How does societal reaction to children's health issues contribute to health policy in Europe? Results of a survey

Abstract

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.

Key Messages.

• There is evidence of increasing societal involvement in dialogue, leading to child health policy development.

• Concerns about child health care in European countries are twofold: (1) devoted to systemic issues (indirect patient orientation) and (2) to the child health and well‐being (direct patient orientation).

• Child health problems are identified across different domains within the health care system such as primary care, specialist care, emergency care and social care. Within those domains, three levels of activity are present: prevention, promotion and intervention.

• Public opinion informs a societal responsibility for children's health and is vital for acceptance of policy.

1. INTRODUCTION

Child health issues are considered to be particularly sensitive; thus, often they provoke strong societal reactions, which in consequence shape national health policies across Europe. The opinions of members of the public contribute to the formation of both health and health policy making. In terms of health services, societal voices can support development of services that “governments are unwilling or unable to deliver because of lack of political interest, inflexible public administrations, resource constraints or lack of trust in certain populations” (Greer, Wismar, Pastorino, & Kosinska, 2017). In order to provide high‐quality health care, the needs of children as well as their carers must be understood and taken into consideration. Members of formal or informal groups—organized in civil society, gathering in informal movements or in public discussions—bring expertise, ideas and diverse perspectives to the field of health policy‐making in general and health child health policy making in particular (Greer et al., 2017). Indeed, the effectiveness of health policy initiatives increases with the involvement of various actors settled within the context. Even though societal actors' input is crucial here, there is scant research in the child health care field.

Our research goal is to explore how increased awareness amongst child health decision‐makers of societal impact affects child health‐oriented policy solutions.

2. METHODS

This particular study was part of a project Models of Child Health Appraised (MOCHA), which aims to identify and appraise primary child health care systems in Europe in 30 European Union and European Economic Area countries. The MOCHA project has a national contact point in each participating country, known as a Country Agent (CA). CAs are national experts in child health or health services who provide data to the MOCHA project researchers. Questions sent to the CAs are developed by the research teams and validated by high‐level European experts in child health care via the MOCHA External Advisory Board.

CAs were asked to identify and characterize up to three cases studies that were related to children's health and which had provoked strong societal reactions and dignified public debate in their countries. A questionnaire consisting of seven open‐ended questions asked for descriptions of cases in the arena of public concern, the context and level of discussion, the vehicles of public expression and the final outcome. The questionnaire was validated by an external advisory group and distributed by the project research coordinator.

The research process was based on a qualitative approach. We conducted an inductive, data‐driven thematic analysis, which we consider as a “method for identifying, analysing, and reporting patterns (themes) within data” (Braun & Clarke, 2006). Thematic analysis is a useful tool, which is used across different methods (Boyatzis, 1998; Braun & Clarke, 2006). The analytic process was led “from description, where the data have simply been organised to show patterns in semantic content, and summarised, to interpretation, where there is an attempt to theorise the significance of the patterns and their broader meanings and implications” (Braun & Clarke, 2006; Patton, 1990).

The data were analysed in accordance with the thematic analysis protocol proposed by Braun and Clarke (2006). The research stages were as follows:

• Collecting data by distributing the questionnaire to the 30 representatives of European countries through the project management office.

• Prereviewing the data and familiarizing with the data.

• Incorporating the obtained data into the software for qualitative analysis, Nvivo 11.

• Generating initial codes by creating a list of ideas emerging from the data, enabling the creation of meaningful groups of data. Assigning the code (name) to the situation described by each CA case study.

• Identification of recurring themes, which, in this study, were referred to as umbrella themes.

• Revision of recurring and umbrella themes.

• Final defining and naming of themes.

The results were synthesized inductively into eight overarching data‐driven themes.

3. RESULTS

The data collection was carried out between June and December 2016. Representatives of 24 countries of the European Union and European Economic Area responded to the question. Countries missing from our analysis were Belgium, Cyprus, Luxembourg, Sweden, Slovakia, Slovenia, and 71 cases were described, which characterized different areas of public concern related to child primary health care in European countries.

