Publications
238 results found
Martakis K, Alexander D, Schloemer T, et al., 2019, Human papillomavirus vaccination and respect for children’s developing autonomy: Results from an European Union wide study, Journal of Child Health Care, Vol: 23, Pages: 343-357, ISSN: 1367-4935
Children’s rights to autonomy of choice are differently expressed throughout Europe. We explored differences regarding expressions of respect for children’s autonomy throughout Europe, using the procedure of human papillomavirus (HPV) vaccination offer as indicator. We used a mixed methods approach, utilizing an expert survey within the frame of “Models of Child Health Appraised” (MOCHA), among all 30 European Union (EU) and European Economic Area states. A questionnaire was designed using vignettes regarding the vaccine provision. Thirty MOCHA country agents were invited to respond from June 2017 to April 2018. In total, 28 country agents responded. We studied the following themes: (i) provision of informed consent, (ii) parental and medical paternalism, (iii) relevance of the child’s chronological age or maturity, and (iv) vaccination programs targeting boys. These are being handled differently across the region. We explored associations of these implemented practices with the national vaccine coverage rate across Europe. We used the processes of HPV vaccination to study child’s autonomy, the paradigm change toward libertarian paternalism and issues of sex-equity. Interestingly, greater respect for children’s autonomy tends to be associated with medium or high vaccination coverage rates and lower respect with lower rates. Respect and empowerment seem to have practical as well as moral benefits. Identifying and transferring the most suitable ethical approaches is crucial and should be strengthened.
Zdunek K, Schröder-Bäck P, Alexander D, et al., 2019, How does societal reaction to children's health issues contribute to health policy in Europe? Results of a survey, Child: Care, Health and Development, Vol: 45, Pages: 364-370, ISSN: 0305-1862
BACKGROUND: In the European context the awareness of societal responsibility for children's health has increased with greater attention to children's rights and child empowerment processes. Child health issues are considered particularly sensitive; thus, they often provoke strong societal reactions, which, as a consequence, influence national health policies across Europe. Effectiveness of societal influences increases with the involvement of various actors in the context. METHODS: A qualitative approach was used to identify the level of societal involvement in health decision-making. A questionnaire was sent to the Country Agents (CAs) of the Models of Child Health Appraised (MOCHA) project. CAs are contact points in each of the 30 participating in the project countries and were asked to identify strong public and professional discussions related to child health services in their countries. Data collection was undertaken between July and December 2016. RESULTS: Based on 71 case studies, we identified eight thematic patterns, which characterize societal reactions to the currently worrisome child health issues across Europe. We devoted our attention to the three most controversial: child vaccination, child poverty and child abuse. The cases described by the CAs show the broad perspective in the perception of child health problems. Child health issues involve the public and raise nationwide debates. Public concerns were directly or indirectly related to child health and depicted the national overtone. CONCLUSIONS: Concerns in Europe about child health care are twofold: they are devoted to systemic issues (indirect patient orientation) and to child health and well-being (direct patient orientation). The phenomenon of societal responsibility for children's health is important for the support of public acceptance of child health policy.
Schröder-Bäck P, Schloemer T, Clemens T, et al., 2019, A heuristic governance framework for the implementation of child primary health care interventions in different contexts in the European Union, INQUIRY: The Journal of Health Care Organization, Provision, and Financing, Vol: 56, Pages: 46958019833869-46958019833869, ISSN: 1945-7243
To adopt and implement innovative good practices across the European Union requires developing policies for different political and constitutional contexts. Health policies are mostly decided by national political processes at different levels. To attain effective advice for policy making and good practice exchange, one has to take different models of governance for health into account. We aimed to explore which concepts of governance research are relevant for implementing child health policies in a European Union context. We argue that taking into account the insights of good intersectoral and multilevel governance in research and practice is essential and promising for future analyses. These governance concepts help to understand what actors and institutions are potentially of relevance for developing and implementing child-centric health care approaches not only within health care but also outside health care. The framework we developed has the potential to advise on and thus support effectively the spreading and implementation of good practices of child-centric health policy approaches across the European Union. With this heuristic framework, the variety of relevant stakeholders and institutions can better be mapped and taken into account in implementation processes. Also, the normative side-particularly stressing values that make governance "good governance"-is to be taken into account.
