Evaluation of the Active and Safe Injury Prevention Initiative 2011-2012 to 2012-2013

Prepared by
Evaluation Directorate
Public Health Agency of Canada/Health Canada

February 2014

Table of contents

• Executive summary

1. Evaluation Purpose
2. Program Description
   • 2.1  Program Context
   • 2.2  Program Profile
   • 2.3  Program Logic Model and Narrative
   • 2.4  Program Alignment and Resources
3. Evaluation Description
   • 3.1  Evaluation Scope, Approach and Design
   • 3.2  Limitations and Mitigation Strategies
4. Findings
   • 4.1  Relevance: Issue #1 – Continued Need for the Program
   • 4.2  Relevance: Issue #2 – Alignment with Government Priorities
   • 4.3  Relevance: Issue #3 – Alignment with Federal Roles and Responsibilities
   • 4.4  Performance: Issue #4 – Achievement of Expected Outcomes (Effectiveness)
   • 4.5  Performance: Issue #5 – Demonstration of Economy and Efficiency
5. Conclusions
   • 5.1 Relevance Conclusions
   • 5.2 Performance Conclusions
6. Opportunities for the Agency to build on current investment

• Appendix 1 - List of Projects
• Appendix 2 - Logic Model
• Appendix 3 - Evaluation Description
• Appendix 4 – Case Study on Healthy Living and Chronic Diseases' Multi-Sectoral Partnerships Approach
• Appendix 5 – Extra Funding Source and Amount
• Appendix 6 – Endnotes

• List of Acronyms

Executive Summary

This report presents the findings of the evaluation of the Active and Safe Injury Prevention Initiative at the Public Health Agency of Canada (PHAC).

Evaluation Purpose and Scope

The purpose of the evaluation was to assess the relevance and performance of the Active and Safe Injury Prevention Initiative. This includes activities funded by PHAC through the recipient non-governmental organizations (NGOs) involved in developing sports and recreation injury prevention projects. The timeframe of this evaluation was from April 1, 2011 (the date the initiative started) until March 31, 2013 (the date of its completion).

Program Description

The Initiative was a two-year $5 million initiative aimed at decreasing the incidence of sport and recreation-related injuries in children and youth (0-19 years) through improving community awareness and enhancing collaboration among injury prevention stakeholders. Initiative funding was distributed through contribution agreements to injury prevention and sports and recreation NGOs to deliver injury prevention projects across Canada. A total of 18 injury prevention projects were funded through three sequential tiers dealing with concussions, fractures and drownings.

Findings

Relevance

Continued Need

Unintended injuries resulting from sports and recreational activities are the leading cause of injuries in children in Canada. These types of injuries may result in hospitalization, impairment and disability, and rarely death. In addition to the negative health outcomes for individuals affected by these types of injuries, there is an economic burden for Canada as these injuries may place additional demands on the health care system and on society. Consequently, there is an ongoing need to address this important public health issue.

Alignment with Government Priorities

The Initiative was aligned with a number of Government of Canada priorities including the commitment to prevent injuries in children and to work collaboratively with non-governmental organizations to address injury, as noted in the 2010 Speech from the Throne, the 2010 Budget, and recent Ministerial announcements. The Initiative was also aligned with Agency priorities and strategic outcomes related to injury as articulated in corporate documents.

Alignment with Federal Roles and Responsibilities

The Initiative was aligned with federal roles and responsibilities as injury prevention is one of the health measures that the Public Health Agency is responsible for. The Department of Health Act^{Footnote i} and the Public Health Agency of Canada Act^{Footnote ii} guide the Public Health Agency's roles and responsibilities for the prevention of illness, including injuries. Under the Department of Health Act, the Minister of Health has a broad mandate to protect Canadians against health risks. As per the PHAC Act, under the leadership of the Chief Public Health Officer, and in collaboration with its partners, the Public Health Agency is mandated to lead federal efforts and to mobilize pan-Canadian action in preventing disease and injury. In addition, federal, provincial and territorial (F/P/T) documents confirm a federal public health role in the area of injury prevention (e.g., Declaration on Prevention and Promotion). Injury prevention crosses provincial and territorial borders, providing the Agency with an opportunity to provide a national leadership role in preventing injury.

Performance

The Active and Safe Injury Prevention Initiative has made progress towards its immediate and intermediate outcomes relative to reducing unintended sports and recreation injuries in children and youth (0 to 19 years).

The Initiative led to collaboration between key national players in injury prevention and sport and recreation. The funded NGOs worked on developing injury prevention policies, programs and practices while accessing evidence-based knowledge in a systematic manner thus ensuring the most up-to-date research and messaging were consistently available in their injury prevention materials. These materials were then disseminated through a variety of means to target audiences that were concerned with preventing sports and recreation related injuries, including vulnerable populations and those living in remote and rural areas across the country.

The Initiative enabled new education and training methods to be developed. More than 50% of projects reported they had developed unique injury prevention activities including developing injury prevention webinars and programs (e.g., the Club Excellence program that recognized organizations committed to injury prevention). Preliminary indications indicate that these materials and methods led to an increase in the understanding of and capacity to prevent injuries in some of the target audience.

Demonstration of Economy and Efficiency

The Active and Safe projects were completed on time, on budget and according to specifications. Some projects were able to leverage additional resources in multiple ways such as in-kind contributions, volunteer hours and additional funding, where possible, to supplement the Agency's financial contributions. The strategy of injury prevention, rather than treatment of injury, has been supported by the literature as being a cost-effective approach. On an operational level, the projects all demonstrated that cost-savings measures were utilized, where possible, to ensure that outputs were produced efficiently (e.g., use of online technology). Performance measurement data were collected for individual projects in support of decision making.  

Opportunities to build on current investment

The Active and Safe Injury Prevention Initiative was time-limited and ended in March 2013. However, should the Agency be asked to develop further work in this area, opportunities to build on the current investment were identified.

The Agency could build on the injury prevention efforts of the Initiative by disseminating the information to a broader audience, which would include further outreach to vulnerable and remote and rural populations. In addition, the Agency could explore models of engaging the private sector to leverage additional resources for injury prevention efforts. Exploring and encouraging private sector partnerships would facilitate an extension of reach and would bring together different stakeholders and unique contributions in order to develop injury prevention projects. As a result, injury prevention efforts could have greater benefit to communities, and would stimulate the sharing of best practices and collaboration over the longer-term.

1.0 Evaluation Purpose

The purpose of the evaluation was to assess the relevance and performance of the Active and Safe Injury Prevention Initiative from April 1, 2011 (the date the initiative started) until March 31, 2013 (the date of its completion).

This was a scheduled evaluation as per the Public Health Agency of Canada/Health Canada's approved Five-Year Evaluation Plan 2013-2014 to 2017-2018, to meet requirements of the Financial Administration Act and the Treasury Board of Canada's Policy on Evaluation (2009).

