State care in childhood and adult mortality: a systematic review and meta-analysis of prospective cohort studies.
State care in childhood and adult mortality: a systematic review and meta-analysis of prospective cohort studies.
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DOI：
10.1016/s2468-2667(22)00081-0
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发表时间：
2022-06
影响因子：
50
通讯作者：
Frank, Philipp
中科院分区：
文献类型：
--
作者：
Batty, G. David;Kivimaki, Mika;Frank, Philipp
将儿童从原籍家庭转移到国家照料可能是一种极具挑战性的童年经历，本身就与成年生活中的一系列不利结果有关。我们的目标是综合关于早期生活中有国家护理史的人成人死亡风险的证据，并根据不同的背景评估这种联系。在这项系统回顾和荟萃分析中，我们重点关注了四个假设与早期国家护理相关的健康结果：总死亡率、心血管疾病、癌症和自杀。我们检索了PubMed和Embase的电子数据库，从最初到2022年1月21日，寻找满足以下标准的研究：这是一项前瞻性研究，其中对护理的评估最大为18岁；它包括一个未暴露的对照组；研究的重点是临时的家庭护理，而不是收养；死亡率监测延伸到成年；提供了关联(例如，相对风险、优势比或风险比)和方差(例如，顺式和顺式)的标准估计；研究发表在同行评议的期刊上；研究发表在英文版。采用改良的Cochrane偏倚风险工具评估研究质量。我们从符合条件的研究中提取了相关性和方差的估计，并通过对两个英国出生队列-即1958年和1970年研究(总计n=21 936)中未发表的参与者的个人数据的分析来补充这些发现。我们分别计算了每项研究中95%的护理依从性和每个健康结果的风险比，然后使用随机效应荟萃分析将结果汇集在一起。这篇综述注册在Propero，CRD42021254665上。我们确定了210篇可能符合条件的已发表文章，其中14篇符合我们的纳入标准(两项研究未发表)。在来自13项研究的3名 223 580人中，那些在童年接受护理的人成年后总死亡的风险是那些没有童年护理史的人的两倍(总风险比2·21[95%CI 1·62-3·02])，研究的具体估计在1·04到5·77之间(I2 =98%)。尽管有一些减弱，但这种联系在对早期生活逆境的其他衡量标准进行调整后仍然存在；延伸到中老年；在更高质量的研究中更强；根据性别、地理区域和出生年份的不同，这种联系的程度相同。有些人认为是接触护理的敏感期，在青春期第一次进入国家护理的人(2.47[0.98-6.52])的死亡率比生命周期早期进入国家护理的人(1.75[1.25-2.45])更高。在包括534名 890人在内的四项研究中，接受照料的儿童成年后完全自杀的风险是未暴露的同龄人的三倍多(3·35[2·41-4·68])，具体研究估计在2·42到5·85之间(I2=72%)。在对多个协变量进行调整后，这种关联的程度较弱；在男性中比在女性中；在质量较低的研究中。我们对成人死亡率的研究结果表明，儿童保护系统、社会政策和护理毕业后的卫生服务不足以减轻可能在被送入托儿所之前以及可能伴随而来的不利经历。没有。
Removal from family of origin to state care can be a highly challenging childhood experience and is itself linked to an array of unfavourable outcomes in adult life. We aim to synthetise evidence on the risk of adult mortality in people with a history of state care in early life, and assess the association according to different contexts. In this systematic review and meta-analysis, we focused on four health outcomes hypothesised to be associated with exposure to early state care: total mortality, cardiovascular disease, cancer, and suicide. We searched the electronic databases PubMed and Embase from inception to Jan 21, 2022, for studies fulfilling the following criteria: it was a prospective study in which the assessment of care was made up to 18 years of age; it included an unexposed comparator group; the focus of the study was temporary out-of-home care and not adoption; mortality surveillance was extended into adulthood; standard estimates of association (eg, relative risk, odds ratios, or hazard ratios) and variance (eg, CIs and SE) were provided; the study appeared in a peer-reviewed journal; and the study was published in English. An adapted Cochrane Risk of Bias Tool was used to assess study quality. We extracted estimates of association and variance from qualifying studies and augmented these findings with analyses of unpublished data from individual participants in two UK birth cohorts—ie, the 1958 and 1970 studies (total n=21 936). We computed hazard ratios with accompanying 95% CIs for care and each health outcome separately for each study, and then pooled the results using a random-effects meta-analysis. This review is registered at PROSPERO, CRD42021254665. We identified 210 potentially eligible published articles, of which 14 met our inclusion criteria (two studies were unpublished). Of 3 223 580 individuals drawn from 13 studies, those who were exposed to care in childhood had twice the risk of total mortality in adulthood relative to those without a history of care in childhood (summary risk ratio 2·21 [95% CI 1·62–3·02]), with study-specific estimates varying between 1·04 and 5·77 (I2 =98%). Despite some attenuation, this association remained following adjustment for other measures of early-life adversity; extended into middle and older age; was stronger in higher-quality studies; and was of equal magnitude according to sex, geographical region, and birth year. There was some suggestion of sensitive periods of exposure to care, whereby individuals who entered state care for the first time in adolescence (2·47 [0·98–6·52]) had greater rates of mortality than those doing so early in the life course (1·75 [1·25–2·45]). In four studies including 534 890 people, children in care had more than three times the risk of completed suicide in adulthood relative to their unexposed peers (3·35 [2·41–4·68]), with study-specific estimates ranging between 2·42 and 5·85 (I2=72%). The magnitude of this association was weaker after adjustment for multiple covariates; in men than in women; and in lower-quality studies. Our results for adult mortality suggest child protection systems, social policy, and health services following care graduation are insufficient to mitigate the adverse experiences that might have preceded placement into care and those that might accompany it. None.