How can school-based interventions reduce health inequalities? Results from two reviews

Abstract Background Even in young people the chances to grow up healthy are unequal, depending on their socioeconomic position (SEP). In order to reduce these health inequalities, the school is an important field of action for health promotion. However, the evidence is limited regarding interventions focusing on health inequalities. Thus, the aim of the current research is to investigate 1) which school-based interventions contribute to the reduction of socio-economic inequalities in health and health behaviour of children and adolescents and 2) how and under what conditions they are successful. Methods A systematic and a realist review were conducted. Some steps of the methodological approach were used synergistically for both reviews: development of the search strategy, selection of the databases (MEDLINE, SSCI, SCIE, DoPHER and TRoPHI) and some inclusion and exclusion criteria. The search covered the years 2000-2020. The screening and subsequent steps were applied specific to each review design. Preliminary results The search resulted in 10,524 hits of which 37 publications were included for the systematic review. Most of the interventions focused on nutrition (14), followed by mental health (8) and substance use (5). The results indicate that structural preventive interventions are more likely to reduce health inequalities compared to behavioral preventive interventions. For the Realist Review 7 studies were included. Intrapersonal, interpersonal, and institutional factors were extracted that are relevant for school-based interventions focusing on adolescents with low SEP. Conclusions The systematic review showed that school-based interventions are able to reduce health inequalities, but also to increase them. Structural preventive measures seem to be helpful in increasing health equity. The Realist review identified mechanisms of interventions which help to address students with lower SEP. Key messages • The evidence regarding interventions with focus on health inequalities is limited. We present two reviews analysing what interventions are needed and how and why they work. • Structural preventive measures seem to be helpful in increasing health equity. Factors on the intrapersonal, interpersonal, and institutional level are important to address students with low SEP.


Background:
Adolescents of lower socio-economic status initiate smoking earlier and smoke more frequently than those of higher socioeconomic status. Tobacco control policies, such as school tobacco policies, aim to reduce adolescent smoking, but their implementation has been found to vary greatly from one school to another. Such differences in the implementation might therefore contribute to social inequalities in smoking.
This study examines whether school tobacco policies are implemented where they are most needed, and how this implementation according to needs has changed over time. Methods: Student (n = 18,805) and staff surveys (n = 438) were conducted in 2013 and 2016 in 38 schools from six European cities in six countries. School tobacco policies were measured as a 10-point score taking into account their multidimensionality, and the perceptions of both students and staff. We used concentration curves and indices to measure the inequality in the implementation of these policies depending on the smoking prevalence and on adolescents' socio-economic status.

Results:
A concentration curve below the perfect equity line indicated a concentration of school tobacco policies where smoking prevalence was lower. Moreover, this inequality was larger in 2016 compared to 2013 (concentration indices of .038 in 2013 and .041 in 2016). On the contrary, a concentration curve overlaying the perfect equity line indicated no inequality in the implementation of these policies depending on adolescents' socio-economic status (concentration indices of .016 in 2013 and -.013 in 2016).

Conclusions:
School tobacco policies have been developed to reduce adolescent smoking. They, however, seem to be less implemented in schools where they are most needed. This confirms that smoking prevention is still driven by the inverse prevention law. Next to evaluating the impact of such policies on smoking outcomes, research should also focus on their contribution to social inequalities in adolescent smoking.

Key messages:
School tobacco policies, developed to reduce adolescent smoking, might contribute to social inequalities in smoking. School tobacco policies are less implemented where they are most needed.

Background:
The number of years -and healthy years -a person is expected to live differs according to gender: women tend to live longer than men, but with a shorter healthy life expectancy (HLE).
Power imbalance, such as income, prestige, or autonomy gaps, may lead to an unequal health distribution across gender in the older ages. The association between gender equality and longer life expectancies has been described, but little is known about its association with HLE. We aimed to study the association between gender equality, and its components, and HLE in Europe, in the last decade.

Methods:
We combined HLE estimates from Eurostat with the Gender Equality Index (and its components) for 27 European countries, from 2013 to 2019. The associations between gender equality and HLE, and its gender gap, were assessed using regression analyses adjusted for Gross Domestic Product, number of medical doctors per 1000 inhabitants (as proxies of economic wellbeing and access to healthcare), and year.