Article Text

Role of contextual and compositional characteristics of schools for health inequalities in childhood and adolescence: protocol for a scoping review
  1. Max Herke1,
  2. Irene Moor1,
  3. Kristina Winter1,
  4. Stephanie Hoffmann2,
  5. Jacob Spallek2,
  6. Jennifer Hilger-Kolb3,
  7. Claudia Pischke4,
  8. Nico Dragano4,
  9. Anna Novelli5,
  10. Matthias Richter1
  1. 1Institute of Medical Sociology, Medical Faculty, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
  2. 2Department of Public Health, Faculty for Social Work, Health, and Music, Brandenburg University of Technology Cottbus-Senftenberg, Senftenberg, Germany
  3. 3Mannheim Institute of Public Health, Social and Preventive Medicine, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
  4. 4Institute of Medical Sociology, Centre for Health and Society, Medical Faculty, Heinrich Heine University Duesseldorf, Duesseldorf, Germany
  5. 5Department of Health Services Management, Ludwig-Maximilians-University Munich, Munich, Germany
  1. Correspondence to Max Herke; max.herke{at}


Introduction Childhood and adolescence are crucial life stages for health trajectories and the development of health inequalities in later life. The relevance of schools for health and well-being of children and adolescents has long been recognised, and there is some research regarding the association of contextual and compositional characteristics of schools and classes with health, health behaviour and well-being in this population. Little is known about the role of meso-level characteristics in relation to health inequalities. The aim of this scoping review is to retrieve and synthesise evidence about the mediating or moderating role of compositional or contextual characteristics of schools for the association between students’ socioeconomic position and health in primary and secondary education.

Methods and analysis We will conduct a systematic search of electronic databases in PubMed/Medline, Web of Science and Education Resources Information Center. Studies must meet the following inclusion criteria: (1) The population must be students attending primary or secondary schools in developed economies. (2) The outcomes must include at least one indicator for individual health, health behaviour or well-being. (3) The study must include at least one contextual or compositional characteristic of the school context and one individual determinant of socioeconomic position. (4) The study must also examine the mediating or moderating role of the contextual or compositional characteristic of the school context for the associations between socioeconomic position and health, health behaviour or well-being. (5) The study must be published since 1 January 2000 in English or German language. We will provide a narrative synthesis of findings.

Ethics and dissemination We will not collect primary data and only include secondary data derived from previously published studies. Therefore, ethical approval is not required. We intend to publish our findings in an international peer-reviewed journal and to present them at national and international conferences.

  • public health
  • health policy
  • community child health

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Strengths and limitations of this study

  • This scoping review follows the guidelines of the ‘Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews’.

  • This study is part of a series of scoping reviews of a joint project examining meso-level determinants of the main socialising contexts of young people: family, kindergarten, school, vocational training, university and work, from ages 0 to 25.

  • Childhood and adolescence are crucial life stages in due to the influence of health trajectories to adulthood.

  • The wide scope of the objective and the expected heterogeneity of included studies only allows for a narrative synthesis of results instead of a meta-analysis.

  • This scoping review only examines children and adolescents from developed economies and focusses on socioeconomic position as a cause of health inequalities.



Childhood and adolescence are periods in life in which the opportunities for health are great and future patterns of adult health are being established.1 2 Encouragingly, the health status of school-aged children and adolescents in Germany and many other European countries has improved over the last decades.3 Despite this positive development, fundamental socioeconomic differences in young people’s health exist. Young people in socioeconomically disadvantaged families (eg, growing up in single-parent families) have a reasonably higher chance of becoming ill or developing early risk factors for chronic non-communicable diseases in later life. For instance, those with a low socioeconomic position report poorer subjective health.4–7 In addition, higher prevalences of overweight, obesity,3 8 tobacco use9 and lower levels of physical activity have been found in this population,10 as well as evidence that these health inequalities have predominantly increased or remained stable over the last two decades.6 11 12 While these health inequalities are receiving renewed scientific interest, little is known about potential factors and mechanisms that impact the relationship between socioeconomic position and health in young people.13

Next to the family, the school represents a key institutional context for young people influencing their physical, psychological and social development.14 Students spend the majority of their weekdays at school and with a group of classmates whom they are required to interact with.15 16 Students share most of their school time with classmates who have different personality traits, social backgrounds and attitudes towards homework and learning. In general, the school environment can be seen as a ‘multilayered phenomenon’17 that consists of classes, schools and school types. Thus, classes represent an important educational setting for young people and differ in terms of learning environment, student participation and the relationships among teachers, students and classmates.15 18 In addition, particularly primary schools are often described as comprehensive schools serving students from different socioeconomic positions and with different levels of ability, leading to a very heterogeneous composition of classes.

