Seventy-one individuals participated in either a key informant interview or focus group. There were no participants that refused to participate. Key informants included public health practitioners and managers (n=12), injury researchers with public policy expertise (n=2), a public health expert (n=1), and not for profit organizations aimed to support injury prevention both provincially (n=2) and nationally (n=3). Site visits included 5 public health units across the province: two representing predominantly rural areas – one being in northern Ontario, two from predominantly urban areas, and one public health unit that provided service to both rural and urban areas. The total number of participants, as well as their positions/roles are shown in Table 1.
Other data collected for this project (e.g., existing provincial standards and guidelines, surveillance data, etc.) provided contextual information for objectives 2 and 3, and are not reported here but provided important information for meaningful discussion of the results.
The major themes that were identified from the data included the current practice challenges in injury prevention, capacity and resource constraints of individuals and the organization, and injury as a low priority area in public health. Although distinct themes, there are relationships between findings across themes which contribute to a more complete picture of the public health practice in injury prevention in Ontario. Within each theme, needs for effective practice were expressed that created opportunity to present areas of potential support. The needs are discussed within each theme, and summarized in Table 2.
Current Public Health Practice Challenges in Injury Prevention
Current public health practice in injury prevention is challenging due to competitive and limited resources, insufficient direction and coordination, collaboration complexity, and emerging injury issues to address. Injury prevention in Ontario includes many passionate and committed practitioners who described injury as a broad practice area that includes several injury topics (e.g., road safety, off-road safety, falls, and violence). Injury prevention cross cuts and competes with other topics, (e.g., requirements to address the opioid crisis as well as cannabis use). Participants spoke of practitioner’s challenges to fulfil expectations described in the Ontario Public Health Standards, citing inadequate resources as a significant barrier to effective practice. Key informants identified insufficient system level guidance and coordination, and inconsistent implementation of programs across the province. Interestingly, there was also a perception that larger public health units in the province would be spared the challenges of smaller units, including those related to the availability of resources and capacity; however, there was little variability in the data between large and smaller units.
Participants stated that collaborative work was challenging. Specifically, they reported difficulty building partnerships and collaborating locally (e.g., many informants described the inability to form collaborative working relationships with sectors outside of health) as well as with other public health units across the province. Participants expressed a gap in knowledge of current research in injury prevention, describing limited knowledge of the research projects happening locally, provincially, and nationally. Practitioners wished for increased connection between the field and injury researchers.
Finally, when asked about the current and emerging issues in injury practice, the following topics were described: i) concussion prevention in the context of sport; ii) the role of public health in older adult falls prevention; and, iii) the need to address cannabis use in the context of impaired driving. These topics were not surprising given the implementation of Rowan’s Law (provincial legislation to support concussion detection, management and prevention)(17) in addition to recent federal legislation in Canada, legalizing the use of cannabis.(18) When addressing current or emerging issues, multiple stakeholders described the potential for “duplication of efforts” across injury topics, specifically where health units are independently summarizing the evidence of effective interventions from the peer-reviewed literature when there is little to no variation in their implementation contexts.
Capacity and Resource Constraints
Capacity and resource constraints were described in relation to the lack of both financial and human support for prevention practice overall, and for injury specifically. Sub-themes related to both individual and organizational capacity. Many of those that work in public heath injury prevention are trained public health nurses; however, participants described a large variability in the capacity of individual practitioners. Some discussed the inability to conduct and/or interpret data analyses as well as to critically appraise and synthesize evidence to inform decision making. Many described the lack of time as a significant factor in the ability to do quality analyses and synthesis work; others described confidence and experience, in addition to a skill set in using this information in planning. There was also a stated lack of organizational capacity that included few staff responsible for addressing the breadth of injury topics (i.e., road and off road safety, sport injury, falls, violence, burns, poisoning, drowning) in addition to the support need to adopt, implement and evaluate new and existing evidence-based interventions.
Across all levels of practice, participants described the lack of access to local data to inform planning and programming for injury. While health administrative data is available (e.g., emergency department visits, hospitalizations, deaths) there is variation in the accessibility and use of other types of pertinent data (e.g., police reported collision data). Some public health units have relationships with data holders where others described the inability to develop these relationships entirely. Informing a plan to prevent injury, across all injury types, is reliant on data that provides information on injury type, mechanism, location, severity, as well as demographic information of those involved.
There was a shared concern over the use and availability of both population level and programmatic indicators in injury prevention. The staff spoke of the lack of specificity in administrative data that can be used to establish an understanding of burden, as well as for use in planning a program of public health action. In addition, it was expressed that there is a lack of specific indicators to accurately measure the effect of the work done in public health.
Injury Prevention as a Low Priority Area
Injury prevention was described as a low priority area in public health. Practitioners used the terms “low”, “lowest” or “competing” priority for injury. There was a feeling of significant mismatch between the burden of injury and its impact on the health of Ontarians and the resources available to address it. Stakeholders described that injury topics “sit in other departments” such as the built environment (e.g., safe and active travel), and family health (e.g., child poisoning or safe home practices for child falls prevention) creating a feeling of disconnection with the work being done in the same public health unit. The stakeholders also described the high rate of staff turnover and lack of senior leadership support compared to other health topics.
Public health staff also spoke of injury as a topic that is not prioritized for data analyses at a local level. For example, there is often one epidemiologist in a public health unit department (and sometimes in the entire organization) that is charged to pull and analyse health administrative data across all health topics; in the context of emerging public health issues (e.g., opioid-related morbidity and mortality), injury analyses are deemphasized.
Data Verification and Setting Priorities
Participants of the online meeting (n=22) and those from each in person meeting (researchers, and not for profit organizations) (n=8) provided confirmation of the themes. No new themes were added to the data collection from information collected in the meeting. From the prioritization exercise, the field ranked the top three needs that included: the need for evidence of effective interventions across injury topics; the need for access to local data and systematic use of both population level and programmatic indicators, and; the need for increased collaboration and networking opportunities both between public health units and research.