Sot. Sci. Med. Vol. 35, No. 11, pp. 1325-1327, Printed in Great Britain. All rights reserved
1992 Copyright 0
0277-9536/92 $5.00 + 0.00 1992 Pergamon Press Ltd
DEVELOPING PARTNERSHIPS FOR HEALTH AND SOCIAL SCIENCE RESEARCH: THE INTERNATIONAL CLINICAL EPIDEMIOLOGY NETWORK (INCLEN) SOCIAL SCIENCE COMPONENT NICK HIGGINBOTHAM
On behalf of the INCLEN Social Science Committee*, Center for Clinical Epidemiology and Biostatistics, University of Newcastle, Newcastle, NSW 2308, Australia Abstract-A decade after its inception, the International Clinical Epidemiology Network (INCLEN) adopted a social science component. Health social science concepts were added to a physician training curriculum encompassing epidemiology, biostatistics and clinical economics, and a position was created for qualified social scientists at 26 clinical epidemiology units in developing country medical schools. This paper describes the INCLEN model for strengthening partnerships among clinical epidemiologists and social scientists. The rationale for interdisciplinary training is presented along with the difficulties inherent in attracting social scientists to a new career path. These include problems of recruitment, training curricula, re-entry, and career sustainability. The need is identified for collaborative international efforts to promote
an infrastructure
Key words-health
for professional
social science, clinical
growth
epidemiology,
This paper briefly describes the social science component of the International Clinical Epidemiology Network (INCLEN). INCLEN was established in 1980 to improve the management and planning of health resources in developing countries, and to increase the quantitative skills and research capabilities of clinical teachers [l]. The method chosen to attain these goals was that of clinical epidemiology, which is the application of epidemiology to such clinical concerns as decision making, therapeutic efficacy, and resource allocation [2]. INCLEN has established Clinical Epidemiology Units (CEUs) in 26 medical schools in Asia, Africa and Latin Ameria [3]. Each unit is comprised of a biostatistician and six physicians from different departments, one of whom has received special training in health economics. Beginning in 1987, each CEU could recruit a social scientist from a neighboring department or university. All these faculty members will receive masters degrees at an INCLEN training center-The University of McMaster University, Newcastle Pennsylvania, University and the University of North Carolina. The INCLEN network is maintained through annual scientific meetings comprising fellows, INCLEN mentors from the five training centers, and invited specialists. It is also maintained through visits between recent graduates and their faculty advisors, through a newsletter, and through electronic mail connections among the CEUs and *Deborah
and sustainable
Bender, University of North Carolina; Doug Ewbank, University of Pennsylvania; David Streiner and Dennis Willms, McMaster University; Mark Nichter (Advisor), University of Arizona; and Stephen West (Advisor), Arizona State University.
careers,
careers
in health
social science.
interdisciplinary.
training centers. Small research grants ($5000) are made available so that recent trainees can implement studies on their return to their country. Each fellow is entitled to attend at least two annual INCLEN meetings to report the results of studies designed during training. Attendance thereafter is earned through submission of abstracts describing subsequent research projects. To date, INCLEN centers have trained over 230 scientists, including 14 social scientists. In 1991 the Rockefeller Foundation provided $4,500,000 in support of core INCLEN activities, such as training, operations of the 26 CEUs, research grants, and the annual meeting [4]. Social science was added to INCLEN 6 years after the program began. Although social science concepts had been a part of the training program since its inception, these were primarily limited to techniques of interviewing, attitude assessment, and questionnaire design [5]. As the debate over the determinants of health unfolded during the 198Os, social science issues became more salient within INCLEN. Health status could not be understood without examining issues of social class, gender, behavior, and cultural beliefs. At the same time, as intervention programs became more important, and physician as well as household behavior became a target of change, social scientists were asked to assess change potential and define possible intervention strategies. Finally, it was increasingly recognized that health problems require interdisciplinary solutions. Neither strengthening social science groups in isolation, nor training physicians in social science techniques within medical facilities was deemed sufficient [6]. 1325
1326
NICK HIGGINBOTHAM THE TRAINING
MODEL
