Introduction
To describe the populations who are experiencing inequitable differences we use the term ‘disadvantaged’ although we recognize that this term may not be acceptable to all. In a methodology review of equity assessment, disadvantage was defined in terms of the avoidability or preventability of health inequalities (12 of 34 studies) [11] by focusing on populations that have experienced health inequities (e.g., Aboriginal populations). |
We have chosen to use the term “disadvantaged” for PRISMA-E 2012 because we felt that despite its limitations (e.g., that it may be considered a condescending or paternalistic term), the term “disadvantaged” more clearly defines a population that is experiencing or has experienced health inequities. Whereas vulnerability encompasses a combination of risk, exposure and resilience that do not always lead to health inequities, and other terms such as “marginalized” are too narrowly focused and do not encompass the breadth of settings, contexts and health inequities of interest. |
Scope of PRISMA-E 2012
Methods PRISMA-E 2012 reporting guideline
Section | Item | Standard PRISMA Item | Extension for Equity-Focused Reviews |
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Title | |||
Title | 1 | Identify the report as a systematic review, meta-analysis, or both. | Identify equity as a focus of the review, if relevant, using the term equity. |
Abstract | |||
Structured summary | 2 | 2. Provide a structured summary including, as applicable: background; objectives; data sources; study eligibility criteria, participants, and interventions; study appraisal and synthesis methods; results; limitations; conclusions and implications of key findings; systematic review registration number. | State research question(s) related to health equity. |
2A | Present results of health equity analyses (e.g., subgroup analyses or meta-regression). | ||
2B | Describe extent and limits of applicability to disadvantaged populations of interest. | ||
Introduction | |||
Rationale | 3 | Describe the rationale for the review in the context of what is already known. | Describe assumptions about mechanism(s) by which the intervention is assumed to have an impact on health equity. |
3A | Provide the logic model/analytical framework, if done, to show the pathways through which the intervention is assumed to affect health equity and how it was developed. | ||
Objectives | 4 | Provide an explicit statement of questions being addressed with reference to PICOS. | Describe how disadvantage was defined if used as criterion in the review (e.g., for selecting studies, conducting analyses, or judging applicability). |
4A | State the research questions being addressed with reference to health equity | ||
Methods | |||
Protocol and registration | 5 | Indicate if a review protocol exists, if and where it can be accessed (e.g., web address), and, if available, provide registration information including registration number. | |
Eligibility criteria | 6 | 6. Specify study characteristics (e.g., PICOS, length of follow-up) and report characteristics (e.g., years considered, language, publication status) used as criteria for eligibility, giving rationale. | Describe the rationale for including particular study designs related to equity research questions. |
6A | Describe the rationale for including the outcomes (e.g., how these are relevant to reducing inequity). | ||
Information sources | 7 | Describe all information sources (e.g., databases with dates of coverage, contact with study authors to identify additional studies) in the search and date last searched. | Describe information sources (e.g., health, non-health, and grey literature sources) that were searched that are of specific relevance to address the equity questions of the review. |
Search | 8 | Present full electronic search strategy for at least one database, including any limits used, such that it could be repeated. | Describe the broad search strategy and terms used to address equity questions of the review. |
Study selection | 9 | State the process for selecting studies (i.e., screening, eligibility, included in systematic review, and, if applicable, included in the meta-analysis). | |
Data collection process | 10 | Describe method of data extraction from reports (e.g., piloted forms, independently, in duplicate) and any processes for obtaining and confirming data from investigators. | |
Data items | 11 | List and define all variables for which data were sought (e.g., PICOS, funding sources) and any assumptions and simplifications made. | List and define data items related to equity, where such data were sought (e.g., using PROGRESS-Plus or other criteria, context). |
Risk of bias in individual studies | 12 | Describe methods used for assessing risk of bias of individual studies (including specification of whether this was done at the study or outcome level), and how this information is to be used in any data synthesis. | |
