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Etiological studies of traumatic injury: are we measuring the right outcome?

A description of the issue Many etiological studies investigate risk factors for the occurrence of acute injury events. The epidemiological approaches used in such investigations include case-control studies, where people are classified based on the occurrence or non-occurrence of an injury and the exposure experience of the two groups is compared. Alternatively, some studies use a cohort approach, which in its simplest form, compares the injury experiences of people over time who have and have not been exposed to a potential risk factor. We have been considering the methods currently used to classify injury outcomes in these types of studies and would like to share these ideas with the readers of Injury Prevention, in the hopes of involving some thought and debate. By definition, the purpose of etiological studies is to quantitatively assess the strength ofpotential risk factors for injury. For example, an investigation might examine how family income levels (or some other measure of socioeconomic status) are associated with the occurrence of certain childhood injuries. What we would normally do in this situation is to classify the outcomes in a dichotomous fashion (that is, as injury or no injury), and perform our analysis based upon this outcome measure. While this is a straightforward and generally accepted method, we wonder whether it is appropriate for all etiological studies. Many injury control specialists view injuries as a form of disease, and this view provides us with a conceptual framework from which preventive interventions can be formulated. But what if acute injury events are really manifestations of a disease process? What if that process is real and the injury only a proxy measurement for the existence of this disease? Ifwe were to accept this idea it might lead to a change in the way we view and measure injuries. Instead of considering injuries to be acute events leading to physical harm, we would need to broaden the definition to include a disease where individuals consistently (and perhaps systematically) place themselves at risk for injury.