business or industrial communities, but that do not contribute to injury reduction and safe environments. Major freeways cut communities into parcels, creating risks for pedestrians, distancing local services and lowering the social cohesion of a former in-tact single community.

 

            If communities are recognized as the key to greater injury control, then it is incumbent to energize them, rather than allow them to continue to crumble. To do so requires a coordinated and systematic approach that requires sustainable solutions, which must be worked out with the communities.  The primary effort must be to maintain and/or rebuild cohesive communities before we introduce collective action in specific domains like the schools, policing, hospitals or senior care centers. It is akin to SMARTRISK’s (2003) Canadian Collaborating Centers for Injury Prevention and Control plan of different governments introducing policies that lead to healthy lives and minimum risk of injury. We suggest that the approach needs to be systemic to uproot deeply planted social inequities. Interventions should be directed outside of the public health domain to address issues like neighborhood stability, housing quality, family breakdown, political participation and influence, industrial profiteering at the cost of safety, open educational opportunity, access to transportation and various forms of discrimination. We need to think globally and act locally. 

The communities’ social capital is the resource stock of neighborhood organizations and their linkages with other organizations, both within andoutside the community (Sampson 1999). Communities need to be supported in their capacity to obtain extra-local resources (e.g., police, fire protection; block grants; health services) that help sustain neighborhood stability and control. Local communities need to be supported to work together with forces of public agencies to achieve social order, principally through interdependence among private (family), parochial (community) and public (state or province) institutions. For example, strong schools help build and maintain strong communities, and they become major stakeholders in safety and family affairs. Well financed community centers support teen activities and house vital civic activities like elections or recreational planning.

Neighborhood-level response may be more effective than policies that simply target individuals or families. By responding proactively to neighborhoods and places that disproportionately generate crimes and adverse health events (e.g., high incidence of heat related deaths, alcohol fatalities, suicides, senior falls), intervention strategies can more efficiently stave off “epidemics ” and their spatial diffusion. Also, neighborhood strategies to monitor the ecological placements of bars, liquor stores, strip-mall shopping outlets, bus stops, and unsupervised play spaces may play an important role in controlling the distribution of high-risk situations. Furthermore governments need to act as catalysts in sparking a sense of local ownership over public space and greater activation of informal social control.

Any intervention must account for the historical circumstances that have contributed to the shaping the current-day situation, and the modern forces that shape the future. One process is to offer greater opportunity for community residents to become critically literate. Critical literacy encourages critical reflection of individual experiences and calls for social analysis and social change (Auerbach 1993). Adult educators can teach critical literacy by (1) connecting learning to learners' lived experiences; (2) helping learners question theory relative to their own cultural experience; (3) giving voice to learners and creating forums in which they can tell their stories (Sheared 1994); (4) helping learners view knowledge as something that they can produce; and (5) giving learners the tools to critique frames of reference, ideas, information, and patterns of privilege and develop critical consciousness (Freire and Macedo 1987). Through critical literacy, learners come to understand not only how events and certain social forces affect their life, but also how they lead to unsafe working conditions, injury and disease. 

Deep rooted community issues like exclusion, youth suicide, alcoholism, licit and illicit drug abuse, alcoholism, semi illiteracy, sexism and racism are problems for which information pamphlet, will not work. Sustained social well being for excluded groups like Aboriginal children, youth and families will only be achieved if there is a recognition of community self-determination and an investment in sustainable community development, of which child and youth well being are critical considerations. To date, social development is based on whatever targeted social programs government decides to fund; not what many communities determine would be helpful and how it could most respectfully and sustainably resourced. Once that is achieved, citizens will once again feel a greater community attachment to their family, friends, schools, clubs and commit to working with local government in the pursuit of citizenship planning that affects people’s lives.

 

 

 

 

 

 

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