Summary measures | 13 | State the principal summary measures (e.g., risk ratio, difference in means). | |
Synthesis of results | 14 | Describe the methods of handling data and combining results of studies, if done, including measures of consistency (e.g., I
2) for each meta-analysis. | Describe methods of synthesizing findings on health inequities (e.g., presenting both relative and absolute differences between groups). |
Risk of bias across studies | 15 | 15. Specify any assessment of risk of bias that may affect the cumulative evidence (e.g., publication bias, selective reporting within studies). | |
Additional analyses | 16 | Describe methods of additional analyses (e.g., sensitivity or subgroup analyses, meta-regression), if done, indicating which were pre-specified. | Describe methods of additional synthesis approaches related to equity questions, if done, indicating which were pre-specified |
Results | |||
Study selection | 17 | Give numbers of studies screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally with a flow diagram. | |
Study characteristics | 18 | For each study, present characteristics for which data were extracted (e.g., study size, PICOS, follow-up period) and provide the citations. | Present the population characteristics that relate to the equity questions across the relevant PROGRESS-Plus or other factors of interest. |
Risk of bias within studies | 19 | Present data on risk of bias of each study and, if available, any outcome level assessment (see item 12). | |
Results of individual studies | 20 | For all outcomes considered (benefits or harms), present, for each study: (a) simple summary data for each intervention group; (b) effect estimates and confidence intervals, ideally with a forest plot. | |
Synthesis of results | 21 | Present results of each meta-analysis done, including confidence intervals and measures of consistency. | Present the results of synthesizing findings on inequities (see 14). |
Risk of bias across studies | 22 | Present results of any assessment of risk of bias across studies (see item 15). | |
Additional analysis | 23 | Give results of additional analyses, if done (e.g., sensitivity or subgroup analyses, meta-regression [see item 16]). | Give the results of additional synthesis approaches related to equity objectives, if done, (see 16). |
Discussion | |||
Summary of evidence | 24 | Summarize the main findings including the strength of evidence for each main outcome; consider their relevance to key groups (e.g., health care providers, users, and policy makers). | |
Limitations | 25 | Discuss limitations at study and outcome level (e.g., risk of bias), and at review-level (e.g., incomplete retrieval of identified research, reporting bias). | |
Conclusions | 26 | Provide a general interpretation of the results in the context of other evidence, and implications for future research. | Present extent and limits of applicability to disadvantaged populations of interest and describe the evidence and logic underlying those judgments. |
26A | Provide implications for research, practice, or policy related to equity where relevant (e.g., types of research needed to address unanswered questions). | ||
Funding | |||
Funding | 27 | Describe sources of funding for the systematic review and other support (e.g., supply of data); role of funders for the systematic review. |
How to use this paper
Item 1: title
Item 2: abstract
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○ “We aimed to systematically assess current evidence for the association between socioeconomic position (SEP) and caries. We included studies investigating the association between social position (determined by own or parental educational or occupational background, or income) and caries prevalence, experience, or incidence” [32].
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“Our primary outcome is the utilization of [post-natal care] PNC services, and determinants of concern are: 1) socioeconomic status (for example, income, education); 2) geographic determinants (for example, distance to a health center, rural versus urban residence); and 3) demographic determinants (for example, ethnicity, immigration status)” [33]
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○ “No strong evidence of differential effects was found for smoking restrictions in workplaces and public places, although those in higher occupational groups may be more likely to change their attitudes or behaviour. Smoking restrictions in schools may be more effective in girls. Restrictions on sales to minors may be more effective in girls and younger children. Increasing the price of tobacco products may be more effective in reducing smoking among lower income adults and those in manual occupations, although there was also some evidence to suggest that adults with higher levels of education maybe more price sensitive. Young people aged under 25 are also affected by price increases, with some evidence that boys and non-white young people may be more sensitive to price” [18].
