One of the key aims of DECIPHer research is to identify interventions that address health inequalities. These are caused by complex interactions between individual and structural factors, meaning they are notoriously difficult to address.
Health improvement interventions may be universal (given to a whole population, such as everyone in a school, city or country), targeted (given to some people, such as those identified as at highest risk or most in need) or somewhere in between (given to everyone but with different ‘scale and intensity’ according to need). In some cases, interventions which lead to overall improvements in population health may worsen health inequalities, because access to the intervention, or the intervention’s effects, vary for different social groups. However, targeted interventions can also fail to affect health inequalities, or make them worse. There may be stigma attached to being identified as in need of health improvement, dissuading the target groups from taking up the intervention (or causing them harm by doing so). Additionally, as many health inequalities are on a gradient, only targeting one group will not fully address inequalities.
Many inequalities in health and health behaviours begin in childhood, so efforts to address these often focus on this period. Although breakfast skipping becomes more common later in life, most primary school-aged children eat breakfast, and it plays an important role in the overall nutritional value of a child’s diet. Eating a healthy breakfast is linked to many aspects of health and cognitive performance, and breakfast skipping and consumption of less healthy breakfasts are more common in children from less affluent families. This makes breakfast particularly relevant to health inequalities.Providing free healthy breakfasts in school is one popular method of attempting to improve children’s health. In England this has so far been done only on a local level, and tended to be concentrated in areas of higher deprivation. In Wales, the Primary School Free Breakfast Initiative (PSFBI) has, since 2005, offered all primary schools resources and guidance to provide free, healthy breakfasts before school.
Evaluating the Primary School Free Breakfast Initiative
DECIPHer, funded by the Welsh Government, conducted a randomised controlled trial of the PSFBI to investigate its effects, in which 111 primary schools were randomly allocated to either receive or not receive the free breakfasts intervention*. This found that the PSFBI had no overall effect on breakfast skipping – instead, children who had breakfast at home before the intervention now had the free school breakfasts. However, having breakfast at school seemed to mean children had healthier breakfasts, and more positive attitudes towards breakfast.This research also showed that children in more deprived schools ate poorer quality breakfasts, and had less positive attitudes towards breakfast, than children in more affluent schools. These findings suggest that because children attending more deprived schools were eating poorer quality breakfasts to start with, the move towards eating healthier breakfasts at school was likely to have had a greater positive effect for these children.
How did the PSFBI affect health inequalities?
Further DECIPHer research, published recently, linked data from the trial of the PSFBI to data on deprivation, to analyse the effect of the free school breakfasts on health inequalities. Funded by the Welsh Government and the Medical Research Council’s National Prevention Research Initiative, the research investigated the PSFBI’s impact on socioeconomic inequalities (inequalities between more and less affluent people) in healthy eating, attitudes towards breakfast, cognitive function, and behavioural problems.
What methods were used?
Data was gathered from around 4500 children in Year 5 and Year 6 (aged 9-11 years). The following were measured before the intervention started and after 12 months:
- Deprivation – measured for the school by recording the proportion of all pupils, and the proportion of Key Stage 2 pupils (those aged 7-11), entitled to free school meals (FSM). Deprivation was also assessed for individual children by identifying whether or not they were entitled to FSM (yes/no). Data on individual FSM entitlement came from the Secure Anonymised Information Linkage (SAIL) databank, whereas school-level data were provided by the Welsh Government.
- Diet – three aspects:
– Whether or not each child had eaten breakfast that day and the previous day;
– The number of ‘healthy’ and ‘unhealthy’ items each child had eaten for breakfast that day;
– The number of ‘healthy’ and ‘unhealthy’ items of other food each child had eaten in the previous 24 hours.
All were measured by getting the child to recall this information.
- Attitudes towards eating breakfast – measured using a questionnaire completed by all pupils.
- Cognitive function – measured during lessons, using pen-and-paper tests completed by pupils.
- Behavioural problems – measured using a survey completed by teachers, assessing the behaviour of a random sub-sample of ten pupils for each school.
The impact of the PSFBI on all of these was assessed, and the effect of the intervention on inequalities was measured by looking at how its impact differed according to the deprivation of both schools and individual pupils.
What were the results?
No effect was found on breakfast skipping overall. However, the intervention led to bigger reductions in breakfast skipping for pupils attending more deprived schools and those from more deprived households.
Overall, the free school breakfast intervention was associated with greater consumption of healthy food, both at breakfast and throughout the day.The increase in consumption of healthy food at breakfast was larger in more deprived schools. At the individual level (comparing individuals rather than schools), intervention effects were smaller, and the only significant overall effects related to consumption of healthy items for breakfast and unhealthy items throughout the day.
The intervention was not found to have any effect on cognitive functioning or behavioural outcomes, and this did not differ according to deprivation.
When deprivation was studied on an individual level, this did not seem to be related to the effectiveness of the intervention. In general, going to a more/less deprived school seemed to be more important than living in a more/less deprived household.
Importantly, no evidence was found that the PSFBI made inequalities worse for any of the outcomes that were measured.
Why is this important?
The fact that the intervention was more effective in improving dietary behaviour for pupils from more deprived households and schools, and did not increase inequalities in any other measured outcome, suggests that this universal intervention could help to reduce social inequalities in diet. Additionally, the different effects for pupils with different levels of deprivation highlight the importance of evaluating impacts of health improvement interventions on health inequalities, whether or not they have an overall effect at the population level.
* ’Control’ schools were put on a waiting list and received the PSFBI later, after the trial had been completed.
This piece is based on the following paper:Moore G, Murphy S, Chaplin K, Lyons R, Atkinson M, Moore L. ‘Impacts of the Primary School Free Breakfast Initiative on socio-economic inequalities in breakfast consumption among 9–11-year-old schoolchildren in Wales‘ Public Health Nutrition 2013. Published online first: 3 December 2013.