Comparing health outcomes for care experienced children and children in the general population in Scotland using linked administrative data
Lead Research Organisation:
University of Glasgow
Department Name: College of Medical, Veterinary, Life Sci
Abstract
Children who are in the care of their local authority (care experienced children, CEC) are one of the most vulnerable groups of people in the society. In 2017 approximately 15,000 children in Scotland were visited by social care workers at home or placed in kinship, residential or foster care. These children often experience disadvantage compared to other young people, such as having to move homes or change schools frequently. Currently, very little is known about the health of CEC or how this compares to other children in Scotland. The small amount of evidence there is suggests that this group of children are more likely to experience poor health, such as worse mental health compared to other children. Our research aims to provide the first national level evidence on the health, pregnancy and mortality rates for CEC in Scotland.
Our project links different administrative data sources, such as social care, hospitalisation, birth and death registrations data, for children who were in school and experiencing care in 2009. The care experiences (the type, length and number of placements) and health outcomes for these children will be followed over seven years up to 2016. The health of CEC will then be compared to the health of school children who did not experience care between 2009 and 2016.
We will investigate the following research questions:
1. Do the health, mortality and pregnancy rates of school-aged CEC differ from the general population of school-age children in Scotland?
2. Do the health, mortality and pregnancy rates of school-aged CEC differ from the general population of school-aged children within deprivation categories across Scotland?
3. Which care experiences (type, length and the number of social care placements) increase the risks of adverse health outcomes, mortality and pregnancy?
4. How do different care experiences interact with deprivation and family socioeconomic status (SES) to affect the risks of adverse health outcomes, mortality and pregnancy?
The first two questions provide an understanding of the health of CEC relative to other children. We will look at a wide range of health outcomes (hospitalization rates, the number and type of prescriptions) to identify the ones for which health disparities between the CEC and other children are the greatest. For hospitalizations, prescriptions and mortality we will first look at overall rates, followed by cause-specific analysis that groups the major causes of illness. The main causes of interest are mental-health related outcomes (hospitalization due to self-harm or anti-depressant use) and mortality due to causes that could have been prevented with effective medical treatment (e.g. asthma) or by other interventions (e.g. accidents). If possible, we will also study other major causes of illness, such as respiratory diseases. These outcomes will be analysed by small-area deprivation to see if and to what extent the health disparities are explained by socioeconomic inequalities.
After getting a sense of the broad differences between the two populations, questions 3 and 4 will investigate in detail how different care paths, family SES, past health and other factors impact health, mortality and pregnancy rates. These results can say whether children who have frequent changes in care placements experience more health problems or whether children in certain types of placements are more likely to have health problems. This will help identify the location and timing for early interventions among CEC in Scotland.
The research results will be published in academic journals, but we will also write a research report for non-academic audiences. This report will present the main findings and is aimed at policy makers, professionals and service providers working with CEC. We will collaborate with the Centre for Excellence for Looked After Children in Scotland to develop the report and present this at a knowledge exchange workshop at the end of the project.
Our project links different administrative data sources, such as social care, hospitalisation, birth and death registrations data, for children who were in school and experiencing care in 2009. The care experiences (the type, length and number of placements) and health outcomes for these children will be followed over seven years up to 2016. The health of CEC will then be compared to the health of school children who did not experience care between 2009 and 2016.
We will investigate the following research questions:
1. Do the health, mortality and pregnancy rates of school-aged CEC differ from the general population of school-age children in Scotland?
2. Do the health, mortality and pregnancy rates of school-aged CEC differ from the general population of school-aged children within deprivation categories across Scotland?
3. Which care experiences (type, length and the number of social care placements) increase the risks of adverse health outcomes, mortality and pregnancy?
4. How do different care experiences interact with deprivation and family socioeconomic status (SES) to affect the risks of adverse health outcomes, mortality and pregnancy?
The first two questions provide an understanding of the health of CEC relative to other children. We will look at a wide range of health outcomes (hospitalization rates, the number and type of prescriptions) to identify the ones for which health disparities between the CEC and other children are the greatest. For hospitalizations, prescriptions and mortality we will first look at overall rates, followed by cause-specific analysis that groups the major causes of illness. The main causes of interest are mental-health related outcomes (hospitalization due to self-harm or anti-depressant use) and mortality due to causes that could have been prevented with effective medical treatment (e.g. asthma) or by other interventions (e.g. accidents). If possible, we will also study other major causes of illness, such as respiratory diseases. These outcomes will be analysed by small-area deprivation to see if and to what extent the health disparities are explained by socioeconomic inequalities.
