EARLY INTERVENTION IN SPAIN OVER THE LAST 3 DECADES
It now has been 30 years since the first early intervention (EI) services were set up in Spain, and they have spread across the entire country. On the basis of many years of experience, a group of professionals from different Autonomous Communities drew up a report entitled Libro Blanco sobre Atención Temprana (EI White Paper), which, it was hoped would become a reference framework for government bodies and professionals that would help to harmonize differences and unify care models for vulnerable children and their families. During this period, intervention models based on different theoretical approaches existed in different centers across Spain. Moreover, the predominant model in each was not always shared by all its members. It should be pointed out that the most widely employed theoretical model was neo-behaviorist. However, the goals the teams set up themselves were similar: the provision of care for the child and family and information and continuous training for the professionals involved. When the child started to attend school, the process was supervised to ensure that their integration into school was successful (Beà, 2001; FEAPS, 2001; GAT, 2000). Later on, an approach based essentially on psychodynamic theory was gradually adopted. This meant the model took on similar characteristics to those described by Cunningham and Davis (1988), in which the professional is seen as an expert and the parents are given guidance so that they can carry out instructions in relation to the goals being pursued.
Little by little, a change of paradigm (Giné, 1998; Giné, García-Dié, Gràcia, & Vilaseca, 2001) has been put forward, especially by those involved in research, based on the suggestions contained in the work of Guralnick (1997a, 2001), Peterander (1999, 2000), and others, that would replace a child-focused model having rehabilitation as its fundamental goal with a family-focused approach.
However, every paradigm shift takes time, since the ideas originating in other countries need to be adapted to the social, economic, political, and cultural reality of one's own country. This explains why, if we look at the proposal contained in the Libro Blanco (GAT, 2000) regarding the consensus definition of EI, the child continues to occupy center stage: “[EI] is the full range of interventions aimed at the child population between 0 and 6 years of age, the family and the environment, whose purpose is to respond as soon as possible to the temporary or permanent needs presented by children with disorders in their development or who are at risk of suffering such disorders. These interventions, which must take into consideration the child's overall situation, must be planned by a team of professionals with an interdisciplinary or transdisciplinary approach” (p. 13). It should be said, however, that although intervention has been fundamentally child-focused, the parents seen at the EI centers regard their relationship with the professionals dealing with their children as adequate and are satisfied with the job that they do (Giné, García-Dié, Gràcia, & Vilaseca, 2002).
In the following sections, we describe the basic principles and components characterizing the intervention model that is slowly gaining ground in Spain. The following principles, therefore, correspond to a consensus theoretical framework pointing in the direction in which it is intended gradually to steer the way EI services operate in Spain, even though they have hitherto followed quite different paths.
The adoption of a social and ecological perspective of development
We are referring here to the gradual acknowledgment that human development is of a social nature (Bronfenbrenner, 1987; Brunner, 1977; Coll, Colomina, Onrrubia, & Rochera, 1992; Rogoff, 1993; Schaffer, 1977, 1993; Wertsch, 1979, 1988; among others). Despite their different approaches and viewpoints, these authors (after Vygotsky, 1978) agree on perceiving human development as a social activity where children take part in actions beyond their competence, through the help of adults or more experienced peers. It is from having opportunities to communicate with adults that children develop advanced psychological processes.
The study of the development of children at biological and/or social risk, as well as those with disabilities, shares this theoretical framework. In consequence, the context (opportunities, conditions, and values present in the interaction) plays a decisive part in determining the direction that the development of these children will take (Bernheimer & Keogh, 1995; Gallimore, Weisner, Kaufman, & Bernheimer, 1989; Guralnick, 1997a, 2001; Gallimore, Weisner, Bernheimer, Guthrie, & Nihira, 1993).
The adoption of a concept of family-centered intervention
The fact that human development has an interactive nature implies attributing to the family, as the basic context where the interaction takes place, a decisive responsibility in the development of all children. As Kaye (1986) reminded us, we should not expect to discover an explanation of development in the child; part of the responsibility belongs to the adults who organize the experiences of the child.
This statement has greater force when we deal with families who have children with disabilities. Moreover, precisely those aspects that make the child more vulnerable assign a more decisive responsibility to the child's family because daily life is the main source of experiences and opportunities for the development of all children. Such a family can be more fragile, however, because of having to deal with numerous problems and excessive demands. Another reason for conceiving development as focusing on the family has to do with the need to provide support in the natural settings in which children live and develop.
