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

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          Abstract

          Background

          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. 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.

          Methods

          Seven 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.

          Results

          Searches 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.

          Conclusions

          Universal 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 number

          CRD42014014548

          Electronic supplementary material

          The online version of this article (doi:10.1186/s12889-015-2244-x) contains supplementary material, which is available to authorized users.

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          Most cited references 62

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          Social determinants of health inequalities

           M Marmot (2005)
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            Social conditions as fundamental causes of health inequalities: theory, evidence, and policy implications.

            Link and Phelan (1995) developed the theory of fundamental causes to explain why the association between socioeconomic status (SES) and mortality has persisted despite radical changes in the diseases and risk factors that are presumed to explain it. They proposed that the enduring association results because SES embodies an array of resources, such as money, knowledge, prestige, power, and beneficial social connections that protect health no matter what mechanisms are relevant at any given time. In this article, we explicate the theory, review key findings, discuss refinements and limits to the theory, and discuss implications for health policies that might reduce health inequalities. We advocate policies that encourage medical and other health-promoting advances while at the same time breaking or weakening the link between these advances and socioeconomic resources. This can be accomplished either by reducing disparities in socioeconomic resources themselves or by developing interventions that, by their nature, are more equally distributed across SES groups.
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              Translating social ecological theory into guidelines for community health promotion.

               D Stokols (2015)
              Health promotion programs often lack a clearly specified theoretical foundation or are based on narrowly conceived conceptual models. For example, lifestyle modification programs typically emphasize individually focused behavior change strategies, while neglecting the environmental underpinnings of health and illness. This article compares three distinct, yet complementary, theoretical perspectives on health promotion: behavioral change, environmental enhancement, and social ecological models. Key strengths and limitations of each perspective are examined, and core principles of social ecological theory are used to derive practical guidelines for designing and evaluating community health promotion programs. Directions for future health promotion research are discussed, including studies examining the role of intermediaries (e.g., corporate decision-makers, legislators) in promoting the well-being of others, and those evaluating the duration and scope of intervention outcomes.
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                Author and article information

                Affiliations
                [ ]DECIPHer, School of Social Sciences, Cardiff University, 1-3 Museum Place, Cardiff, CF10 3BD UK
                [ ]Jack Brockhoff Child Health and Wellbeing Program, School of Population and Global Health, University of Melbourne, Melbourne, Australia
                Contributors
                02920879609 , MooreG@cardiff.ac.uk
                LittlecottH@cardiff.ac.uk
                TurleyRL@cardiff.ac.uk
                ewaters@unimelb.edu.au
                MurphyS7@cardiff.ac.uk
                Journal
                BMC Public Health
                BMC Public Health
                BMC Public Health
                BioMed Central (London )
                1471-2458
                17 September 2015
                17 September 2015
                2015
                : 15
                4574356 2244 10.1186/s12889-015-2244-x
                © Moore et al. 2015

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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                Research Article
                Custom metadata
                © The Author(s) 2015

                Public health

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