Child health is determined by a complex interplay of factors. Conflicting explanations for differences in child health outcomes between and within child populations have been advanced: one large school of thought has focused on parenting and variables within the child's micro environment; the opposing school has focused on the macro environment in which child populations live with particular emphasis on the socioeconomic determinants. This chapter explores the relationship between macro and micro environmental influences on child health using data from a range of studies and the causal pathways by which socioeconomic and socio-cultural variables in the macro environment may influence the child's micro environment. The concept of proximal and distal causes is used to consider causal models. The chapter concludes by proposing a framework for the use of causal pathways in the study of child health outcomes.
The main determinants of child health have been the subject of a long and intense debate (Spencer, 1996). The chief protagonists advance apparently conflicting explanations for child health outcomes: one school of thought focuses on the immediate environment of the child influenced mainly by parental health-related and culturally determined behaviours; the other school is concerned with structural and material influences which are mainly centred outside the child's immediate environment and are without parental control. In ecological terms, the former is concerned with the micro environment and the latter with the macro environment.
These explanations are frequently seen as mutually exclusive and data analyses, following the 'germ theory' on which much of modern medicine is based, are directed to finding the single most important determinant using statistical techniques which weight the relative strength of co-variables (Logan and Spencer, 1996). This pursuit of single causative agents or correlates has not only generated many misleading conclusions but is fundamentally incapable of accounting for the complexity of the processes by which child health is determined (Rutter, 1988).