Resource Sheet
Number 11 September 2007

Defining the public health model for the
child welfare services context

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Defining the public health model for the child welfare services context

This resource sheet aims to answer the questions: What is the public health model and how does it apply to the Australian child welfare and child protection system?

There are many theoretical and conceptual frameworks that inform our thinking about the structure of the service system and the delivery of services to vulnerable families. Prominent approaches include: the developmental - ecological framework, situational crime prevention models, attachment theory, trauma theory, child development, gender theory, victimology, developmental - psychopathology, responsive regulation, community development, the public health model, and models of therapeutic engagement. Theories and models help us to frame our thinking and interpret findings when investigating the nature and prevalence of a problem, its aetiology, or its consequences. Theories and models also help us to plan and review the structure of the service system in responding to problems.

In this resource sheet, the public health model is applied to the Australian child welfare and child protection system to explore how the service system responds to child abuse and neglect. The public health model is commonly used to describe the child welfare service system and is a prominent theory applied in critical appraisals and strategic planning for the sector (Scott, 2006). The resource sheet concludes with a discussion of the utility of the public health model for identifying service needs and directions.

The public health model

The public health model is a concept with currency in many disciplines including health, education and welfare. When applied to the child protection and child welfare sector, the public health model provides a theoretical framework that spans the service continuum. Broadly, child maltreatment interventions aim to prevent the occurrence or re-occurrence of child abuse and neglect. The targeting of prevention programs at different groups with varying degrees of risk for child maltreatment is referred to as a 'composite approach' to prevention. A composite approach to prevention originated in the public health model of disease prevention. In the public health model of disease prevention, preventative interventions are described as either: primary, secondary, or tertiary interventions (Tomison & Poole, 2000). Child maltreatment interventions are also commonly categorised in the same way.

Primary or universal interventions

Primary (or universal) interventions are strategies that target whole communities in order to build public resources and attend to the social factors that contribute to child maltreatment. The Australian Childhood Foundation's 'Every Child is Important' campaign is an example of a primary intervention (Australian Childhood Foundation, 2004). The program uses television, radio and print material to educate the community in relation to the importance of a child's early years and the need for a child to have a safe and secure home environment.

Secondary or targeted interventions

Secondary interventions target families who are 'at risk' for child maltreatment. The term 'at risk' is used to mean families who exhibit risk factors for child maltreatment. Risk factors for maltreatment include: poverty, parental mental health problems, marital discord, family violence, and parental drug and alcohol use. Note that such risk factors are not causative (meaning the presence of a risk factor does not mean that a child will experience maltreatment). However, the presence of identified risk factors can be a cue to service professionals that the capacity or likelihood of abuse and/or neglect occurring is greater as a child and family's vulnerability is greater where there is financial strain, family violence and so on. Where families are at risk for child maltreatment (due to the presence of one or more risk factors for child maltreatment), secondary approaches prioritise early intervention. Secondary interventions generally involve early screening to detect children who are most at risk, followed by a combination of interventions (for example, home visiting, parent education, and skills training) to address the risk factors for child maltreatment (Thyen et al., 1995).

Tertiary interventions

Tertiary interventions target families in which child maltreatment has already occurred. Tertiary interventions seek to reduce the long-term implications of maltreatment and to prevent maltreatment recurring. Given that tertiary interventions operate once child maltreatment has occurred or is believed to have occurred, they have been assessed as reactive and 'after-the-fact' approaches (Thyen et al., 1995). Tertiary interventions (for example, statutory child protection services which operate in each state and territory throughout Australia) initially dominated the child protection domain. However, primary and secondary interventions have gained increasing attention as government bodies, non-government organisations, and community alliances have recognised the importance of proactive strategies, which intervene before maltreatment occurs (Thyen et al., 1995).

The emphasis on primary and secondary interventions followed greater awareness of the cost of maltreatment (both to individuals and the community) and to the publication of research, which suggested that tertiary-level child protection services are not as successful as is often assumed (Geeraert et al., 2004). To illustrate, Geeraert et al. (2004) reported that the difficulty of treating abusive parents at the tertiary level is more pronounced than at the primary or secondary prevention levels, as abusive parenting may have become a fixed pattern of parent-child interaction.

