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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 worrying.

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.

Past research on the immigrant health paradox suggests that children with immigrant parents may have a health advantage over those with US-born parents, especially if the parent is a recent immigrant. Other research emphasizes the social and economic challenges children with immigrant parents face, in part due to disadvantaged social class and racial/ethnic positions. Underlying physiological changes due to chronic stress exposures among children in immigrant families is one potential health disadvantage that may not yet be apparent in traditional health measures. To explore these biological disparities during childhood, I use national biomarker and survey data from the National Health and Nutrition Survey (NHANES) (N = 11,866) to evaluate parent nativity and educational status associations with low-grade inflammation, indicated by C-reactive protein (CRP), in children ages 2–15 years. I find that children with an immigrant parent, and particularly a low-educated immigrant parent, have higher CRP, net of birth, body mass index (BMI) and other factors, than children with a US-born parent with either a low or higher education. Comparing children with low-educated parents, those with a foreign-born parent have higher predicted CRP. The findings from this study provide new evidence that children living in immigrant families in the US may be facing higher levels of chronic stress exposure, as indicated by the increased risk of low-grade inflammation, than those with US-born parents. The physiological changes related to increased risk of inflammation, could set children in immigrant families on pathways toward mental and physical health problems later in the life course.

The study assesses public health programs to shed light on the experiences of low-income and minority women with children seeking health services. Thirteen focus groups were conducted with 111 pregnant women or women with children. Women consumers of public health services experience difficulties accessing health services due to a lack of insurance, information and language barriers about programs and eligibility, a shortage of Medicaid providers and specialist services, long waits, bureaucratic barriers, and dismissive treatment. Accessibility and information barriers were more prominent in rural regions whereas bureaucratic barriers were more pronounced in urban areas. Lower satisfaction with services was reported among ethnic minority women compared to whites.

Children experience toxic stress if there is pronounced activation of their stress-response systems, in situations in which they do not have stable caregiving. Due to their exposure to multiple poverty-related risks, African American children may be more susceptible to exposure to toxic stress. Toxic stress affects young children’s brain and neurophysiologic functioning, which leads to a wide range of deleterious health, developmental, and mental health outcomes. Given the benefits of early care and education (ECE) for African American young children, ECE may represent a compensating experience for this group of children, and promote their positive development.

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.

