08 SES 06 B, Gender, Sexuality and Health Inequalities
Inequalities are the result of complex interactions, which are caused by a number of factors at proximal, intermediate and distal levels. At the local level, families, communities and schools have an important role to play in the aim of achieving equity in early years of life (Langford et al., 2014). There is a wide consensus globally about the importance of ‘whole school approaches’ also called Health Promoting Schools (HPS) approaches (WHO, 1998) that take integrated action to address health determinants at school level via: school policies, school’s physical and psycho-social environment, the curriculum, family and community links, and health services( WHO, 2000; Lewallen, Hunt, Potts‐Datema, Zaza, & Giles, 2015).
This paper focuses on exploring the relationship between health promotion interventions in schools and health inequalities. Specifically, we aim to shed light on the following four questions:
- To what extent does the health promoting school approach contribute to reducing health inequalities?
- Are there any effects of the health promoting school approach on health and education outcomes related to specific vulnerable categories, e.g. pupils with minority ethnic background, pupils with low socioeconomic family status, pupils with a disability or chronic disease…?
- Which components of the school health promotion policies/programmes are conducive to addressing health inequalities?
- What are the dominant research methodologies used to investigate the influence of the health promoting schools interventions on health inequalities?
In order to address these research questions we conducted a two-step scoping literature review strategy. The first step aimed at identifying studies describing the link between health promoting schools and inequalities. The second step aimed at identifying the key components of the health-related interventions in schools which demonstrated positive influence on inequalities.
The main definitions used in the search strategy are as follows:
We refer to an intervention as a “programme, service, policy or product that is intended to influence or change people’s social, environmental, and organisational conditions as well as their choices, attitudes, beliefs, and behaviour” (Bowen et al., 2009).
- School-based health promoting interventions
Designated health promoting schools programmes (i.e. aligned with the HPS framework in the five criteria: health promoting school policies, the school’s physical and social environment, the curriculum, family and community links, and health services)
- Health related interventions in schools
Any educational or preventative intervention implemented in a school setting. After inclusion, we identified if these interventions were aligned with one or more of the five HPS framework criteria.
- Health inequalities
Measurable differences in health outcomes between different population groups - according to socioeconomic status, geographical area, age, disability, gender or ethnic background.
When considering complex interventions, based on a holistic view of health, that involve multiple stakeholders at various stages in the process of development and implementation, it is imperative to define what will be explored in terms of outcomes, i.e., what nature of outcomes is considered and how are outcomes evaluated. With regard to outcomes, we focused on two categories: (a) health outcomes at individual (pupil) level and (b) outcomes at proximal health determinants level.
We used the methodological framework of scoping reviews as it can provide a relatively quick mapping of an area that is complex or that has not yet been subject to a comprehensive review. It maps the main sources and types of available evidence, as well as key concepts deployed in emerging research areas (Mays, Roberts, & Popay, 2001). We argue that scoping review methodology is appropriate for this study because the field combines public health, health education and health promotion interventions; it is characterised with high level of complexity and emerging evidence of differing strength. Database search The searches were conducted in May and June 2017. To identify relevant research-based evidence, a combination of several search strategies were used: electronic database queries, hand searching of key journals and consultation with experts and stakeholders. In addition, the reference lists of pertinent articles were checked for studies of relevance to the review. We reviewed papers in English, French, Portuguese, and Spanish. The databases included: Medline, Global health, Cinalh, Psycinfo, Cochrane, ERIC, Google scholar, Scopus, Pascal and Francis. Keywords used in the search and their relations were as follows: • School and (“health promotion” or “health promotion” or “health education” or “whole school” or prevention or “wellbeing promotion”) • Children or adolescents or pupils or students and • Health or healthy eating or physical activity or drug or tobacco or addiction or obesity or overweight or sexuality or sex • Equality or equity or inequality or inequalities or equality Inclusion criteria In a first phase, we included papers reporting on empirical studies and reviews which described: (a) a health promoting schools intervention (policy or programme) focused on children and adolescents (6-16 years old); (b) interventions based on a whole-school approach; (c) research which includes focus on the impact of the intervention on health inequalities; and (d) papers which provides explicit information about the outcomes of the intervention on a structural, organisational and/or individual level. In the second phase, we included papers with the following criteria: (a) any school-based health related intervention (policy or programme) focused on children and adolescents (6-16 years old), (b) focus on any relation between the intervention and health inequalities.