Based on collaboration between professionals and parents, the adoption of a model for working with parents
A new concept based on collaboration between parents and professionals, where the parents are not only recipients of information but also suppliers of it, has clearly emerged. Turnbull, Blue-Banning, Turbiville, and Park (1999) call it “Partnership Education: An ecological perspective of the quality of the lives of children and families implies the admission that not all the expertise belongs to the professionals…; therefore, the professionals need, to a great extent, not only the expertise of the parents but also the expertise of other key members of the community” (Turnbull et al., 1999, p. 168). Along this same line of thought, Winton, Sloop, and Rodriguez (1999, p. 159) added “The professionals will never know how to help parents unless they have devoted a certain amount of time to learning the facts, situations, or behaviors from them that are the object of collective attention.”
Promoting the child's involvement
This component needs to be understood from twin standpoints, which we might call psychological and social. From the psychological point of view, in order for learning to take place, the child must actively take part in culturally valued activities, with the help of adults or more skillful peers (Vygotsky, 1978). Therefore, all initiatives aimed at advising and guiding the family, as well as those focusing on the child, must be designed so as to promote the child's direct involvement in the diverse activities of daily life. The young child must gradually move on from the role of spectator to that of actor if the child's development is to be stimulated.
From the social point of view, every effort must be made to encourage to the maximum the child's involvement in the common activities proper to the community in which he or she lives and, above all, in the school environment (nursery, primary, and secondary school). Interaction with peers and adults in both formal and informal situations and contexts will become a decisive factor in the child's progress, in spite of the difficulties and reluctance that still exist in some members of the community.
The promotion of community-based intervention
Intervention must always be aimed at achieving maximum integration of children and their families in the community's services network and optimizing the possibilities that the community offers them to further their progress. Viewed from another angle, it should also be borne in mind that the quality of an EI system depends on the existence and effectiveness of coordination at local, national, and even international levels.
The promotion of an interdisciplinary approach
Delivering an adequate service to children and families requires joint work by professionals from different disciplines at various points in the process. Moreover, such interdisciplinary cooperation is needed at 2 levels: among the different services involved and within each service. In practice, the response to a child's needs is very often provided by a number of services (health, social, educational) run by different government departments and even different levels of government whose coordination is essential.
The promotion of competence among professionals and the development of an efficient organization
The last component of our model is the need to promote competence among professionals who specialize in different areas but work together. First, there is the need to find regular opportunities during work time for professionals to reflect together on their practice and, compare their different points of view regarding the diagnosis, intervention, and assessment (commenting on their observations, watching video recordings, analyzing difficulties, looking at successful solutions, among other things). Second, specific training activities need to be planned in conjunction with an outside consultant for the team to engage in. Third, it is important to consider conducting and evaluating studies.
We also need to look at how teams are organized. In this respect, we believe that an EI center needs to have explicit criteria regarding its organization, which all members of the team have been involved in drawing up and which they are therefore familiar with. The organizational criteria should be decided on collectively by all members of the professional team, and it should be possible to share them with other centers and the families, which could help to improve them. Finally, we believe that one of the conditions for ensuring a quality service is periodic self-assessment and external assessment of the team, allowing identification of its strong and weak points and establishment of relevant improvement processes.
THE EMERGING QUALITY MODEL IN EI
In the following sections we describe the EI system in Spain following, as far as possible, the Developmental Systems Model put forward by Guralnick (2001). In this model, an identification of a series of structural components required of effective systems has been made. The status of each of the structural components in Spain is discussed.
Screening and referral
In Spain, children and their families usually enter the EI system via a screening and referral process. Screening here refers to regular checkup and monitoring programs applied to healthy children in which all children take part. These checkups, which are very general, are normally carried out by pediatricians or their nurses. The instruments they generally use to perform the checkups are protocols designed to detect whether there are any warning signs, including direct observation of the children and information gathered by interviewing the parents. At all times, if parents detect a problem that the pediatrician or pediatric nurse has failed to pick up, they can go to the EI center themselves and request an appointment. They will either be seen at the center or referred to the appropriate assessment and diagnostic service, which comes under the Autonomous Community government, and the child will be assessed there. The same thing happens with the social and educational services (kindergartens, nursery schools). Whenever they detect a possible problem, they can ask for an examination by a professional at an EI center. Once the child has been seen, a decision is made either to monitor the child or for the child to enter an intervention program at an EI center.
