Public health approaches to health problems as diverse as the spread of infectious diseases, heart disease or cancer have been stunningly effective in lowering the prevalence of these conditions.
This has been achieved through primary prevention (such as clean water), secondary prevention (targeting smokers as a high risk group for cancer or heart disease, for example) and tertiary prevention (early diagnosis and treatment).
Similar thinking has been applied to road safety with great success.
Now it is being advocated for child abuse and neglect.
A new approach to child abuse and neglect
A public health approach to child abuse and neglect is important for three reasons:
- There is a moral imperative to prevent child abuse and neglect wherever possible, due to the suffering and possible long-term harm it causes.
- Child protection services in many nations are becoming overwhelmed and cannot cope with the demands placed upon them.
- Child protection intervention, particularly removing children from their parents and exposing them to multiple placements, can have serious adverse consequences.
Current approaches to child protection focus predominantly on sifting through reports of alleged abuse to assess the level of risk, responding to this at case level.
A public health approach addresses the underlying contributory factors in order to achieve a population-level reduction in the prevalence of child maltreatment.
This doesn’t replace individual services, but aims to reduce the need for such intervention.
Evidence that this approach works
The reduction in certain types of injuries to very young children – injuries typically associated with supervisory neglect (such as ingestion of medication or poisons, burns, falls and drownings) – was achieved by a combination of “engineering out” the risk wherever possible (childproof medication containers, for example) and public education campaigns.
We need to build the evidence base for prevention strategies for other forms of child maltreatment, learning more about their “causal pathways” and how to intervene effectively at a whole community level.
And we need to understand more about how positive social changes have come about “naturally”, such as the declining use of physical punishment in many societies in the past generation or two, with or without legislation.
Population-based measures and tackling key risk and protective factors
Strategies aimed at reducing the prevalence of child maltreatment must tackle both risk and protective factors.
Risk factors include a parental history of family violence, alcohol and other drug use and mental health problems, as well as poverty-related situational stress.
In essence: “The challenge of ending child abuse is the challenge of breaking the link between adults’ problems and children’s pain.” (UNICEF, A League Table of Child Maltreatment Deaths in Rich Nations, September 2003).
To take one example, reducing parental alcohol abuse at a population level requires evidence-based measures such as a ban on alcohol advertising, minimum pricing, taxing different products according their actual volume of alcohol, and reduced retail outlets.
Health promotion messages such as “alcohol and children don’t mix” may also prove to be as valuable in changing social norms as drink-driving social marketing was. Child advocacy organisations need to lend their voices to those lobbying for such reform.
At a secondary prevention level, making evidence-based treatment programmes – such as Parents Under Pressure – readily available for parents can prevent harm to young children.
Protective factors vary according to the type of child maltreatment, but a key protective factor is parent-child attachment; this is fundamental to a parent’s motivation to protect and nurture their child. There is some evidence that conducting ultrasound consultations during pregnancy in ways that help prospective parents individualise their unborn child can enhance post-birth attachment to the infant.
Similarly, there is evidence that breastfeeding is a protective factor for maternal child physical abuse. Other protective factors include social support for families facing high levels of situations stress.
There are many programme models shown to reduce the risk of child abuse and neglect, but we are yet to see the implementation of a systematic policy of tackling the broad range of risk and protective factors associated with child abuse.
A public health approach to child protection for the future
A strong government commitment to a public health approach is essential – it’s not an approach that can be delivered by a child protection service. There is a compelling case for the cost-effectiveness of prevention strategies.
The founders of the UK’s child protection movement shared a vision of prevention and embodied the word in the name of the NSPCC. We have the capacity to turn that vision into reality.
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Emeritus professor Dorothy Scott was the founding director of the Australian Centre for Child Protection at the University of South Australia. She holds adjunct professorial appointments there and in social work at the University of Melbourne.
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