2.0  Program Description

2.1 Program Context

In 2011, an F/P/T task group of the Pan Canadian Public Health Network (PHN) identified sport and recreation injuries as one of four priority areas for coordinated preventive action. In their advice to governments, the task group members expressed support for an improved public health role in the prevention of injuries in sport and recreation activities and highlighted the need for strengthened government leadership in this area.

In the March 2010 Speech from the Throne, the Government of Canada announced its intention to collaborate (through the Public Health Agency of Canada) with non-governmental organizations (NGOs) on childhood injury prevention.

In 2011, the Government of Canada announced $5M over two years for the Active and Safe Injury Prevention Initiative. The Initiative, delivered by the Public Health Agency of Canada, aimed to decrease the incidence of sport and recreation-related injuries in children and youth (aged 0-19) through improving community awareness and enhancing collaboration among injury prevention stakeholders. The Centre for Health Promotion (CHP) of the Health Promotion and Chronic Disease Prevention (HPCDP) Branch within the Public Health Agency of Canada held overall accountability for the achievement of outcomes. 

2.2  Program Profile

The Active and Safe Injury Prevention Initiative was a two-year, $5 million initiative with the following main objectives:

• Strengthen multi-sectoral collaboration among injury prevention stakeholders (this could include, for example, injury prevention organizations, sport and recreation organizations, and provincial and territorial governments) and
• Increase sport and recreation injury prevention awareness and promotion through support at the community level.

The Initiative was designed to have a positive impact on injury prevention activities at the community level and more specifically, to contribute to the prevention of serious injuries (e.g., concussions, drownings and fractures) sustained in high participation activities, such as hockey, swimming and cycling among children and youth (ages 0-19).

A total of 18 projects were funded through the Initiative. Each project was structured with a lead NGO and involved partnerships with organizations spanning various public health, sport, physical activity and other sectors (e.g., education, sport, recreation). Leveraging of additional financial support or in-kind contributions (e.g., office space, staff time, and expertise) was encouraged. All projects involved the development and distribution of injury prevention resources aligned with the overall priorities of the Initiative. See Appendix 1 for a list of each funded project.

In terms of delivery, the Initiative funding was distributed using a phased approach, in which projects were organized into a cascading system of three sequential tiers. Each tier consisted of a collection of projects aimed at addressing a specific injury prevention theme. This design was used to allow later tiers to collaborate with organizations in earlier tiers to build upon existing knowledge and to ensure injury prevention efforts and information were complementary, consistent and coordinated across Canada.

The first tier involved a direct solicitation of select NGOs that were leaders in their field and had the capacity to deliver results in a relatively short time frame. A total of approximately $3 million was allocated to this tier, for two projects dealing with concussions and drownings ($1.5 million for each project). The first project targeted the prevention of concussions and head injuries in team sports and the second targeted child and youth drowning prevention with a focus on natural bodies of water. The Agency funded these areas as there was evidence that effective preventive measures existed (e.g., use of personal flotation devices to prevent drowning) and there was growing public attention through media coverage on these issues (e.g., concussions in hockey). The first tier projects began in October 2011.

The second tier involved a targeted solicitation of a small number of well-established NGOs for their extensive experience and access to community networks. Five projects were funded at approximately $200,000 each. Each project addressed key injury concerns, selected to address areas resulting in significant rates of serious injury in children and youth, according to the best available national data at the time of program development. The five themes focused on recreational activities including: recreational cycling; recreational snow sports; playgrounds and neighbourhood play spaces; afterschool physical activity programs; and physical literacy. These projects began in February 2012.

The third tier was an open, competitive process whereby NGOs were invited through a letter of intent to submit their ideas for child and youth injury prevention projects in sports and recreation. A total of 11 projects were funded for approximately $100,000 each, and focused on injury issues consistent with the first and second tiers. These projects were meant to complement projects under the first two tiers and engage the injury prevention community more broadly to leverage the expertise produced under the first and second tiers. Third tier projects began in July 2012.

2.3  Program Logic Model and Narrative

The logic model (see Appendix 2) is a depiction of the causal or logical relationship between the inputs, activities, outputs and outcomes of a given policy, program or initiative. For the Active and Safe Initiative, it demonstrated how activities were expected to contribute to the intended injury prevention outcomes, illustrating the links between activities, outputs and outcomes. The target audience included parents, children and youth, and coaches and trainers from the sports community.

The focus of the Initiative was to support opportunities for multi-sectoral collaborative action with NGOs, communities, provincial/territorial governments and other government departments to achieve a co-ordinated approach to the prevention of child and youth injuries in sport and recreation. The organizations engaged by the NGOs came from various health and physical activity sectors (e.g., education, sport, recreation, medicine).   

The Initiative focussed on a number of expected outcomes. While the achievement of immediate outcomes was expected, complete achievement of the intermediate outcomes was not anticipated given the short time frame of the Initiative (two years).

Immediate outcomes include:

• Targeted multi-sectoral stakeholders have opportunities to collaborate in pan-Canadian initiatives aimed at preventing sports and recreation related injuries.
• Targeted multi-sectoral stakeholders have access to evidence-based knowledge needed to increase awareness of sports and recreation injury prevention.
• Target audiences have access to awareness/education products aimed at preventing sports and recreation related injuries.

Intermediate outcomes include:

• Targeted multi-sectoral stakeholders are equipped to design and develop injury prevention policies, programs, and practices that promote safety and prevent and reduce injuries.
• Target audiences understand how to prevent injury and take actions to increase their safety.
• Target audiences have the capacity to promote safety and prevent sports related injuries.

Ultimate outcome:

• Unintentional injuries in Canada are prevented and mitigated.

2.4  Program Alignment and Resources

The Initiative formed part of the Agency's Program Alignment Architecture (PAA): Program 1.2: Health Promotion and Disease Prevention, Sub-Program 1.2.3: Chronic Disease and Injury Prevention.

The financial data for the years 2011 through 2013 is presented below (Table 1).

Source:    Office of the Chief Financial Officer and Program Administration Staff

Over the period of 2011-2013, the Initiative spent a total of $4.97 million in grants and contribution funding, $21,000 in operations and maintenance (O&M) funding, and $520,000 in salaries and EBP. The O&M and salary costs were reallocated from other activities within the Centre of Health Promotion and covered such activities as travel for technical meetings, translation, and professional services.

3.0  Evaluation Description

3.1  Evaluation Scope, Approach and Design

The scope of the evaluation included recipient NGO injury prevention activities funded by PHAC and excluded other work undertaken by the NGOs outside of the PHAC- funded projects. The timeframe of this evaluation was from April 1, 2011 (the date the initiative started) until March 31, 2013 (the date of its completion).

The evaluation issues were aligned with the Treasury Board of Canada's Policy on Evaluation (2009) and considered the five core issues under the two themes of relevance and performance, as shown in Appendix 3. Corresponding to each of the core issues, specific questions were developed based on program considerations and these guided the evaluation process.

An outcome-based evaluation approach was used for the conduct of the Active and Safe Injury Prevention evaluation to assess the progress made towards the achievement of its expected outcomes.

