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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.

This study aims to ascertain the personal characteristics of a group of successful academic entrepreneurs in a South African university enterprise and the prevalent barriers and enablers to their entrepreneurial endeavour.

The authors used a Delphi process to identify and rank the characteristics, enablers, barriers and behaviours of entrepreneurial academics, with a Nominal Group Technique applied to establish challenges they encounter managing their enterprise and to propose solutions.

Perseverance, resilience and innovation are critical personal characteristics, while collaborative networks, efficient research infrastructure and established research competence are essential for success. The university’s support for entrepreneurship is a significant enabler, with unnecessary bureaucracy and poor access to project and general enterprise funding an impediment. Successful academic entrepreneurs have strong leadership, and effective management and communication skills.

The main limitation is the small study participant group drawn from a single university enterprise, which complicates generalisability. The study supported the use of Krueger’s (2009) entrepreneurial intentions model for low- and middle-income country (LMIC) academic entrepreneur investigation but proposed the inclusion of mitigators to entrepreneurial activation to recognise contextual deficiencies and challenges.

Skills-deficient LMIC universities should extensively and directly support their entrepreneurial academics to overcome their contextual deficiencies and challenging environment.

This study contributes to addressing the paucity of academic entrepreneur research in LMIC contexts by identifying LMIC-specific factors that inhibit the entrepreneur’s movement from entrepreneurial intention to entrepreneurial action.

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.

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.

The purpose of this paper is to feedback the results of a survey of paediatric occupational therapists completed by the Paediatric Advisory Group (PAG) regarding perceptions and practices of the assessment of need (AON) process. This survey was completed to gather feedback from occupational therapists about the impact of the AON process on paediatric occupational therapy practice in Ireland.

A questionnaire was developed by the authors, who were on the PAG committee, to specifically gather quantitative and qualitative information about the AON. A snowball sampling method was utilised. The results were grouped into themes related to the practices and recommendations from occupational therapists nationally.

Surveys were returned from 98 paediatric occupational therapists with a wide national geographical spread with the majority working in the HSE. The amount of time spent on AON assessments, as well as the length of reports, varied nationally. The process of how assessments were completed (unidisciplinary or multidisciplinary) and whether a diagnosis was provided was inconsistent. Concerns were raised about the negative ethical impact of the AON on service provision and intervention and the need for further training of staff along with more frequent assessment reviews. The respondents also highlighted concerns about the increasing age of the AON criteria, with no increase in resources, and they provided suggestions for improvements for the future.

The survey was sent to all AOTI and PAG members via gatekeepers and then forwarded to others, resulting in a snowball sampling technique; however, this does not represent all paediatric occupational therapists nationally as membership in these groups is voluntary.

The concerns and inequities raised in the survey regarding occupational therapy practices of completing the AON process need to be shared with relevant stakeholders both at the occupational therapy management level and in the HSE and Department of Health/Disability. The PAG will continue to highlight these concerns from their members to relevant parties and by disseminating findings in articles such as this.

Ethical concerns were raised by some members about the equity of access to interventions as a result of the AON process. The social implication of this for families and children is pertinent, particularly in the context of the increased age in the AON criteria without any increase in resources.

The PAG aims to support paediatric occupational therapists nationally and the committee often gathers feedback from members regarding concerns which affect day-to-day practice in paediatric OT. Sharing of this information with IJOT readers helps to highlight the challenges faced by paediatric occupational therapists nationally.

Genetic risk for depressive disorders is poorly understood despite consistent suggestions of a high heritable component. Most genetic studies have focused on risk associated with single variants, a strategy which has so far only yielded small (often non-replicable) risks for depressive disorders. In this paper we argue that more substantial risks are likely to emerge from genetic variants acting in synergy within and across larger neurobiological systems (polygenic risk factors). We show how knowledge of major integrated neurobiological systems provides a robust basis for defining and testing theoretically defensible polygenic risk factors. We do this by describing the architecture of the overall stress response. Maladaptation via impaired stress responsiveness is central to the aetiology of depression and anxiety and provides a framework for a systems biology approach to candidate gene selection. We propose principles for identifying genes and gene networks within the neurosystems involved in the stress response and for defining polygenic risk factors based on the neurobiology of stress-related behaviour. We conclude that knowledge of the neurobiology of the stress response system is likely to play a central role in future efforts to improve genetic prediction of depression and related disorders.

