Volume 23
Number 4
2002

[Table of Contents]

The population health perspective (PHP) is commonly used in addressing a wide range of health issues. In this article, the determinants of health that are an integral part of the PHP are used as a framework in considering the range of outcomes associated with exposure to child maltreatment. The article examines the strengths and limitations of the perspective and outlines directions for further research.

Key words: child maltreatment; outcomes; population health perspective

Introduction

Since the 1990s, child maltreatment has increasingly been viewed as a major public health problem in Canada. This has occurred, in part, because mounting evidence highlights the relationship between child maltreatment and impairment in both emotional and physical health. This paper examines the usefulness of the population health perspective (PHP) as a framework for studying child maltreatment outcomes by critiquing the approach and by applying the PHP-adopted list of determinants of health to these outcomes. It also outlines future directions for research in examining health outcomes related to child maltreatment from a PHP.

Population health perspective

The overarching goal of the PHP is “to maintain and improve the health of the entire population and to reduce the inequalities in health between population groups [emphasis added].”1 Defining populations is problematic; there are some examples given in the PHP, such as children and Aboriginal people. But what is a “population”. Is it a neighbourhood? A nation? Further, what constitutes “population groups” and why are boundaries created in some instances and not in others?² The unit of analysis is important if we are considering the impact of factors on the “health” of a population. For instance, increased economic prosperity at a national level is not necessarily reflected at regional or local levels,³ resulting in uneven health outcomes in these population groups which, when aggregated, may appear to have no impact on health.

Changes in our view of health affect our definition of “health problems” and affects how research is conducted. The PHP “places the person within a broader context”.⁵ However, concern has been raised that a concentration on larger circumstances can obscure important elements of individual experiences.⁶ The balance between macro and micro factors is important. Individuals can alter some determinants of health; others must be changed by groups or organizations.¹ Income inequality, for example, is a characteristic of a population rather than of an individual.⁵ Personal income level is partly attributable to personal skills, but also to tax policies and redistributive programs, factors beyond the control of the individual. Thus, the PHP addresses issues on conceptually distinct levels encompassing the individual, family, community and society. These different levels take into account the antecedents, developmental processes and experiences of the individual. Health issues, then, have to be addressed at several levels simultaneously.

The PHP has something to offer both “neo-conservatives” and “welfare state advocates” in that it simultaneousl addresses economy and equity. This has contributed to widespread support.⁷ Economic growth (a conservative argument) is seen as an essential component to improved health status at the population level, as is equitable distribution of wealth (a social welfare argument). Populations with more equitable income distribution are healthier than other populations.⁸

Another important feature of the PHP is its multidisciplinary nature. This has broad appeal at one level, but it also poses certain challenges: terminology differences, difficulty evaluating the quality of “evidence” from other disciplines,“turf wars” or “health imperialism.”

Determinants of health

The Canadian Institute of Advanced Research (CIAR)^b influenced the development of the PHP by publishing policy reports that provided information on determinants of health. They identified a broad range of determinants. Initially, sex and gender were not differentiated,⁹ and ethnicity and religion were used solely as control variables in analyses.¹⁰ More recently, the importance of social environment, gender and culture has been recognized (Table 1).

This section addresses child maltreatment and PHP. There are four main types of child maltreatment: physical, sexual, and emotional abuse, and neglect. Child physical abuse includes acts such as hitting, shaking, choking, biting, kicking, burning, slapping, poisoning or any other dangerous use of force.²⁴ Child sexual abuse occurs when someone involves the child in any activity for the purpose of his or her own sexual pleasure. This might involve intercourse, touching, or exposure to developmentally inappropriate sexual behaviour, including exposure to pornographic material.²⁴ Child emotional abuse may involve degrading, rejecting, terrorizing, isolating and corrupting acts; it includes witnessing domestic violence.²⁴ Child neglect occurs when a caregiver fails to provide one or more of the following: adequate food, clothing, shelter, cleanliness, supervision, medical care, protection from harm and exploitation, and denial of emotional responsiveness.²⁴

No national figures for the prevalence of child maltreatment are available. The best information comes from the Ontario Mental Health Supplement (1990), a province wide community survey. A history of child physical and/or sexual abuse is common: child physical abuse was reported more often by males (31.2%) than females (21.1%) whereas child sexual abuse was more common among females
(12.8%) than males (4.3%).²⁵ Researchers studying the long-term correlates of childhood maltreatment have shown an association with a variety of physical, emotional, social and cognitive impairments in later life^26–28 – impairments which may result in increased health care costs and, most importantly, human suffering. This has led to an emphasis on early intervention and treatment both to assist survivors and to reduce demands on the health care system.²⁹ Child maltreatment is a serious population health problem, given that it affects almost one in three Canadian children, and its consequences early and later in life are often widespread and negative.