Each of the 26 Clinical Epidemiology Units supported by INCLEN has an opportunity to add one social scientist to the existing group of 6 physicians and one biostatistician. The social scientist is awarded a fellowship to pursue a Masters degree at one of four Training Centers in industrialized countries alongside other INCLEN fellows. This training is designed to give fellows a common language of epidemiology and biostatistics; to stimulate ideas about how social science can contribute to the design, implementation and application of clinical epidemiology research; to build the personal relationships necessary for subsequent collaboration; and to expose fellows to a variety of substantive and methodological research problems. The ideal candidate for an INCLEN social science fellowship is an established scientist in an existing social science department who can serve as a bridge between the wider social science community and the CEU. At the same time, a senior social scientist (department chairman, dean, or director) is recruited to ‘sponsor’ or administratively encourage the new INCLEN social science activities. INCLEN has not sought to build social science units inside medical schools unless no other options are available. Descriptions of the training curricula for INCLEN social scientists are available elsewhere [7]. Strategies for training differ among the four centers, but all of them emphasize research design and implementation. SUPPORT
FOR SOCIAL SCIENTISTS INCLEN TRAINING
AFTER
Several strategies help to integrate social scientists with other CEU members on their return. First, the felt needs of the clinicians have partially determined the choice of the social scientist. Second, social science fellows are encouraged to develop research protocols during training which will maximize their opportunities for collaboration with clinical colleagues back home (e.g. measles immunization compliance in Southeast Asia). Third, collaboration is encouraged through INCLEN’s pharmacoepidemiology seed grant project [8]. Fourth, the fellows are encouraged to teach a tailored health social science curriculum within their local medical faculties. Finally, social science faculty act as role models by joining clinical colleagues in various INCLEN collaborative and multicenter studies, such as a multicenter cardiovascular risk factor study [9]. EVALUATING
INCLEN SOCIAL SCIENCE
TRAINING
How will we know if the training model is working‘? One criterion is the number of collaborative studies presented at annual INCLEN meetings, and their subsequent publication in peer-reviewed national or international journals. We would judge INCLEN social scientists to be established successfully in their CEUs if they design and complete research projects
after they return home. Another criterion would be whether INCLEN clinical epidemiologists increasingly incorporated social science variables and methods in their studies. David Streiner content analyzed abstracts presented at the annual INCLEN meetings, 1986-1992, and found a stable, low rate of research projects with social science content from 19861989 in areas of questionnaire development, health belief measures, behavior change, and qualitative methods. During 1990 to 1992 he detected a surge in the percentage of INCLEN abstracts with social science content, from about 7% (7/103 abstracts) to 19% (42/219). Does INCLEN’s collaborative research approach produce more effective and efficient ways for a society to reduce its burden of illness? This broader question is more difficult to answer. One strategy would be to look for ‘dose-response’ effects by comparing intervention outcomes between those CEUs with and without a social science component. Generalizability of the collaborative model beyond the INCLEN environmnent is highly problematic. However, it would be instructive to compare INCLEN to the Applied Diarrhea1 Disease Research Project, which also advocates an interdisciplinary mix (see papers by Trostle and Simon [IO] and Good [l l] in this issue), and to compare both of these to the approach taken by the World Health Organization’s Tropical Disease Research, Social and Economic Research Programme (TDR). Rosenfield [12] describes the TDR model in this issue as strengthening health social science applications independent of medically dominated organizations. What are the long term advantages and disadvantages of each model? One approach advocates training and support for partnerships, the other builds competency within social science groups, without explicit links to medical research units.
IMPLEMENTATION ISSUES FACED BY THE INCLEN SOCIAL SCIENCE COMPONENT
A. Recruitment Several CEU sponsors preferred to use the traineeship to upgrade skills of social scientists already employed within the medical school or of physicans with an ‘interest’ in behavioral research. They felt that this arrangement would bring the returned fellow under the authority of the medical dean, and that this control would increase the likelihood that the fellow would not drift away to other pursuits. Where there is no internal social science group, the process of forging ties to other universities can be time-consuming and can cause resentment that the fellowship is not going to an ‘internal’ candidate. It can also be difficult to find a qualified candidate who: has an interest in epidemiology; is willing to modify his or her career path to work within a medical environment; ‘matches’ CEU needs; is not overcommitted and preoccupied with other donor projects; and can leave home for a year.