Hoang U, Liyanage H, Coyle R, et al., 2019, Determinants of inter-practice variation in childhood asthma and respiratory infections: cross-sectional study of a national sentinel network, BMJ Open, Vol: 9, ISSN: 2044-6055
OBJECTIVES: Respiratory infections are associated with acute exacerbations of asthma and accompanying morbidity and mortality. In this study we explore inter-practice variations in respiratory infections in children with asthma and study the effect of practice-level factors on these variations. DESIGN: Cross-sectional study. SETTING: We analysed data from 164 general practices in the Royal College of General PractitionersResearch and Surveillance Centresentinel network in England. PARTICIPANTS: Children 5-12 years. INTERVENTIONS: None. In this observational study, we used regression analysis to explore the impact of practice-level determinants on the number of respiratory infections in children with asthma. PRIMARY AND SECONDARY OUTCOME MEASURES: We describe the distribution of childhood asthma and the determinants of upper/lower respiratory tract infections in these children. RESULTS: 83.5% (137/164) practices were in urban locations; the mean number of general practitioners per practice was 7; and the mean duration since qualification 19.7 years. We found almost 10-fold difference in the rate of asthma (1.5-11.8 per 100 children) and 50-fold variation in respiratory infection rates between practices. Larger practices with larger lists of asthmatic children had greater rates of respiratory infections among these children. CONCLUSION: We showed that structural/environmental variables are consistent predictors of a range of respiratory infections among children with asthma. However, contradictory results between measures of practice clinical care show that a purely structural explanation for variability in respiratory infections is limited. Further research is needed to understand how the practice factors influence individual risk behaviours relevant to respiratory infections.
Rigby M, Deshpande S, Blair M, 2019, Credibility in published data sources, The Lancet, Vol: 393, Pages: 225-226, ISSN: 0140-6736
Zdunek K, Blair M, Jansen D, 2019, National and Public Cultures as Determinants of Health Policy and Production, Issues and Opportunities in Primary Health Care for Children in Europe: The Final Summarised Results of the Models of Child Health Appraised (MOCHA) Project, Pages: 345-357, ISBN: 9781789733549
The Models of Child Health Appraised (MOCHA) project recognises that child health policy is determined to a great extent by national culture; thus, exploring and understanding the cultural influences on national policies are essential to fully appraise the models of primary care. Cultures are created by the population who adopt national rituals, beliefs and code systems and are unique to each country. To understand the effects of culture on public policy, and the resulting primary care services, we explored the sociocultural background of four components of policy-making: content, actors, contexts and processes. Responses from the MOCHA Country Agents about recent key national concerns and debates about child health and policy were analysed to identify the key factors as determinants of policy. These included awareness, contextual change, freedom, history, lifestyle, religion, societal activation and tolerance. To understand the influence of these factors on policy, we identified important internal and external structural determinants, which we grouped into those identified within the structure of health care policy (internal), and those which are only indirectly correlated with the policy environment (external). An important childfocused cultural determinant of policy is the national attitude to child abuse. We focused on the role of primary care in preventing and identifying abuse of children and young people, and treating its consequences, which can last a lifetime.
