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

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.

Examining subgroup effects by socioeconomic status of public health interventions targeting multiple risk behaviour in adolescence

“…Despite the recognition that interventions may increase or reduce inequalities, concerns have been raised that most evaluations do not assess the differential impact by socioeconomic group [11, 32]. Many studies do not record the demographic information needed for subgroup analysis, or are insufficiently powered [16, 22, 33].…”

“…Many studies do not record the demographic information needed for subgroup analysis, or are insufficiently powered [16, 22, 33]. Moore et al [11] suggest that this inattention to inequality within public health interventions may reflect a utilitarian perspective in focusing on achieving the greatest benefit for the most amount of people. Lynch et al [34] address this idea through a discussion of ‘absolute’ and ‘relative’ inequality.…”

“…Additionally, studies were restricted to universal interventions (i.e. aimed at a whole population, such as a school) [11], as interventions that target specific demographic or high-risk groups would be unable to detect difference in effect by SES. If a study was described as universal, but participants were predominantly from one socioeconomic group, it was excluded from this analysis.…”

“…In response, strategies to improve health behaviour of young people have often targeted low SES groups. However, targeting ignores the social gradient to health and may result in stigma or failing to reach at-risk schools or pupils [11]. Thus, some researchers argue for ‘proportionate universalism’ [12] as “universal interventions which disproportionally benefit low SES groups may have the greatest potential to improve population health, while reducing inequality” [11].…”

“…However, targeting ignores the social gradient to health and may result in stigma or failing to reach at-risk schools or pupils [11]. Thus, some researchers argue for ‘proportionate universalism’ [12] as “universal interventions which disproportionally benefit low SES groups may have the greatest potential to improve population health, while reducing inequality” [11]. However, proportionate universalism has potential challenges that have not been tested in practise, such as assessing the proportion of resource that should be allocated to each level of disadvantage [13].…”