This was a scheduled evaluation as per the Public Health Agency of Canada and Health Canada 5-year Evaluation Plan 2013-2014 to 2017-2018. This was the first evaluation of the Initiative and it was considered a “small” evaluation (i.e., small materiality, not horizontal, low risk).

Data for the evaluation were collected using various methods: a literature review, a document review, 30 key informant interviews, and a case study. Data were analyzed by triangulating information gathered from the different methods listed above. The use of multiple lines of evidence and triangulation were intended to increase the reliability and credibility of the evaluation findings and conclusions. More specific details on the data collection and analysis methods are detailed in Appendix 3.

3.2  Limitations and Mitigation Strategies

Most evaluations face constraints that may have implications for the validity and reliability of evaluation findings and conclusions. Table 2 outlines the limitations encountered during the evaluation of the Initiative. Also noted were the mitigation strategies put in place to address the limitations.

4.0  Findings

4.1  Relevance: Issue #1 – Continued Need for the Program

Sport and recreation-related injuries represent the leading cause of unintentional injury for children in Canada.

According to the most recent statistical data available, unintended injuries remain the leading cause of death^{Footnote 1} and a major contributor to hospitalizations^{Footnote 2} for children and youth (both males and females) in Canada. While this statistic refers to the entire age group between 1-19 years of age, unintended injuries are consistently the leading cause of death for each of the more specific age brackets (1-4, 5-9, 10-14 and 15-19) as well. This is consistent with surveillance data from 2005^{Footnote 3}, emphasizing both the historical and on-going need for action in this area. Further demonstrating the severity of this issue is evidence that more children, youth and young adults die from injuries than all diseases combined^{Footnote 4}. Indeed, the frequency, severity and potential for life-long disability and death, along with the associated economic costs involved, make injury a critical health problem and major public health issue^{Footnote 5}.

While there are numerous causes of unintended injuries, those resulting from sports and recreational activities are the leading cause of injury for children in Canada^{Footnote 6}. Recent surveillance data reported by the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) show that over 40% of all child and youth injuries treated in emergency rooms were caused by sports and recreational activities^{Footnote 7}. This value varies across the specific age ranges where 30% of injuries are caused by sports and recreation activities for five to nine year olds, 68% for 10-14 year olds, and 55% for 15-19 year olds. It is also important to note that children and youth account for more sports and recreation-related injuries than all other age groups^{Footnote 8},^{Footnote 9}.

While there are health and social benefits of sports and recreation, it is important to minimize the risk of injuries. The Active and Safe Initiative focussed on decreasing the incidence of three such consequences: concussions, drownings and fractures. Injuries caused by sports and recreation activities may result in hospitalization, impairment and disability. Common among these types of injuries are concussions. The Kelly Leitch report^{Footnote iii}, Reaching for the Top, estimated that 6,000 Canadian children sustain a major head injury, resulting in life-long disability, annually^{Footnote 10}. These disabilities may include cognitive impairments or paralysis caused by traumatic brain injuries. Of particular importance is that head injuries in youth are primarily sustained from sports. This is supported by a recent study that showed that more than 60% of head injuries in children aged 10-19 years, were sustained during sports and recreational activities^{Footnote 11}.

Drowning has been the leading cause of death from recreational and sporting activities from 1991-2010 in Canada for all ages^{Footnote 12},^{Footnote 13}. Recent data from 2013 indicated that more than two-thirds of children who drowned were between the ages of 1-15^{Footnote 14}. Within this age range, those aged 1 to 4 are at the highest risk in or near water and drown at twice the rate of children aged 10-14^{Footnote 15}. The rates of death from drowning are particularly high in the north. Recent statistics show that children in the Territories (i.e., Yukon, Northwest Territories and Nunavut) are 5.5 times more likely to drown than children in other parts of Canada^{Footnote 16}. This is particularly concerning for First Nations populations, many of whom reside in the Territories.

While concussions represent only 2.2% of reported injuries for children aged 12 and up, bone fractures represent 16.9%^{Footnote 17}. CHIRPP data shows that fractures were the most common sports-related injury for children involved in seven team sports^{Footnote iv} (with the exception of ringette) between 2007-2010.

The need for action to help address the rates of unintended injuries in Canadian children, as shown by the statistics above, is further corroborated by key informants. They noted that recent and significant injuries to professional hockey players (e.g., Sydney Crosby) have highlighted to Canadians the need for injury prevention in sports and recreation, specifically concussion awareness, prevention and treatment initiatives.

It should also be noted that, in addition to causing significant personal harm, unintended injuries are a large economic burden in Canada. In 2005, injuries to Canadians cost $19.8 billion in health care costs and lost productivity, of which $16.01 billion (81%) were attributable to unintentional injuries^{Footnote v},^{Footnote 18}. According to published research, injuries in children cost society an estimated $5.1 billion per year^{Footnote 19}. Overall, the complete extent of the burden is often beyond the direct care costs and losses in productivity resulting from the injury. For young injury survivors, the costs of care and rehabilitation of the injury and the potential for permanent disability can have far-reaching impacts on their health, education and social inclusion and on their parents' livelihood^{Footnote 20}. All of this serves to highlight the magnitude of this public health issue.

4.2 Relevance: Issue #2 – Alignment with Government Priorities

The Active and Safe Initiative was aligned with Government of Canada and Public Health Agency priorities.

Injury prevention is one of the Government of Canada's public health priorities. In 2010, the Pan-Canadian Healthy Living Strategy was strengthened by identifying new areas of opportunity, which included injury prevention. The Minister of Health endorsed the Declaration on Prevention and Promotion Footnote 21, and Curbing Childhood Obesity: A Federal, Provincial and Territorial Framework for Action to Promote Healthy WeightsFootnote 22 which focussed on the prevention of disease, disability and injury, and the promotion of health; and prevention of obesity in children respectively. All levels of government agreed that the prevention of injury, especially injury in children and youth, is crucial given the prevalence of childhood injuries, and the Government of Canada's objectives in moving toward addressing obesity through the promotion of physical activity. As children are encouraged to increase their levels of physical activity, the risk of injuries also increases.

Since announcing injury prevention work in Budget 2010, the Government further reinforced its commitment to on-going work in injury prevention in the 2013 Speech from the Throne. It specifically committed to collaborating with “injury prevention organizations to reduce the injury rate in Canada”^{Footnote 23} Shortly thereafter, in November 2013, the Minister of Health announced support for national injury prevention activities, including funding 19 new research projects on concussions with a focus on improving prevention, diagnosis and treatment. Of these projects, five projects will focus their work on concussions in children and youth^{Footnote 24}.

In addition to alignment with federal government priorities, the Active and Safe Initiative was aligned with the Public Health Agency's priorities. Injury prevention and mitigation were a key element of the Public Health Agency's strategic outcome in 2010-11 and 2011-12 – “Canada is able to promote health, reduce health inequalities and prevent and mitigate disease and injury”. Although the 2013-14 Public Health Agency strategic outcome is broader – “protecting Canadians and empowering them to improve their health” – it is still in line with activities conducted under the Initiative.

