Causal frameworks in child unintentional-injury prevention policy in New Zealand.

• Author: Reeve, Belinda

Abstract

This paper begins by outlining Nick Spencer's (1999) argument that there is a split in causal frameworks in child health research. One body of research looks at the micro-level causes of child health outcomes, while another body of research examines the more macro-level causes such as socio-economic inequalities in society that lead to differences in outcomes between population groups. The paper then attempts to show that this causal split is also found in child unintentional-injury research, and how this may lead to different prevention methods being advocated. The policy analysis section of this paper demonstrates how this split is also found in policy documents from different government departments. Documents from ACC focus on micro-level causes of injury such as individual behaviour, while the Ministry of Health emphasises macro-level factors such as socio-economic status. These documents are then compared to British policy documents on child unintentional-injury prevention (produced by the Department of Health), which provide a very different causal story. It is argued that the different portrayal of the causes of unintentional injury by different government departments in New Zealand serves to allocate responsibility for injury and justify the different injury prevention measures advocated by ACC and the Ministry of Health. The paper concludes with a discussion of the limitations of the causal stories presented, and the possible need for central government policy that solely focuses on child unintentional-injury prevention.

INTRODUCTION

Unintentional injury is a major health problem among New Zealand children. Injuries are the leading cause of death in the age group one to four years, and the second leading cause of hospitalisation of children, after respiratory diseases (Ministry of Health 1998a:47). Despite the importance of child unintentional injuries to child health, research on the causation of injuries has some limitations, similar to those found in research into the causation of child health in general. Nick Spencer (1999:175) argues that there is a split between research that examines either the micro-level or the macro-level causes of child health problems. Research into micro-level causes focuses on the immediate environment of the child, influenced mainly by parental health and culturally determined behaviour. Research into macro-level causes is concerned with structural and material influences that are mainly centred outside the child's immediate environment and are beyond parental control (Spencer 1999:175). Using playground injuries and unintentional poisonings as a case study, the literature review section of this paper investigates how these two conflicting explanations of child health determinants exist in research into the causes of child unintentional injuries. It also shows how the study of a particular cause leads to different interventions being advocated, and the possible limitations of studying a singular cause in isolation from other causes or levels of causation.

An analysis of the selected policy documents that touch on child unintentional injury similarly shows a split between focusing on the micro-level or macro-level causes of injury. Policy documents from ACC focus on the individual-level causes of injury such as behaviour, while documents on child health from the Ministry of Health centre on population-level causes of ill health such as economic inequalities in society. This contrasts to British unintentional-injury prevention policy, which specifically focuses on children as a target group, and discusses both the micro-level and macro-level causes of child unintentional injury.

It is possible that the reasoning behind the contrasting causal frameworks of the two government departments in New Zealand is different to that of scientific research. Deborah Stone (2002:204) argues that, in the political world, causes are strategically portrayed in order to allocate blame and responsibility for a particular problem. Causal theories are not right or wrong, nor are they mutually exclusive (Stone 2002:204). The policy analysis section of this paper attempts to show how ACC and the Ministry of Health strategically frame the causes of child unintentional injuries in policy documents in order to legitimise their role in unintentional-injury prevention and assign responsibility to different groups. The analysis also shows that although the reasoning behind contrasting causal models in scientific research and policy documents may be different, there is a similar outcome, in that the causal frameworks presented have several limitations, leading to an incomplete representation of causation in child unintentional injuries.

LITERATURE REVIEW

Nick Spencer notes that the main determinants of child health have been the subject of a long and intense debate (Spencer 1996, cited in Spencer 1999:175), with two apparently conflicting explanations. One school of thought focuses on the immediate environment of the child, influenced mainly by parental health-related and culturally determined behaviour. The other school of thought is concerned with structural and material influences that are mainly centred outside the child's immediate environment and are beyond parental control (Spencer 1999:175).

Micro-environmental explanations of child health centre on the parents, particularly the mother, and the physical and emotional environment in which they nurture their children. Micro-level variables tend to be studied in isolation from their socio-economic context and are broadly viewed as the individual responsibility of the parent, or the result of wider cultural factors independent of economic and other environmental influences (Finerman 1994, cited in Spencer 1999:177).

On the other hand, macro-level explanations of child health outcomes shift the focus from the individual to the wider society. Child health is seen as being determined primarily by social, political and economic forces outside the control of the individual and by established structures of society that favour privileged minorities (Spencer 1999:177). The implicit message in this causal framework is that child health is most likely to improve in response to social and economic changes that minimise poverty and favour the majority.

However, research focusing on a single causal factor or a single level of causation has several limitations. There is evidence that the macro-level and micro-level variables that influence child health do not operate independently, but are closely linked by causal chains made up of a range of mediating variables operating on different levels (Spencer 1999:182). Research focusing on a single causal factor sheds little light on how those factors interact with others to cause health problems such as injuries and their outcomes (Whitelaw 1991:190), and how the mediating variables between micro-level and macro-level causes operate.

Although the general trend in scientific research is to investigate a single causal factor, research in the field of epidemiology attempts to address how different factors interact to cause a particular health problem. The belief that population patterns of disease and health can be explained by a complex web of numerous interconnected risk and protective factors has become one of epidemiology's central concepts (Susser 1985, Buch et al. 1988, cited in Krieger 1994:887). This has led to the widespread adoption of multi-causal conceptual frameworks in epidemiological research (Krieger 1994:887). For example, William Haddon (1972, 1973, cited in Runyan 2003) has developed two complementary conceptual frameworks for understanding how injuries occur and for developing strategies for intervention. Haddon's matrix considers both the proximal causes of injuries, in terms of interactions between the host, the agent and the environment, and the distal causes of injury, such as the socio-political milieu affecting the process, which could include cultural norms and mores and the political environment (Runyan 2003:61).

Child Unintentional Injury Causation

Despite the existence of complex causal frameworks such as Haddon's matrix, and proven links between macro-level and micro-level causes in other areas of child health, a large amount of research on child unintentional injuries still focuses on one cause or a single level of causation. It is evident in the case studies of this literature review (child unintentional injuries and playground falls) that there is very little research that investigates the connections between micro-level and macro-level causes of child unintentional injuries.

Child Unintentional Poisoning

Research on the micro-level causes of unintentional poisoning mainly focuses on the traditionally studied causes of child unintentional injury; namely the child's development, environmental hazards and parental behaviour. The characteristics of the child--in particular, his or her intelligence level and psychomotor skills--have all been implicated in any predisposition to accidents (Sand 1991:82). Children's physiological differences to adults during the maturation process, such as metabolic rate (Guzelian et al. 1992, cited in Schneider and Freeman 2000:4), also contribute towards children's greater susceptibility to the adverse effects of environmental exposure (Schneider and Freeman 2000:4). In the context of poisoning, an ingested dose of a toxic agent in an adult would pose less of a threat than the same size dose for a child, as the reduced body mass of the child is less able to deal with the insult (Schneider and Freeman 2000:4).

Environmental hazards are thought to be a main cause of child unintentional poisonings, particularly unsafe packaging and storage. Medications involved in suspected poisoning are most frequently packed in containers without child-resistant sealants (63%) or transparency blisters (20%) (Wiseman et al. 1987b). Wiseman et al...