From the 71 case studies we identified eight overarching data‐driven themes, which characterize societal reactions to child health issues across Europe that currently cause most societal concern. In this paper we devoted our attention to the three particularly sensitive thematic case studies: the antivaccination movement, children as victims of the economic crisis and child abuse as an example of infringement of children's rights.

3.1. Antivaccination movement

Concern about the safety of vaccination is increasing in Europe and has become a great public health challenge. The scale of the problem varies in its intensity and the numbers of actors involved. Immunization has been present in the public arena in most European countries especially because safety issues have been questioned. Both supporters and opponents of voluntary vaccination are robust in their attitudes. Arguments emerged that are linked to a discourse on human rights, a strained trust in science and in relevant authorities on one side and the voice of public health on the other. It is clear that the antivaccination movement influences not only an individual child's health but it impacts significantly on the population behaviour and also on the political and judicial aspects of health care organizations. In countries where mandatory vaccination exists, the impact of the opponents of vaccination acts as a crucial contextual factor on child health care and policy at the macro level.

A debate linking national family benefits with mandatory vaccination occurred in Estonia in the context of a coalition government agreement, who introduced it in 2015. The agreement included a clause that proposed linking the disbursement of family benefits to compulsory periodic visits to a family physician. The initiative was supported by an Estonian family physician, Marje Oona, who claimed in the press that politicians should definitely support the initiative. The press coverage prompted a heated debate amongst the general public about the benefits and drawbacks of vaccination and whether deciding not to vaccinate your child should affect the payment of national family benefits. Vaccination has not been declared mandatory in Estonia, nor do parents who refuse vaccination for their child receive less family benefits. However, the public discussion continues (Estonian CA).

Vaccine‐hesitancy in France has involved both political and medical constituents. The vaccination schedule is published annually in cooperation with the Ministry of Health, following the advice of the High Council of Public Health. However, in 2015, a dispute was revived when a petition was collated protesting the commercial cessation of the trivalent vaccine DTP. This initiative met strong public approval as the petition had collected more than 1 million signatures (French CA). Despite strong opposition the DTP vaccine became obligatory in France in 2018.

The Italian CA reported that the anti‐vaccination movement in Italy originates in part from the controversy over research carried out by Wakefield in the 1990s, where it was erroneously claimed that there was a correlation between the Measles‐Mumps‐Rubella (MMR) vaccine and the risk of autism. Despite worldwide rejection of the results, and numerous studies proving that there is no link, there remains in Italy doubt about the vaccination safety in some sections of the public (Italian CA). The issue emerged in the public agenda in 2012 as the consequence of the decision of the Court of Rimini. The judgment condemned the Ministry of Health's decision to refund a couple of parents who had sued, claiming that their son had become autistic after the administration of the trivalent vaccine justifying it partly with the results of Wakefield's report. Sectors of the public feared that such adverse rulings could lead to further distrust of vaccinations, also strengthen the voice of organizations and groups opposed to vaccines. In Italy, groups exist that promote antivaccination campaigns, urging parents to refuse not only MMR (which is optional) but also those mandatory vaccinations. In consequence, the controversy on the possible connection between vaccines and autism was reopened, even though there was already sufficient scientific proof that no correlation or causation of the MMR vaccination with autism exists (Italian CA). However in 2017, the Italian government, concerned at the decrease in the vaccination rate, made the decision to introduce vaccines for measles and nine other diseases as obligatory, which has since been overturned.

In an attempt to constrain the antivaccination attitudes in Lithuania, the former Minister Vytenis Povilas Andriukaitis issued an order that unvaccinated children would not be allowed to attend kindergartens in 2014. This policy provoked public debate and initiated a societal movement involving actors from both proximal and distal child environments: parents, parents' representatives, nongovernmental organizations (NGOs) and governmental institutions and individual authorities protested against the policy. Ultimately, the Constitutional Court stated that the order was contravening the Lithuanian Constitution; however, the debate is ongoing and the problem of decreasing numbers of vaccinated children has not yet been resolved (Lithuanian CA).