If the child is referred to an assessment and diagnostic service for an assessment, entry into an EI program is likely. Sometimes certain circumstances, such as premature birth or low birth weight, siblings with a congenital pathology (healthcare sphere), or a history of abuse or neglect (social services sphere), mean that inclusion in a monitoring program is automatic, and this often leads to their being referred directly to an EI program.
We agree with Guralnick (2001) that the value of parents' concerns and worries about the development and behavior of their children should not be underestimated. There are data showing that parents are the first to detect problems in their children in a high percentage of cases (Giné et al., 2003). For the most part scant attention is paid to such concerns, and there are no instruments in general use enabling, for example, problems in the development of communication and language to be identified; although a proposal has recently been made in this regard (Galván-Bovaira, Gràcia, & del Rio, 2002).
There is doubtless a need to improve the checkup system and make it more similar across the different Autonomous Communities, as pointed out in the Libro Blanco. There is likewise a need for instruments to be used that are capable of picking up possible developmental problems; although protocols enabling warning signs to be spotted are being increasingly employed.
It may also be necessary to review certain matters such as the frequency, risk criteria, cost, and effectiveness of the checkup and monitoring system. In our opinion, it is pediatricians and pediatric nurses who need to make a greater effort in this regard. Although it is true that such a campaign to raise awareness among professionals—essentially pediatricians and pediatric nurses in the public sector—of such early signs that may be key to detecting a developmental problem was begun several years ago in our immediate setting (ie, Catalonia); we believe that much still remains to be done. However, raising these professionals' awareness is certainly not enough. Campaigns are also required to improve knowledge of many professionals, whether they work in the educational sphere (nursery nurses and infant school teachers) or are part of the social services that deal with very young children. Likewise, the education and training available to parents before they have a child and during the first few years of their child's life is something else that needs to be improved.
In Catalonia, children who are not referred to an EI center, but who are suspected of having developmental problems, are placed on a monitoring program consisting in their being seen periodically by an EI professional at the EI center itself, at school, or at the health center. Monitoring by an EI professional is sensitive to psychological consequences. If at any time during the monitoring process there is concern over anything that is regarded as requiring treatment by EI specialists, the child is immediately passed on to an EI center to begin an appropriate program. Children in Catalonia who are suspected of presenting developmental disorders are monitored by a professional from an EI center and participate in the usual process of periodic checkups performed by healthcare professionals; however, this practice is not sufficiently widespread.
Point of access
In Spain there is no clearly defined common point of access to the EI system, but rather a moment in the process. When a child is regarded as presenting a concern or risk on the basis of the screening and referral or monitoring process, he or she is at the point of access and the family is then advised to go to one of the official assessment and diagnostic centers set up by the autonomous governments. In view of the situation described here, we think that families in Spain should have the opportunity of taking a more active part at this stage in the decision to move from monitoring to assessment of the child and entrance into an EI program.
Comprehensive interdisciplinary assessment
In Spain, assessment is performed by professionals belonging to the assessment and diagnostic services to which families are allocated on a catchment area basis. However, what these professionals do is assess the possible disability with a view to determining the degree of disability in the psychological, medical, and social areas. In addition, they also determine, among other things, the length of the intervention required by the infant. In short, the assessment has a legal focus and enables families to be included in an EI program and apply for financial assistance for their children.
Once the degree of disability has been determined, the child is referred to an EI center. While taking into account the assessment made by the assessment and diagnostic service, the EI center carries out its own assessment of the child's level of development in each of the different areas. In this case, the assessment is closely linked to the intervention plan. The EI centers use specific tests to evaluate the child's overall development as well as the child's development in particular spheres, such as language and cognition.
At all times, the assessment team seeks to produce a diagnosis (eg, cerebral palsy, developmental delay, or something else), containing enough information to establish biological, environmental, or multiple etiology. We agree with Guralnick (2001) that families should benefit a great deal more from this information. In certain Autonomous Communities and services in our country, this information is not passed on in a way that is desirable. In practice, the family is given no information, or the information is passed on to them in an extremely summarized form, sometimes employing terminology and procedures that considerably diminish the usefulness it could have for the family. Intervention usually begins while the assessment by the professionals at the EI center is being carried out. This means that, generally speaking, the children and their families receive some initial intervention, which as will be described in the following section, is gradually shaped as the assessment process is completed.
