ROUND TABLE
Stirring the pot
Joan Ozanne-Smith
Department of Forensic Medicine, Monash University, Melbourne, Vic., Australia (e-mail: joan.ozanne-smith@med.monash.edu.au )
The recently launched WHO/UNICEF World report on child injury prevention, reported reductions in the rate of child injury mortality by more than 50% in 30 years in high-income countries in the late 20th century.1 The global challenge is to reduce injuries in all countries to similar levels, using existing and new knowledge over a similar or shorter timeframe. Sustaining effort in high-income countries, where injury remains the leading cause of death post-infancy, is equally challenging.1
These goals should be feasible and a priority, since many known solutions are cost effective and have short lead times to measurable injury reductions. Yet, as Dr Barry Pless indicates, the necessary widespread support from ministries of health is lacking and there are challenges in the translation of research to implementation.
Injury is a health problem
While I agree with Dr Pless that injury is a health problem, I would add to his arguments and note some cautions. A coordination role by health is necessary since other ministries lack the overview capacity of the health ministry, and hence the capacity to coordinate action. Injury prevention requires health data to inform and drive prevention and to monitor trends. While the health sector is responsible for the treatment of injuries, it must also take direct responsibility for solutions where these fall within its jurisdiction (e.g. poisoning).
Although injury is a health problem, it is clear that the budget allocations of WHO itself were heavily skewed towards infectious diseases in 2006-2007, with less than 1% of the WHO budget allocated to injuries and violence.2,3 Vested interests in certain diseases by ministries of health reflect similar patterns, ensuring that injury prevention resources are not commensurate with the size and preventability of the problem.
Despite commitment to injury prevention through World Health Assembly and United Nations resolutions,4 ministries of health can and do fail their constituencies with regard to injury prevention, exemplified by the Australian Department of Health and Ageing axing its Injury Prevention unit in 2009,5 despite injury remaining the leading cause of death for Australians aged 1-44 years. Injury is also absent from major Australian prevention initiatives.6
But injury is not only a health problem. Other sectors must also take greater responsibility. Indeed, safety is written into the responsibilities of many jurisdictions though the scientific and systematic approach, demonstrated to good effect by road safety authorities in many countries, is not necessarily broadly understood and embraced. Nevertheless, examples exist of sector-led progress including product safety, sport and recreation, planning and building sectors.
Despite alternative leadership examples, health must fulfil the fundamental role of providing detailed quality data and coordinating action and must not abdicate these responsibilities.
Translation of research to implementation
While Pless notes that injury research is not enough, an even more fundamental problem is the lack of adequate child injury data from many countries. Even within high-income countries, statistical blind spots mask product, work-related and sports and recreational injury. Importantly, the standard practice of grouping mortality and morbidity into 0-4 years of age masks high rates of injury in the 1-4 years age group. Problem definition is lacking because of poor data: how big are specific injury problems and where are they located in countries or regions?
As noted by Pless, many countermeasures to child injury problems are known and their efficacy proven. Confusion exists, however, with regard to translating research to implementation both within and between countries. Countermeasure efficacy is surely transferable, so long as the problems are similar, as it is based on physical and biological principles.
A successful model for translation of research to policy and practice has been used by the Monash University Accident Research Centre (MUARC) in Australia for more than 20 years. MUARC has worked with government and industry to identify major unresolved injury problems and undertaken applied research to solve them. A limited term project advisory committee is appointed comprised of key stakeholders and funders with the capacity to advise on the research and to implement its findings. This process garners engagement with the project and a level of ownership by the committee. Many MUARC research results, while also disseminated through the scientific and stakeholder literature, have been taken forward into state and national regulations, Australian and international standards, the Australian Building Code and a wide range of government policies and strategies. The media also engages closely with MUARC research findings, stimulating public debate and reinforcing translation to prevention.
In my view, "knowledge brokers" are not a likely solution, as the strongest and most credible advocates remain the researchers themselves so long as they commit to the extension of the research process through policy reviews, standards committees, media and other implementation strategies. Of course, research funders must also adapt their funding model to include these functions.
The other outstanding question highlighted by Pless is whether or not similar implementation methods, as opposed to countermeasures, work in different countries, climates, social circumstances and cultures? This question remains to be answered by intervention trials and other effectiveness studies. 
Competing interests: None declared.
References
1. Peden M, Oyegbite K, Ozanne-Smith J, Hyder AA, Branche C, Rahman AKMF, et al., eds. World report on child injury prevention. Geneva: World Health Organization & UNICEF; 2008.
2. Stuckler D, King L, Robinson H, McKee M. WHO's budgetary allocations and burden of disease: a comparative analysis. Lancet 2008;372 Issue 9649;1563-9. doi:10.1016/S0140-6736(08)61656-6 PMID:18984189
3. Lopez A. Health and health-research priorities: has WHO got it right? Lancet 2008;372 Issue 9649;1525-7. doi:10.1016/S0140-6736(08)61632-3 PMID:18984173
4. Sminkey LA. Ministry of Health focal persons for injury and violence prevention commit to increased action. Inj Prev 2006;12;270. doi:10.1136/ip.2006.012740
5. Albany P, Thenabadu G. Child injury prevention: a public health issue? Canberra, ACT: In Touch, Public Health Association;2009. Available from: www.phaa.net.au/intouch2009.php [accessed on 20 March 2009] .
6. New health taskforce on prevention - tobacco, alcohol and obesity priorities. Canberra, ACT: Department of Health and Ageing; 2008. Available from: www.health.gov.au/internet/ministers/publishing.nsf/Content/mr-yr08-nr-nr046.htm [accessed on 20 March 2009] .