As injury came to be perceived as a disease, John Gordon, a researcher in public health in the 1940s, proposed that injury, like other types of disease, had epidemic events, seasonal changpes, long-term trends, and high-risk groups in its demographic distribution. Accordingly, an idea began to emerge that properly controlling the three factors related to diseases-the host, agent (or vector), and environment-can prevent injury [1]. In that regard, community-based programs for injury prevention are being considered an essential element in lowering injury rates of communities and improving health and safety [2].

The concept of "Safe Communities" was introduced at the First World Conference on Accident and Injury Prevention held in Stockholm, Sweden in 1989, and a declaration that "All human beings have an equal right to health and safety" was adopted at the conference [3]. Safe Communities refer to municipalities such as counties, cities, or districts of cities that carry out projects for safety promotion; prevention of injury, violence, and suicide; and management of damage by natural disasters for all age groups, sexes, and geographical areas. These communities also join international networks according to authorization processes [4].

Since 1989, about 280 communities have been approved to be Safe Communities across the world, including ones in Sweden, Norway, Australia, New Zealand, China, Vietnam, South Africa, the US, and Canada [5]. In Korea, the city of Suwon was first approved to be a Safe Community [6], and Gangbuk-gu was also granted authentication as an International Safe Community in 2012, after forming organizations for Safe Community Programs and conducting fundamental research since 2008.

Similarly, diverse areas across the world are carrying out Safe Communities Programs. Nonetheless, studies on the evaluation of effectiveness of the programs on injury have not yet been widely performed [7]. Furthermore, research on injury in general in Korea is very rare [8]. Against this backdrop, in this study we introduce the contents of the Safe Communities Program implemented in Gangbuk-gu and identify overal results and problems resulting from the program implementation based on the comparisons between the following: injury death rates of Gangbuk-gu before and after the program; trends in injury deaths between Gangbuk-gu and Seoul metropolitan city; and program participants and beneficiaries' satisfaction with the effectiveness of the program, and their intention to voluntarily participate.

When implementing safety promotion programs in communities, long-term programs, rather than short-term ones, are essential because effectiveness of the program in the broader community is difficult to achieve in programs with short spans owing to limitations in the scope and focus of the programs. Continuous operation of programs leads to increased awareness of community residents regarding injury prevention and safety and encourages their active participation in the initial stage. Short-term results of the programs, such as changing individuals' risk behaviors, along with achieving the targets of sub-projects can be anticipated. Ultimately, changes in health status such as the reduction in injury incidence rates and mortality due to injury can be expected. In implementing such continuous and long-term programs, management of processes are of the paramount importance. To that end, management of the program takes places in different phases from the analysis of the current status at the planning stage-when feasibility of the program is evaluated-to the process evaluation stage during the implementation of the program, and then to the outcome evaluation stage, in order to determine ways to improve the programs and decide whether to renew them after completion [9]. To develop the Safe Communities Program, in 2008, before launching the program, Gangbuk-gu conducted a survey of 1866 community residents on the level of awareness of the Safe Communities program and priorities for sub-projects. The results showed the need for projects in seven categories: child safety, suicide prevention, road safety, local community safety, fire safety, senior safety, and first aid and emergency medical services. Gangbuk-gu selected 25 sub-projects as priority projects, consulting the contents of the Safe Communities Program and evaluation criteria of another district, Songpa-gu [10], which was authorized as a Safe Community by the World Health Organization before Gangbuk-gu started the program, and had been running the program since 2009.

In this study, we analyzed the injury mortality rates of Gangbuk-gu before and after the program, using death certificate data. The results showed that total injury death rates increased slightly while child injury death rates and seniors' injury death rates decreased, demonstrating that the Safe Communities Program of Gangbuk-gu did not reduce injury deaths significantly. Internationally, a systematic review evaluated whether Safe Communities Programs were effective in lowering injury morbidity and mortality of the total population of 21 communities of countries such as Austria, Sweden, and New Zealand. However, the findings of the survey were inconsistent: Some countries succeeded in reducing injuries in the total population but others did not show any changes [7]: specifically, injury fatalities decreased after the program in Vorarlberg, Austria [11], and the incidences of total injury [12] and injury in children [13] and the elderly [14] decreased in Motala, Sweden. In contrast, no difference was seen in the number of hospitalizations due to injury before and after the program in Waitakere, New Zealand [15]. The reason behind the inconsistent findings on the effects of Safe Communities programs on injury among different areas is thought to be attributable to the following: the heterogeneity of program implementation approaches; diversity in efficacy of activities and strategies and intensity of implementation; and methodological limits inherent to community-based evaluations [7]. A closer investigation of international studies appraising the effects of Safe Communities Programs reveals that in the case of Motala, Sweden, no change was seen in severe or fatal traffic-related injuries, while non-fatal injuries decreased by nearly 50% [16]. In addition, the total child injury incidence declined by 25% after the program compared to the rate before the program, and while severe injuries did not show any changes, non-fatal injuries decreased by about 50% [13]. In the meantime, in Kashmar, Iran, fatality rates fell significantly after the program compared to the control group. However, the overall injury incidence trend increased slightly, compared to the trend before the program [17]. The reason behind such trends seems to be the fact that countries that are in their early days of Safe Communities Program implementation, including Iran, have more reports about minor injuries in the early stage of the program because they build an injury registration system specifically for the program. That, in turn, may have made the program seem to have no preventive effects on injury or show reports of even higher total injury incidence. This is a contrast to the situation in countries including Sweden that have a long history of Safe Communities Programs and effectively provide interventions. In such countries, the programs yield more effective outcomes in reducing minor injuries than severe injuries. In countries where Safe Communities Programs are still fledgling-for example, Korea, South Africa, Bangladesh, China, and Vietnam, the effectiveness of the programs has not yet been evaluated concretely [7]. Therefore, collecting data such as the incidence of injury and death longitudinally and conducting studies on the effectiveness of the programs is necessary.

