From injury research to injury prevention: facilitating the connection.

Abstract

large when there is a perception that the solution to a problem is within reach. Campaigns against AIDS, drug abuse and tobacco smoking have a vision of ultimate success, however remote or even unreasonable that vision might be. There has never been any illusion that injuries can be eliminated; indeed, the progress in the field of injury prevention has always been slow, incremental and painful. This, however, should not lead to discouragement but rather to realistic efforts for re-orientation of preventive strategies. The crucial question is: how could the scientific community use most effectively the results of injury research for the implementation of injury prevention projects? There is no easy answer, but some issues deserve consideration. In order to rationalize injury prevention approaches one could borrow from other fields of research some important concepts. Preventive effectiveness could be viewed at three levels: theoretical, pragmatic (in other fields termed ‘clinical’) and population-based. Theoretical effectiveness requires optimal performance of all involved parties and perfect function of all equipment. For instance, effectiveness of car restraints could exceed 80% in simulation crashes. In pragmatic terms, this effectiveness is closer to 60%, because of poor adjustment, quality control or maintenance of the materials involved, or because the actual use deviates from the foreseeable use. The population-based effectiveness is much lower for the simple and sad reason that many car passengers fail to comply with legal requirements or indeed plain logic. The terms ‘theoretical,’ ‘pragmatic’ and ‘population-based’ effectiveness may be more relevant to planning, implementing and evaluating preventive measures than the terms ‘individual’ and ‘population attributable’ risk, in that population attribution is incorporated in populationbased effectiveness and preventive effectiveness assumes, as a rule, a reduction rather than an increase in risk and the traditional measures of strength of the association. It is obvious that minimizing the difference between pragmatic and population-based effectiveness of preventive measures is as important as the introduction of new preventive measures of high theoretical effectiveness. Different fields or different economic sectors may be responsible for studies focusing on theoretical effectiveness, those addressing pragmatic effectiveness and those concerned with population effectiveness of injury prevention measures. It is not unusual for engineers to take the lead in devising preventive measures of high theoretical effectiveness and for social scientists to concentrate on behaviors that compromise population effectiveness. It is important, however, to develop a mutually agreed conceptual framework that allows ‘decomposition’ of the effectiveness, or lack thereof, of the various proposed or implemented preventive measures. For instance, is the failure of a new safety product or procedure inherent (an issue of theoretical effectiveness) or is it due to poor development (an issue of pragmatic effectiveness) or rather due to lack of compliance in the uptake of the product or the procedure (an issue of population effectiveness)? A second suggestion may seem obvious and already generally appreciated. It refers to the need for evaluation of preventive interventions at both the pragmatic and the population-based level. There is considerable room for improvement, however, not necessarily through sophisticated randomized trials but with use of simple epidemiological techniques, including the assessment of time trends and cross population comparisons. Classical examples are the reduction of childhood poisonings following legislation requiring childproof packaging of medicines and the decrease of highway injuries following the introduction of speed limits.