Is It Enough? A Comparative Examination of 'Care Leaver's' Health Trajectories in Scotland and Ontario

自愿或通过法律命令置于国家托管所的儿童在离开托管所后面临许多挑战，包括--但不限于--缺乏支持性住房和潜在的无家可归者(Dixon 2008；Randall 1988，)，较低的教育程度和职业地位(O‘Sullivan和Westman 2007；Day等人)。2012年)，经历贫困的可能性更大(Tarren-Sweeney，2008；Dixon等人)。2006年；桑德斯和布罗德1997年)。这些相互关联的不良后果决定了儿童现在和未来的健康状况(Dixon 2008)。那些在护理中和离开护理的人更有可能经历不利的身心健康结果，如过早死亡、药物滥用、抑郁和焦虑(Akister等人。2010年；HJern等人。2004年；Kerker和Dore，2006年；Meltzer等人。2003年；国家审计署2015年；Pilowsky和Wu 2006年；Tarren-Sweeney 2008年；Tine和Mette 2009年)。虽然这在一定程度上可能是由于进入托儿所的人的特点，因为6%的残疾儿童位于托儿所内(Gordon等人。2000年)，其中大部分可归因于他们在离开照料之前、期间和之后暴露在社会劣势和孤立中。虽然有大量的研究阐明了这群有护理经验的年轻人的不稳定地位，但它未能将他们置于更广泛的公共政策环境中(Power和Raphael 2017)。目前将护理经验与后来的结果联系起来的模式一般侧重于个人行为/特征、通过发展支持性网络巩固积极认同以及与这一群体密切相关的具体社会政策的影响。虽然这些模型提供了丰富的信息，但它们忽略了塑造这一弱势群体生活和工作条件的关键环境和背景因素。因此，有必要重新评估现有的模型和见解，这些模型和见解研究了那些在护理中和离开护理中的人的不良健康轨迹。在对处于和离开护理中的年轻人的不良健康轨迹进行评估时，Power和Raphael(2017)将现有文献中的见解纳入到一个模型中，该模型阐明了背景特征对护理离职者健康的影响(图1)。这一整体模式包括个人机制、家庭和地方特点、健康的社会决定因素、公共政策环境以及与权力分配相关的宏观结构概念。它结合了一个路径模型，展示了生命过程中的各个阶段如何与这些因素相互作用，以塑造护理者的健康。该项目将比较两个政策环境：苏格兰的爱丁堡和加拿大的多伦多。这样做的理由是，卫生文献的政治经济学将这些国家归类在“自由福利国家”的旗帜下(Esping-Andersen 1990,1999)。尽管有用，但该模型未能认识到这些司法管辖区内的复杂性。此外，苏格兰的帝国主义政治和加拿大的联邦制度的作用使这些有趣的案例研究。因为虽然威斯敏斯特和渥太华在制定社会政策方面都有一定程度的自主权，但威斯敏斯特和渥太华的经济主导地位可能会受到限制。拟议的研究项目将使用反映鲍尔和拉斐尔开发的模型的两级方法方法。第一阶段将是人口概况调查和健康筛查问卷(EQ-5D)，第二阶段将是半结构化、非标准化访谈。此外，该项目应采用混合方法方法(布鲁尔和亨特，2006年)，这将使人们能够(1)阐明量化变量之间的联系和(2)定性地确定和理解这些关系。因此，这有可能导致根据护理离职者的经验制定经验知情的政策。

Children placed in State care, either voluntarily or through legal orders, experience numerous challenges upon leaving care that include - but are not limited to - a lack of supportive housing and potential homelessness (Dixon 2008; Randall 1988, 1989), lower educational attainment and occupational status (O'Sullivan and Westerman 2007; Day et al. 2012), and greater likelihood of experiencing poverty (Tarren-Sweeney 2008; Dixon et al. 2006; Saunders and Broad 1997). These adverse outcomes - which are interrelated - shape children's present and future health status (Dixon 2008). Those in and leaving care are more likely to experience adverse physical and mental health outcomes such as premature mortality, drug abuse, depression, and anxiety (Akister et al. 2010; Hjern et al. 2004; Kerker and Dore 2006; Meltzer et al. 2003; National Audit Office 2015; Pilowsky and Wu 2006; Tarren-Sweeney 2008; Tine and Mette 2009). While some of this may be due to the characteristics of those entering care, as 6% of children with disabilities are located within care facilities (Gordon et al. 2000), most of this can be attributed to their exposure to social disadvantage and isolation prior to, during, and after leaving care. Whilst there exists a significant body of research illuminating the precarious position of this population of care experienced young adults, it fails to situate them within a wider public policy environment (Power and Raphael 2017). Current models linking care experience to later outcomes generally focus on individual behaviours/characteristics, the consolidation of positive identities though the development of supportive networks, and the effects of specific social policies germane to this group. Whilst informative, these models neglect key environmental and contextual factors that shape the living and working conditions of this vulnerable population. Accordingly, there is a need to revaluate existing models and insights which examine the poor health trajectories of those in and leaving care.Within their evaluation of poor health trajectories amongst young people in and leaving care, Power and Raphael (2017) incorporate insights from existing literature into a model that illuminates the implications of contextual characteristics on care leaver's health (Figure 1). This holistic model incorporates individual mechanisms, family and local area characteristics, social determinants of health, the public policy environment, and macro-structural concepts associated with power distribution. It incorporates a pathway model to show how stages in the life course interact with these factors to shape care leavers health.This project shall be a comparative of two policy environments: Edinburgh, Scotland and Toronto, Canada. The rationale for this is that the political economy of health literature groups these countries together under the banner 'liberal welfare state' (Esping-Andersen 1990, 1999). Whilst useful, this model fails to acknowledge complexity within these jurisdictions. Moreover, the role of devolutionary politics in Scotland and the federal system in Canada makes these interesting case studies. For while both have a level of autonomy in constructing social policies, the economic dominance of Westminster and Ottawa can be restricting.The proposed research project shall utilize a two-tier methodological approach that will reflect the model developed by Power and Raphael. The first stage will be a demographic profile survey alongside a health screening questionnaire (EQ-5D) and the second will be semi-structured, non-standardised interviews. Moreover, the project shall utilize a mixed-methods approach (Brewer and Hunter 2006) which will enable one to (1) illuminate associations between quantified variables and (2) qualitatively contextualize and understand these relations. This consequently has the potential to lead to the development of empirically informed policies that derive from the experiences of care leavers.