Developing
partnerships
for health
Why would CEU membership and further training in epidemiology be sought by already established social scientists, some of whom have a list of donors seeking their services? Our efforts to involve the social science faculty at one university failed because good researchers there were fully absorbed into long-standing rural economic development projects. Also, an additional masters degree is not too appealing to most, who, for career advancement, desire Ph.D. scholarships. Two of the first four fellows have extended their training into Ph.D. programs. B. Re-entry
and integration
It is still early to evaluate the long-term impact and sustainability of the INCLEN social science component. We can anticipate some of the issues of integration our returned fellows could face. Social scientists operating in a medical hierarchy will not have equal status but will be asked to prove their credibility at times in the face of skeptical attitudes. Acceptance within the CEUs may not easily transfer to the wider medical community. Social scientists in comparison with physician CEU members may have different social status, lower incomes, and different sociocultural backgrounds (e.g. ethnicity or tribe). In some instances status differences by gender are an additional consideration. Several CEUs have all male fellows except for the social scientist. These social differences, subtle though they may be, may prove more detrimental to collaboration than crossdisciplinary differences. Social scientists may also become sensitive to how joint research funds are administered. Social scientists nominated as co-investigators on interdisciplinary projects may find themselves lacking control of the budget or left out of decision-making because of the heirarchical nature of medical institutions. It is also possible that the social scientists’ research agenda may be pre-defined by their colleagues, and that they will be assigned roles as junior researchers. A key issue in the continuing education of CEU leaders which is carried out at the University of Toronto, is preparing them to manage interdisciplinary teams effectively and to take advantage of the unique skills of a social scientist. SUSTAINING
HEALTH SOCIAL SCIENCE CAREERS-A CHALLENGE FOR ALL
Once we have trained a cohort of social scientists in population health research, will adequate career paths be available to them? In order to apply health social science perspectives effectively to local priorities, fellows require a sustainable career, including academic security, continuing research grants, consultation with content experts, further education, involvement in major research projects from an array of donors, and access to policy makers and planners. INCLEN aims to build a transdisciplinary perspective into international health by equipping social
and social science research
1327
scientists to speak a common language with clinical epidemiologists and by showing clinicians how social sciences contribute to research and policy. The INCLEN model’s success depends on whether CEU members are willing to integrate returned social science fellows into their team, and whether social scientists experience long-term advantages as coequal CEU members. Our first progress review indicates that the initial cohort of returned fellows are well accepted and highly active CEU members. Success would be further enhanced through a wider infrastructure of career supports at the international level. Donor and operating agencies must nourish the emergence of health social science through research grants, advanced training fellowships, curricula development, and designated roles in major health programs. Acknowledgements-INCLEN is supported through grants from the Rockefeller Foundation, United States Agency for International Development, World Health Organization and the International Development Research Centre. Generous assistance with the early development of the INCLEN social science component was provided by Scott Halstead, Dick Heller, Peter Tugwell, Annette Dobson, John Eisenberg, Gordon DeFriese, Kathy Bennett, Pat Rosenfield, Michael Hensley, David Evans, Peter Kunstadter and many others. The authors thank James Trestle for his incisive comments on earlier versions of this manuscript.
REFERENCES
1. Halstead S. B., Tugwell P. and Bennett K. The International Clinical Epidemiology Network (INCLEN): a progress report, J. clin. Epidemiol. 44, 579, 1991. 2. Last J. M. The Dictionary of Epidemiology. Oxford University Press, Oxford, 1988. at Claude Bernard 3. A CEU has also been established University, Lyon, France. 4. Rockefeller Foundation. 1991 Annual Report. Rockefeller Foundation, New York, 1991. Foundation. Report of the First Annual 5. Rockefeller Meeting of the International Clinical Epidemiology Network (INCLEN), Honolulu, Hawaii, 27 February-l March 1983. H. N. and Streiner D. L. The social 6. Higginbotham science contribution to pharmacoepidemiology. J. c/in. Epidemiol. 44, Suppl. II, 73S, 1991. 7. Materials available on request from N. Higginbotham. I?. Kunin C. M. and Halstead S. Pharmacoepidemiology for developing countries. Lancer 336, 617, 1990. disease 9. Heller R. et 2. Risk factors for cardiovascular in the developing world: A multicentre collaborative study in the Internantional Clinical Epidemiology Network (INCLEN). J. clin. Epidemiol. In press. 10. Trestle J. A. and Simon J. Building applied health research capacity in developing countries: Problems encountered by the ADDR Project. Sot. Sci. Med. 35, 137991387, 1992. M. J. Local knowledge: Research capacity II. Good building in international health. Sot. Sci. Med. 35, 135991367, 1992. P. The potential of transdisciplinary 12. Rosenfield research for sustaining and extending linkages between the health and social sciences. Sot. Sci. Med. 35, 134331357, 1992.