Due to its multidisciplinary nature and because it is possible for it to incorporate ideas from other perspectives, the PHP is useful in studying child maltreatment. The major contribution of PHP may be the holistic approach – the equitable consideration of both societal and personal factors. The determinants of health provide an opportunity to study child maltreatment across the whole spectrum from
prevention through rehabilitation. For example, there is some evidence to suggest that persons who have knowledge of child development are less abusive.³⁰ Obtaining this knowledge is an individual responsibility, but it is also the obligation of society to provide the opportunity for learning.³¹

Determinants of health and outcomes of maltreatment

Health Canada's interpretation of the determinants of health (Table 1) provides a framework for the following section. Outcomes of child maltreatment are considered at the individual level, and where data exists, at the community
and societal level.

Few studies have discussed the income level of adults abused as children. Findings from a followup study of adults physically abused in childhood showed that many of the respondents had never been employed, “despite being in the so-called prime of their life”^.32 The National Lesbian Health Care Survey (1985) (n = 1,925) found that the average income in adulthood of child sexual abuse survivors was lower than non-abused women.³³ Furthermore, abuse victims may have additional costs associated with a need to feel safe.³⁴ Higher income allows a wider range of possibilities for rehabilitation; for example, it could provide the means for counselling or legal follow up. The moderating effects of income on consequences of maltreatment have not been investigated.³⁵ Since income is an important determinant of health, it merits further investigation. Decreased earning capacity for a substantial portion of a population has far-reaching effects on that population.

A strong social support network may be a protective factor for coping with abusive experiences. However, the social support system can also be an obstacle. Individuals within a social support network may focus on protecting the
abuser instead of the abused. At the community and society levels, support of survivors after disclosure is needed, in the form of information and access to resources.

The experience of child maltreatment may create difficulties in developing social support networks. Abused children may have to establish new relationships in foster care or in institutions. This can be beneficial if a positive relationship with the new caregiver is developed. Some children, however, move from foster home to foster home;³⁶ this can present difficulties in creating and maintaining social networks. Further, abusive experiences as well as acculturation problems (especially for Aboriginal children and youth) have been reported.³⁷ As adults, intimate relationships are harder to form and maintain for the sexually abused³⁸ due to fear of rejection,³⁹ and divorce rates are higher.³⁸

Does education affect the outcomes of child maltreatment? Several studies have found that abuse is associated with negative outcomes in college-based studies as well as in population-based studies^40–45 Are college students better able to cope with exposure to sexual abuse than persons in the general population?⁴⁶ Or are survivors with more adverse outcomes not attending college?⁴⁷ If it is true that survivors are less likely than the non-abused to attend college, then society loses in innovation and productivity In one study, severely abused men were found to be more likely to be unemployed than those who had not experienced abuse^.48 However, there may be confounding factors, such as interpersonal problems or social isolation that may antedate the abuse or the outcome. As in the case with income, higher levels of unemployment decrease earning capacity and affect the health of the nation.

Exposure to child sexual abuse is associated with fear and anxiety in adulthood.⁴⁹ Any number of factors in the physical environment, for instance, place and circumstances of residence, may increase the anxiety level of survivors. These relationships need to be explored; research is needed to determine if the feeling of safety or fear in the physical environment varies after exposure to child maltreatment.

Intelligence, which is at least partly a genetic endowment, may affect the response to child maltreatment. Research suggests that intelligent children who have suffered exposure to maltreatment may have more effective coping skills. These children do better in school, which may create a sense of competence; this in turn influences self concep^t.50 A positive school experience creates self worth and a sense of control, both important components of recovery.⁵¹ Some survivors turn to unhealthy coping mechanisms, such as alcohol, as a way of avoiding traumatic memories related to child abuse.^52–53 Research indicates that resilient survivors have less tendency to blame themselves; they tend to minimize the impact, cognitively re-frame the experiences and refuse to dwell on them.⁵⁴ There is a danger in using the term “resilience” too loosely, however: it could lead to blaming the victim, implying that if people were just resilient enough they would survive adversity. It could be used as a reason for refusing assistance to people in need^.55