There has been a growing interest in unravelling the impact of this multilevel environment of schools on students’ health and academic outcomes (eg, academic self-concept and performance), taking into account characteristics of schools and classes.18–20 Accordingly, it is important to distinguish between compositional and contextual features of schools and classes to explain differences in student outcomes not only by individual-level but also by class-level and school-level characteristics.15 19 Compositional characteristics generally refer to the (social) composition of the student body within schools and classes. They are often measured by aggregating individual student information, such as sociodemographic, socioeconomic or school-related factors (eg, perception of the learning environment or class climate) at the class-level.21–23 In contrast, contextual characteristics of schools or classes include institutional features of different school types, as well as organisational, structural, cultural and physical factors of schools and classes (eg, qualification of the teaching staff, written and unwritten school norms and values, class or school size, equipment, facilities or schooling hours). Based on this literature, it is generally assumed that these characteristics are associated with cognitive and non-cognitive outcomes above and beyond students’ individual cultural and social resources.15 18–23

Beyond individual-level determinants, it is important to take environmental determinants into account and consider that inequalities in child and adolescent health may be shaped by institutional contexts in which they grow up.24 Previous systematic literature reviews examined the association of school-level determinants on students’ health. The wide range of school-level determinants can be broken down into several broad categories, which are not conclusive, but allow for a rough classification. These categories are school composition, school climate, policies, facilities and obesogenic environment.

School or class composition includes determinants that are derived from aggregating individual-level characteristics at the school-level or class-level. These might include determinants, such as the average socioeconomic position or school achievements of students, gender ratios, ethnic composition, rates of school attendance or common health behaviours of students. The impact of social comparison and reference group effects25 have been well studied in educational and psychological sciences in relation to outcomes, such as self-esteem, academic self-concept and performance,17 25 26 but rarely with regard to health outcomes.20

School climate or school culture includes determinants describing the quality of the interactions within schools and the overall character of school life. These might relate to the teacher–student relationships, such as the way teachers control students and demand school achievements, how teachers promote autonomous learning and interactions between students, or students’ perception of teaching practices, in general. Relationships between students are relevant as well, which pertain to the relationships between students, or student’s and school staff’s norms regarding life in school. A positive school climate is associated with higher school satisfaction and attachment, and such a school environment in turn promotes a healthy physical, psychological and social development.20 27 28

Policies include the usually codified norms and expectations present in schools, which are often enforced by staff, and which relate to aspects, such as alcohol consumption or substance use. These have been studied extensively with regard to these health behaviours and are often targeted by school interventions.20 29–31

School facilities and the physical school environment, in general, can have an impact on students’ health, well-being or health behaviour. The availability of, for example, a gymnasium, sports equipment on the school grounds, or a swimming hall might provide students with opportunities for physical activities (ie, improved health behaviour), or the structural conditions of the school or its surroundings might impact students’ health as well.20 32

An obesogenic environment includes all aspects of schools that reinforce unfavourable eating behaviours. This overlaps with aspects of other categories, such as policies (eg, guidelines for healthy school meals), or school facilities (eg, the availability and stocking of vending machines on school grounds). Though this might be included in other categories, it is listed separately due to the considerable attention it has gained in previous research.33–39

These school-level determinants were examined for their impact on numerous health outcomes. The outcomes most often focused on include alcohol consumption, smoking and substance use,20 29–31 40 eating behaviour and obesity,35 36 38 41 42 behavioural and conduct problems,20 31 43 or physical activity and sedentary behaviours.33 34 37 39 41

The evidence of the association between school-level characteristics and student health, well-being and health behaviours suggests that the average impact is low to moderate (eg, the impact of tobacco control policies on smoking, the association of high school attendance rates with lower rates of substance use, the relationship between a good school climate and better subjective well-being.20 29 30 Some studies consider individual characteristics to mediate the effects of school-level characteristics20 30 34 37 or to act as a moderator.39

While associations between school characteristics and overall health are well studied, little is known about possible effects of meso-level factors on the strength and direction of health inequalities prevalent among young people. This is a relevant lack because it can be assumed that contextual and compositional characteristics of schools are likely to shape socioeconomic inequalities in health among young people above and beyond individual-level determinants.

The examination of the wider social determinants of health24 44 is necessary to extend the predominant focus on factors at the individual level as drivers of health inequalities. According to existing approaches linking more proximal macro-level determinants (eg, welfare state regimes) to health and health inequalities,45 46 it is conceivable that meso-level determinants (eg, school composition, school climate, policies, facilities or obesogenic environment) have a direct effect on health and possibly mediating or moderating the association between socioeconomic position and health.47 48 This expanded focus could contribute to a more comprehensive understanding of the drivers behind socioeconomic inequalities in young people’s health.

This review is not limited to specific categories of school determinants, but seeks to examine all possible characteristics of the school level in terms of how they influence health inequalities. This very large scope on the side of school-level determinants will be complemented by a wide range of health outcomes, that is, objective and subjective physical, as well as mental health, and health behaviours. At the level of individual characteristics; however, a restriction to socioeconomic characteristics is made and other determinants of inequalities, such as gender, age or ethnicity are taken into account, if differential results found or if these are essential characteristics of a study’s population. Regarding the population, this work focuses on students in developed economies.49 Student bodies of schools in developing economies often do not represent adolescents' health in a region very well, due to low school retention rates50 51 and differences in school environments (sometimes fundamental, for example, regarding water, sanitation, hygiene, or facilities52 53) further compound the comparison and synthesis of findings. The aim is to answer the following research question:

Is the association between socioeconomic position and child health mediated or moderated by compositional or contextual characteristics of schools?