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○ “Conditional cash transfer programmes have been the subject of some well-designed evaluations, which strongly suggest that they could be an effective approach to improving access to preventive services. Their replicability under different conditions - particularly in more deprived settings - is still unclear because they depend on effective primary health care, and mechanisms to disburse payments. Further rigorous evaluative research is needed, particularly where [conditional cash transfers] CCTs are being introduced in low income countries, for example in Sub-Saharan Africa or South Asia.” [37]
Introduction section
Item 3: rationale
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○ “CCT programs are justified on the grounds that demand-side subsidies are needed to address constraints and bottlenecks of service delivery. CCT programs usually aim to increase demand for preventive health services and education because these services have positive spillover effects that justify the expense. CCT help overcome barriers to access of services. These programs address social equity concerns because CCT can help to “level the playing field” thus creating equal opportunities” [37].
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○ “Many lay health worker programs aim to address inequity by providing services to underserved communities” [38].
Item 4: objectives
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○ “For the purposes of this review, the term’disadvantaged’ is taken to denote women whom the primary investigators considered to be of low socio-economic status or educationally disadvantaged, or who are under the age of 20[children born to teenage mothers in the UK have been estimated to have a 63 % increased likelihood of being born into poverty], or who are caring for children in single-parent households” [55].
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○ “Parents with children up to the age of school entry and who were socially disadvantaged in respect of poverty, lone parenthood or ethnic minority status.” [17]
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○ “We will retrieve studies implemented in LMICs, as defined by The World Bank Group’s classification… which study access to or utilization of PNC services by birthing women living in resource strained settings.” [33]
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○ 2 objectives “To determine the effectiveness of school feeding programs in improving physical and psychosocial health outcomes for low income school children.” And “To compare the effectiveness of school feeding programmes for socio-economically disadvantaged children and advantaged children” [53].
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○ “To assess the impact on maternal and infant health and on infant development of programmes offering home support in addition to the standard service for teenaged mothers (ages less than 20 years) who had recently given birth and who were socially or economically disadvantaged, for example because they were poor, lived inner city or were single parents” [54].
Methods section
Item 6: eligibility criteria
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○ “Cross-sectional quantitative study designs, qualitative study designs, or a combination of the two (mixed-methods studies). Specifically, we included, first, any type of cross-sectional study design reporting quantitative data. Second, qualitatively-based studies had to have used either individual interviews or focus group interviews to collect data about [female genital mutilation/cutting] FGM/C and used qualitative data analysis methods, such as thematic analysis, to be eligible for inclusion. Third, mixed-methods studies that incorporated both quantitative and qualitative components where the research design matched the nominated study designs were included. Both the quantitative and the qualitative components of the study were subjected to the same inclusion criteria as the mono-methods studies and the study was only included when the inclusion criteria were met” [57].
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○ “We included qualitative studies and studies using descriptive statistics which met the following criteria:1.reported on interventions as identified as “farmer field schools”, although not necessarily the same interventions as those included in the review of effects (review question 1);2.assessed determinants of service delivery quality, knowledge acquisition, adoption of technological improvements, diffusion, or sustainability (either directly or indirectly – for example, studies that were relevant to addressing barriers to and enablers of [farmer field schools] FFS effectiveness)…” [58]
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○ “Other smoking-related outcomes included compliance with age-of-sale legislation, density of advertising and vending machines, brand appeal, and awareness and receptivity to antismoking campaigns. This broad range of smoking-related outcomes was included in order to encompass the diverse ways in which tobacco control policies can influence youth smoking-related outcomes” [60].
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○ “Changes in equity of access - increased access for disadvantaged groups or a reduction in gaps in coverage – could also be an important outcome measure. This required a preliminary analysis and categorisation of the population of interest along a socio-economic scale. We accepted any relevant methodology (e.g., wealth/asset index) provided it was rigorous and described in detail” [37].