After getting a sense of the broad differences between the two populations, questions 3 and 4 will investigate in detail how different care paths, family SES, past health and other factors impact health, mortality and pregnancy rates. These results can say whether children who have frequent changes in care placements experience more health problems or whether children in certain types of placements are more likely to have health problems. This will help identify the location and timing for early interventions among CEC in Scotland.
The research results will be published in academic journals, but we will also write a research report for non-academic audiences. This report will present the main findings and is aimed at policy makers, professionals and service providers working with CEC. We will collaborate with the Centre for Excellence for Looked After Children in Scotland to develop the report and present this at a knowledge exchange workshop at the end of the project.
Planned Impact
Care experienced children (CEC) are a vulnerable group of population, but little is known about their health in Scotland. International evidence suggests that compared to other children CEC suffer higher rates of mental health illness and mortality from causes that could have been treated or otherwise avoided. To plan policy interventions in Scotland we need to know which illnesses CEC are likely to suffer from and which causes contribute most to the potential health inequalities between CEC and other children.
Our work can contribute towards evidence-based policy-making, inform practitioners, enhance public services, and most importantly, improve the health and other long-term outcomes for CEC. The main beneficiaries from this will be the Scottish Government, the practitioners and social service providers at the local authority level, and ultimately the care experienced children. In addition, much this work, such as the findings on teenage pregnancy, should also be of interest to policy makers and practitioners in the rest of the UK.
In their report Getting It Right for Looked After Children (GIRFLAC) the Scottish Government (2015a) has identified that better health and well-being are necessary to achieve better outcomes for CEC. Our research supports achieving these goals through the evidence we can provide on health. Once we know which are the major causes of illness among CEC and which outcomes contribute most to the health differences between CEC and other children, we may be able to make recommendations on which health services to provide for the CEC. The analysis of health outcomes by deprivation categories will allow us to judge the role deprivation plays in the health of CEC, providing evidence on what effect policies aimed at reducing deprivation may have on health for this group of children.
We will provide information on the effects of permanence of care (the number of different placements) on health. If those who experience a large number of episodes during the study period have more health problems, then our recommendation to the policy makers would be to improve care permanence, particularly in the case of children who already exhibit health problems when entering the care system. We will analyse how the type of care affects health. If it is found that those in a specific type of care experience more health problems, the recommendation may be to review this particular care type. Together, these results can be used to motivate policy efforts to improve permanence and provide the most appropriate type of care for CEC.
In addition, one of the high priority goals of the Scottish Government's (2015b) Looked after Children Data Strategy published alongside GIRFLAC is to understand the long-term outcomes of CEC by linking the Children Looked After Statistics return to health data. Our research directly achieves this.
Our work provides evidence to implement the Scottish Government's (2016) Pregnancy and Parenthood in Young People Strategy, aimed to support young women in pregnancy, and may also support the English Teenage Pregnancy Prevention Framework (Public Health England 2018). By analysing the effects of deprivation and care experience on pregnancy rates, we can identify the population of young women who might benefit the most from policy interventions. Finally, the results on mental health outcomes can help the Scottish Government implement the suggestions put forth by the recent Audit Scotland report (2018), such as identify the level of mental health services required and how to target funding to best meet the needs of children.
Our research is conducted in a time and context where there are both clearly stated policy objectives and sufficiently good data to have a real chance to influence policy making and to improve outcomes for CEC, including those beyond health. Better health of CEC can support the goals of improved school attendance and educational or employment outcomes later in life.
Our work can contribute towards evidence-based policy-making, inform practitioners, enhance public services, and most importantly, improve the health and other long-term outcomes for CEC. The main beneficiaries from this will be the Scottish Government, the practitioners and social service providers at the local authority level, and ultimately the care experienced children. In addition, much this work, such as the findings on teenage pregnancy, should also be of interest to policy makers and practitioners in the rest of the UK.
In their report Getting It Right for Looked After Children (GIRFLAC) the Scottish Government (2015a) has identified that better health and well-being are necessary to achieve better outcomes for CEC. Our research supports achieving these goals through the evidence we can provide on health. Once we know which are the major causes of illness among CEC and which outcomes contribute most to the health differences between CEC and other children, we may be able to make recommendations on which health services to provide for the CEC. The analysis of health outcomes by deprivation categories will allow us to judge the role deprivation plays in the health of CEC, providing evidence on what effect policies aimed at reducing deprivation may have on health for this group of children.