The developmental level of the child at the time of the abuse mediates the response to maltreatment. For instance, toddlers and preschoolers may exhibit behaviour problems, and have less ability to communicate verbally. In middle
childhood, exposure to maltreatment is associated with academic problems in addition to emotional and behavioural impairment, such as depressive symptoms and sleeping disturbance.^26,49 However, studies into child abuse rarely
distinguish between the time of exposure to the abuse and the response, nor do they control for pre-existing health status. The developmental stage of the child when she/he experiences abuse may also affect response to abuse as an
adult.²⁶ Professionals in the health and social services sectors are uniquely positioned to identify and respond to abuse. It is important that such services be well equipped to provide assistance and referrals for support. When abuse goes
unrecognized as it frequently does, the necessary services do not reach those exposed to maltreatment.56 Detecting and reporting the abuse initiates the medical, social services and legal intervention that may prevent further harm to the
child and begin rehabilitation. At the same time, it is important to underscore that detection alone does not necessarily lead to better outcomes, and may do more harm than good if it is not linked to services.

Gender mediates the response to child maltreatment. Evidence about the negative effects of child abuse on women is mounting. Fewer studies have been conducted on men. The risk of psychiatric disorder in adulthood after exposure to child maltreatment is greater for women than men.⁵² Differences between genders may be attributable to age at time of abuse and relationship to perpetrator.⁵⁷
Protective factors may be different for boys and girls who have been maltreated.⁵⁸ Gender and child maltreatment merits further investigation.

Limited research has been conducted on outcomes of child maltreatment across different cultures. However, in the abuse literature there has been some discussion regarding culture and healing; for instance “blaming the victim”
attitudes may introduce barriers to healing.⁵⁹

In instances where the social environment conveys a sense of familiarity and comfort, it provides a safe place where individuals can address fears, desires, beliefs and feelings.⁶ An environment where abused persons can feel safe is important. If foster homes and shelters do not exist, or do not meet the needs of the abused, the street may be the only solution to escaping an abusive home. Evidence suggests that many runaway and homeless children have been abused.⁶⁰

The PHP does not include the legal system as a determinant of health. Legislation is needed to deter child maltreatment and to assist victims after disclosure. The aim of the law is to protect and provide support to victims, and to punish and rehabilitate perpetrators. Child maltreatment involves both civil and criminal law. The focus of criminal law is punishment, while civil law focuses on protection (“best interest of the child”).⁶¹ Civil law also deals with claims for harm and suffering. In the civil law context, treatment of victim and perpetrator is considered humane.⁶¹ However, it may not be so straightforward. Is punishment of the abuser helpful to the victim? Is the victim further hurt if the perpetrator and provider go to jail, assuming that they are one and the same? Is there a stigma that outweighs the potential benefits of reporting? Does an abused person do better if s/he receives financial compensation? These are all questions that need to be considered in examining the outcomes of child maltreatment.

Dorne presents the following arguments from a criminal law perspective.⁶¹ The victim may not directly benefit from punishment of the perpetrator but society as a whole does. First, there is a symbolic value; second, the punishment may prove to be a deterrent to others; third, society is safer when the perpetrator is in prison; and last, retribution is achieved.⁶¹

Court proceedings are traumatic for victims of abuse, whose testimony under cross-examination may not be believed.⁶¹ However, there are some procedures now available to protect the child victim such as closed courtrooms, interviews by as few people as possible, and in camera testimony.

Availability of legal services is a population issue; services are expensive, and not within everyone's reach, although some are provided free of charge to those on social assistance. A criminal justice system that provides public defenders would be consistent with the philosophy of PHP.

Further conceptual developments

The PHP is an evolving approach and some earlier criticisms have led to modifications. One of these changes is a shift to the increased use of qualitative approaches. Quantitative data with an implicit notion of “objectivity” used to be
preferred.⁶² “Quantitative data allows us to estimate the magnitude and type of health issues in the population, and to identify health outcomes. Qualitative data add a richness and a depth to quantitative data that is necessary to understand why health problems occur in the population and what strategies are needed to address them”.¹ This is important in child maltreatment research since data and
in-depth information must be gathered about underlying circumstances and children's experiences. It is important to study what determines health but also to establish strategies by which the determinants can be influenced.³ A combination of approaches may be most useful.