In Croatia, the lack of trust in vaccination was the consequence of certain media announcements, which introduced debate on the potential adverse effects (autoimmune disorders) of the H1N1 vaccine in 2009. In 2011 an article was published in the Medical Gazette (the Gazette of Croatian Medical Chamber), outlining the negligible risks of vaccination. Consequently “there was and still is strong controversy over the vaccination of school and preschool children mandated by the Act on communicable diseases population protection (OG79/07)” (Croatian CA). The discussion was provoked by the strong voice of parents, who supported the change in vaccination legislation from mandatory to voluntary. The parent‐driven antivaccination movement was supported by the Croatian Association for Patient Rights Promotion and individual medical doctors, but the majority of experts and medical professional organizations such as the Croatian Immunological Society and the Croatian Epidemiological Society were against voluntary vaccination. The debate is still ongoing in the country. “So far, the anti‐vaccination movement did not manage to force changes in state laws regarding mandatory vaccination” (Croatian CA). Changes to mandatory vaccination legislation did not appear in the currently proposed revisions of the Act on communicable disease population protection.

In 2002, mandatory vaccination became a public issue in the Czech Republic. An association advocating freedom of choice in vaccination, known as Paracelsus, raised concern about compulsory vaccination policies. By referring to the Charter of Fundamental Rights and Freedoms, the association has turned its agenda into support for voluntary vaccination of children and the rights of parents to refuse mandatory vaccination without risk of financial sanctions. In accordance with Czech legislation, vaccination of children is mandatory: thus, “it happened that parents who refused to have their child vaccinated were issued administrative fines, which can reach up to 10,000 Crowns (350 EUR)” (Czech Republic CA). Also discussed were issues linked to adverse effects of vaccination and issues of responsibility and financial compensation when they occur. In consequence, “vaccination remains mandatory. But the state prepares for settling claims for complications (adverse effects) of vaccination in the form of the ‘Compensation fund for compensation for complications of vaccination’. This fund is to be financed from contribution of the sickness funds (health insurance companies) active in the Czech Republic” (Czech Republic CA).

Even though the antivaccination movement is ever more present in Europe, our data revealed that the European community reacts in situations of limited access to vaccines as well. In Spain, strong societal disapproval occurred when pneumococcal and varicella vaccines were excluded from the vaccination scheme. In Greece where the financial crisis and waves of migration provoked discussion on the limited access to immunization amongst children, many NGOs started to implement immunization programs for children mostly for unemployed and uninsured families, refugee/migrant children and children from Roma populations.

3.2. Children as victims of the economic crisis

The problem of poverty in Europe was another theme identified. The economic situation in Europe worsened significantly in the late 2000s and into the 2010s. This was mirrored by a change in child health status across Europe. Austerity policies required the undertaking of measures, which directly or indirectly affected the distribution of health services within the country. The economic downturn contributed to the increase of poverty, unemployment and inequality rates, which in turn contributed to the deterioration of the socio‐economic status of the family and, in consequence, child health and well‐being. The negative consequences of such macroeconomic processes negatively affect the biological, mental and social functioning of the child, and as such we can state that the child may be considered as a victim of the economic crisis.

In Spain, child poverty resulted in cases of malnourishment and the deterioration of living conditions adversely affecting child health and well‐being, and brought with it the risk of social exclusion, increased rise in evictions of families with young children due to mortgage nonpayment. The national discussion centred around a perceived lack of prompt and effective actions by the government to protect children and families at risk of social exclusion. A public outcry occurred relating to cuts in the provision of meal grants, thus increasing the risk of malnourishment of children in poverty and reduction in year‐round access to school canteens even during summer vacations. As a result, the “Plan for social inclusion of the Kingdom of Spain” for 2013–2016 was implemented by regional and local governments.

Social concern about child poverty was apparent in Portugal. “This topic has been discussed because it is assumed that it is an effect of the economic crisis that we are living in in Portugal” (Portuguese CA). The debate was broadly discussed in the media and involved mainly social institutions. Like Spain, the education sector responded to the crisis by opening school canteens during the school holidays in order to minimize the risk of social exclusion.