4.3 Relevance: Issue #3 – Alignment with Federal Roles and Responsibilities

There is a clear federal public health role in injury prevention in Canada.

The Department of Health Act^{Footnote 25} and the Public Health Agency of Canada Act^{Footnote 26} guide the Public Health Agency's roles and responsibilities for the prevention of illness, including injuries. Under the Department of Health Act, the Minister of Health has a broad mandate to protect Canadians against health risks. The Minister's duties, functions and powers include the promotion and preservation of the physical, mental and social well-being of Canadians. Both Health Canada and the Public Health Agency can exercise various functions on behalf of the Minister. As per the PHAC Act, under the leadership of the Chief Public Health Officer, and in collaboration with its stakeholders, the Public Health Agency is mandated to lead federal efforts and to mobilize pan-Canadian action in preventing disease and injury. It is also mandated to promote and protect national public health.

A number of documents discuss a federal public health role in injury prevention in Canada. For example, a 2007 government-appointed review of health and wellness programs for children and youth, “Reaching for the Top: A Report by the Advisor on Healthy Children & Youth”, recognized, and recommended, a federal public health leadership role in preventing injury in children and youth^{Footnote 27}. A federal public health role in injury prevention is further reinforced through the Government's Pan-Canadian Healthy Living Strategy, including the signing of the Declaration on Prevention and Promotion^{Footnote 28}. These documents confirm that there is a federal public health role in the area of injury prevention.

The federal public health role is further strengthened through the Active and Safe Initiative's funding authority where the Public Health Agency was given the mandate to increase sports and recreation safety awareness, and strengthen multi-sectoral collaboration among stakeholders.

The federal public health role in injury prevention does not appear to duplicate the provincial and territorial role.

The Public Health Agency of Canada Act and the Department of Health Act both refer to a federal public health role in cooperating with provincial and territorial governments. Some of the key roles of the Public Health Agency, according to the Public Health Agency of Canada Act, are to foster collaboration and coordination in the field of public health and to promote cooperation and consultation with the provinces and territories. This federal public health role is further confirmed through the Pan-Canadian Healthy Living Strategy and the work conducted by the Public Health Agency in the Active and Safe Initiative, both of which recognize the importance of multi-sectoral collaboration in preventing disease and injury.

An environmental scan provided by Active and Safe staff confirmed that most of the provinces and territories (i.e., seven provinces and one territory) have an injury prevention strategy in place. Like the federal Initiative, the mandate of the provincial/territorial strategies focus on increasing awareness of injury prevention practices as well as supporting various evidence-based initiatives, at a local level. However, unlike the federal Initiative, the provincial/territorial strategies are not national in scope and they encompass injuries beyond sports and recreation (e.g., falls, motor vehicle collisions) and are not specific to children and youth. The federal public health role in this area therefore does not duplicate existing provincial or territorial roles, nor does it duplicate activities currently being conducted – it addresses a gap.

4.4  Performance: Issue #4 – Achievement of Expected Outcomes (Effectiveness)

4.4.1 To what extent have the immediate outcomes been achieved?

Immediate outcome #1:   Targeted multi-sectoral stakeholders have opportunities to collaborate in pan-Canadian initiatives aimed at preventing sports and recreational related injuries.

Opportunities to collaborate, across various sectors and system levels, were available to NGOs involved in funded projects and their partners and stakeholders.  

The Active and Safe Initiative was successful in providing opportunities for collaboration to NGOs and their partners and stakeholders involved in injury prevention work. This was facilitated by the design of the Initiative's funding distribution to involve many organizations (i.e., 18 projects, involving 25 different NGOs) from across Canada. The deliberate design of the tiered approach of the Initiative facilitated collaboration in the development of projects. The majority of funded NGOs noted that collaboration was key to the success of their projects. The resulting collaboration occurred not only among these funded NGOs, but also extended to the NGOs collaborating with their partners and stakeholders.

With respect to collaboration that occurred among the funded NGOs, in tier one, the Agency directed collaboration between key players involved in injury prevention/sport to work on specific deliverables (e.g., concussion app, personal flotation devices) from product development to dissemination. This collaboration helped strengthen existing relationships (e.g., Parachute and Hockey Canada) and also resulted in the development of new relationships (e.g., Parachute interacting with the Coaching Association of Canada and the Canadian Centre for Ethics in Sports on the issue of concussions, and the Canadian Red Cross and Life Saving Society on the issue of drowning). Collaboration among the funded NGOs was further facilitated by the cascading nature or tiered design of the initiative. Although not a requirement for funding, this phased approach provided opportunities for all NGOs involved in later tiers (tier 2 and 3) to build upon ongoing or recently completed work from tier one.

Collaboration extended to the funded NGOs working with external stakeholders from multiple sectors. The NGOs involved in projects from all three tiers were strongly encouraged to work in close collaboration at the community, regional, provincial and national level. This collaboration was intended to help expand program reach and facilitate potential complementary efforts or synergies. In support of this goal, opportunities to collaborate (with external organizations) needed to be identified and included in each funded project. These opportunities facilitated the linking of key players involved in injury prevention in the development of injury prevention material which contributed to consistency of messaging. For example, L'Association des Station de Ski du Quebec collaborated with the private sector to conduct their education campaign in 35 snow park resorts throughout the province.

While performance measurement data provides high level details on the involvement of stakeholders from multiple sectors as collaborators involved with the projects, it was not always clear from the information provided whether the data included metrics only for funded NGOs or also their partners and stakeholders. However, it was noted that, as intended, collaboration was evident across multiple sectors for the majority of projects. All 18 projects involved collaboration with stakeholders from not-for-profit and/or voluntary organizations. The majority of projects also involved collaboration with the public sector (governments) (72%) and/or private sector (61%). Specifically, collaboration with government occurred at various levels. For example, the majority of projects (89%) involved collaboration at the provincial/territorial level, and national/federal level (72%), while approximately one-half of the projects noted collaboration at the local or regional level. Collaboration often involved organizations with a focus on education (89%), health (72%), and Aboriginal issues (50%).

With respect to the sustainability of the collaborations beyond the funding period, for the majority of NGOs the collaboration appears to have ended with the completion of the Initiative.
However, individual cases of sustained collaboration were noted. For example, the partnership between the Coaching Association of Canada (CAC) and Speed Skating Canada, where the latter is hosting the e-learning module on the CAC website, is ongoing and has contributed to sustained access and usage of the injury prevention products. Similarly, some project partners have continued to collaborate by co-presenting results of their Active and Safe projects at national conferences and co-authoring articles in academic journals.

Immediate outcome #2: Targeted multi-sectoral stakeholders have access to evidence-based knowledge needed to increase public awareness of sports and recreation injury prevention.

Evidence-based knowledge on injury prevention was exchanged among the funded NGOs on an individual project level, and there were efforts to ensure access to this knowledge among their partners and stakeholders.