The research on determinants of health has been criticized for concentrating on positivist methodologies. There is a risk that this methodology comes to represent “objective” knowledge rather than one way of obtaining knowledge. Theory (ideology) needs to be made explicit. Robertson states “...[the] argument is not to get the ideology out of science but to get the ideology out of hiding”.⁶³ There is a further risk that experiencing, for example, racism and poor housing is devalued by “objective” risk factors like heart
disease and smoking.²

The CIAR model of population health has been criticized for simplifying complex phenomena by flowcharting them. A model substitute is created, instead of actually describing, theorizing and explaining.⁹ The notion of social structure is
foreign to CIAR.³ How do the pieces in the model fit together?20 In the writings of CIAR, wealth creation is championed even though the data suggest that it is
inequality of distribution rather than lack of prosperity that is the problem.⁶² The PHP proponents have not educated the public adequately on the impact of the health determinants outside the health care system. That is one of the reasons for lack of “political motivation or public appetite for developing an integrated policy framework dedicated to promoting just and equitable social relations”.⁶⁴

Other determinants

The list of determinants is still evolving. Spirituality could be identified as a component of the PHP. Health may have a spiritual dimension partly linked to social support. Religious advisors have been shown to have a supportive role.55
Religious affiliation and church attendance have been identified as factors contributing to positive health outcomes.⁵⁵ The link between healthy outcomes and spirituality may also arise from optimism, hope and belief in the meaning of life^.55

Should age be considered a determinant of health? Age influences the risk and protective factors for different health problems. Physical health and functional ability decline with age; there is more stress and depression in the extremes of
life – young and old.⁶⁵ Further, age is socially constructed when a person is judged based on assumptions related to age instead of abilities. Both young people and seniors may have this experience.⁶⁶

Technology has consequences for our health, in relation to accessibility and knowledge. Knowledge production in medical technology has increased the survival rate but has also created complex health needs.⁶⁷ In rural and socially
disadvantaged areas, there may problems in having access to medical technology.⁶⁷ Politics is another area often absent from lists of determinants of health.²³ For example, changes in population health status were related to mode of production in the transformation of the Soviet Union. In the Ottawa Charter, peace is discussed as influencing health.⁶⁸ These “new determinants” need to be investigated in relation to child maltreatment.

Conclusion

The PHP addresses a range of determinants of health at multiple levels that are relevant to maltreatment outcomes. The literature indicates that because child maltreatment is a significant health problem in terms of its human and economic costs, it is important to PHP. Clearly, those who have experienced maltreatment are at increased risk for a wide range of health problems.

The social and economic determinants of health have demonstrated relevance to the health status of populations. Thus, PHP is useful in examining outcomes of child maltreatment at both the individual and societal level. Investment in the non-medical determinants, such as anti-poverty measures which may alleviate some parental stress, and support for healthy child development, which fosters healthy children, are important in reducing exposure to child maltreatment and promoting the health of the population.

Acknowledgment

This work has been supported by the Canadian Institutes of Health Research (CIHR) Institutes of Gender and Health; Aging; Human Development, Child and Youth Health; Neuroscience, Mental Health and Addiction; and Population and Public Health. Harriet MacMillan is supported by the Wyeth-Ayerst Canada Inc. CIHR Clinical Research Chair in Women's Mental Health.

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Author References

Lil Tonmyr, Department of Sociology and Anthropology, Carleton University, Ottawa Ontario

Harriet L MacMillan, Departments of Psychiatry and Behavioural Neurosciences and Pediatrics, Canadian Centre for Studies of Children at Risk, Faculty of Health Sciences, McMaster University and Hamilton Health Sciences, Hamilton, Ontario

Ellen Jamieson, Department of Psychiatry and Behavioural Neurosciences, Canadian Centre for Studies of Children at Risk, Faculty of Health Sciences, McMaster University, Hamilton, Ontario

Katharine Kelly, Department of Sociology and Anthropology, Carleton University, Ottawa, Ontario

Correspondence: Lil Tonmyr, Department of Sociology and Anthropology, Carleton University, 1125 Colonel By Drive, Ottawa, ON Canada K1S 5B6; Fax: (613) 520-4062; E-mail: Lil_Tonmyr@hc-sc.gc.ca

^b CIAR contributes to research in many different disciplines. The Institute has a program in population health that supports research on the determinants of health.

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