1992 Copyright 0
0277-9536/92 $5.00 + 0.00 1992 Pergamon Press Ltd
DEVELOPING PARTNERSHIPS FOR HEALTH AND SOCIAL SCIENCE RESEARCH: THE INTERNATIONAL CLINICAL EPIDEMIOLOGY NETWORK (INCLEN) SOCIAL SCIENCE COMPONENT NICK HIGGINBOTHAM
On behalf of the INCLEN Social Science Committee*, Center for Clinical Epidemiology and Biostatistics, University of Newcastle, Newcastle, NSW 2308, Australia Abstract-A decade after its inception, the International Clinical Epidemiology Network (INCLEN) adopted a social science component. Health social science concepts were added to a physician training curriculum encompassing epidemiology, biostatistics and clinical economics, and a position was created for qualified social scientists at 26 clinical epidemiology units in developing country medical schools. This paper describes the INCLEN model for strengthening partnerships among clinical epidemiologists and social scientists. The rationale for interdisciplinary training is presented along with the difficulties inherent in attracting social scientists to a new career path. These include problems of recruitment, training curricula, re-entry, and career sustainability. The need is identified for collaborative international efforts to promote
an infrastructure
Key words-health
for professional
social science, clinical
growth
epidemiology,
This paper briefly describes the social science component of the International Clinical Epidemiology Network (INCLEN). INCLEN was established in 1980 to improve the management and planning of health resources in developing countries, and to increase the quantitative skills and research capabilities of clinical teachers [l]. The method chosen to attain these goals was that of clinical epidemiology, which is the application of epidemiology to such clinical concerns as decision making, therapeutic efficacy, and resource allocation [2]. INCLEN has established Clinical Epidemiology Units (CEUs) in 26 medical schools in Asia, Africa and Latin Ameria [3]. Each unit is comprised of a biostatistician and six physicians from different departments, one of whom has received special training in health economics. Beginning in 1987, each CEU could recruit a social scientist from a neighboring department or university. All these faculty members will receive masters degrees at an INCLEN training center-The University of McMaster University, Newcastle Pennsylvania, University and the University of North Carolina. The INCLEN network is maintained through annual scientific meetings comprising fellows, INCLEN mentors from the five training centers, and invited specialists. It is also maintained through visits between recent graduates and their faculty advisors, through a newsletter, and through electronic mail connections among the CEUs and *Deborah
and sustainable
Bender, University of North Carolina; Doug Ewbank, University of Pennsylvania; David Streiner and Dennis Willms, McMaster University; Mark Nichter (Advisor), University of Arizona; and Stephen West (Advisor), Arizona State University.
careers,
careers
in health
social science.
interdisciplinary.
training centers. Small research grants ($5000) are made available so that recent trainees can implement studies on their return to their country. Each fellow is entitled to attend at least two annual INCLEN meetings to report the results of studies designed during training. Attendance thereafter is earned through submission of abstracts describing subsequent research projects. To date, INCLEN centers have trained over 230 scientists, including 14 social scientists. In 1991 the Rockefeller Foundation provided $4,500,000 in support of core INCLEN activities, such as training, operations of the 26 CEUs, research grants, and the annual meeting [4]. Social science was added to INCLEN 6 years after the program began. Although social science concepts had been a part of the training program since its inception, these were primarily limited to techniques of interviewing, attitude assessment, and questionnaire design [5]. As the debate over the determinants of health unfolded during the 198Os, social science issues became more salient within INCLEN. Health status could not be understood without examining issues of social class, gender, behavior, and cultural beliefs. At the same time, as intervention programs became more important, and physician as well as household behavior became a target of change, social scientists were asked to assess change potential and define possible intervention strategies. Finally, it was increasingly recognized that health problems require interdisciplinary solutions. Neither strengthening social science groups in isolation, nor training physicians in social science techniques within medical facilities was deemed sufficient [6]. 1325
1326
NICK HIGGINBOTHAM THE TRAINING
MODEL