We will provide information on the effects of permanence of care (the number of different placements) on health. If those who experience a large number of episodes during the study period have more health problems, then our recommendation to the policy makers would be to improve care permanence, particularly in the case of children who already exhibit health problems when entering the care system. We will analyse how the type of care affects health. If it is found that those in a specific type of care experience more health problems, the recommendation may be to review this particular care type. Together, these results can be used to motivate policy efforts to improve permanence and provide the most appropriate type of care for CEC.
In addition, one of the high priority goals of the Scottish Government's (2015b) Looked after Children Data Strategy published alongside GIRFLAC is to understand the long-term outcomes of CEC by linking the Children Looked After Statistics return to health data. Our research directly achieves this.
Our work provides evidence to implement the Scottish Government's (2016) Pregnancy and Parenthood in Young People Strategy, aimed to support young women in pregnancy, and may also support the English Teenage Pregnancy Prevention Framework (Public Health England 2018). By analysing the effects of deprivation and care experience on pregnancy rates, we can identify the population of young women who might benefit the most from policy interventions. Finally, the results on mental health outcomes can help the Scottish Government implement the suggestions put forth by the recent Audit Scotland report (2018), such as identify the level of mental health services required and how to target funding to best meet the needs of children.
Our research is conducted in a time and context where there are both clearly stated policy objectives and sufficiently good data to have a real chance to influence policy making and to improve outcomes for CEC, including those beyond health. Better health of CEC can support the goals of improved school attendance and educational or employment outcomes later in life.
Organisations
Publications
Bradford D
(2023)
Assessing the risk of endogeneity bias in health and mortality inequalities research using composite measures of multiple deprivation which include health-related indicators: A case study using the Scottish Index of Multiple Deprivation and population health and mortality data
in Health & Place
Bradford DRR
(2022)
Physical health of care-experienced young children in high-income countries: a scoping review protocol.
in BMJ open
Shaw RJ
(2022)
Biases arising from linked administrative data for epidemiological research: a conceptual framework from registration to analyses.
in European journal of epidemiology
Description | Health outcomes among care experienced children and young people are worse and in some cases the differences are very large, including 5-fold differences in mortality and almost 10-fold differences in mental health hospitalisations. Inequalities in health between care experienced and other children were not explained by socioeconomic status and small-area deprivation - children who have experienced care have consistently high rates of poor health and mortality across different levels of deprivation and socioeconomic status. Unlike previous work in the UK, we were also able to show that health outcomes are often worse before children enter social care and after leaving care, and health is improved while in care placements, particularly for children and young people in kinship and foster care. Our results have raised the question of whether some health conditions, such as chronic illnesses, disabilities (not exclusive to physical disabilities) and neurodevelopmental conditions may be a contributing factor to why some children enter care. This has led to new research questions on how maternal-child health link, early childhood health and pre-existing illnesses impact entry to care. Related to this, it has also led to questions around how preventive health behaviours, such as vaccinations, missing outpatient appointments and adhering to medication impacts health. With this in mind, we submitted new data access applications to extend the scope and time-frame of our study. These applications have been now approved and we are looking for further funding to expand our study. We have also made new connections with researchers in Wales and Northern Ireland to collaborate on grant applications, a particular area of focus here is the health of young care-leavers. In past years access to care has been extended in all four home nations and with future work we hope to assess whether young people to take advantage of this policy change have improved health in their late teens and early 20s compared to those who have not stayed in care after ages 16-18. The researchers involved in the analysis of the data have undertaken different specialist statistical training courses that have had a substantial positive impact on producing outputs and improving opportunities for career development. This applies especially to the research assistant on this project who is now in a much stronger position to apply for PhD posts. |
