title: Socioeconomic gradients in the effects of universal school-based health behaviour interventions: a systematic review of intervention studies.
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.
  CRD42014014548.
authors.affiliation: DECIPHer, School of Social Sciences, Cardiff University, 1-3 Museum Place, Cardiff, CF10 3BD, UK. MooreG@cardiff.ac.uk.
authors.forename: Graham F
authors.initials: GF
authors.lastname: Moore
authors.affiliation: DECIPHer, School of Social Sciences, Cardiff University, 1-3 Museum Place, Cardiff, CF10 3BD, UK. LittlecottH@cardiff.ac.uk.
authors.forename: Hannah J
authors.initials: HJ
authors.lastname: Littlecott
authors.affiliation: DECIPHer, School of Social Sciences, Cardiff University, 1-3 Museum Place, Cardiff, CF10 3BD, UK. TurleyRL@cardiff.ac.uk.
authors.forename: Ruth
authors.initials: R
authors.lastname: Turley
authors.affiliation: Jack Brockhoff Child Health and Wellbeing Program, School of Population and Global Health, University of Melbourne, Melbourne, Australia. ewaters@unimelb.edu.au.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Waters
authors.affiliation: DECIPHer, School of Social Sciences, Cardiff University, 1-3 Museum Place, Cardiff, CF10 3BD, UK. MurphyS7@cardiff.ac.uk.
authors.forename: Simon
authors.initials: S
authors.lastname: Murphy
mesh_terms: D000428:Alcohol Drinking; D004032:Diet; D005060:Europe; D015444:Exercise; D015438:Health Behavior; D006293:Health Promotion; D006801:Humans; D009656:North America; D011203:Poverty; D012574:Schools; D012907:Smoking; D012923:Social Class; D012959:Socioeconomic Factors