Through collaboration on individual projects, the funded NGOs actively engaged in knowledge exchange to improve their understanding of injury prevention and to facilitate development of injury prevention awareness products. For example, in tier one, Parachute, Coaching Association of Canada, Canadian Centre for Ethics in Sport and Hockey Canada exchanged knowledge and practices that contributed to the development of a concussion awareness smartphone app. In tiers two and three, seven of the sixteen funded NGOs indicated that they had leveraged efforts from the Concussion/Brain Injuries in Team Sports project, and felt that Parachute had acted as a major source of evidence-based knowledge for them. For example, the Winter Sport Safety E-learning Program project (funded in tier three) utilized concussion information from Parachute to develop an on-line tool for coaches, officials, first responders and facility operators regarding safety and injury prevention in speed skating, skiing and snowboarding activities.

In addition to knowledge exchange between the funded NGOs, knowledge exchange also occurred between the funded NGOs and external experts. For example, advisory groups of injury prevention field experts, such as physicians and neurosurgeons, were invited to provide advice on the development of injury prevention concussion materials developed in tier one. This guidance not only benefited this particular project, but as discussed above, was utilized by NGOs in the later tiers in the development of their injury prevention materials. In addition, a number of the funded NGOs were successful in accessing evidence-based knowledge from other sources, including research institutions, academia, other government departments, and provincial jurisdictions. For example, Le Réseau du Sport Étudiant linked with the Quebec Ministry of Education and Sports when developing their injury prevention materials and indicated that the Ministry also facilitated a connection to sport and medical associations, an additional source of injury information which was used to populate their website.

Also, all projects included an effort to ensure awareness of materials developed among their stakeholders, including community partners. The majority of funded NGOs distributed materials directly to their identified stakeholders, while others promoted their products and ensured that partners knew how to access the material directly. For example, research developed through Active and Safe for Life – Physical Literacy Project was incorporated into training materials that were shared with 1,900 leaders in local government through a quarterly magazine.

Although there are numerous examples of NGOs utilizing knowledge exchange to develop injury prevention awareness products, it is not possible to conclude on the extent to which knowledge exchange occurred throughout all projects as this information was not reported systematically in the performance measurement data.

Immediate outcome #3:  Target audiences have access to education products aimed at preventing sports and recreation related injuries.

NGOs produced education products and disseminated them through a variety of means in order to maximize reach to the target audience.

A range of education products were developed and disseminated across all of the funded projects. To maximize target audience access to the information, education products took on a variety of forms and were made accessible through a variety of means. Common types of educational products included awareness products (e.g., brochures, pamphlets, and posters), newsletters and training materials. These were made available through websites, presentations (at conferences and schools), media campaigns and webinars.

A number of the projects relied on traditional methods to disseminate education products. An example of a traditional approach is the tier three project Sport Safety and Injury Prevention in Community Sport project by SportMedBC. This project involved the development of training materials and in-person workshops, along with an online community, webinars and an online booklet to build the capacity of coaches and provide them with best practices and guidelines for injury prevention (e.g., concussion education, injury management). Another example from tier two involved the use of a multi-media campaign on bike safety by Parachute and Cycling Canada (Enabling Active and Safe Cycling for Canadian Children and Youth). These groups developed a public service announcement (PSA) which aired on OMNI TV and two national CBC radio outlets. This PSA was translated into four languages and reached an estimated 17 million Canadians.

While a number of traditional or well-established methods were employed to facilitate target audience access to educational materials, several new or innovative approaches were also piloted as part of the Initiative. For example, in a tier three project by The Community Against Preventable Injuries (You're Probably Not Expecting to Need a Helmet Today), a public outreach program on helmet safety was created that engaged high school students in the development of an in-school education program. This program used creative methods in the dissemination of education materials, including interactive activities (e.g., displays, flash mobs, presentations, YouTube video), to more effectively reach high school aged individuals. Another example of a new approach is the development of a smartphone app by Hockey Canada (as part of tier one) related to educating people about concussions and return to play protocol. Versions of this app were tailored to both children and adults (e.g., parents, coaches) and were made available in both official languages. As of October 29, 2012 there were 6,400 downloads of the application and by June 26, 2013, downloads totalled 19,324. A third example is the innovative and targeted campaign in the Open Water Wisdom Campaign project. This project supported community-based approaches to raising awareness about and engagement in safe practices in open waterways among young children (0-4), school-aged children (5-12) and youth (13-19) and their parents, in rural, remote and northern communities. The campaign involved the distribution of promotional and educational materials to these communities, as well as supplying lifejackets for communities to loan out to the target groups going forward.

Overall reach for the Initiative as a whole is difficult to measure. The nature (i.e., scope, message medium and specific topic area) of each project was different which resulted in challenges in employing consistent measurement of data. However, performance reports reveal that projects encompassed different levels of geographic reach, including national (39%), provincial/territorial (44%) and municipal/local (17%). Important to note is that overall, the Initiative material was accessed by a diverse audience from different regions of Canada. As intended, children/youth, coaches/sport staff and parents were the most commonly reached audience. Additionally, a number of projects (72%) were able to reach individuals in remote/isolated/rural communities and Aboriginal communities (56%), for example, the Open Water Wisdom Campaign described above.

4.4.2 To what extent have the intermediate outcomes been achieved?

Intermediate outcomes are typically influenced by external factors, but ultimately mirror the objectives of the Initiative. These longer-term outcomes are expected to occur as a result of the Agency's immediate efforts, but beyond the two year duration of the Initiative. The Performance Measurement Strategy for the Active and Safe Injury Prevention Initiative articulated that the intermediate outcomes would not be measured in an evaluation given that the Program was of a short two year duration. Recognizing this limitation, the evaluation attempted to report on the efforts made towards addressing the intermediate outcomes by reviewing the performance data collected and by discussing outcome achievement during key informant interviews.

However, it is important to highlight that, as expected, there were limited performance data available at the intermediate outcome level. Furthermore, data was not reported consistently across projects. It was therefore not possible to compare impact between projects or to speak to impact at the Initiative level. Instead, brief summaries of successes to date are provided, building on individual project examples. Given the significant amount of funding ($3 million in funding representing 60% of Initiative funding) provided to the project on concussion awareness and the project on drowning prevention, and the design of the Initiative whereby these projects received funding first, the majority of examples utilized to demonstrate achievement of intermediate outcomes are from these two projects.

Intermediate outcome #1:   Targeted multi-sectoral stakeholders are equipped to design and develop injury prevention policies, programs, and practices that promote safety and prevent and reduce injuries.

There was evidence that the majority of NGOs were equipped to design and develop injury prevention policies, programs and practices and some examples of how stakeholders were equipped to better inform their injury prevention activities.

The majority of projects resulted in NGOs being better equipped to do work in the area of injury prevention. All key informant interviewees were able to speak to how the opportunity to participate in the Initiative provided them with additional resources and the ability to focus efforts on key injury prevention projects.