Exploitation Route | Within academia, the work we have produced opened up many new research questions related to the timing of adverse health events with regard to specific care placements and life-course. The work shifts the focus to health events and outcomes that precede care and might be contributing to children entering care in the first place. Similarly, the work shows a worsening of health soon after children leave care, suggesting that more support (and not necessarily financial support) is required for young care-leavers when they start independent life. Given we found very limited relationship between deprivation and health among those with experiences of care, the work also raised issues around access to services, and whether this is significantly worse among some children and young people in the most deprived areas. Children, young people and their families in the most deprived areas might not be as aware of the different community services and support available to them or are afraid of feeling judged when reaching out. And, of course, it is equally likely that support services are very oversubscribed such that help is simply not received by families in deprived areas, meaning that the socioeconomic inequalities are there and potentially quite larger, we are just unable to pick up on these with the data we have. For non-academic audiences, such as for policy and practice, our work suggests that more support services are needed for all families with children with additional health needs as these families may be at higher risk of family breakdown. Similarly, it suggests that the resect extensions in care up to the ages of 21-26 might have a positive impact on the health of care-leavers and policies and practices to help young people stay in the care placements after turning 16-18 should be supported. |
Sectors | Communities and Social Services/Policy Healthcare |
Description | It has contributed to some change in views and attitudes among professionals who work with care experienced children and young people. For example, we have been able to show social workers within council areas how the longitudinal data they collect can be useful for improving the lives of children and young people. Entering and collecting detailed data is very time-consuming and costly for councils and they often voice concerns and objections to doing this. At an engagement event organised by the Scottish Government, we were able to show local authority staff how the detailed data led to new understandings with regard to health and care and how this can now be used to plan policy interventions. The participants at the event stated that this substantially changed their views with regard to the importance of data collection and they now understood much better why this aspect of their work was also very important. Our project team has also started to receive more request for research results and presentations from third sector organisations and different Scottish Government departments when planning their future activities. Since these activities are all fairly recent (from October 2022) and our main non-academic report was only recently published, the impacts in terms of actual changes in policy or practice are yet to be seen. |
First Year Of Impact | 2022 |
Sector | Communities and Social Services/Policy,Healthcare |
Impact Types | Policy & public services |
Description | Association for Fostering, Kinship and Adoption (AFKA) Scotland - Health Conference |
Geographic Reach | Local/Municipal/Regional |
Policy Influence Type | Participation in a guidance/advisory committee |
Description | Consultation workshop on National Outcomes |
Geographic Reach | National |
Policy Influence Type | Participation in a guidance/advisory committee |
URL | https://consult.gov.scot/national-performance-framework-unit/call-for-evidence/ |
Description | Project advisory group |
Geographic Reach | National |
Policy Influence Type | Participation in a guidance/advisory committee |
Description | Children's Health in Care in Scotland: effects of maternal health, health behaviours and early childhood health on entering care. |
Amount | £100,000 (GBP) |
Organisation | Scottish Graduate School for Social Sciences |
Sector | Academic/University |
Country | United Kingdom |
Start | 09/2023 |
Description | 15 minutes on health inequalities Podcast |
Form Of Engagement Activity | A broadcast e.g. TV/radio/film/podcast (other than news/press) |
Part Of Official Scheme? | No |
Geographic Reach | Regional |
Primary Audience | Professional Practitioners |
Results and Impact | We recorded a podcast to explain why we need to study the health of care experienced children, what implications it has for health inequalities and what are our future plans. The aim was to introduce and advertise our research and reach potential audiences who would be interested in the results. the podcast was advertised via twitter. |
Year(s) Of Engagement Activity | 2021 |
URL | https://soundcloud.com/user-776545020 |
Description | CHiCS online KE and cafe |
Form Of Engagement Activity | Participation in an activity, workshop or similar |
Part Of Official Scheme? | No |
Geographic Reach | National |
Primary Audience | Professional Practitioners |
Results and Impact | The 3-day webinar (21-23.09.2021) introduced the findings from the CHiCS project and invited participants to discuss these in small online cafés. It was ran over three days (three hours per day), each focusing on a specific aspect of health. As well as introducing results from the CHiCS project, the webinar also included guest presentations by other researchers, including research from Wales and Northern Ireland. Using the World Café method, the participants explored questions around the context of the results, how to talk to children and young people about these, and what policy responses might be required to reduce inequalities in health. We concluded with an open discussion where the different cafés feed back key ideas from their discussions to all participants. The feedback and ideas from the event will be used in a non-academic report. The feedback showed that the audience enjoyed the event and reported that they learned new information and changes in views. |
Year(s) Of Engagement Activity | 2021 |
URL | https://www.gla.ac.uk/researchinstitutes/healthwellbeing/research/mrccsosocialandpublichealthscience... |
