Socioeconomic gradients in the effects of universal school-based health behaviour interventions: a systematic review of intervention studies.

Graham F Moore,Hannah J Littlecott,Simon Murphy,Ruth Turley,Elizabeth Waters

doi:10.1186/s12889-015-2244-x

Graham F Moore, Hannah J Littlecott + Show 3 more

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https://doi.org/10.1186/s12889-015-2244-x

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Abstract

BackgroundSocioeconomic inequalities in health behaviour emerge in early life before tracking into adulthood. Many interventions to improve childhood health behaviours are delivered via schools, often targeting poorer areas. However, targeted approaches may fail to address inequalities within more affluent schools. Little is known about types of universal school-based interventions which make inequalities better or worse.MethodsSeven databases were searched using a range of natural language phrases, to identify trials and quasi-experimental evaluations of universal school-based interventions focused on smoking, alcohol, diet and/or physical activity, published from 2008–14. Articles which examined differential effects by socioeconomic status (N = 20) were synthesised using harvest plot methodology. Content analysis of 98 intervention studies examined potential reasons for attention or inattention to effects on inequality.ResultsSearches identified approximately 12,000 hits. Ninety-eight evaluations were identified, including 90 completed studies, of which 20 reported effects on SES inequality. There were substantial geographical biases in reporting of inequality, with only 1 of 23 completed North American studies testing differential effects, compared to 15 out of 52 completed European studies. Studies reported a range of positive, neutral or negative SES gradients in effects. All studies with a negative gradient in effect (i.e. which widened inequality) included educational components alone or in combination with environmental change or family involvement. All studies with positive gradients in effects included environmental change components, alone or combined with education. Effects of multi-level interventions on inequality were inconsistent. Content analyses indicated that in approximately 1 in 4 studies SES inequalities were discussed in defining the problem or rationale for intervention. Other potential barriers to testing effect on inequality included assumptions that universal delivery guaranteed universal effect, or that interventions would work better for poorer groups because they had most to gain.ConclusionsUniversal school-based interventions may narrow, widen or have no effect on inequality. There is a significant need for more routine testing of the effects of such interventions on inequality to enable firmer conclusions regarding types of interventions which affect inequality.PROSPERO registration numberCRD42014014548Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-015-2244-x) contains supplementary material, which is available to authorized users.

Highlights

Socioeconomic inequalities in health behaviour emerge in early life before tracking into adulthood
This review examines the extent to which, and the ways in which effects of universal school-based interventions on socioeconomic inequality have been evaluated in peer-reviewed evaluations published since 2008
Conclusions the review indicates that universal schoolbased interventions may narrow inequalities, or make them worse

Summary

Introduction

Socioeconomic inequalities in health behaviour emerge in early life before tracking into adulthood. Many interventions to improve childhood health behaviours are delivered via schools, often targeting poorer areas. Targeted approaches may fail to address inequalities within more affluent schools. Attempts to improve young people’s health behaviours commonly involve school-based interventions, often targeting lower SES pupils or schools [7]. While intuitively appealing, targeting usually ignores the graded nature of associations between socioeconomic status and health [1] and may produce stigma [8], while imprecise targeting methods often fail to reach at-risk individuals. Targeting deprived schools for example may fail to reach poorer children in more affluent schools, or address inequalities within such schools [9]. Universal interventions which disproportionately benefit lower SES groups may have greater potential to improve population health, while reducing inequality [1]. Depending on the nature of intervention, universal approaches may worsen inequalities [10, 11]

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