More specifically, according to performance measurement data, 11 out of 18 projects reported that there were new and/or additional programs and activities developed as a result of the Active and Safe funding. For example, Concussion/Brain Injuries in Team Sports project created a “club excellence” program that recognized community, provincial and national sport organizations who demonstrated that they provide safe sport environments. This was done in addition to their concussion app for smartphones, which was a first for a national sports organization. This type of success was also seen in projects funded through the later tiers. For example, Play Spaces for Vulnerable Children and Youth in Canada developed a new tool to assess the safety of play spaces, for use by community members. The Initiative also enabled some NGOs to develop their own injury prevention policies, with key informant interviewees suggesting that some of these policies are being considered at a national level. For example, a literature review on physical literacy conducted by Canadian Sport for Life as part of the Active and Safe for Life Physical Literacy Project, as well as primary data collected from target audiences, is currently being reviewed by Sport Canada as they consider a policy on physical literacy.

In addition, there were a small number of examples of how stakeholders were able to utilize knowledge acquired through this Initiative to better inform their own activities. In Active and Safe After School, sport and recreational organizations in the targeted communities increased their available injury prevention program options, and in Active and Safe Kids Manitoba Recreation Connections, local municipalities were provided with information (e.g., data on use of protective equipment, environmental scans) to take further actions to prevent injury and were encouraged to assess and/or adapt their own injury prevention programs. Only five of the 18 projects provided information on how the project benefitted their stakeholders, and it is therefore not possible to speak to the extent to which this occurred across the entire Initiative.

Intermediate outcome #2:   Target audiences understand how to prevent injury and understand actions necessary to increase their safety.

There was evidence that individual projects increased target audience understanding of their specific injury prevention topic.

The primary source of data utilized to assess the increase in target audience understanding as a result of project activities were the individual assessments completed by the majority of projects. In Concussion/Brain Injuries in Team Sports project, participants who took the Aboriginal Coaching Module supplement were surveyed and reported an increase in their understanding of and ability to identify concussions (n=12). With respect to the Open Water Wisdom Campaign project, anecdotal evidence from a small number of local champions who had undertaken the Open Water Wisdom activities in their community suggests that the campaign led to an increase in water safety awareness and safer behavior around open water. It is important to note that most local champions had limited opportunities to deliver the Open Water Wisdom campaign in their community due to the seasonal nature of the work. However, there exists the opportunity to use the resources and administer the program in future years. Although projects in tiers two and three were funded later, and had less time to develop and implement their injury prevention activities, there is evidence from some of these projects that target audience understanding of their specific topic increased. For example, in Active and Safe After School project, a large majority of participants (ranging from 70-80% per webinar) felt that the webinar increased their knowledge and understanding of safety standards for after-school programs with respect to concussion and fracture prevention.

An additional source of impact data was derived from the pre- and post-assessment tool, which was designed to detect changes that occurred as a result of injury prevention training sessions offered by the projects. It is important to highlight that this tool was only applicable to the seven projects that provided training sessions as one of their project deliverables (thus eliminating the remaining 11 projects). Across these seven projects, there was a 29% increase on average in the target audience's (primarily coaches and trainers) knowledge of the specific injury prevention topic.

While there is evidence of short-term impact on the target audience, it is premature to determine the long-term impact at this point in time. However, based on a small number of follow-up surveys, there is preliminary evidence that the knowledge gained has been sustained. For example, in the Concussion/Brain Injuries in Team Sports project, follow-up with coaches who participated in the training module as part of the National Coaching Certification demonstrated that their belief in their ability to deal with concussions effectively has persisted over time, with content related to facts and practical knowledge showing the greatest effect. It is reasonable to assume that understanding can be sustained, and eventually lead to behaviour change, if there are continued opportunities to use and be exposed to the knowledge through continued education.

Intermediate outcome #3: Target audiences have the capacity to promote safety and prevent sports related injuries.

There was evidence that knowledge and understanding acquired through some of the projects resulted in an increase in the target audience's capacity to promote safety and to prevent sports related injuries within their community.  

Individual project assessments documented evidence of the impact on the target audience's capacity to utilize knowledge and tools to promote safety and prevent sports related injuries. For example, in Concussion/Brain Injuries in Team Sports, 35% of respondents (n=296) who utilized the adult version of the concussion app (tailored for the use of parents and coaches) indicated that the information provided informed and/or influenced their course of action when dealing with a concussion. Furthermore, 40% of respondents utilized the information to assist someone who potentially suffered from a concussion. With respect to the Open Water Wisdom Campaign project, shifts in capacity were difficult to ascertain at this point in time; however, there are indications that Local Champions felt that the provision of both lifejackets and educational material would provide them with the ability to share knowledge with neighbouring communities and partners, blend water safety education with traditional activities and demonstrate proper use and fit of lifejackets on an ongoing basis.

In addition to capacity change in tier one projects, some projects in tiers two and three were also able to demonstrate how their activities led to a change in the target audience's capacity. For example, in a two-month follow-up survey, 56% of coaches and community leaders who participated in the SportSmart workshop (developed by Sport Safety and Injury Prevention in Community Sport project) indicated that they had taken action in one or more of the areas covered by the workshop (e.g., change to warm up/cool down activities, developed emergency action plans), with 96% attributing these changes to the learning gained in that workshop. In another project, the Arctic Institute of Community-Based Research created an interactive map which strengthened networks and increased the capacity of their stakeholders by encouraging them to share injury prevention resources and knowledge. Recreation PEI, in their Active and Safe PEI project, increased the capacity of Certified Playground Inspectors which resulted in additional playground inspections in 11 different municipalities. Furthermore, the pre- and post-assessment tool, confirmed that a change in target audience capacity occurred in seven projects, where participants indicated an average increase of 21% in their ability to promote community awareness about injury prevention and an average increase of 24% in their ability to help the community develop ways to prevent injuries.

As NGOs were encouraged to engage rural/remote/northern communities, it is interesting to note that a number of projects were able to demonstrate a capacity change in this context. The Alberta Schools Athletic Association, for example, created an online injury prevention tool which increased accessibility of resources for coaches and physical education teachers working in rural locations thus increasing their injury prevention capacity. In addition, anecdotal evidence suggests that there was an increase in the capacity of the 18 youth who took part in an intensive training camp on injury prevention offered by Kwanlin Dunn First Nations in their Back to the Land project to promote safety measures, with many becoming certified in CPR and First Aid and then sharing this knowledge with others. In addition, youth who participated in sessions offered by the Pauktuutit Inuit Women of Canada as part of the Active and Safe Inuit Children and Youth project, indicated that their ability to promote community awareness of injury prevention and to help their communities develop ways to prevent recreation and sports injuries had increased.

4.5 Performance: Issue #5 – Demonstration of Economy and Efficiency

Observations on Economy

According to the Treasury Board Secretariat, economy is the assessment of whether the program minimized the cost of resources to achieve expected outcomes^{Footnote 29}.

Over the period of the Initiative, there was a total of $24,716 that was not committed due to a combination of amounts requested and PHAC funding approval decisions and $6,070 of underspending by the NGOs (see Table 1). Project reports indicated that the level of resources provided by PHAC allowed the projects to be completed on time, on budget, and according to specifications. With respect to salaries and EBP, planned spending in this area was $560,520 and actual spending was $520,244. Planned O&M was $20,000 and actual O&M was $20,706. Salaries and EBP and O&M combined represent 10.8% of the proportion of the funds allocated to the G&C component of the Initiative. It is important to note that the complexities of the program (e.g., national in scope, tight timelines) required significant personnel resources.