Blair M, Rigby M, Menon A, et al., 2019, The Limited Inclusion of Children in Health and Health-related Policy, Issues and Opportunities in Primary Health Care for Children in Europe: The Final Summarised Results of the Models of Child Health Appraised (MOCHA) Project, Pages: 121-127, ISBN: 9781789733549
Whilst nations have overall responsibility for policies to protect and serve their populations, in many countries, health policy and policies for children are delegated to regions or other local administrations, which make it a challenging subject to explore at a national level. We sought to establish which countries had specific strategies for child and adolescent health care, and whether primary care, social care and the school-healthcare interface was described and planned for, within any policies that exist. In addition, we established the extent to which a child health strategy and meaningful reference to children’s records and care delivery exist in an e-health context. Of concern in the Models of Child Health Appraised (MOCHA) context is that 40% of European Union and European Economic Area countries had reported no health strategy for children, and more than a half had no reference to supporting delivery of children’s health in their e-health strategy. We investigated the differences in ownership and leadership of children’s policy, which was a range of ministry input (health, education, labour, welfare or ministries of youth and family); as well as cross-ministerial involvement. In terms of national policy planning and provider planning, we investigated the level of discussion, consultation and interaction between national healthcare bodies (including insurance bodies), providers and the public in policy implementation. The MOCHA project scrutinised the way countries aim to harness the latest technologies by means of e-health strategies, to support health services for children, and found that some had no explicit plans whereas a few were implementing significant innovation. Given that children are a key sector of the population, who by very nature have a need to rely on government and formally governed services for their well-being in the years when they cannot themselves seek or advocate for services, our findings are particularly worryin
Blair M, Rigby M, Alexander D, 2019, The MOCHA Project: Origins, Approach and Methods, Issues and Opportunities in Primary Health Care for Children in Europe: The Final Summarised Results of the Models of Child Health Appraised (MOCHA) Project, Pages: 1-12, ISBN: 9781789733549
Primary care (PC) is a strong determinant of overall health care. Children make up around a fifth of the population of the European Union and European Economic Area and have their own needs and uptake of PC. However, there is little research into how well PC services address their needs. There are large differences in childhood mortality and morbidity patterns in the EU and EEA countries, and there has been a major epidemiological shift in the past half century from predominantly communicable disease, to non-communicable diseases presenting and increasingly managed in PC. This increase in multifactorial morbidities, such as obesity and learning disability, has led to the need for PC systems to adapt to accommodate these changes. Europe presents a challenging picture of unexplained variation in health care delivery and style and of children’s different health experiences and health-related behaviour. The Models of Child Health Appraised (MOCHA) project aimed to describe the PC systems in detail, analyse their components and appraise them from a number of different viewpoints, including professional, public, political and economic lenses. It did this through nine work packages supported by a core management team, and a network of national agents, individuals in each MOCHA country who had the expertise in research and knowledge of their national health care system to answer a wide range of questions posed by the MOCHA scientific teams.
Alexander D, Kurup U, Menon A, et al., 2019, Affiliate Contributors to Primary Care for Children, Issues and Opportunities in Primary Health Care for Children in Europe: The Final Summarised Results of the Models of Child Health Appraised (MOCHA) Project, Pages: 303-330, ISBN: 9781789733549
There is more to primary care than solely medical and nursing services. Models of Child Health Appraised (MOCHA) explored the role of the professions of pharmacy, dental health and social care as examples of affiliate contributors to primary care in providing health advice and treatment to children and young people. Pharmacies are much used, but their value as a resource for children seems to be insufficiently recognised in most European Union (EU) and European Economic Area (EEA) countries. Advice from a pharmacist is invaluable, particularly because many medicines for children are only available off-label, or not available in the correct dose, access to a pharmacist for simple queries around certain health issues is often easier and quicker than access to a primary care physician or nursing service. Preventive dentistry is available throughout the EU and EEA, but there are few targeted incentives to ensure all children receive the service, and accessibility to dental treatment is variable, particularly for disabled children or those with specific health needs. Social care services are an essential part of health care for many extremely vulnerable children, for example those with complex care needs. Mapping social care services and the interaction with health services is challenging due to their fragmented provision and the variability of access across the EU and EEA. A lack of coherent structure of the health and social care interface requires parents or other family members to navigate complex systems with little assistance. The needs of pharmacy, dentistry and social care are varied and interwoven with needs from each other and from the healthcare system. Yet, because this inter-connectivity is not sufficiently recognised in the EU and EEA countries, there is a need for improvement of coordination and with the need for these services to focus more fully on children and young people.
Blair M, Sampaio MMA, Rigby M, et al., 2019, Models of Primary Care and Appraisal Frameworks, Issues and Opportunities in Primary Health Care for Children in Europe: The Final Summarised Results of the Models of Child Health Appraised (MOCHA) Project, Pages: 13-51, ISBN: 9781789733549
The Models of Child Health Appraised (MOCHA) project identified the different models of primary care that exist for children, examined the particular attributes that might be different from those directed at adults and considered how these models might be appraised. The project took the multiple and interrelated dimensions of primary care and simplified them into a conceptual framework for appraisal. A general description of the models in existence in all 30 countries of the EU and EEA countries, focusing on lead practitioner, financial and regulatory and service provision classifications, was created. We then used the WHO ‘building blocks’ for high-performing health systems as a starting point for identifying a good system for children. The building blocks encompass safe and good quality services from an educated and empowered workforce, providing good data systems, access to all necessary medical products, prevention and treatments, and a service that is adequately financed and well led. An extensive search of the literature failed to identify a suitable appraisal framework for MOCHA, because none of the frameworks focused on child primary care in its own right. This led the research team to devise an alternative conceptualisation, at the heart of which is the core theme of child centricity and ecology, and the need to focus on delivery to the child through the life course. The MOCHA model also focuses on the primary care team and the societal and environmental context of the primary care system.