Loretta Bass, Assistant Professor of Sociology at the University of Oklahoma, earned her Ph.D. in Sociology from the University of Connecticut in 1998. Dr. Bass focuses her research on children and stratification issues in West Africa and the U.S. For her dissertation, Working for Peanuts: Children’s Work in Open-Air Markets in Senegal, she collected and examined both qualitative and quantitative data of child workers and their families. Dr. Bass lived in Senegal from 1994 to 1996, and completed follow-up research in Senegal during the summer of 2000. Her chapter in this collection draws on this research. Her research has appeared in the Population Research and Policy Review, Political Behavior, Anthropology of Work Review, and the International Journal of Sociology and Social Policy.Marilou C. Legazpi Blair is the Assistant Director of Institutional Research at Erie Community College. She received her Ph.D. from Penn State, and has performed a substantial amount of research on issues of child development. Aside from her interests in adolescent status attainment, she has also studied the impact of immigration on both adults and children in the United States. She is currently involved in an examination of adults who return to school for the continuation of uncompleted degree work.Sampson Lee Blair is an Associate Professor at The State University of New York at Buffalo. As a family sociologist, most of his research to date has focused on family relationships, and particularly those between parents and children. More recently, he has been involved in studies of justice issues within the familial context. He recently completed his term as editor of Sociological Inquiry, and is scheduled to be a co-editor of Social Justice Research next year.Sally Bould is Professor of Sociology at the University of Delaware with a joint appointment in the department of Individual and Family Studies. She has published numerous articles in the area of the family, family policy and poverty policy. Another article on this research concerning families and neighborhoods will appear in the 2003 Journal of Family Issues. She is the author of the book, Eighty-five Plus, which examines issues of state and family responsibilities for the oldest old and several articles on the oldest old population in the United States, including disability, caregiving and living arrangements. Currently she is a member of the board of The Carework Network.Tiffani Chin recently finished her Ph.D. in Sociology at UCLA. Her dissertation examined how children’s peer cultures intersect with the schools’ social, academic, and evaluative objectives to influence children’s educational experiences. She is currently a Post-Doctoral Scholar with the Middle School Transition Study, studying oppositional culture and students’ transition from elementary school to middle school. Chin is the author of “‘Sixth Grade Madness’: Parental emotion work in the private high school application process” (Journal of Contemporary Ethnography, April 2000) and a co-author of Tutoring Matters: Everything you ever wanted to know about how to tutor (Temple 1999).Amitai Etzioni is the first University Professor of The George Washington University. He served as president of the American Sociological Association from 1994 to 1995, was Senior Advisor to the White House from 1979 to 1980, and was guest scholar at the Brookings Institution in 1978–1979. From 1958 to 1978, he served as Professor of Sociology at Columbia University. He is the editor of The Responsive Community: Rights and Responsibilities, a Communitarian quarterly. He is the author of twenty-one books, including The Monochrome Society (Princeton: Princeton University Press, 2001), Next: The Road to the Good Society (New York: Basic Books, 2001), The Limits of Privacy (New York: Basic Books, 1999), and The New Golden Rule: Community and Morality in a Democratic Society (New York: Basic Books, 1996), which received the Simon Wiesenthal Center’s 1997 Tolerance Book Award.David A. Kinney received his Ph.D. in Sociology from Indiana University-Bloomington and did post-doctoral work at the University of Chicago. He is currently Associate Professor of Sociology at Central Michigan University and a faculty affiliate at the Center for the Ethnography of Everyday Life at the University of Michigan. His publications have appeared in Sociology of Education, Youth and Society, Personal Relationships During Adolescence (Sage), and New Directions for Child and Adolescent Development (Jossey-Bass). He is currently conducting ethnographic research with children and their parents in a study of how families manage work, home life, and children’s activity involvement in a fast-paced society.Jennie Jacobs Kronenfeld is a Professor in the Department of Sociology, Arizona State University. She holds a doctorate (1976) and a master’s (1973) in sociology from Brown University and a B.A. (1971) in sociology and history from the University of North Carolina. She has published over ninety articles and book chapters in medical sociology, public health, medicine, and health services research. She has authored or co-authored fifteen books, on topics such as the social and economic impact of coronary artery bypass surgery, the federal role in health policy, public versus private models of service delivery in several different human services areas, controversial issues in health care policy and schools and child health services. Her current research interests include health policy issues, especially access to health care and child health care issues, and research on preventive aspects of health care.Yun-Suk Lee is a Ph.D. candidate in the Department of Sociology at the University of Chicago. He is completing his doctoral dissertation on the role of familial relationship in the effect of performance of household tasks on subjective outcomes for children and married people. His research includes comparing several measures of time spent on housework, and studying about changes in working time. In the fall of 2002, he became a Postdoctoral Research Associate with the Cornell Employment and Family Careers Institute.Anna B. V. Madamba is a Research Associate at TIAA-CREF in New York City. With a doctorate in demography, most of her research interests are in the field of educational attainment and performance. Her current research involves the examination of the academic performance of children of single mothers.Kimberly A. Mahaffy is Assistant Professor of Sociology. Her research interests are gender, transitions to adulthood, and adolescent sexual risk taking. She recently edited a special issue for the Journal of Mundane Behavior entitled Mundane Sex. She teaches statistics, research methods, social psychology, social problems, and a senior seminar in gender and adolescence at Millersville University of Pennsylvania.Sarah H. Matthews is Professor of Sociology at Cleveland State University. Her current research focuses on the everyday lives of children whose mothers are in a drug treatment program. Her earlier research in the sociology of aging has appeared in gerontology and family journals. Her research on relationships among members of older families is reported in a forthcoming book, Sisters and Brothers/Daughters and Sons: Meeting the Needs of Old Parents.Kathleen M. Mathieson is currently a doctoral student in the Department of Sociology, Arizona State University. She holds a master’s degree in Sociology from ASU. Her research interests focus on medical sociology, including concerns of aging, child health and mental health as impacted by work and family conflicts. She has published on the maintenance of functional independence for the elderly, and has presented papers on this topic as well as on child health and child health policy issues.Meredith Phillips is Assistant Professor of Policy Studies and Sociology at UCLA. Phillips’s research focuses on the relationship between social inequality and academic success. Her current projects include a mixed-method study of the academic achievement of college students at a highly-selective university, an ethnographic study of the development of oppositional culture during students’ transition from elementary to middle school, and a statistical study of the distribution of school quality nationally. Phillips is the co-editor of The Black-White Test Score Gap (Brookings, 1998).Katherine Brown Rosier is currently Assistant Professor of Sociology at Central Michigan University. Her recent book, Mothering Inner-city Children. The Early School Years, was published in 2000 by Rutgers University Press. Other publications have appeared in The Journal of Contemporary Ethnography, Human Development, The Journal of Comparative Family Studies, and several other journals and edited volumes. While continuing to write on experiences of low-income African American children and families, she is also conducting research and writing a book with colleague Scott L. Feld on Louisiana’s Covenant Marriage.Barbara Schneider is Professor of Sociology at the University of Chicago and the Co-Director of the Alfred P. Sloan Center on Parents, Children, and Work. Author of several books, articles and monographs, Dr. Schneider is concerned with encouraging the cognitive and social development of America’s children by reshaping the responsibilities of families, schools, and society. Most recently Dr. Schneider has completed two books, The Ambitious Generation: America’s Teenagers, Motivated but Directionless, and Becoming Adult: How Teenagers Prepare for the World of Work. In both works she discusses how adolescents develop attitudes, skills and expectations about their adult careers.Kimberly A. Scott, Ed.D. is Assistant Professor in Hofstra University’s Foundations, Leadership, and Policy Studies department. She specializes in sociology of education, sociology of childhood, and qualitative research methods. Her research interests include examinations of race, class, and gender influences on the social and academic self-development of elementary school students. She has publications in Equity and Excellence, Journal of Negro Education, and Childhood: A Global Journal of Childhood Research. Currently, she is co-authoring a Rowmann and Littlefield book with Sarane Book entitled, Sociology of Children and Childhood.Linda J. Waite, Ph.D. is the Lucy Flower Professor of Sociology and Co-Director of the Alfred P. Sloan Center on Parents, Children and Work at the University of Chicago, where she also directs the Center on Aging. She is past Chair of the Family Section of the American Sociological Association and Past President of the Population Association of America. Her current research interests include the working family, especially dual-career couples with children and the impact of job characteristics on parenting. She is also interested in the role of the family at older ages in functioning of individuals, intergenerational transfers and exchanges, and employment. She has published widely on the family, including an award-winning book with Frances Goldscheider, New Families, No Families: The Transformation of the American Home. Her most recent book, The Case for Marriage: Why Married People are Happier, Healthier, and Better Off Financially, with Maggie Gallagher, won the 2000 book award from the Coalition for Marriage, Family, and Couples Education.