Leveraging occurs when funding recipients receive additional resources (e.g., financial, human) through collaborative partnerships and other external funding sources. Leveraging can occur in the form of in-kind contributions (from recipient organizations themselves), volunteers, loaned staff, and additional funding. While not mandatory, the Initiative did encourage leveraging by the funding recipients. A majority of projects did leverage supplementary resources from a wide range of stakeholders, other organizations, community parties and volunteers. Table 3 illustrates the extent of leveraging achieved through this Initiative.

The most common type of leveraging reported by the funded NGOs was in-kind contributions. These contributions ranged from administrative costs (e.g., office supplies, printing costs, postage, travel costs) to other types of physical assets such as office equipment, furniture and use of office space. All in-kind contributions to the Initiative totalled $906,901, which represents 18% in addition to the $5 million allocated to the Initiative. Volunteers and loaned staff were also leveraged by the majority of the organizations involved in the Initiative, with the most common type of loaned staff being identified as program directors or managers. Note that it was difficult to determine the actual financial benefit from the volunteers and loaned staff.

Source:  Active and Safe Initiative: Consolidation and Analysis of Self-Reported Project Performance, Fair Findings (October 15, 2003)

Key informants articulated that Initiative funding provided credibility for NGOs to leverage additional financial resources. Although there were a number of examples of successful leveraging of financial resources, there was general consensus among both internal and external key informants that there was insufficient time to maximize leveraging efforts due to the short timelines of the Initiative. In particular, the tiered structure of the Initiative resulted in extremely tight timelines for those NGOs funded under the second and third tier, which meant that they had had to focus their efforts primarily on ensuring that project deliverables were completed on-time. Annex 5 provides details on the financial leveraging achieved. For example, Alberta Schools Athletic Association was able to leverage a significant contribution from Cenovus Energy for the development of their project.

To add further value to the funding, there were also opportunities to obtain discounts and free services from private sector partners. For example, in projects that involved dissemination of safety equipment (e.g., helmets), private sector partners were able to provide a discount on the purchase of the equipment as well as logistical support to house and ship the equipment. Other partners were able to offer goods and services related to the production of promotional materials and items at discounted rates (e.g., videos, t-shirts, frisbees). These partners also volunteered their expertise and guidance in the delivery of the projects to ensure that they were as effective as possible. For example, in a third tier project, private sector partners provided advice on designing an outdoor safety awareness program. While actual cost savings as a result of these activities is not available, it is clear that these discounts allowed for the same impact/outputs with less expenditures.

Observations on Efficiency

Efficiency focuses on the relationship between resources and outcomes and resources and outputs.

The Initiative demonstrated efficiency by using a strategy that ensured outcomes and impacts were maximized for the input (e.g., funding). The Initiative was a prevention strategy, mitigating risks before the injury occurred. The literature supports this approach as there is evidence that unintended injuries can be predicted and prevented. Studies in the literature confirm that a majority of injuries in children were predictable and preventable, with estimates upwards of 90%^{Footnote 30},^{Footnote 31}. Moreover, if current injury prevention strategies were fully implemented, research suggests that the burden of injury could be reduced by 40%^{Footnote 32} thus supporting the approach of prevention as being cost effective.

Proven prevention strategies, such as education, enforcement of bike helmet use and child passenger restraints, have been assessed as cost effective yet remain underutilized. The Initiative supported these strategies where possible, particularly with the enforcement of the use of equipment. Key informants agreed that the need for improving the usage of safety equipment in children remains important, especially with respect to improving their awareness of safe practices. The academic literature confirms that children continue to not wear safety equipment during physical activities and sports (e.g., helmets with skateboarding, cycling). Moreover, there is evidence that prevention is more cost effective than a focus on treatment. In other words, the cost of primary interventions/programs is cheaper than treating a child after the injury occurs. There are demonstrated, effective strategies that already exist to save lives and financial resources. For example it is estimated that:

• $1 spent on bicycle helmets saves $29
• $1 spent on child safety seats saves $32
• $1 spend on road safety improvements saves $3
• $1 spent on prevention counselling by pediatricians saves $10^{Footnote 33}

There was evidence that, on a project level, each NGO used techniques appropriate for their context to ensure efficient use of resources to produce their deliverables. According to the project reports, the NGOs, where applicable, used various methods to demonstrate cost efficiencies (e.g., use of volunteers, in-kind contributions). The project reports revealed that NGOs were able to produce efficiencies in the administration of their projects, which contributed to the effective use of the Initiative's funding. For example, five projects reported efficiencies created by engaging with partners and volunteers. Of the five projects, four reported careful planning of travel to locations to create efficiencies, three used electronic means for meetings and four distributed materials electronically which resulted in cost savings. Overall, the Initiative was funded and carried out as expected with no overspending and it was implemented as designed. However, due to the various ways that efficiency was reported between projects, it was difficult to compare and contrast the results of the different projects and to determine the overall efficiency and economy of the Initiative.

Performance Measurement

Significant performance measurement data were collected for individual projects; however, the information was inconsistent and therefore it was not possible to compare across all funded projects. Furthermore, insufficient time has passed to be able to report on the achievement of longer-term outcomes.

A formal Performance Measurement Strategy (PMS) was developed by the Initiative and implemented at the outset to monitor progress and assist with programmatic decision making. Performance measurement data (e.g., mid-term and final project reports, individual project-level evaluation reports) were produced by all funded NGOs, in accordance with the PMS, and yielded useful information which was utilized by the Initiative to track performance. Although the PMS was useful, the evaluators noted that the interpretation of “targeted multi-sectoral stakeholders” was varied, with the majority of reports only providing information on the benefits to funded NGOs, and excluding the impact on other stakeholders (e.g., community partners, private sector).

It should be noted that due to the limited duration of the Initiative (two years), success indicators for intermediate outcomes were not developed as insufficient time would have elapsed for meaningful measurement to occur.

5.0  Conclusions

Given that the Initiative has ended, formal recommendations were not deemed to be appropriate. Rather, the synthesis and analysis of the findings from this evaluation resulted in conclusions about the relevance and performance of the Active and Safe Injury Prevention Initiative. In turn, this led to the formulation of opportunities for the Agency to build on the current investment.

5.1.  Relevance Conclusions

5.1.1  Continued Need

Unintended injuries remain the leading cause of death and a major contributor to hospitalizations for children and youth ages 0-19 years in Canada. Unintended injuries resulting from sports and recreational activities are the leading cause of injury for children and youth. Common among sports and recreation related injuries are head injuries and fractures, with drownings being less common but of significant concern. These types of injuries pose a health and safety risk and may result in hospitalization, impairment and disability or death. In addition to the negative health outcomes for individuals affected by these types of injuries, there is an economic burden for Canada as these injuries may place additional demands on the health care system and on society. Consequently, there is an ongoing need to address this important public health issue.