Item 7: information sources
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○ “We chose to restrict our search of electronic databases to the 20 databases that had produced the highest yield in the search for a previous systematic review on a related topic, the health effects of new roads. We developed our search syntax iteratively. We first conducted a scoping search with a provisional set of terms, retrieved the 100 most relevant abstracts, and then added additional indexing or text word terms used in those references to our search strategy. We then adapted the search syntax for each database or interface used. We did not limit the search using terms for study design. We decided not to attempt a “systematic” internet search. Instead, we used three quality assured gateway sites...and our own knowledge to generate lists of potentially relevant web sites, from which we selected a purposive sample of 16 sites that contained bibliographies or searchable databases of documents. These represented a range of types of organisation (academic, government, and voluntary), countries of origin (Canada, all the countries of the European Union, Norway, and the United States of America), and language of publication (Danish, English, French, Norwegian, and Swedish)” [65].
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○ “We searched the following electronic databases for primary studies:
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The Cochrane Central Register of Controlled Trials (CENTRAL) 2009, Issue 1, part of the The Cochrane Library (www.thecochranelibrary.com) including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (searched 3 March 2009)
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MEDLINE, Ovid In-Process & Other Non-Indexed Citations and MEDLINE, Ovid (1948 to present) (searched 24 June 2011)
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EMBASE, Ovid (1980 to 2009 Week 09) (searched 2 March 2009)
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PsycINFO, Ovid (1806 to February Week 4 2009) (searched 4 March 2009)
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EconLit, Ovid (1969 to February 2009) (searched 5 March 2009)
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Sociological Abstracts, CSA (1952 to current) (searched 8 March 2009)
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Social Services Abstracts, CSA (1979 to current) (searched 8 March 2009)
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LILACS (searched 6 May 2009)
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WHOLIS (searched 7 May 2009)
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World Bank
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Science Citation Index Expanded (SCI-EXPANDED) (1975 to present) (searched 8 September 2010)
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Social Sciences Citation Index (SSCI) (1975 to present) (searched 8 September 2010). In addition we selected relevant databases from the LMIC database list at: http://epocoslo.cochrane.org. We did not search CINAHL or International Pharmaceutical Abstracts, so it is possible that studies relating to nursing or pharmaceuticals were missed. However, the general searches, including in websites focused on this topic, did not suggest that we had missed any relevant studies. We will add these databases when the review is updated” [66].
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Item 8: search
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○ See Additional file 1: Table S2
Caution should be used when developing the search strategy. Limiting the search using equity-related search terms is not recommended as many studies are not indexed using equity-related terms and potentially relevant studies could be missed. For equity-focused reviews, the search strategy may need to be broadened to reduce the risk of missing potentially included studies. Review authors should plan more time for screening. |
Item 11: data items
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○ “…extracted data on study design, description of the intervention (including process), details on participants (including age, sex, number in each group), length of intervention, definition of poor/low income, other socio-demographic variables, including place of residence, race/ethnicity, age, and nutritional status, critical appraisal (see below), physical, cognitive, and behavioural outcomes. We had planned to extract data on cost-effectiveness, but found none. Where possible, we recorded effects by socio-economic position.” [53]
Item 14: synthesis of results
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○” Studies demonstrating an overall effect on anthropometric outcomes were initially categorized according to whether they were effective or not effective among lower SEP groups. Within these categories, we then analysed studies to identify common characteristics between interventions, including the degree to which they addressed structural barriers to behavioural change; as noted earlier, particular structural barriers may be more or less prevalent among different SEP groups in a population” [70].
Item 16: additional analyses
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○ “Effect modifiers, such as high/low energy, compliance, substitution, and duration of the intervention were examined. In addition, study quality was considered since studies of lower quality often show higher effect sizes than those of higher quality. For example, biased outcome assessment is possible if the outcome assessors are not blinded to study group. This review tabulated the effects for each study by sorting them according to these effect modifiers (type of study, blinding versus unclear blinding, date of study, and high versus low energy) (Kristjansson et al. 2007). The effect of school feeding on learning outcomes may also be affected by contextual factors as teacher absenteeism and availability of learning materials, both of which may be worse in more disadvantaged communities.” [53]
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○ “This study examined the influence of program implementation, program activities, program environment, and individual characteristics on welfare-to-work programs. The authors also considered the unemployment rate for each to determine whether the programs were affected by the availability of jobs in the area in which the program was implemented” [79].