Cho and Park [9] noted that it is important to shift Safe Communities Programs from a practitioner-driven to client-oriented approach in order to induce voluntary participation of members of communities, the clients of the programs, and to disseminate the contents of the programs to others around them as major agents. Therefore, in order to evaluate the satisfaction level of the participants and identify the problems that have occurred during implementation, we studied the effectiveness of the Safe Communities Program and the degree of voluntary dissemination by participants-those who actively engaged in the program-and beneficiaries-those who only benefited passively from the program-after running the program. The comparison and analysis between the participants and beneficiaries' views on the effectiveness of the program and intention to voluntarily participate in sub-projects of the Safe Communities Program demonstrated the following: There was no significant difference between participants and beneficiaries in the effectiveness of the program. However, beneficiaries' intention to voluntarily participate was significantly lower than that of the participants in some projects. Therefore, we estimate that the dissemination of the injury prevention measures by participants of the program to the people around them as well as the influence of preventive effects may have been weak.

The result of this study also showed that Gangbuk-gu had a very high injury death rate of the elderly, making them a vulnerable group to injury. Worldwide, 28% to 35% of those aged over 65 and 32% to 42% of those aged over 70 experience falls annually [18]. In particular, serious falls are considered a "gateway event" that is, an event that ends the healthy and independent life of an elderly person. Thus, fall prevention is set as a priority agenda among various projects of the Safe Communities Programs for the safety of older adults [19]. For example, Japan, where the health of the elderly has become a major social issue owing to its aged population, offers various programs in communities to prevent accidents among senior citizens. Among various health issues, falls have a major impact on older people's mortality rates: Falls are the second leading cause of injury-caused death by accidents. Therefore, the Japanese government is carrying out fall prevention projects under Safe Community Programs in six regions of Japan [19]. In addition, Shanghai has implemented a Safe Communities Program to prevent falls for adults aged over 60. After the project, the participants' knowledge, attitude, and practice regarding falls was found to have improved [20]. However, changes in patterns of injury incidence in the total population were not evaluated in the Japanese and Shanghai studies.

Furthermore, this study demonstrated that seniors' suicide rates, among various injury death rates of the elderly, increased after the program, which signifies the importance of prevention of seniors' suicide. Recent studies show that lack of social relationships-besides depression-is the most common risk factor for suicide in the elderly [21-23], highlighting the need for community-based interventions for this issue. In Japan, implementing a community-based suicide prevention program-including mental health workshops, group activity programs, and self-assessment for depression-for people aged over 65 over eight years reduced the suicide incidence rates of the female elderly by 76% [24]. Also, after offering community-based interventions focusing on the empowerment of residents of six rural areas with large geriatric populations in Japan, suicide rates declined to a statistically significant extent [25]. Therefore, communities' continuous efforts to avert elderly suicides through programs like the Safe Communities Program are deemed necessary.

Gangbuk-gu carried out sub-projects under a Safe Communities Program, including projects on education for prevention of child injury and maintaining school safety guards for children's safety. The city of Busan developed a web-based children's safety education program to raise public awareness of the importance of injury prevention and safety promotion for children in an attempt to prevent children's injury. The city is now evaluating the program participants' changes in knowledge, attitudes, and behavior regarding child safety [26].

The limitations of this study include that the total injury incidence, including minor injury incidence, could not be identified, because we used only injury mortality in the evaluation of the Safe Communities Program. In addition, the study did not make direct appraisals as to whether the activities performed by safety leaders and beneficiaries who joined the program influenced injury death rates of the entire Gangbuk-gu district. Hence, it is important to identify the impact of Safe Communities Programs through the analysis of social networks in the future [27,28] to understand how relationships between safety leaders and beneficiaries and the degree of their participation influence injury and death rates in their communities.

Conclusively, the study results showed that beneficiaries of the Safe Communities Program had a relatively low intention to voluntarily participate in the program. Therefore, we can estimate that such a factor can serve as a challenge in implementing the program in terms of disseminating the effects of injury prevention among all of the residents of Gangbuk-gu. Furthermore, it is deemed necessary to carry out programs focusing on the elderly-who have been found to be a group particularly vulnerable to injury-and to maintain intervention programs consistently for the entire elderly population in communities to prevent elderly suicide. In Korea, as Safe Communities Programs have not been implemented extensively, it is difficult to obtain data on changes in injury incidents after implementing the programs. Therefore, in the short and mid-term, it would be necessary to analyze changes in knowledge, attitudes, and behaviors to evaluate individuals' changes in risk behaviors related to accidents in order to determine the effects of Safe Communities Programs. In the long run, conducting longitudinal assessments observing the trends of injury incidence and death or comparing injury incidence between communities that had Safe Communities Programs and control communities will be needed. In Gangbuk-gu, since the Safe Communities Program was implemented mainly through the Community Health Center focusing on vulnerable groups such as older adults, young children, and pregnant women, the program had a limitation in demonstrating its effects on injury prevention in the entire population. Therefore, it is necessary for governmental administrative agencies to take a major role in the implementation of Safe Communities Programs when expanding the programs nationwide because they have the ability to exert a broader influence on communities and the entire population.