5.1.2  Alignment with Government Priorities

The Initiative was aligned with Government of Canada priorities including the commitment to prevent injuries in children and to work collaboratively with non-governmental organizations to address injury. This Initiative was also aligned with the Agency's priorities and strategic outcomes related to injury, as articulated in corporate documents such as the Departmental Performance Report, the Reports on Plans and Priorities and the Agency's mandate to promote public health in Canada.

5.1.3  Alignment with Federal Roles and Responsibilities

The Active and Safe Initiative was aligned with Federal roles and responsibilities, primarily as articulated in the Public Health Agency of Canada Act. Injury prevention is one of the health measures that the Public Health Agency is responsible for in Canada. Corporate planning and reporting documents also articulated and supported the role of the Agency in injury prevention. Injury prevention crosses provincial and territorial borders, providing the Agency with an opportunity to provide a national leadership role in preventing injury for this specific target audience. While previous analyses reveal that some provinces and territories have their method of addressing injury, they are not placed to address national issues and do not overlap with the activities of the Active and Safe Initiative. Overall, the mandated role of injury prevention ensures that the Agency continues to keep Canadians healthy by preventing injury, illness and premature death.

5.2  Performance Conclusions

5.2.1  Achievement of Expected Outcomes (Effectiveness)

The Active and Safe Injury Prevention Initiative made progress towards its immediate and intermediate outcomes relative to reducing unintended sports and recreation injuries in children and youth (0 to 19 years).

This Initiative led to collaboration between key national players in injury prevention in building a collaborative approach to injury prevention. The 18 funded NGOs developed injury prevention policies, programs or practices while accessing evidence-based knowledge, thus ensuring the most up-to-date research and messaging were consistently available to all stakeholders. These policies, programs and practices were then disseminated through a variety of means to those target audiences that were concerned with preventing sports and recreation related injuries, while facilitating access to vulnerable populations and those living in remote areas across the country.

The Initiative also enabled new education and training methods to be developed. More than 50% of projects reported they had developed unique injury prevention activities including developing injury prevention webinars and unique programs (e.g., the Club Excellence program that recognized organizations committed to injury prevention). Performance data show preliminary indications of an increase in some target audience's understanding and capacity to prevent injuries.

In terms of sustainability, it is important to note that some of the products that were developed are still available for use although the extent to which they are being used varies. Further, there is potential to apply some of the training modules and injury prevention products to other regions and sports. Some of the collaborative relationships formed during the Initiative have persisted as evidenced by the fact that project results are being co-presented at conferences and in journals beyond the end of the project.

5.2.2  Demonstration of Economy and Efficiency

The Active and Safe projects were completed on time, on budget and according to specifications. Where possible, projects were able to leverage additional resources in multiple ways such as in-kind contributions, volunteer hours and additional funding, to supplement the Agency's financial contributions. There was insufficient time however to maximize leveraging through engagement of private partners.

The Active and Safe Initiative was efficient. The strategy of injury prevention, rather than treatment, is supported in the literature as being a cost effective strategy. The Initiative was efficient in producing the desired outcomes as it supported solutions that were already proven effective (e.g., applying a combination of education, enforcement, equipment and engineering approaches, such as helmet use, and personal floatation device use in preventing injuries) in preventing injuries. On an operational level, the projects all demonstrated that cost-savings measures were utilized, where possible, to ensure that outputs were produced efficiently (e.g., use of online technology). Finally, performance measurement data were collected for individual projects in support of programmatic decision making.

6.0  Opportunities for the Agency to build on current investment

The Active and Safe Injury Prevention Initiative was a time-limited program and ended March 2013. However, should the Agency be asked to develop further work in this area, opportunities to build on the current investment were identified as follows:

Opportunity 1: The Agency could build on the injury prevention efforts of the Initiative by disseminating the information to a broader audience which includes further outreach to vulnerable and remote and rural populations.

Dissemination of information on injury prevention to a broader audience will extend reach and deepen community awareness, understanding and capacity in injury prevention. Evidence shows that due to the lack of time and the exhaustion of the funds from the Active and Safe Initiative, injury prevention information was not fully distributed to those audiences in need. To address these needs, additional signage in playgrounds, more train the trainers programs and concussion, fracture and drowning prevention material could be disseminated to a broader audience. Although 13 of the 18 projects (72%) had a component of their injury prevention projects that reached vulnerable and remote and rural populations, there still exists a need for outreach given the significant number of such communities. As noted previously, recent statistics show that children in the Territories (i.e., Yukon, Northwest Territories and Nunavut) are 5.5 times more likely to drown than children in other parts of Canada^{Footnote 34}. This is particularly concerning for First Nations populations, many of whom reside in the Territories. For vulnerable and remote and rural populations, a swim to survive program specific for rural communities, funding for additional workshops in smaller and rural communities, technology and infrastructure development to support e-learning tools and applications to facilitate access to under serviced areas could be considered should future funding be available. In conclusion, there exists an opportunity to build on the momentum generated by the Initiative to continue to raise awareness, build skills and reach a greater number of Canadians to better prevent these injuries.

Opportunity 2: The Agency could explore models of engaging the private sector to leverage additional resources for injury prevention efforts.

To build on the Initiative's objective of strengthening multi-sectoral collaboration among injury prevention stakeholders, further exploration of models of engaging the private sector could occur. A multi-sectoral approach involving private sector partnerships can facilitate bringing together different stakeholders and types of expertise in order to develop injury prevention projects and leverage additional resources. In turn, the projects will have greater benefit to communities, and will stimulate the sharing of best practices and collaboration over the longer-term. Exploring and encouraging private sector partnerships will facilitate an extension of reach and bring all facets of expertise to complement each other. The Case Study on Healthy Living and Chronic Diseases' Multi-sectoral Partnerships Approach (please refer to Appendix 4 for further detail) found value in exploring partnerships with the private sector. Evidence from the case study shows that the Centre for Chronic Disease Prevention's Multi-sectoral Partnerships Program has been successful in engaging the private sector by ensuring that all project proposals secure matched funding from non-taxpayer funded sources or the private sector. This strategy could be explored should future injury prevention funding be available.

Footnotes

List of Acronyms

BCIRPU

British Columbia Injury Research and Prevention Unit

CAC

Coaching Association of Canada

CBC

Canadian Broadcasting Corporation

CHIRPP

Canadian Hospitals Injury Reporting and Prevention Program

CHP

Centre for Health Promotion

EBP

Employee Benefit Package

F/P/T

Federal/Provincial/Territorial

G&Cs

Grants and Contributions

HC

Health Canada

HPCDP

Health Promotion and Chronic Disease Prevention

NGO

Non-Governmental Organizations

O&M

Operations and Maintenance

OECD

Organization for Economic Cooperation and Development

PAA

Program Alignment Architecture

PERT

Project Evaluation and Reporting Tool

PHAC

Public Health Agency of Canada

PHE

Physical and Health Education

PHN

Public Health Network

PSA

Public Service Announcement

TBS

Treasury Board of Canada Secretariat