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Background: Implementing health improvement is often perceived as diverting resource away from schools' core business, reflecting an assumption of a "zero-sum game" between health and education. There is some evidence that health behaviors may affect young people's educational outcomes. However, associations between implementation of school health improvement and educational outcomes remains underinvestigated. Methods: The study linked school-level data on free school meal (FSM) entitlement, educational outcomes, and school attendance, obtained from government websites, with data from the School Environment Questionnaire (SEQ) on health improvement activity collected in Wales (2015/2016). Spearman's rank correlation coefficients and linear regression models tested the extent of association between health improvement activity and attendance and educational outcomes. Results: SEQ data were provided by 100/115 network schools (87%), of whom data on educational performance were obtained from 97. The percentage of pupils entitled to FSM predicted most of the between-school variance in achievement and attendance. Linear regression models demonstrated significant positive associations of all measures of health improvement activity with attainment at Key Stage (KS) 3, apart from mental health education in the curriculum and organizational commitment to health. Student and parent involvement in planning health activities were associated with improved school attendance. There were no significant associations between health improvement and KS4 attainment. Conclusion: Implementing health improvement activity does not have a detrimental effect on schools' educational performance. There is tentative evidence of the reverse, with better educational outcomes in schools with more extensive health improvement policies and practices. Further research should investigate processes by which this occurs and variations by socioeconomic status.

Health inequalities emerge during childhood and youth, before widening in adulthood. Theorising, testing and interrupting the mechanisms through which inequalities are perpetuated and sustained is vital. Schools are viewed as settings through which inequality in young people's health may be addressed, but few studies examine the social processes via which institutional structures reproduce or mitigate health inequalities. Informed by Markham and Aveyard's theory of human functioning and school organisation, including their concept of institutional boundaries, critical theories of marketisation and the concept of micro-political practices within schools, this paper presents analysis of student survey data (N = 9055) from 82 secondary schools in Wales. It examines the role of socioeconomic composition, social relationships at school and institutional priorities in mitigating or perpetuating health inequality. It finds that affluent schools were most unequal in terms of student health behaviours and subjective wellbeing. In relation to health behaviours, students from affluent families accrue a disproportionate benefit. For wellbeing, students from poorer families reported lower subjective wellbeing where attending more affluent schools. Student--staff relationships appear to be a key mechanism underpinning these effects: poor relationships with staff were predicted by a pupil's position within schools' socioeconomic hierarchy and associated with worse health outcomes. That is, students from the poorest families reported better relationships with teachers where attending less affluent schools. Universal approaches engaging with these social processes are needed to reduce health inequalities.

Background: Interventions to address inequalities in adolescent health behaviors often target children from less affluent families, or schools in poorer areas. Few studies have examined whether school- or family-level affluence predicts health behaviors independently, or in combination. Methods: This article reports secondary analysis of the Welsh Health Behavior in School-aged Children (HBSC) survey. Mixed-effects logistic regression models test associations of school and family socioeconomic status (SES) with smoking, fruit and vegetable consumption, alcohol consumption, and physical activity. Results: Higher family SES was associated with healthier behaviors, except in relation to alcohol consumption. For all behaviors except physical activity, school-level SES was independently associated with healthier behaviors. In higher SES schools, a stronger association of family SES with health behavior was observed, particularly in relation to smoking and physical activity. Conclusions: School and family SES may exert independent and combined influences upon adolescent health behaviors. Targeting interventions toward deprived schools may fail to address substantial inequalities within more affluent schools. Targeting deprived families may fail to address behaviors of children from affluent families, attending more deprived schools. Identifying universal health improvement interventions which have greater effects among children from poorer backgrounds may be a more effective means of reducing inequalities.

