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Going international: what are the implications?
  1. Charles Larson
  1. Pediatrics, Epidemiology and Biostatistics, Montreal Children's Hospital, 2300 Tupper, Montreal, Quebec H3H 1P3, Canada
  1. Correspondence to: Dr Larson.

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In absolute terms, the magnitude of childhood mortality and disability caused by injury has become a priority public health problem, recognized by developed and, more recently, developing countries worldwide. By the year 2020, injuries will constitute one of the most important, if not the leading, causes of disease burden worldwide.1 For this compelling reason alone, there is an urgent need for scientifically based knowledge with which to guide the development of effective injury prevention programs. This implies, at the very least, the presence of three important conditions: (1) the capacity to conduct relevant, well designed research in developing, as well as developed countries, (2) the existence of funding to support such research, and (3) the ability to effectively apply research findings to health policies and program development.

Underwood and Carter's Opinion in this issue points to the need all countries share in identifying “...initiatives of proven value”. They argue that this is inhibited, not only by limited scientific support for community—or family based injury prevention programs—but by studies weakened due to inadequate sample size or non-randomized designs. Underwood and Carter do identify important exceptions, such as Robert's meta-analysis of antenatal home visitation and its relation to reduced early childhood injuries. They take the position, however, that such interventions will not significantly impact on the global problem of childhood injury because they are too expensive and high risk, as opposed to universal or population based programs. As a strategy to overcome these limitations, Underwood and Carter recommend the development of collaborative, multinational studies, which mix the experiences of developed with developing countries. They argue that a randomized field trial of a varied (site appropriate) education and support intervention package could conclusively answer whether or not such programs work.

At what point is a randomized field trial the appropriate design of choice? Given the lack of support from observational studies for “stand on their own” universal educational or support injury prevention interventions, the cost and resource consumption required of a randomized field trial is not justified. This would be particularly the case in a developing country. It is important to understand that within developing countries, there also exists the great need to support descriptive and observational studies, upon which they can establish their own knowledge base. This information can then be applied to appropriately formulated injury intervention programs. This implies greatly increased funding, beyond current levels, from developed countries to support research which is not necessarily tied to their own research agendas.

While international collaboration in injury prevention research is a goal I would heartily support, I caution that such initiatives do carry the potential of doing more harm than good. This is especially the case in settings where resources are already well under optimal. Multicenter trials will be beyond the funding capacities of most developing countries, which ultimately leads to questions of who will fund and control such studies. This, by extension, then leads to consideration of a nation's research agenda and their ability to independently define and pursue health research priorities. It is also the case that well funded, internationally supported studies often engage the best, most productive of a developing nation's researchers. The potential consequence of this is to deflect a precious resource away from other, equally compelling problems.

Beyond the issues of research conduct and funding is the question of the interpretation and application of a study's results, in particular a large, multinational trial. The pooling of outcomes from highly variable settings may produce a result that has little connection with reality. This is analogous to the consideration of pooled, or mean, per capita income in developing countries, a value that is representative of almost nobody. It is conceivable that a specific intervention may be highly productive in a few settings, but not in the majority. The pooled result will rest somewhere in between, its interpretation will be difficult, and its applicability highly questionable. In the end, one returns to the need to design studies with sufficient power to address the issue of interpopulation variability in response.

There is also the question to whom would one generalize the results of an investigation with an international study population? Will a mean change in injury rates be the appropriate outcome? Is this likely with an educational intervention in light of existing knowledge? Is the focus on preschool age children justified?

Yes, by all means we should encourage Underwood and Carter's underlying thesis of international collaboration in injury prevention research. This should be done in many settings, and in a manner that facilitates the exchange (not just transfer) of appropriate research technologies and experience. We live in a world which, despite its unjustifiable disparities, is more than ever before vulnerable to shared determinants of health, be these economic, environmental, behavioral, or political. We all stand to gain by working together. The problem is that this is far easier said than done!

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