We believe that the professionals who make the assessments within the assessment and diagnostic services should be specialists in early childhood, which means that they should have the necessary knowledge of normal development, pathologies, and various relevant assessment tools, as well as know how to relate to the family so that they are equipped to work with them to obtain as much information as possible. Once this has been achieved, the next step, or requirement, would be for the teams to gradually specialize in different types of disorders, such as autism spectrum disorders, abuse and neglect, or metabolic disorders, and for such teams to be interdisciplinary.
EI and program eligibility
In Spain, families are assigned to an EI center on a catchment area basis and are not able to choose either the center or a specific EI program. The public administrators justify this on the grounds that all the centers are capable of providing the child and his or her family with the same service because they do not specialize in any specific disorder or problem. The different Autonomous Communities need to establish criteria for admission to an intervention program that will ensure that each child and family receives the care and attention they require. The first step would be to set up specific intervention programs for different problems on the basis of criteria serving to guide the assessment. These criteria would also make it possible to choose the most suitable program for each child and family.
Admission to preventive and EI programs
Although we might discuss the admission of the child and family into an intervention program under this heading, we cannot say that in Spain this is done on the basis of an assessment of the stressors that may be perturbing family interaction patterns, as happens in many instances in the United States (see Guralnick, in press). This does not mean that within this first stage there is not a time at the beginning when a preliminary intervention program is put in place that is gradually adapted and adjusted as the team gets to know the child better.
We believe that communities should have a broad range of EI centers and programs available. In addition, we share Guralnick's view (Guralnick, 2001) that they should have the ability to place children in different programs quickly, set up a preliminary intervention program, elect a service coordinator, and begin to organize the assessment of the stressors. Although we agree with the needs raised by Guralnick (2001), in Spain, we are a long way from such a goal, which means that certain aspects have to be prioritized.
Assessment of stressors
The assessment of stressors (information needs of families, interpersonal and family distress, resource needs, threats to confident parenting) is specially designed to acquire information intended to guide interventions that generate optimal family patterns of interaction. In our country, both the families of children with a clearly diagnosed disability and families with children at risk go through an initial information-gathering process normally involving oral interviews with the parents. In these interviews, special care is taken to assess how the family perceives their child's problem, how it affects them, and how they function in everyday life. For the most part, written questionnaires and standard protocols are not used as they are in other countries. Generally speaking, the preferred option is to establish a good rapport between the professional and the family enabling different matters that might affect the family to be broached. The child is often present at these interviews so that the pattern of interaction between parents and child can be observed directly.
We regard communication and the passing of information between the family and the professionals involved as a fundamental aspect that still has to be improved in our country. The assessment of stressors associated with family characteristics and child characteristics must be carried out with great care and sensitivity, but in Spain we are a long way from performing this task systematically in a way agreed upon by all professionals working in the EI field. Nevertheless, over the past few years, some centers have started to consider involving the parents in this stage as a priority. As a result of taking part in conferences and learning about approaches that were beginning to be employed in other countries (Björck-Äkesson and Granlund, 1995, 1997; Guralnick, 1997b), some centers have started to realize that the information parents can furnish about their own children, about themselves, about their child's participation in other care or therapeutic processes, about how the problem was detected, about their coping experiences following detection, about how they see their own involvement, and other things (Guralnick, 2001) is of fundamental importance, and the professionals dealing with the child should be aware of it so as to be able to make a more accurate and fuller assessment of the situation.
Developing and implementing a comprehensive program
Once the initial interviews have been completed, an agreement is reached with the family for the child with clearly established disabilities or the at-risk child to be placed in an EI program. The professionals concerned usually make a specific intervention proposal, which in most cases focuses direct attention on the child with difficulties. Although most authors agree that the family is the natural context for any child, whether typical or with disabilities, and that parents need to be involved in EI programs (Bromwich, 1981; Fornós, 1997; Gray & Wandersman, 1980; Guralnick, 1997b; Shearer & Shearer, 1976; Worobey & Brazelton, 1986), such involvement is tackled in many different ways at the various EI centers in Spain. In fact, according to our experience in this field (Giné et al., 2001), we can say that, generally speaking, EI in Spain remains almost entirely focused on the child.