Results section
Item 18: study characteristics
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○ “Of the 82 studies included in this review, 55 studies (67 %) were conducted in six high income countries: Australia, Canada, Ireland, New Zealand, the UK, and the USA. Forty-one of the 82 studies were conducted in the USA. Twelve studies (14.6 %) were conducted in eight middle income countries (Brazil, China, India, Mexico, Philippines, Thailand, Turkey, and South Africa). Fifteen trials (18.3 %) were from 10 low income countries Bangladesh, Burkina Faso, Ethiopia, Ghana, Iraq, Jamaica, Nepal, Pakistan, Tanzania, and Vietnam). In 59 studies the intervention was delivered to patients based in their homes. Five interventions were based solely in a primary care facility…A further eight studies involved a combination of home, primary care, and community based interventions. Four studies delivered the intervention mainly by telephone…while one implemented the intervention through community meetings. For five studies, other sites were used such as the workplace, churches, or homeless shelters” [38].
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○ “Study participants had a mean age of 12.6 years and were described as of American Indian descent and representing the Pueblo, Navajo, Hopi, and Jicarilla Apache Indian Nations. The study setting was described as a boarding school exclusively for American Indian youth and promoting academic excellence” [88].
Item 21: synthesis of results
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○ “This review sought to identify studies which had reported on sociodemographic characteristics known to be important from an equity perspective. For this process, the PROGRESS (Place, Race, Occupation, Gender, Religion, Education, Socio-economic status (SES), Social status) framework was utilised. All studies reported the gender of participants at baseline. Four studies reported the race of participants and the level of education of parents…and two studies included information about the employment status of parents at baseline… included information on SES of participants at baseline based on parental income… reported some indicators related to place (the proportion of participating schools in a rural or urban region) and SES (the proportion of participating schools in an urban region which were also in an area considered to be underprivileged). When analysing data on outcomes, only three studies analysed results by any of the PROGRESS items. …analysed outcomes by gender…analysed outcomes by the same indicators of place and SES that were collected at baseline (these data are discussed above)” [20].
The impact of user fees on access to health services in low- and middle-income countries | ||||
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Population: Anyone using any type of health service in low- and middle-income countries. | ||||
Settings: Burkina Faso, Kenya, Lesotho, Papua New Guinea. | ||||
Intervention: Introducing or increasing user fees | ||||
Comparison: No fees | ||||
Outcomes | Relative change in utilisation1
| Number of studies | Quality of the evidence (GRADE)a
| Comments |
Equity outcome - health utilisation by quartile | N/A | 1 | ⊕ ⊖ ⊖ ⊖ Very low3
| This study where quality improvements were introduced at the same time as user fees found an increase in utilisation for poor groups. The authors did not report the results in a way that the relative change in utilisation could be calculated. |
Vitamin A supplementation for preventing morbidity and mortality in children from six months to five years of age | ||||||
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Patient or population: Children aged between 6 months and five years | ||||||
Intervention: Vitamin A supplementation | ||||||
Comparison: Placebo or usual care | ||||||
Outcomes | Illustrative comparative risksa (95 % CI) | Relative effect (95 % CI) | No. of Participants (studies) | Quality of the evidence (GRADE) | Comments | |
Diarrhoea-related mortality | Low risk population | RR 0.72; 95 % CI 0.57 to 0.91 | 90,951 (7 studies) | +++O moderate2
| Total number of participants reflects number randomised to studies. The analysis combined cumulative risk and risk per/1000 years follow-up. | |
3 per 10001
| 2 per 1000 (2 to 3) | |||||
Follow-up: 48–104 weeks | Medium risk population | |||||
4 per 10001
| 3 per 1000 (2 to 4) | |||||
High risk population | ||||||
9 per 10001
| 6 per 1000 (5 to 8) |
Positive | Neutral | Negative | Mixed | Unclear | Total | |
