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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 socio-cultural 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 child-focused 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.

Identifying the qualities of primary care that have the potential to produce optimal health outcomes is only half the story. The Models of Child Health Appraised (MOCHA) project has not only explored how to transfer these to other national contexts, but also which successful components should be transferred. It is important to assess the population criteria of the identified sociodemographic, cultural and social characteristics and the population perspectives on a care system’s components. The project analysed public experiences and perceptions of the quality of primary care for children from a representative sample of the general public in five European Union member states. The public perception of children’s primary care services, in particular the perceived quality of care and expectations with regard to care for children, is important to understand before MOCHA lessons can be effectively adopted in a country. We found that the socio-cultural characteristics of a country inform the population perceptions and preferences with regard to the care system. In the five countries surveyed, there was agreement about aspects of quality of care – such as accessible opening hours, confidential consultations for children and timeliness of consultation for an illness, but there was a difference in opinion about giving priority to items such as making an appointment without a referral, or a child’s right to a confidential consultation. The cultural context of transferability and the means of addressing this such as defining the target audience and the different means of disseminating important messages to the wider community to address contextual factors can act as barriers or facilitators to the introduction of new components of primary care models.

The child is at the centre of all Models of Child Health Appraised research and indeed all primary care delivery for children. Appraising models of primary care for children is incomplete without ensuring that experiences of primary care, design, treatment, management and outcomes are optimal for the child. However, the principle of child centricity is not implicit in many healthcare systems and in many aspects of life, yet it is extremely important for optimal child health service design and child health. By exploring the changing concept of ‘childhood’, we understand better the emergence of the current attitude towards children and their role in today’s Europe and the evolution of child rights. Understanding child centricity, and the role of agents acting on behalf of the child, allows us to identify features of children’s primary care systems that uphold the rights of a child to optimum health. This is placed against the legal commitments made by the countries of the European Union and European Economic Area to ensure that children’s rights are respected.

Children’s voices are seldom heard directly. Most often, children, particularly young children, are represented by adults acting on their behalf who may or may not best represent the child’s views or best interests. This can be beneficial or problematic, if the child’s needs are not appreciated or recognised. This chapter looks at the changing attitudes to listening to young people, and the growing recognition of the value of children’s needs, as well as the growing voices of the children themselves, who make their needs increasingly clear. The results of our Models of Child Health Appraised (MOCHA) interviews with children and young people via the DIPEx International organisation give us clear direction as to the importance children using primary care services place on being taken seriously, being listened to and being able to make their own decisions. Other researchers asked input from primary care professionals on children’s autonomy and how the current and future primary care systems can best address the needs of young people, as well as the placing of these issues in a wider cultural context, and how this influences and is influenced by children’s choices. Finally, we look at how the MOCHA country agents have reported the assessment of the importance and function of listening to young people in our research.

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.