A total of 2026 publications were identified in the first search phase, none of which met the inclusion criteria (health promoting school approach and health inequalities). This finding points to a serious lack of research focusing on the relationship between health promoting schools interventions and health inequalities. The second search phase resulted in selection of 15 articles focusing on universal approaches to health improvement targeting all kind of schools and pupils, and measuring the variation of outcomes depending on SES categories. Some of the studies showed no impact or negative impact of the interventions on inequalities (e.g. De Bourdeaudhuij et al., 2011; Bonell et al., 2013; Grydeland et al., 2014). A few studies found more favourable intervention effects for the pupils with a low-SES background than for those from a high-SES background (e.g. (Bambra et al., 2015). A single intervention showed differential effects depending on the outcomes considered (Berger, Jourdan, & Barnoin, 2006). The review points to differences in the kinetics of the effects; the impact of a programme is quicker and more powerful if the school as an intervention setting is located in a privileged milieu (Jourdan, 2013). Further, the review shows that when positive impact is found (i.e. reduction of the inequality gap), the studies are mostly focused on meal/fruit provision, physical activity promotion, obesity prevention or dental health. Expectedly, it seems that positive influence is easier to document when the outcomes are related to topical interventions with single outcomes rather than for complex interventions with multiple outcomes (Newman, Baum, Javanparast, O’Rourke, & Carlon, 2015). Most of the included programmes are limited to a top-down process of implementation. The last part of the presentation will be devoted to the discussion about what kind of local interventions could contribute to influencing health inequalities.
Bambra, C. L., et al.. (2015). How effective are interventions at reducing socioeconomic inequalities in obesity among children and adults? Two systematic reviews. Southampton (UK): NIHR Journals Library. Berger, D., Jourdan, D., & Barnoin, J. (2006). Health Education in Primary Schools: The Effects of an Educational Programme on the Representations of HIV/AIDS in Children. Science Education International, The Official Journal of ICASE, 17(4), 221–290. Bonell, C. et al. (2013). The effects on student health of interventions modifying the school environment: systematic review. Journal of Epidemiology and Community Health, 67(8), 677–681. https://doi.org/10.1136/jech-2012-202247 Bowen, D. J., et al. (2009). How we design feasibility studies. American Journal of Preventive Medicine, 36(5), 452–457. De Bourdeaudhuij, I., et al. (2011). Are physical activity interventions equally effective in adolescents of low and high socio-economic status (SES): results from the European Teenage project. Health Education Research, 26(1), 119–130. Grydeland, M., et al. (2014). Effects of a 20-month cluster randomised controlled school-based intervention trial on BMI of school-aged boys and girls: the HEIA study. British Journal of Sports Medicine, 48(9), 768–773. Jourdan D. (2013) “Learning to live better together”: enabling schools and communities to implement a health promotion policy and minimize health inequalities in France » in WHO Improving the lives of children and young people: case studies from Europe Volume 3. Langford, R.,et al. (2014). The WHO Health Promoting School framework for improving the health and well‐being of students and their academic achievement. The Cochrane Library. Lewallen, T. C., et al.. (2015). The Whole School, Whole Community, Whole Child model: a new approach for improving educational attainment and healthy development for students. Journal of School Health, 85(11), 729–739. Mays, N., Roberts, E., & Popay, J. (2001). Synthesising research evidence. Studying the Organisation and Delivery of Health Services: Research Methods, 188–220. Newman, L., et al. (2015). Addressing social determinants of health inequities through settings: a rapid review. Health Promotion International, 30 Suppl 2, ii126-143. WHO. (2000). Local action creating health promoting schools. World Health Organization. Retrieved from www.who.int/ school_youth_health/media/en/88.pdf
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