The objective is to retrieve and synthesise evidence about the mediating or moderating role of compositional or contextual characteristics of schools for the association between students’ socioeconomic position and health.

Methods and analysis

The scoping review will follow an extension to the original Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement,54 the PRISMA extension for Scoping Reviews (PRISMA-ScR)55 are conducted to comprehensively assess the existing literature on a complex situation and/or problem which is not well suited for a systematic review. Following the PRISMA-ScR, we will not critically appraise the quality and risk of bias of the included studies and will not conduct a meta-analysis.

Eligibility criteria

We will include all studies and publications in the scoping review, that fulfil the criteria regarding population, determinants, outcomes, study design, language and publication date given in table 1.

Table 1

Overview of inclusion and exclusion criteria

Information sources

We will search the following electronic databases:

  • PubMed/Medline.

  • Web of Science.

  • Education Resources Information Center.

We will also search the references of studies that meet the inclusion criteria for further eligible studies. However, we will exclude other databases as we already cover health, medical, educational and social sciences. Grey literature will not be included.


We will conduct the electronic searches using four blocks of search terms, as well as an additional restriction by date. The summary of the electronic search strategy is as follows:

  • Block 1: Schools.

  • Block 2: Context.

  • Block 3: Outcomes.

  • Block 4: Socioeconomic position.

  • Other: Date.

A full overview of all search terms for each block is given in online supplemental appendix 1. The search terms within each block will be linked with the OR logical operators, and the blocks will be linked with the AND operator. We will search titles and if these are inconclusive the abstracts as well. For PubMed/Medline, some of the search terms are also marked as ‘Medical Subject Headings’ terms.42 The full syntax that will be used for the electronic search in PubMed/Medline can be found in online supplemental appendix 2.

Selection of sources of evidence

All search results will be combined and then automatically deduplicated using a reference management software (Citavi V.6).56 Titles and abstracts will be screened by two reviewers independently. Disagreements will be resolved by discussion between both reviewers. In case agreement between both reviewers cannot be achieved, a third researcher who is familiar with the topic of the review will make the final decision. Full texts of the articles remaining will then be screened independently by two reviewers. Disagreements will be discussed and resolved by a third researcher in case no agreement can be achieved between both reviewers.

Data charting process

Two authors will independently extract the data from all studies included in this review using a previously developed data extraction form. A third author will compare and review the extracted data. In contradictory cases, this third author will make a final decision.

In case of missing data which are not relevant for the inclusion of the study (eg, number of males or females), respective columns in the data extraction form will be left empty.

Data items

The data will be extracted, using a previously developed and tested data extraction form. Extracted information will include, but is not limited to, the following data:

  • Author names.

  • Year of publication.

  • Year that study was conducted.

  • Country of sample origin.

  • Study design.

  • Number of participants.

  • Sociodemographic and socioeceonomic characteristics of participants.

  • Compositional and contextual characteristics of schools.

  • Determinants of health inequalities.

  • Outcome measures.

  • Main findings.

Critical appraisal of individual sources of evidence

We will not provide a critical appraisal of individual sources of evidence.

Synthesis of results

Due to the wide scope of the review, the expected heterogeneity in methods, outcomes and determinants in included studies, we will conduct a narrative synthesis of findings. We will provide the synthesis following the guidance of the Centre for Reviews and Dissemination.57 The narrative synthesis is supplemented by further approaches to summarise the studies and visualise their key findings. A tabulated summary will provide an overview over the studies’ characteristics. Harvest plots might help visualise the results,58 for example, by providing a simple overview how many studies show either a mediating or moderating role of school-level determinants or not, similar to a cross table.

Patient and public involvement

This research is done without patient involvement. Patients are not invited to comment on the study design and not consulted to develop patient relevant outcomes or interpret the results. Patients are not invited to contribute to the writing or editing of this document for readability or accuracy.

Ethics and dissemination

We will not collect primary data for this scoping review and will only include secondary data derived from previously published studies. Therefore, an ethical approval is not required. We intend to publish our findings in an international peer-reviewed journal and to present them at national and international conferences.


Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.


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  • Contributors MH drafted the manuscript. MH, JH-K, IM and MR contributed to the development of the selection criteria. SH, JS, JH-K, IM, KW, CP, ND, AN, and MR critically revised the draft manuscript for important intellectual content. All authors read and approved the final version of the manuscript.

  • Funding This work was supported by the German Research Foundation grant number FOR2723 (project number 384210238). The individual grant numbers for this subproject and the coordination project are RI2467/8-1 and RI2467/9-1.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.