The purpose of this study was to explore inter-professional clinicians’ perspectives on resident leadership in the context of inter-professional teams and to identify a definition for leadership in the clinical context. In 2015, CanMEDS changed the title of one of the core competencies from manager to leader. The shift in language was perceived by some as returning to traditional hierarchical and physician-dominant structures. The resulting uncertainty has resulted in a call to action to not only determine what physician leadership is but to also determine how to teach and assess it.

Focus groups and follow-up individual interviews were conducted with 23 inter-professional clinicians from three pediatric clinical service teams at a large, Canadian tertiary-level rehabilitation hospital. Qualitative thematic analysis was used to inductively analyze the data.

Data analysis resulted in one overarching theme: leadership is collaborative – and three related subthemes: leadership is shared; leadership is summative; and conceptualizations of leadership are shifting.

Not all members of the three inter-professional teams were able to attend the focus group sessions because of scheduling conflicts. Participation of additional clinicians could have, therefore, affected the results of this study. The study was conducted locally at a single rehabilitation hospital, among Canadian pediatric clinicians, which highlights the need to explore conceptualization of leadership across different contexts.

There is an evident need to prepare physicians to be leaders in both their daily clinical and academic practices. Therefore, more concerted efforts are required to develop leadership skills among residents. The authors postulate that continued integration of various inter-professional disciplines during the early phases of training is essential to foster collaborative leadership and trust.

The results of this study suggest that inter-professional clinicians view clinical leadership as collaborative and fluid and determined by the fit between tasks and team member expertise. Mentorship is important for increasing the ability of resident physicians to develop collaborative leadership roles within teams. The authors propose a collaborative definition of clinical leadership based on the results of this study: a shared responsibility that involves facilitation of dialog; the integration of perspectives and expertise; and collaborative planning for the purpose of exceptional patient care.

The purpose of this paper is to explore the way “hybrid” clinical managers in Kenyan public hospitals interpret and enact hybrid clinical managerial roles in complex healthcare settings affected by professional, managerial and practical norms.

The authors conducted a case study of two Kenyan district hospitals, involving repeated interviews with eight mid-level clinical managers complemented by interviews with 51 frontline workers and 6 senior managers, and 480 h of ethnographic field observations. The authors analysed and theorised data by combining inductive and deductive approaches in an iterative cycle.

Kenyan hybrid clinical managers were unprepared for managerial roles and mostly reluctant to do them. Therefore, hybrids’ understandings and enactment of their roles was determined by strong professional norms, official hospital management norms (perceived to be dysfunctional and unsupportive) and local practical norms developed in response to this context. To navigate the tensions between managerial and clinical roles in the absence of management skills and effective structures, hybrids drew meaning from clinical roles, navigating tensions using prevailing routines and unofficial practical norms.

Understanding hybrids’ interpretation and enactment of their roles is shaped by context and social norms and this is vital in determining the future development of health system’s leadership and governance. Thus, healthcare reforms or efforts aimed towards increasing compliance of public servants have little influence on behaviour of key actors because they fail to address or acknowledge the norms affecting behaviours in practice. The authors suggest that a key skill for clinical managers in managers in low- and middle-income country (LMIC) is learning how to read, navigate and when opportune use local practical norms to improve service delivery when possible and to help them operate in these new roles.

The authors believe that this paper is the first to empirically examine and discuss hybrid clinical healthcare in the LMICs context. The authors make a novel theoretical contribution by describing the important role of practical norms in LMIC healthcare contexts, alongside managerial and professional norms, and ways in which these provide hybrids with considerable agency which has not been previously discussed in the relevant literature.

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.