Family health can be studied using the 1994–1995 National Health Interview Survey Disability Supplement by linking children to their mothers and other family members. However, the data item required to link is missing for 13% of children. We found that unlinked children and their probable mothers differed in many respects from their counterparts who could be linked, and exclusion of these mothers and their children from the analysis could bias results by introducing error due to incomplete coverage of the target population. We developed and validated a simple algorithm to match these children with their probable mother.

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.

In order to assess the state of health of Europe’s children, or to appraise the systems and models of healthcare delivery, data about children are essential, with as much precision and accuracy as possible by small group characteristic. Unfortunately, the experience of the Models of Child Health Appraised (MOCHA) project and its scientists shows that this ideal is seldom met, and thus the accuracy of appraisal or planning work is compromised. In the project, we explored the data collected on children by a number of databases used in Europe and globally, to find that although the four quinquennial age bands are common, it is impossible to represent children aged 0–17 years as a legally defined group in statistical analysis. Adolescents, in particular, are the most invisible age group despite this being a time of life when they are rapidly changing and facing increasing challenges. In terms of measurement and monitoring, there is little progress from work of nearly two decades ago that recommended an information system, and no focus on the creation of a policy and ethical framework to allow collaborative analysis of the rich anonymised databases that hold real-world people-based data. In respect of data systems and surveillance, nearly all systems in European society pay lip service to the importance of children, but do not accommodate them in a practical and statistical sense.