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Increases in price/tax of tobacco products | 14 | 6 | 4 | 1 | 2 | 27 |
Smokefree-voluntary, regional, partial | 1 | 1 | 19 | 0 | 4 | 25 |
Smokefree-compulsory, national, comprehensive | 2 | 9 | 6 | 1 | 4 | 19 |
Mass media campaigns | 3 | 2 | 5 | 2 | 6 | 18 |
Mass media campaigns-quitlines and NRT | 5 | 3 | 3 | 0 | 1 | 12 |
Controls on advertising, promotion and marketing of tobacco | 2 | 7 | 0 | 0 | 9 | |
Population-level cessation support interventions | 4 | 2 | 0 | 1 | 2 | 9 |
Setting based interventions(community, workplace, hospital) | 2 | 4 | 1 | 0 | 0 | 7 |
Multiple policies | 0 | 2 | 0 | 1 | 1 | 4 |
Total policies | 33 | 36 | 38 | 6 | 17 | 130a
|
Total studies | 31b
| 30 | 37 | 6 | 14b
| 117 |
Item 23: additional analyses
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○ “Effect modifiers were age and socioeconomic status. Younger students had larger effects than older students and students with lower socioeconomic status (SES) had larger effects than those with higher SES.” [96]
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○ “This review used weighted regression analyses to investigate which elements of the programs were independently related to bullying and victimization effect sizes. These analyses showed that the most important elements of the program that were related to a decrease in bullying were parent training/meetings and disciplinary methods. Of all the intensity and duration factors, the most important program elements were intensity for children and parent training/meetings.” [97]
Discussion section
Item 26: conclusions
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○ “This review included studies from high income countries as well as lower-middle- and upper-middle-income countries, with five studies conducted in countries within the latter two groupings (Thailand, Brazil, Chile and Mexico). This means that, while predominantly conducted within high-income settings, the findings from this review may be generalisable to a number of settings. A total of nineteen studies specifically reported incorporating strategies to target socio-economic and/or cultural diversity or disadvantage. One such study was conducted outside of the high-income country setting, in Chile, an upper-middle-income country. Of the remaining eighteen studies, seven studies conducted in the USA were of interventions targeting African American children and their communities and another two studies targeted Native American communities. Other studies targeted participants of low socio-economic status, or were implemented in areas of social disadvantage. By far the most common setting for interventions included in this review were schools (43 studies). Other interventions were (or included) home-based (14 studies), community based (six studies), or were set in a health service (two studies) or care setting (two studies). Eleven studies incorporated interventions across multiple settings.” [20]
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○ “The body of evidence in this review provides some support for the hypothesis that obesity prevention interventions in children can be effective, and where examined, have not caused adverse outcomes or increased health inequalities. To this end, the direction of research and evaluation must move into how to implement effectively to scale, sustain the impacts over time and ensure equitable outcomes. In addition, interventions need to be developed that can be embedded into ongoing practice and operating systems, rather than implementing interventions that are resource intensive and cannot be maintained long-term.” [20]
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○ “Future research should promote the development of effective interventions to enhance the online health literacy of consumers. Thus there is a need for well-designed and rigorously conducted randomised controlled trials (RCTs). These RCTs should involve diverse participants (regarding disease status, age, socio-economic group and gender) to analyse to what extent online health literacy reduces a barrier to using the internet for health information, or if socio-economic group, gender and age are more important in influencing internet use (Livingstone 2006). Trials should be conducted in different settings (including low, middle and high income countries) and should examine interventions to enhance consumers online health literacy (search, appraisal and use of online health information) like internet training courses.” [103]