Blair M, Rigby M, Alexander D, 2019, ISSUES AND OPPORTUNITIES IN PRIMARY HEALTH CARE FOR CHILDREN IN EUROPE: The Final Summarised Results of the Models of Child Health Appraised (MOCHA) Project, ISBN: 9781789733549
The ebook edition of this title is Open Access and freely available to read online. This book reports on a project which studied of how primary care services are delivered to children. The study, the first of its kind, has been undertaken over three years, with 20 scientific partners, and an expert agent in each country. Chapters address key questions such as professional patterns, service structure, and e-health. But it also addresses cross-cutting issues which have emerged, such as equity, listening to children and parents, quality, children's increasing autonomy across the life course, and inter-professional coordination. Summarising the current policies for children's primary care in each country in the EU/EEA, authors consider the differences of structure and delivery, and of outcomes including financing, professional education, e-health and other supports.
Blair M, 2019, Foreward, ISBN: 9781789733549
When I reflect back on the last 35 years of clinical practice as a paediatrician, I am very aware of the considerable changes to children’s health which have occurred in my country and in Europe. Many diseases I saw as a student and young trainee have all but disappeared through the development and administration of new vaccines or the introduction of novel technological discoveries such as artificial surfactant, home ventilation and new drugs for cancer treatment. These have resulted in improved survival of so many children and young people who would have otherwise suffered premature death from the myriad of different congenital or acquired conditions. At the same time, I am all too cognisant of the effects of the degree of social change both in terms of the changing nature of family structure and stability, of unacceptable levels of poverty and inequity, environmental challenges such as nutrition, housing and pollution, the effects of national and international conflict leading to unprecedented movement of families between continents and of the huge changes in the speed and breadth of communication and social media. In parallel, there are increased levels of mental health disorder, obesity, neurodevelopmental issues such as specific learning difficulties, ADHD and autism and the sheer complexity of multimorbidity of twenty-first-century children and young people.
Blair M, Rigby M, Jansen D, 2019, Evidence to Achieve an Optimal Model for Children’s Health in Europe, Issues and Opportunities in Primary Health Care for Children in Europe: The Final Summarised Results of the Models of Child Health Appraised (MOCHA) Project, Pages: 371-383, ISBN: 9781789733549
Models of Child Health Appraised (MOCHA) was a wide-ranging, multidisciplinary and multi-method study that aimed to identify the best models of provision of primary care for the children of the European Union. The research has identified two main conclusions: (1) The depth of interdependency of health, economy and society. Primary care needs to be an active partner in public debate about current child health concerns. It should orientate more effectively in addressing wider societal influences on child health through advocacy and collaborative intersectoral public health approaches with those agencies responsible for public and community health if it is to address effectively issues such as childhood obesity, mental health and vaccine hesitancy. As part of this, it needs to address its workforce composition and skills, not least in two-way communication. (2) The European Community has many visions and commitments to children and child health policies, but their effectiveness is largely unfulfilled. The Commission can strengthen its impact on children’s health and healthcare services within current remits and resources by focusing on a number of key fields: planned and structured research, providing insight into optimal human resources and skills in child primary care, developing and using ethical means of listening to children’s views, remedying the invisibility of children in data, measuring the quality of primary care from a child-centric perspective, understanding the economics of investing in children’s health, developing e-health standards and evaluation, collaborative and harmonised use of downloaded research databases, understanding and respecting children’s rights and equity, and appreciating and allowing for children’s evolving autonomy as they grow up. An optimal model of primary care for children is proactive, inclusive, corporately linked, based on and providing robust evidence, and respects the wider determinants of health
Blair M, Alexander D, 2019, Equity, Issues and Opportunities in Primary Health Care for Children in Europe: The Final Summarised Results of the Models of Child Health Appraised (MOCHA) Project, Pages: 99-119, ISBN: 9781789733549
Equity is an issue that pervades all aspects of primary care provision for children and as such is a recurring theme in the Models of Child Health Appraised project. All European Union member states agree to address inequalities in health outcomes and include policies to address the gradient of health across society and target particularly vulnerable population groups. The project sought to understand the contribution of primary care services to reducing inequity in health outcomes for children. We focused on some key features of inequity as they affect children, such as the importance of good health services in early childhood, and the effects of inequity on children, such as the higher health needs of underprivileged groups, but their generally lower access to health services. This indicates that health services have an important role in buffering the effects of social determinants of health by providing effective treatment that can improve the health and quality of life for children with chronic disorders. We identified common risk factors for inequity, such as gender, family situation, socio-economic status (SES), migrant or minority status and regional differences in healthcare provision, and attempted to measure inequity of service provision. We did this by analysing routine data of universal primary care procedures, such as vaccination, age at diagnosis of autism or emergency hospital admission for conditions that can be generally treated in primary care, against variables of inequity, such as indicators of SES, migrant/ethnicity or urban/rural residency. In addition, we focused on the experiences of child population groups particularly at risk of inequity of primary care provision: migrant children and children in the state care system.
