Health promotion, inequalities and young people's health: a systematic review of research

BackgroundThis report describes an attempt to look at how much health promotion and public health research relating to young people has tackled health inequalities, and in what ways it has done this.Health inequalities are recognised as an important problem nationally and internationally.There is policy interest in improving the health of the most disadvantaged, reducing the gap between the most and least disadvantaged, and reducing gradients across the whole population.Health inequalities arise from variations in social, economic and environmental influences along the life course.Health promotion, particularly when it uses social and structural interventions developed by multi-disciplinary teams working with young people, not merely for them, has the potential to reduce health inequalities among young people immediately, and in their later lives.Inequalities research draws on a range of evidence.Observational studies describe the magnitude and severity of health problems and of inequalities.The findings of these studies can guide the targeting of interventions to reduce disadvantage or inequalities.Interventions evaluated using controlled trials or some other evaluation design can answer questions about effective ways of reducing inequalities.Research reporting people's views and experiences adds valuable qualitative data to observational and intervention evaluations. Results What research has been done? The systematic mapOur systematic map of the research included studies across a wide range of health promotion and public health topics, settings and study designs.There were a total of 191 studies: 154 were found in the inequalities research dataset and 43 in the intervention research dataset, with 6 common to both.The most common health status measured in the inequalities research was physical health (Body Mass Index (BMI), disease) and, in the intervention research, health-related behaviours.Most of the studies were conducted in the USA (55% in the inequalities and 72% in the intervention research datasets).Most of the studies used observational designs.We found only 46 outcome evaluations of health promotion and public health interventions that addressed health inequalities by comparing distinct groups; only 12 of these studies evaluated structural interventions or environmental modifications, and 6 evaluated interventions at the level of social networks.Most studies sampled broad populations rather than well-defined disadvantaged groups.The most common difference examined in the research was gender (56% of the inequalities and 81% of the intervention research datasets), followed by ethnicity (56% and 35%) and SES-relevant differences (55% and 21%).Almost half the studies included comparisons relevant to SES.A wide range of methods were used to measure socio-economic status, including single measures such as occupational class, parental education and income, and multiple measures comprising combinations of these.Ten studies used nine different composite measures of SES.The bulk of the studies in the inequalities dataset contained data relevant to both gaps and gradients (51% compared with 23% of the studies in the intervention dataset).In the inequalities dataset, 25% of the studies focused on gaps only (mostly gender comparison) and 23% on gradients.The comparable figures for the intervention research dataset were 67% gaps studies (again, mostly focused on gender) and 9% gradients studies. How has the research been done? The methods studyMost of the outcome evaluations of interventions we reviewed in depth recruited young people through schools or agencies such as social services.In many studies the recruitment methods used would have excluded the most disadvantaged.A notable feature of these studies was that, although most (n=21 of 28) gave figures for attrition, only about half of these (n=11) reported on the socio-demographic characteristics of participants who dropped out.Few studies involved young people or their parents actively in choosing research priorities or intervention aims (n=2), or developing interventions (n=3).More elicited their views as research participants for the needs assessment (n=4) or process evaluation (n=7).Most studies did not explicitly aim to measure or reduce inequalities.Half the studies (n=15) provided subgroup data, but this was not always analysed appropriately.disconnected literatures of: observational studies addressing inequalities; discourses about inclusive research and public involvement for tackling inequalities; evaluations of health promotion (but not of its effects on inequalities); and methodologies for assessing health inequalities that had been applied almost exclusively to observational studies.Knowledge from these different literatures needs to be joined up in order to build an evidence base to support effective health promotion for young people that reduces, or at least does not increase, health inequalities.There are implications throughout the research pathway for: research priorities, the research community, study designs, methods for data collection and analysis, reporting and publishing.1.