Prevention programs and their target groups

Prevention programs differ in their focus. Some strategies involve working directly with the parent (such as parent education programs), while other programs target children (such as school-based personal safety programs). In contrast, home visiting programs target the family unit, but may differ as to whether the program goals relate to outcomes specifically for the child, the parent, or the family. Table 1 illustrates the way child maltreatment prevention programs can be conceptualised according to a public health model (that is, primary, secondary, and tertiary interventions) based on their level of operation or focus (that is, children, parents or community).

Table 1: Types of child maltreatment prevention programs

	Intervention level
Focus	Primary	Secondary	Tertiary
Child	Personal safety programs	Assertiveness training for 'at risk' children	Therapeutic programs (eg, group or individual therapy for abused children)
Parents/Family	Universal nurse home visiting programs	Parent education programs	Child protection service referrals (eg, anger management programs
Community	General media awareness campaigns	Targeted media campaigns in 'at risk' communities	Intensive community interventions (eg, alcohol zero tolerance zones)

Limitations of the public health model

Note that while the public health model attempts to categorises programs and services as either primary, secondary or tertiary, some programs are both primary and secondary, or secondary and tertiary. For example, a parenting program may contain parents who have been referred because their children are considered to be at risk of abuse and neglect, as well as parents who have been referred from child protection services because their children have already experienced actual abuse and neglect and they are required to complete the program to help ameliorate the risk of further maltreatment. Another example that illustrates the difficulty of rigidly applying the public health model to child maltreatment interventions can be found in the use of therapeutic treatment programs for maltreated children. For example, therapeutic interventions for maltreated children can be considered tertiary interventions (as maltreatment has already occurred) and also secondary interventions as addressing the consequences of maltreatment may reduce the likelihood of inter-generational effects (Tomison & Poole, 2000).

Conclusion

While there are some limitations to the public health model with respect to clearly identifying where programs 'sit' along the service continuum (i.e., whether primary, secondary, or tertiary services), the public health model is one of the most useful and widely applied frameworks for strategic planning regarding service provision (e.g., recognising the types and range of services needed and identifying service gaps along the continuum). In summary, according to the public health model, primary, secondary and tertiary services are all critical elements in the child welfare and child protection system. However, a well-balanced system has primary interventions as the largest component of the service system, with secondary and tertiary services progressively smaller components of the service system. There are thought to be many benefits to such as approach. For example, research into the cost-effectiveness of early intervention programs has shown that $1 spent early in life, can save $17 by the time a child reaches mid-life (Blakester, 2006). But most importantly, investment in primary prevention programs has the greatest likelihood of preventing progression along the service continuum and sparing children and families from the harmful consequences of abuse and neglect.

References

Australian Childhood Foundation. (2004). Every child is important: A booklet for parents. Melbourne, Vic: Australian Childhood Foundation.

Blakester, A. (2006). Practical child abuse and neglect prevention: A community responsibility and professional partnership. Child Abuse Prevention Newsletter (National Child Protection Clearinghouse), 14(2).

Geeraert, L., Noortgate, W. V. D., Grietens, H., & Onghena, P. (2004). The effects of early prevention programs for families with young children at risk for physical child abuse and neglect: A meta-analysis. Child Maltreatment, 9(3), 277-291.

Scott, D. (2006). Towards a public health model of child protection in Australia. Communities, Children and Families Australia, 1(1), 9-16.

Thyen, U., Thiessen, R., & Heinsohn-Krug, M. (1995). Secondary prevention: Serving families at risk. Child Abuse & Neglect, 19(11), 1337-1347.

Tomison, A., & Poole, L. (2000). Preventing child abuse and neglect: Findings from an australian audit of prevention programs. Melbourne, Australia: Australian Institute of Family Studies.

This resource sheet is based on extracts from Child Abuse Prevention Issues, no.24 Autumn 2006, The effectiveness of parent education and home visiting child maltreatment prevention programs.

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