The results of our pilot study (Giné et al., 2001), show that professionals devote most of their time to dealing with children at the center, usually on an individual basis, and have little time available for carrying out family assessments in the home or at the center. In any case, family assessments in the home often consist of giving them guidelines on what they should do, particularly in relation to the more psychomotor and physiotherapeutic spheres. In most cases, work with families at the centers, in spite of being an objective in itself (Fornós, 1997), is in the form of 1-way counseling, ie, the parents are given information and guidelines by the professionals on how they should behave in certain situations, without their role in the intervention process being taken sufficiently into account. Moreover, the parents see the professionals as experts, and therefore they regard themselves as mere receivers of the information given to them, which they must then try to act on for the benefit of their child.
Offering parents all the information on the prospects for their child's development is one of the most effective forms of cooperation in regard to the intervention. As Peterander (2000) had pointed out, information helps parents to establish a dialogue with the professionals that facilitates the acquisition of skills and enables them to cope better with the problems of everyday life. According to the findings of our pilot study (Giné et al., 2001), the EI center professionals devote part of their time to enhancing the child's independence (dressing themselves, eating on their own, etc), but they do not pay much attention to the parents' role as necessary active participants and mediators in the child's development in each and every one of the other areas of the child's life.
Again, according to our study, the EI centers do not appear to provide parents with ongoing information on their child's progress. Customary practice is to produce an annual report on the child's progress during the school year that does not include any aspects of the way the family functions, as this is not part of the intervention. However, there is usually a more informal, though rather shallow, exchange of information at the end or at the start of the sessions with the child that often depends on the family's interest in finding out whether or not the child is improving in the course of treatment. It seems that much remains to be done to improve parents' educational skills and bring about a change of paradigm that will assign a leading role to the family such as the one we are putting forward. Our research (Giné et al., 2001) shows that this is certainly one of the areas in which progress needs to be made in Spain.
Monitoring and outcome evaluation
Throughout the period in which the intervention with the child takes place at the EI center, the professionals periodically hold interviews with the family, generally speaking every month or two. In these interviews, the child's progress is evaluated in relation to the goals that were set at the beginning of the intervention and it may be possible to work on some guidelines with the family. In most cases the assessment is one way. In other words, the professionals give the parents information and guidelines on how to act in certain situations, without taking their role in the intervention process sufficiently into account.
As a general rule, when it comes to outcome evaluation, the professional again performs a battery of assessment tests, most of them on the child, in order to determine his or her level of development in different areas. These results are communicated to the family, and a decision is made whether or not to continue the treatment. In some cases, it is decided to terminate the treatment because the child has reached the goals that were established. In other cases, it is decided to discontinue treating the child directly but to monitor him or her for a certain length of time, which involves planning 3 or 4 visits over a period of approximately 6 months; although, this is not an option in every Autonomous Community. In many instances it is the child's age that determines the end of the treatment received from the EI center, and that is done according to the relevant regulations.
In the future the monitoring and outcome evaluation processes need to become less child-focused and take greater account of the stressors facing families because of children's characteristics that do not permit optimal family patterns of interaction. What is needed is a stronger evaluation culture that takes into consideration the progress of both the child and family.
There are many different types of transition: from hospitals to EI centers, from health centers to EI centers, from EI centers to nursery schools, special schools, and other children's services. The children and their families coming from hospital neonatal units are often referred to the EI centers directly. However, according to a survey (Giné et al., 2003) carried out in the Autonomous Community of Catalonia, 50% of hospitals do not know how to refer families to EI services. There is a certain tendency to delay referral of infants and their families to EI services or to make the referral via the child's pediatrician.
Another point of transition is when professionals in the healthcare service refer children and their families to EI services. According to the same survey, when healthcare professionals refer a family to an EI center, they do so in writing in only 35% of cases. In only 43% of these reports is the reason for referral spelled out, and in just 35% is general reference made to the family situation. Transitions to EI centers from education agencies (most commonly nursery schools and educational psychology school support services) are generally better coordinated. The study cited above found that 61% of the professionals working in the educational sphere said they had regular liaison channels with the EI center and were extremely satisfied with them.
