Abstract
Background: Children in state care face a unique set of complex challenges due to divided loyalties to the people they live with, varying degrees of contact with birth families and pre-placement experiences. Little is currently known about the health outcomes of this vulnerable population in Aotearoa New Zealand (NZ), with policy-makers and practitioners relying largely on overseas research to inform practice.
Aims: This thesis aimed to understand what is currently known about the health outcomes of children in state care across several domains both in NZ and overseas via a narrative review. Additionally, this thesis sought to compare the all-cause hospitalisation and all-cause mortality of children in the custody of the chief executive of Oranga Tamariki with other NZ children through original quantitative research.
Method: The narrative review in chapter two was produced using PubMed, Google Scholar and Scopus. The main search was conducted in PubMed using the following search terms: children, youth, under 18, and adolescents; hospitalisation, mortality, and health outcomes; and state care, foster care, out-of-home care, CYFS and Oranga Tamariki. The quantitative study was a retrospective cohort study using the Integrated Data Infrastructure (IDI). An estimated resident population for NZ was constructed from the IDI (IDI-ERP) and resulted in a population of 1,014,027. These individuals were classified as being in-care or not-in-care on the 31st of December 2013 and then followed up until the 31st of December 2018, during which time the outcomes of all-cause-hospitalisation and all-cause-mortality were analysed. Data were extracted from the IDI, following Statistics NZ approval, using SAS Enterprise 7.1 and analysed using Stata MP version 16.1. A Poisson regression with a log link and robust variance estimators was used to produce unadjusted and adjusted incidence rate ratios (uIRRs and aIRRs). The adjusted model corrected for age, sex, ethnicity, level of socioeconomic deprivation and rural/urban status.
Results: The narrative review highlighted the paucity of research on the health outcomes of children in care in NZ. No quantitative studies comparing health outcomes of children in care with other children in NZ were identified. However, there are several reports by independent groups and the Oranga Tamariki Evidence Centre that publish a selection of information pertaining to health outcomes. Overseas literature illustrates that health outcomes for children in care are worse than for children who have never been involved with child protection systems (CPS’) across the domains of mental health, physical health, suicidality, mortality and hospitalisation. The quantitative study conducted in this thesis adds to what is known about the health outcomes of children in state care in NZ. Children aged 0-17-years who were in-care on the 31st of December 2013 were found to be 32% (aIRR 1.32, 95% CI 1.27-1.38) more likely to be hospitalised than not-in-care children between 1 January 2014 and 31 December 2018. In-care children were also 3.64 times as likely to die than not-in-care children within the same time period (aIRR 3.64, 95% CI 2.47-5.40). Unadjusted cumulative incidence rates (CIRs) of hospitalisation and mortality were higher in in-care children across all sociodemographic variables than in not-in-care children.
Conclusion: This cohort study highlights that the care and protection system prior to 2018 was not preventing children in its care from experiencing severe adverse health outcomes. Overseas research has previously been relied on when making practice and policy decisions around care and protection of children in NZ, so this research will provide valuable evidence to guide best practice in an NZ context.