Blair M, Gage H, Mac Pepple E, et al., 2019, Workforce and Professional Education, Issues and Opportunities in Primary Health Care for Children in Europe: The Final Summarised Results of the Models of Child Health Appraised (MOCHA) Project, Pages: 247-282, ISBN: 9781789733549
Given that the workforce constitutes a principal resource of primary care, appraisal of models of care requires thorough investigation of the health workforce in all Models of Child Health Appraised (MOCHA) countries. This chapter explores this in terms of workforce composition, remuneration, qualifications and training in relation to the needs of children and young people. We have focused on two principal disciplines of primary care; medicine and nursing, with a specific focus on training and skills to care for children in primary care, particularly those with complex care needs, adolescents and vulnerable groups. We found significant disparities in workforce provision and remuneration, in training curricula and in resultant skills of physicians and nurses in European Union and European Economic Area Countries. A lack of overarching standards and recognition of some of the specific needs of children reflected in training of physicians and nurses may lead to suboptimal care for children. There are, of course, many other professions that also contribute to primary care services for children, some of which are discussed in Chapter 15, but we have not had resources to study these to the same detail.
Kocken P, Vlasblom E, De Lijster G, et al., 2019, The Transferability of Primary Child Healthcare Systems, Issues and Opportunities in Primary Health Care for Children in Europe: The Final Summarised Results of the Models of Child Health Appraised (MOCHA) Project, Pages: 331-344, ISBN: 9781789733549
There is considerable heterogeneity between primary care systems that have evolved in individual national cultural environments. Models of Child Health Appraised (MOCHA) studied how the transfer of models or their individual components can be achieved across nations, using examples of combinations of settings, functions, target groups and tracer conditions. There are many factors that determine the feasibility of successful transfer of these from one setting to another, which must be recognised and taken into account. These include the environment of the care system, national policy-making and contextual means of directing population behaviour - in the form of penalties and incentives, which cannot be assessed or expected to work by means of rational actions alone. MOCHA developed a list of criteria to assess transferability, summarised in a population characteristics, intervention content, environment and transfer (PIET-T) process. To explore the process and means of transferability, we obtained consensus statements from the researchers on optimum model scenarios and conducted a survey of stakeholders, professionals and users of children’s primary care services that involved three specific health topics: vaccination coverage in infants, monitoring of a chronic or complex condition and early recognition of mental health problems. The results give insight into features of transferability - such as the availability and the use of guidelines and formal procedures; the barriers and facilitators of implementation and similarities and differences between model practices and the existing model of child primary care in the country. We found that successful transfer of an optimal model is impossible without tailoring the model to a specific country setting. It is vital to be aware of the sensitivity of the population and environmental characteristics of a country before starting to change the system of primary care.