Each of the 26 Clinical Epidemiology Units supported by INCLEN has an opportunity to add one social scientist to the existing group of 6 physicians and one biostatistician. The social scientist is awarded a fellowship to pursue a Masters degree at one of four Training Centers in industrialized countries alongside other INCLEN fellows. This training is designed to give fellows a common language of epidemiology and biostatistics; to stimulate ideas about how social science can contribute to the design, implementation and application of clinical epidemiology research; to build the personal relationships necessary for subsequent collaboration; and to expose fellows to a variety of substantive and methodological research problems. The ideal candidate for an INCLEN social science fellowship is an established scientist in an existing social science department who can serve as a bridge between the wider social science community and the CEU. At the same time, a senior social scientist (department chairman, dean, or director) is recruited to ‘sponsor’ or administratively encourage the new INCLEN social science activities. INCLEN has not sought to build social science units inside medical schools unless no other options are available. Descriptions of the training curricula for INCLEN social scientists are available elsewhere [7]. Strategies for training differ among the four centers, but all of them emphasize research design and implementation. SUPPORT
FOR SOCIAL SCIENTISTS INCLEN TRAINING
AFTER
Several strategies help to integrate social scientists with other CEU members on their return. First, the felt needs of the clinicians have partially determined the choice of the social scientist. Second, social science fellows are encouraged to develop research protocols during training which will maximize their opportunities for collaboration with clinical colleagues back home (e.g. measles immunization compliance in Southeast Asia). Third, collaboration is encouraged through INCLEN’s pharmacoepidemiology seed grant project [8]. Fourth, the fellows are encouraged to teach a tailored health social science curriculum within their local medical faculties. Finally, social science faculty act as role models by joining clinical colleagues in various INCLEN collaborative and multicenter studies, such as a multicenter cardiovascular risk factor study [9]. EVALUATING
INCLEN SOCIAL SCIENCE
TRAINING
How will we know if the training model is working‘? One criterion is the number of collaborative studies presented at annual INCLEN meetings, and their subsequent publication in peer-reviewed national or international journals. We would judge INCLEN social scientists to be established successfully in their CEUs if they design and complete research projects
after they return home. Another criterion would be whether INCLEN clinical epidemiologists increasingly incorporated social science variables and methods in their studies. David Streiner content analyzed abstracts presented at the annual INCLEN meetings, 1986-1992, and found a stable, low rate of research projects with social science content from 19861989 in areas of questionnaire development, health belief measures, behavior change, and qualitative methods. During 1990 to 1992 he detected a surge in the percentage of INCLEN abstracts with social science content, from about 7% (7/103 abstracts) to 19% (42/219). Does INCLEN’s collaborative research approach produce more effective and efficient ways for a society to reduce its burden of illness? This broader question is more difficult to answer. One strategy would be to look for ‘dose-response’ effects by comparing intervention outcomes between those CEUs with and without a social science component. Generalizability of the collaborative model beyond the INCLEN environmnent is highly problematic. However, it would be instructive to compare INCLEN to the Applied Diarrhea1 Disease Research Project, which also advocates an interdisciplinary mix (see papers by Trostle and Simon [IO] and Good [l l] in this issue), and to compare both of these to the approach taken by the World Health Organization’s Tropical Disease Research, Social and Economic Research Programme (TDR). Rosenfield [12] describes the TDR model in this issue as strengthening health social science applications independent of medically dominated organizations. What are the long term advantages and disadvantages of each model? One approach advocates training and support for partnerships, the other builds competency within social science groups, without explicit links to medical research units.
IMPLEMENTATION ISSUES FACED BY THE INCLEN SOCIAL SCIENCE COMPONENT
A. Recruitment Several CEU sponsors preferred to use the traineeship to upgrade skills of social scientists already employed within the medical school or of physicans with an ‘interest’ in behavioral research. They felt that this arrangement would bring the returned fellow under the authority of the medical dean, and that this control would increase the likelihood that the fellow would not drift away to other pursuits. Where there is no internal social science group, the process of forging ties to other universities can be time-consuming and can cause resentment that the fellowship is not going to an ‘internal’ candidate. It can also be difficult to find a qualified candidate who: has an interest in epidemiology; is willing to modify his or her career path to work within a medical environment; ‘matches’ CEU needs; is not overcommitted and preoccupied with other donor projects; and can leave home for a year.