Objectives: To examine the prevalence of electronic(e)-cigarette use, prevalence of e-cigarette and tobacco use by age, and associations of e-cigarette use with sociodemographic characteristics, tobacco and cannabis use among young people in Wales. Design: Data from two nationally-representative cross-sectional surveys undertaken in 2013-2014. Logistic regression analyses, adjusting for school-level clustering, examined sociodemographic characteristics of e-cigarette use, and associations between e-cigarette use and smoking. Setting: Primary and secondary schools in Wales. Participants: Primary-school children aged 10-11 (n=1601) and secondary-school students aged 11-16 (n=9055). Results: Primary-school children were more likely to have used e-cigarettes (5.8%) than tobacco (1.6%). Ever use of e-cigarettes remained more prevalent than ever use of tobacco until age 14-15. Overall, 12.3% of secondary-school students (aged 11-16) reported ever using e-cigarettes, with no differences according to gender, ethnicity or family affluence. The percentage of 'never smokers' reporting having used e-cigarettes was 5.3% at age 10-11 to 8.0% at age 15-16. The proportion of children who had ever used an e-cigarette and reported currently smoking increased from 6.9% among 10-11 year olds to 39.2% in 15-16 year olds. Only 1.5% (n=125) of 11-16 year-olds, including 0.3% of never smokers, reported regular e-cigarette use (use at least once a month). Current weekly smokers were 100 times more likely than non-smokers to report regular e-cigarette use (relative risk ratio (RRR=121.15; 95% CI 57.56 to 254.97). Regular e-cigarette use was also more likely among those who had smoked cannabis (RRR 53.03; 95% CI 38.87 to 80.65). Conclusions: Many young people (including never-smokers) have tried e-cigarettes. However, regular use is less common, and is associated with tobacco cigarette use. Longitudinal research is needed to understand age-related trajectories of e-cigarette use and to understand the temporal nature of relationships between e-cigarette and tobacco use. [ABSTRACT FROM AUTHOR]

Background: Interventions to improve young people's health are most commonly delivered via schools. While young people attending the lowest socioeconomic status (SES) schools report poorer health profiles, no previous studies have examined whether there is an 'inverse care law' in school health improvement activity (i.e., whether schools in more affluent areas deliver more health improvement). Nor have other factors that may explain variations, such as leadership of health improvement activities, been examined at a population level. This paper examines variability in delivery of health improvement actions among secondary schools in Wales, and whether variability is linked to organisational commitment to health, socioeconomic status and school size., Methods: Of the 82 schools participating in the 2013/14 Health Behaviour in School-aged Children (HBSC) survey in Wales, 67 completed a questionnaire on school health improvement delivery structures and health improvement actions within their school. Correlational analyses explore associations of delivery of health improvement activity among schools in Wales with organisational commitment to health, socioeconomic context and school size., Results: There is substantial variability among schools in organisational commitment to health, with pupil emotional health identified as a priority by 52 % of schools, and physical health by 43 %. Approximately half (49 %) report written action plans for pupil health. Based on composite measures, the quantity of school health improvement activity was greater in less affluent schools and schools reporting greater commitment to health. There was a consistent though non-significant trend toward more health improvement activity in larger schools. In multivariate analysis deprivation (OR = 1.06; 95 % CI = 1.01 to 1.12) and organisational commitment to health were significant independent predictors of the quantity of health improvement (OR = 1.60; 95 % CI = 1.15 to 2.22)., Conclusions: There is no evidence of an 'inverse care law' in school health, with some evidence of more comprehensive, multi-level health improvement activity in more deprived schools. This large-scale, quantitative analysis supports previous smaller scale, qualitative studies/process evaluations that suggest that senior management team commitment to delivering health improvement, and formulating and reviewing progress against written action plans, are important for facilitating the delivery of comprehensive interventions.

Objective: Small increases in smoking restrictions in cars and homes were reported after legislation prohibiting smoking in public places. Few studies examine whether these changes continued in the longer term. This study examines changes in restrictions on smoking in cars and homes, and child exposure to secondhand smoke (SHS) in these locations, since 2008 postlegislation surveys in Wales., Setting: State-maintained primary schools in Wales (n=75)., Participants: Children aged 10-11 years (year 6) completed CHETS (CHild exposure to Environmental Tobacco Smoke) Wales surveys in 2007 (n=1612) and 2008 (n=1605). A replication survey (CHETS Wales 2) was conducted in 2014, including 1601 children., Primary Outcome Variable: Children's reports of whether smoking was allowed in their car or home and exposure to SHS in a car or home the previous day., Results: The percentage of children who reported that smoking was allowed in their family vehicle fell from 18% to 9% in 2014 (OR=0.42; 95% CI 0.33 to 0.54). The percentage living in homes where smoking was allowed decreased from 37% to 26% (OR=0.30; 95% CI 0.20 to 0.43). Among children with a parent who smoked, one in five and one in two continued to report that smoking was allowed in their car and home. The percentage reporting SHS exposure in a car (OR=0.52; 95% CI 0.38 to 0.72) or home (OR=0.44; 95% CI 0.36 to 0.53) the previous day also fell. Children from poorer families remained less likely to report smoking restrictions., Conclusions: Smoking in cars and homes has continued to decline. Substantial numbers of children continue to report that smoking is allowed in cars and homes, particularly children from poorer families. A growing number of countries have legislated, or plan to legislate, banning smoking in cars carrying children. Attention is needed to the impact of legislation on child health and health inequalities, and reducing smoking in homes., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)