Description | Engagement video introduction produced, shared through project Twitter page during a Scotland wide online research engagement event Explortathon 2020 |
Form Of Engagement Activity | Engagement focused website, blog or social media channel |
Part Of Official Scheme? | No |
Geographic Reach | National |
Primary Audience | Public/other audiences |
Results and Impact | We produced a short video to explain the aims of our research project. The goal was to share it during the Scotland wide online engagement event to get more followers for our project twitter page. We will later use the twitter page to disseminate findings and advertise project related events. |
Year(s) Of Engagement Activity | 2020 |
URL | https://twitter.com/CHiCS_project |
Description | European Public Health Week: "A healthy and health literate youth", May 16, 2022 |
Form Of Engagement Activity | Participation in an activity, workshop or similar |
Part Of Official Scheme? | No |
Geographic Reach | National |
Primary Audience | Schools |
Results and Impact | An online interactive webinar of 1.5hours for school pupils held as part of European Public Health Week. Delivered together with SHINE, Claire Goodfellow and SCRAMS. We used Menti to engage young people during the webinar. It was attended by approximately 15 SHINE network students but the registration was open also for general public and the full attendance was between 20-30 people. |
Year(s) Of Engagement Activity | 2022 |
Description | Meeting with Scottish Government policy team |
Form Of Engagement Activity | A talk or presentation |
Part Of Official Scheme? | No |
Geographic Reach | National |
Primary Audience | Policymakers/politicians |
Results and Impact | The aim was to introduce the Children's Health in Care in Scotland project and it's initial results to Scottish Government children's policy team representatives and discuss with them the work. I introduced some of the initial results and discussed these with the participants. Participants gave suggestions and asked questions relevant for their work. |
Year(s) Of Engagement Activity | 2022 |
Description | Online meeting with WCS NRB members |
Form Of Engagement Activity | A talk or presentation |
Part Of Official Scheme? | No |
Geographic Reach | Regional |
Primary Audience | Patients, carers and/or patient groups |
Results and Impact | First online meeting with WC?S National Representative Body members to discuss our work on the health of care experienced children and young people. This was a small group discussion with formerly care experienced people. we introduced our project and some early results by sharing an infographic. We discussed the work and hear feedback and questions from NRB members. |
Year(s) Of Engagement Activity | 2021 |
Description | Presentation given at the Scottish Centre for Administrative Data Research (SCADR) network meeting (D.Brown) |
Form Of Engagement Activity | A talk or presentation |
Part Of Official Scheme? | No |
Geographic Reach | Regional |
Primary Audience | Other audiences |
Results and Impact | Presented work on investigating health outcomes for care experienced children. Was asked to share details of the project, initial findings and challenges with the data linkage. Around 25 SCADR network members (academics, SG, eDRIS) participated, and the presentation generated discussion around networking and future work. |
Year(s) Of Engagement Activity | 2020 |
Description | Press release for CHiCS final report |
Form Of Engagement Activity | A press release, press conference or response to a media enquiry/interview |
Part Of Official Scheme? | No |
Geographic Reach | National |
Primary Audience | Public/other audiences |
Results and Impact | Press release to coincide with the publication of the main non-academic report from the CHiCS project. The release was covered in print and online media and I gave a live radio interview to BBC Scotland and a recorded TV interview for STV. Examples listed below Hospitalisations and deaths among young people in care 'avoidable' (Web) STV - 28/10/2022 Many hospitalisations and deaths among children and young people who have been in care are "completely avoidable", it has been claimed. STV Central East - Fri, 28 Oct 2022 18:14:35 BST STV Central East - 28/10/2022 18:14:35 Many hospitalisations and deaths of children who've been in the care system could have been avoided, according to a report by researchers at the University of Glasgow. BBC Radio Scotland FM - Fri, 28 Oct 2022 11:02:42 BST BBC Radio Scotland FM - 28/10/2022 11:02:42 Many hospitalisations and deaths among children and young people who have been in care are completely avoidable, according to a report from Glasgow University. BBC 1 Scotland - Fri, 28 Oct 2022 08:31:06 BST BBC 1 Scotland - 28/10/2022 08:31:06 Many deaths and hospitalisations among children and young people who have been in care are completely avoidable, according to a report from Glasgow University. |
Year(s) Of Engagement Activity | 2022 |
URL | https://www.gla.ac.uk/news/headline_890649_en.html |
Description | Press release for cohort profile paper |
Form Of Engagement Activity | A press release, press conference or response to a media enquiry/interview |
Part Of Official Scheme? | No |
Geographic Reach | National |
Primary Audience | Media (as a channel to the public) |
Results and Impact | Press office and our research team wrote a press release that came out as the Cohort profile paper was published 15.09.2021. The release was picked up by a number of papers and radio stations. Altmetric and news details here https://bmj.altmetric.com/details/113473962/news |
Year(s) Of Engagement Activity | 2021 |
URL | https://www.gla.ac.uk/news/headline_811017_en.html |