Developing
partnerships
for health
Why would CEU membership and further training in epidemiology be sought by already established social scientists, some of whom have a list of donors seeking their services? Our efforts to involve the social science faculty at one university failed because good researchers there were fully absorbed into long-standing rural economic development projects. Also, an additional masters degree is not too appealing to most, who, for career advancement, desire Ph.D. scholarships. Two of the first four fellows have extended their training into Ph.D. programs. B. Re-entry
and integration
It is still early to evaluate the long-term impact and sustainability of the INCLEN social science component. We can anticipate some of the issues of integration our returned fellows could face. Social scientists operating in a medical hierarchy will not have equal status but will be asked to prove their credibility at times in the face of skeptical attitudes. Acceptance within the CEUs may not easily transfer to the wider medical community. Social scientists in comparison with physician CEU members may have different social status, lower incomes, and different sociocultural backgrounds (e.g. ethnicity or tribe). In some instances status differences by gender are an additional consideration. Several CEUs have all male fellows except for the social scientist. These social differences, subtle though they may be, may prove more detrimental to collaboration than crossdisciplinary differences. Social scientists may also become sensitive to how joint research funds are administered. Social scientists nominated as co-investigators on interdisciplinary projects may find themselves lacking control of the budget or left out of decision-making because of the heirarchical nature of medical institutions. It is also possible that the social scientists’ research agenda may be pre-defined by their colleagues, and that they will be assigned roles as junior researchers. A key issue in the continuing education of CEU leaders which is carried out at the University of Toronto, is preparing them to manage interdisciplinary teams effectively and to take advantage of the unique skills of a social scientist. SUSTAINING
HEALTH SOCIAL SCIENCE CAREERS-A CHALLENGE FOR ALL
Once we have trained a cohort of social scientists in population health research, will adequate career paths be available to them? In order to apply health social science perspectives effectively to local priorities, fellows require a sustainable career, including academic security, continuing research grants, consultation with content experts, further education, involvement in major research projects from an array of donors, and access to policy makers and planners. INCLEN aims to build a transdisciplinary perspective into international health by equipping social
and social science research
1327
scientists to speak a common language with clinical epidemiologists and by showing clinicians how social sciences contribute to research and policy. The INCLEN model’s success depends on whether CEU members are willing to integrate returned social science fellows into their team, and whether social scientists experience long-term advantages as coequal CEU members. Our first progress review indicates that the initial cohort of returned fellows are well accepted and highly active CEU members. Success would be further enhanced through a wider infrastructure of career supports at the international level. Donor and operating agencies must nourish the emergence of health social science through research grants, advanced training fellowships, curricula development, and designated roles in major health programs. Acknowledgements-INCLEN is supported through grants from the Rockefeller Foundation, United States Agency for International Development, World Health Organization and the International Development Research Centre. Generous assistance with the early development of the INCLEN social science component was provided by Scott Halstead, Dick Heller, Peter Tugwell, Annette Dobson, John Eisenberg, Gordon DeFriese, Kathy Bennett, Pat Rosenfield, Michael Hensley, David Evans, Peter Kunstadter and many others. The authors thank James Trestle for his incisive comments on earlier versions of this manuscript.
REFERENCES
1. Halstead S. B., Tugwell P. and Bennett K. The International Clinical Epidemiology Network (INCLEN): a progress report, J. clin. Epidemiol. 44, 579, 1991. 2. Last J. M. The Dictionary of Epidemiology. Oxford University Press, Oxford, 1988. at Claude Bernard 3. A CEU has also been established University, Lyon, France. 4. Rockefeller Foundation. 1991 Annual Report. Rockefeller Foundation, New York, 1991. Foundation. Report of the First Annual 5. Rockefeller Meeting of the International Clinical Epidemiology Network (INCLEN), Honolulu, Hawaii, 27 February-l March 1983. H. N. and Streiner D. L. The social 6. Higginbotham science contribution to pharmacoepidemiology. J. c/in. Epidemiol. 44, Suppl. II, 73S, 1991. 7. Materials available on request from N. Higginbotham. I?. Kunin C. M. and Halstead S. Pharmacoepidemiology for developing countries. Lancer 336, 617, 1990. disease 9. Heller R. et 2. Risk factors for cardiovascular in the developing world: A multicentre collaborative study in the Internantional Clinical Epidemiology Network (INCLEN). J. clin. Epidemiol. In press. 10. Trestle J. A. and Simon J. Building applied health research capacity in developing countries: Problems encountered by the ADDR Project. Sot. Sci. Med. 35, 137991387, 1992. M. J. Local knowledge: Research capacity II. Good building in international health. Sot. Sci. Med. 35, 135991367, 1992. P. The potential of transdisciplinary 12. Rosenfield research for sustaining and extending linkages between the health and social sciences. Sot. Sci. Med. 35, 134331357, 1992.