In Malta, the case of child poverty “has been provoked by reports being issued regularly by Eurostat showing an increase in children at the risk of poverty as well as a local NGO (…) that has issued a report on poverty in Malta” (Maltase CA). The problem was highlighted on TV and in the other media. The risk of poverty was associated with single‐parent households. “As marriage breakdown becomes more common, divorce has been introduced and a significant number of immigrants are living in Malta, the traditional socio‐cultural milieu associated with the Roman Catholic religion and the upholding of the family as a traditional value has been eroded. As a result, more and more children are living in single‐parent households and these are at the highest risk of poverty” (Maltase CA). Despite a downward trend in rates of poverty overall reported in 2015, the debate is ongoing.

Socioeconomic adversity and instability in Greece were linked to the financial crisis, which resulted in severe wage cuts and high unemployment rates. It “contributed to worsening poverty and economic inequality affecting mostly the unemployed, single parent families and non‐EU migrants” (Greek CA). Alarming figures published in the United Nations Children's Fund report, as well as concerns raised by teachers and parents because of fainting incidents in schools attributed to hunger, brought to the fore the problem of food insecurity and hunger amongst school children, and criticism was directed not only at the educational system but also towards the political and economic situation. “Greek public schools (from kindergarten onwards) do not provide meals for students in any income bracket. Only day care centres provide school meals for children up to about five years of age. Once children enter kindergarten and primary school, parents either need to provide their children's lunch (even in all day schools) or students can purchase snacks from canteens which operate within school premises and sell snacks and beverages. Legislation regulates the items sold by school canteens, but there is limited evidence of its enforcement” (Greek CA). In order to respond to the problem of food insecurity in Greece, the DIATROFI project was implemented. “The DIATROFI program is designed and implemented to serve a dual purpose. It indiscriminately provides all students of participating schools with a daily free healthy meal and promotes healthy eating through educational activities targeting students and their families” (Greek CA). This initiative is supported by other governmental actions to address the food insecurity through schools.

The question of poverty and economic downturn in Ireland was associated with an increase in homelessness, in particular family homelessness. Several circumstances were highlighted as contributing to homelessness: the unfavourable economic situation of the family, housing shortages and the associated contraction of the construction industry, availability of rental properties and rising rents and the number of landlords exiting the private rental market. Concerns about children's welfare in relation to being homeless centred on emergency accommodation conditions, which were not appropriate spaces for families, due to limited cooking facilities and little access to safe play and recreation space. Emergency accommodation may be located far away from school facilities, meaning that it increases travel expenses. Homelessness has a negative impact on children's physical health and psychological well‐being. “The current homelessness situation in Ireland can be related to the interplay between the economic recession which started in 2008, and the resultant negative impact on income, employment, and the contraction of the construction industry which contributed to the current housing shortage” (Irish CA). Outcomes from the debate about homelessness and the government's efforts to address the issue include the establishment of a specific government department, namely, Department of Housing, Planning, Community and Local Government. Its main task was to develop sustainable solutions to the housing shortage in Ireland. Additionally, “in July 2016, the government launched its Rebuilding Ireland: Action Plan for Housing and Homelessness which aims to decrease homelessness and deliver 47,000 social homes by 2021” (Irish CA).

3.3. Child abuse

Closely linked to the infringement of children's rights, child abuse is one of the most striking issues around child health care discussed in the public arena within recent years. The controversial issues emerged with an increased intensity as the consequence of sustained historical silence around the issue. Increasingly, the problem of child abuse is considered in terms of sexual abuse or exploitation and psychological mistreatment; many of these cases could be identified earlier, or possibly even avoided the societal and institutional reaction had occurred previously. The problem of a so‐called “blind eye,” which refers to the lack of appropriate reaction from relevant authorities as they act in accordance with the conviction that “you don't see what you don't believe,” was revealed in Norway. An 8‐year old boy, Christopher, who had been diagnosed with attention deficit hyperactivity disorder, died of child abuse in 2005. An outcry of public concern disclosed the lack of appropriate communication between the individuals and institutions responsible for the boy. As a result, “the board of health supervision published a report in 2014 on the Duty of Health Care Personnel to report to Child Welfare Services, a review of knowledge from experience gained from supervision and other sources” (Norwegian CA). In accordance with the board's suggestions, knowledge of health personnel about the duty to report concerns to child welfare services was strengthened. The issue also prompted a discussion about the limits of their duty of confidentiality. The case resulted in the introduction of changes to the Act of criminal investigations and increased awareness of everybody's responsibility in child protection. A lower threshold for alerting child services was also announced.