Rigby M, Deshpande S, Blair M, 2018, Published mortality datasets – is perfection the enemy of credibility?, European Journal of Public Health, Vol: 28, ISSN: 1101-1262
Rigby M, Greenfield R, Deshpande S, et al., 2018, Are we Serious – and Ethical – about HPV Vaccination in Europe?, European Journal of Public Health, Vol: 28, ISSN: 1101-1262
Rigby M, Greenfield R, Deshpande S, et al., 2018, Who holds Tetanus Records when they are Needed?, European Journal of Public Health, Vol: 28, ISSN: 1101-1262
Blair M, Rigby M, Alexander D, 2018, Critical factors for child primary: child-centricity, core principles and context sensitivity, European Journal of Public Health, Vol: 28, ISSN: 1101-1262
Visser A, Kocken P, Reijneveld SA, et al., 2018, Primary care in Europe: starting points to improve primary care from school health services and adolescent health services for children and adolescents, European Journal of Public Health, Vol: 28, ISSN: 1101-1262
Zdunek K, Schröder-Bäck P, Vlasblom E, et al., 2018, European capacity to implement evidence-based child health policy, European Journal of Public Health, Vol: 28, ISSN: 1101-1262
Brenner M, O'Shea MP, Larkin P, et al., 2018, Management and integration of care for children living with complex care needs at the acute-community interface in Europe, Lancet Child and Adolescent Health, Vol: 2, Pages: 822-831, ISSN: 2352-4642
With improvements in neonatal and paediatric care, more children living with complex care needs are surviving beyond infancy into late childhood and adulthood than in the past. We examined the current approach to the management and integration of care of children living with complex care needs in 30 European countries, as well as the implications for primary care service delivery. This descriptive study, with an embedded qualitative aspect, consisted of questions adapted from the Standards for Systems of Care for Children and Youth with Special Health Care Needs, and included questions on a complex care European survey of change, adapted from the Eurobarometer survey. The analysis indicates that few systems are in place in countries across Europe to identify all the health-care providers who deliver care to a child living with complex care needs, and that less than half of all countries surveyed have policies in place to support care coordination for these children. Primary care physicians have little involvement in care planning for children before their discharge to the community setting, and there is little parental participation in policy development. Access to, and governance of, care for these children varies widely. Particular issues identified pertain to parents as catalysts of optimum integration of care, pathways to specialist care, and the need for comprehensive national integrated care programmes.
Brenner M, O'Shea MP, McHugh R, et al., 2018, Principles for provision of integrated complex care for children across the acute-community interface in Europe, Lancet Child and Adolescent Health, Vol: 2, Pages: 832-838, ISSN: 2352-4642
This Viewpoint presents and discusses the development of the first core principles and standards for effective, personalised care of children living with complex care needs in Europe. These principles and standards emerged from an analysis of data gathered on several areas, including the integration of care for the child at the acute–community interface, the referral–discharge interface, the social care interface, nursing preparedness for practice, and experiences of the child and family. The three main principles, underpinned by a child-centric approach, are access to care, co-creation of care, and effective integrated governance. Collectively, the principles and standards offer a means to benchmark existing services for children living with complex care needs, to influence policy in relation to service delivery for these children, and to provide a suite of indicators with which to assess future service developments in this area.
Blair M, Jansen D, Vervoort H, et al., 2018, Integrated school health services in Europe: an overview, International Journal of Integrated Care, Vol: 18, Pages: 289-289, ISSN: 1568-4156
Blair M, 2018, Well Child Care and Preventive Services in Europe, International Society for Social Paediatrics and Child Health
Blair M, 2018, What Can European Community Pharmacies Offer Children and Young People? - A MOCHA Survey, European Academy of Paediatric Societies
Blair M, 2018, Assessing Which Models of Child Health Services Provide Best Outcomes for Children and Young People in Europe - MOCHA Evaluation and Key Findings, European Academy of Paediatric Societies
Blair M, 2018, Well Child Care in Europe - A Comparison of 26 Countries - A MOCHA Project, European Academy of Paediatric Societies
Blair ME, Menon A, 2018, Community pharmacy use by children across Europe: a narrative literature review, Pharmacy, Vol: 6, ISSN: 2226-4787
The use of community pharmacies across Europe has potential to alleviate the burden on overstretched healthcare providers. Children and young people (0–18 years) account for a large number of primary care attendances. This narrative literature review between January 2000 and December 2017 examines the use of community pharmacy by paediatric patients in Europe. The results report both positive and negative perceptions of community pharmacy by parents and children, opportunities for an extended role in Europe, as well as the need for further training. The main limitations were the inclusion of English language papers only and an initial review of the literature carried out by a single researcher. It remains to be seen whether a ‘new-look’ role of the community pharmacist is practical and in alignment with specific European Commission and national policies
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