Final transitions or discharges from the EI center to other external services are also an important part of the process that needs to be evaluated in order to get a full picture of the quality of EI in Spain. As the Libro Blanco points out, in our country when a child reaches the statutory age limit but is judged to be in need of ongoing psychological and/or educational care, the transition is made to mainstream schools with pedagogical support or to special schools. According to the study cited above (Giné et al., 2003), the professionals in the EI centers set up agreements with the educational services prior to enrollment in 89% of cases. This is regarded as being extremely positive for both the children and their families. Most children enter mainstream schooling, some attend special schools, and a few divide their time between mainstream and special schools. When the time comes for transition to a mainstream or special school, a process is generally established that involves the professionals from the EI center visiting the new setting, meeting the professionals working at the school to explain the child's educational needs to them, and helping the family choose the best school for their child, among other things, until they are sure that the transition has been completed. The survey by Giné et al. (2003) also found that when children have to leave the EI service as a result of their age, some 65% still require ongoing educational and/or healthcare. Existing public sector resources are clearly insufficient to meet this demand, particularly in the healthcare domain (speech therapy, psychotherapy, etc).
These transitions require a properly planned process. This already happens to some extent in Spain, although the goal of planned processes in all cases and all Autonomous Communities is still a long way off. In fact, there are manifest limitations at these transition points. Some of these deficiencies stem from the fact that the professional functions involved in EI (medical, educational and social) belong to different agencies, which hampers rapid and efficient coordination. The most important shortcoming of the existing EI network has to do with the transitions at the point of discharge from the EI center to other services. Continuity of care must be ensured when the children reach the end of the EI phase, especially in the case of state-run services. Poor liaison among the different healthcare, educational, and social services bodies, coupled with the lack of public sector provision to meet demand, means that transition planning is often slow and therefore involves a certain waiting time in order to gain access to the other services that are required. If access to such services were set up earlier and there existed a well-coordinated network, the continuity of care received by children and their families would no doubt be improved.
In this article we have described the EI situation in Spain, with special reference to Catalonia, in spite of the difficulties of such a task and given the diversity in the traditions of training and professional practice. In summary, it has to be acknowledged that EI has made considerable progress in our country over the past few decades. In the first place, EI is today within reach of practically all families. Both the central government and the governments of the Autonomous Communities have incorporated it into their network of services, and some of the latter fully fund it. Second, this progress has been made possible by a broad sector of professionals across the country that have gradually acquired training and experience and built up a network structured around professional associations that has enabled them to exchange experiences and often reflect together on certain aspects of the future development of this field. Third, there has been an obvious increase in awareness in society as a whole and the professional sectors involved regarding EI.
Nevertheless there still remains a great deal of work to be done to bring our EI practices regarding the care of families and children up to the quality standards such as those reflected in the Developmental Systems Model. However, it seems appropriate to stress the following points. First, although progress has been made in the availability and funding of EI, in many places it still needs to be made accessible and free to families. Similarly, effectual intervention depends on supplying families with clear information, heightening the awareness and enhancing the training of healthcare professionals in relation to the psychological and educational problems of children and their families, and ensuring better coordination between the healthcare network and the EI services. Third, it would seem necessary to effectively incorporate monitoring into the components of EI in Spain, implementing it prior to attendance at an EI center to enhance prevention and while any EI program is being carried out. Fourth, and this is probably the most far-reaching change proposed, it is necessary to promote a shift away from a child-focused model to a family-focused model that includes the parents as major actors at every stage of the process. A model of collaboration with families that recognizes that expertise resides not only in the professionals, but also in the parents must gradually be adopted. Fifth, an assessment culture needs to be promoted and disseminated among professionals and agencies regarding the outcome from the child's and the family's point of view and that of the organization carrying out the intervention. There is little doubt that EI will improve in so far as we are able to both plan and evaluate on the basis of the results and progress achieved, and reflect on our own practice.
Finally, one of the fields in which the need for improvement in our country is most evident is the transition and continuity of services when a child reaches the end of the EI stage, especially when the needs are mostly in the healthcare sphere. Generally speaking, educational services are accessible to all children, and there is normally a good relationship and liaison between these services and the EI centers. However, when the child requires psychiatric care, speech therapy, or rehabilitation, the parents are often forced to resort to privately run services, which they have to pay for themselves. Accordingly, although clear progress is evident in EI in Spain, the directions for future improvement are equally clear.
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