At the beginning of the 2010s there was a surge in reports of historical sexual abuse of children who were in the institutionalized care of the Roman Catholic Church and the youth care system in the Netherlands. The investigation was supported by two committees: the Committee of Inquiry Deetman (Roman Catholic Church) and the Committee of Inquiry Samson (youth care system). “The sexual abuse had taken place in situations where minors were entrusted into the care of official institutions or organisations. The minors that were abused in the Roman Catholic Church were often going to boarding school there. The minors that were abused in youth care were especially vulnerable because they were taken out of an unsafe situation at home, only to be placed in a new unsafe situation in residential youth care or foster care” (Dutch CA). As a consequence of extensive studies about the problem, guidance including the mechanisms of investigations of sexual child abuse was developed.

The Netherlands was struggling also with severe cases of child abuse that resulted in the death of the child. “Around 50 children a year die in the Netherlands as a consequence of neglect or abuse. Most of these cases are cases of neglect or abuse are in the home and family setting” (Dutch CA). This prompted debate about the roles and responsibilities of involved authorities supports in the treatment of those children and the need for the preventive initiatives in order to avoid such incidents in the future. Local government and municipalities have been responsible for child safety since 2015. There is a legal framework in place which aims to ensure that children are safe. In Norway, two systems are responsible for the guidance in the case of suspected child abuse. The first one is “Meldcode” (reporting code) and “Meldplicht” (notification obligation). “In 2015 the new Child in Youth act came into force. In this act, the newest ideas about how to care for children and youth are incorporated. (…) This new act should also help decrease the number of children that are being abused and die as a consequence of this abuse. Since the act has just come into force there are no numbers yet about the effect on the number of abused children. And the discussion is still ongoing and will be ongoing for a lengthy period since child abuse isn't 100% preventable. At the moment the discussion about the “Meldcode,” “Meldplicht” and registration of voluntary counselling is still ongoing” (Dutch CA).

In Romania concern about child abuse related to the issue of overmedication, in particular to the prescription of medication for long periods with no review, and without the provision of psychotherapy or other forms of therapy in addition. Investigative journalism revealed such a case. The “reporters found out that 12 out of 28 children aged between 6 and 16 in the foster home Dacia, on the outskirts of a large Romanian city, Brasov, were administered narcoleptic medication for behaviour disorders, although the centre was not a special needs centre, but one for children at risk in their families, or abandoned mostly for family poverty” (Romanian CA). This provoked the National Agency for Child Protection and Adoption to act. As a resulting consequence of its formal investigation, it was “declared that 5,483 from 19,333 children from residential care (…) are getting medication for psychiatric disorders (conduct disorder, hyperactivity and attention deficit disorder). This represents 28% of the children in residential placement centres, excepting the thousands of children fostered in settings for special needs children” (Romanian CA). The report on children sedated in residential care units explained that these overmedication procedures were applied in order to maintain the appropriate compliance level. As the outcome of the case, the National Authority for Child protection launched the Association of young people in residential care. The mission of this NGO was to look after children in the residential care system and identify early and report any case of abuse or other maltreatment, which affects their dignity.

Public discussion on child abuse in Croatia started when a parent witnessed child abuse by a medical nurse in one of the Croatian specialist hospitals. “The parent then shared what she had witnessed through social networks” (Croatian CA), which provoked a heated national discussion, with strong media involvement. “A police investigation was conducted and forwarded to the district attorney, and the Ministry of Health also conducted its investigation. No elements of the criminal offence were found by the police and the Ministry of Health found no malpractice in the provision of care in the hospital” (Croatian CA). However, the unethical behaviour of the nurse “displayed high level of public consciousness regarding child welfare and serves as a constant reminder to the health bodies for the need of high‐quality child health” (Croatian CA).

In Iceland child abuse has been on the agenda for about two decades. The scope of the discussion included sexual abuse, physical and psychological abuse and neglect: “Historical cases of sexual abuse of primary school children by teachers have also been highly debated and caused a general public outcry, abuse not only in boarding schools but also in public schools by teachers. Further, it is not only girls who have suffered sexual abuse but also boys, formerly not considered to be a problem” (Icelandic CA). Preventive health services have been aware of potential child abuse for a long time. Nevertheless, many of health professionals responsible for reporting child abuse case have been reluctant to do so because of the delicate relationship with parents and carers. Despite the fact that no one particular case provoked the debate, national concern about child abuse has gradually evolved as a consequence of various cases of child abuse reported in different kinds of schools over time. The issue is still present in public awareness, and this has resulted in legislation changes, greater penalties for physical and sexual abuse and the introduction of changes in the educational structure to improve child safety.

A new form of child abuse has been recognized in the United Kingdom (Northern Ireland): the “form of sexual abuse in which a person(s) exploits, coerces and/or manipulates a child or young person into engaging in some form of sexual activity in return for something the child needs or desires and/or for the gain of the person(s) perpetrating or facilitating the abuse” (UK CA; definition by Safeguarding Board Northern Ireland). The problem was investigated by the police in what they termed Operation Owl, which was originally an initiative to investigate missing persons in Northern Ireland. As a result of this investigation into missing children, “22 cases of suspected child sexual exploitation of children in care were identified” (UK CA). The issue was discussed widely in the media and in the political arena.

4. DISCUSSION

Child health and well‐being issues involve the public and raise nationwide debates in many European countries. Predominantly, public concerns were directly or indirectly related to child health and were present in national awareness.

We collected a variety of cases described by MOCHA CAs, which shows that there is a broad perspective in the perception of child health problems. Based on our data, we have observed a significant change in attitudes towards vaccinations. Two trends are noticeable. On the one hand, the antivaccination movement is present and it can be considered to be a consequence of the lack of trust in medicine and in the decision makers' expertise. In countries such as Croatia, Czech Republic, Estonia, France, Lithuania and Italy the introduction of mandatory measures with the aim of reducing the increasing number of unvaccinated children has provoked strong societal reactions. On the other hand, limitations in access to vaccines are seen as a consequence of the socio‐economic crisis across Europe. Austerity policies and migration crisis in Europe provoked limitations in access to vaccines, what was the case of Spain and Greece. Thus, the discussion around vaccines in Europe is seen as the consequences of social capital crisis and the socio‐economic crisis.

The recent recession was also an important factor in the public consciousness, which is seen to increase the level of child poverty. Problems of hunger and homelessness were reported by countries, which were the most severely affected by the consequences of economic crisis, namely, Spain, Portugal, Greece and Ireland. Society was particularly sensitive to restricted austerity policies, which affected the most vulnerable groups. Our data also revealed that Europe is facing a problem of child abuse, and one which also recognizes historical incidences of abuse. Increased awareness of children rights together with greater child empowerment and a rejection of the stigma associated with child abuse has brought to prominence old and consciously or unconsciously neglected issues. The CAs' case studies show the variety of settings of child abuse occurrence, from home to institutional care. A problem might be even deeper as a result of the “blind eye” paradox, which refers to the limited willingness to notice cases of abuse amongst children. This dulls societal vigilance, in particular in terms of emergence of forms of abuse such as sexual exploitation of children.

In summary, the MOCHA evidence shows that concerns about child primary health care in European countries are focused on the health system itself and the issues of its structure and activities (indirect patient orientation) and on patient/child health and well‐being (direct patient orientation).

Child health problems are considered via different interfaces within the health care system such as primary care, specialist care, emergency care and/or social care. Within those domains three levels of activity were observed that provoke societal discussion if they are seen to be mismanaged not addressed or not present. These are prevention of illness for the well child embedded in the family context, promotion of a good social and physical environmental or preventive care context, and timely and necessary intervention if a child is sick, have long‐term health or complex care needs.

Zdunek K, Schröder‐Bäck P, Alexander D, Rigby M, Blair M. How does societal reaction to children's health issues contribute to health policy in Europe? Results of a survey. Child Care Health Dev. 2019;45:364–370. 10.1111/cch.12657