Pons-Vigués et al. BMC Public Health 2014, 14:198
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RESEARCH ARTICLE

Open AccessSocial and health policies or interventions totackle health inequalities in European cities: ascoping review
Mariona Pons-Vigués1,2,3*, Èlia Diez1,2,4, Joana Morrison5,2,1,4, Sergio Salas-Nicás1, Rasmus Hoffmann6, Bo Burstrom7,
Jitse P van Dijk8,9 and Carme Borrell1,2,4,10Abstract
Background: Health inequalities can be tackled with appropriate health and social policies, involving allcommunity groups and governments, from local to global. The objective of this study was to carry out a scoping
review on social and health policies or interventions to tackle health inequalities in European cities published inscientific journals.
Methods: Scoping review. The search was done in “PubMed” and the “Sociological Abstracts” database and waslimited to articles published between 1995 and 2011. The inclusion criteria were: interventions had to take place inEuropean cities and they had to state the reduction of health inequalities among their objectives.
Results: A total of 54 papers were included, of which 35.2% used an experimental design, and 74.1% were carriedout in the United Kingdom. The whole city was the setting in 27.8% of them and 44.4% were based on promoting
healthy behaviours. Adults and children were the most frequent target population and half of the interventions had
a universal approach and the other half a selective one. Half of the interventions were evaluated and showed
positive results.
Conclusions: Although health behaviours are not the main determinants of health inequalities, the majority of theselected documents were based on evaluations of interventions focusing on them.
Keywords: Health inequalities, Public policies, Interventions, Cities, Urban health, Scoping review

Background
Disadvantaged populations have worse health and higher
morbidity and mortality [1]. These inequalities are due todifferent opportunities and resources in relation to healthaccording to social class, gender, country of origin, territory and age [2,3]. Health inequalities tend to be greater inurban areas with disadvantaged and poor populations, affecting, as a result, all city residents [4]. Although cities
offer many opportunities, jobs and services, their density, diversity, urban segregation and heterogeneous socioeconomic characteristics contribute to inequalities inhealth [5].

* Correspondence: mponsv@idiapjgol.info
1
Agència de Salut Pública de Barcelona, Barcelona, Spain
2
CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
Full list of author information is available at the end of the article

Research on the association between place or environment and health and well-being has been carried out bymany scholars from a diversity of disciplines focusing on
assessing differences between and within cities [6]. This
research has permitted identification of the determinantsof health inequalities in urban areas or neighbourhoods
which are: the physical context (e.g. environmental characteristics, etc.) including the built-up environment (e.g.
urbanisation and housing) and the socioeconomic context (e.g. economic factors, employment, public services,safety, etc.) (see Figure 1). Furthermore, the way inwhich cities are organised and managed has an impact
on health inequalities, and can contribute to exacerbate
or reduce them [7-9]. Health in urban populations is inturn shaped by municipal determinants and global andnational trends [6]. Cities are complex systems, and, in© 2014 Pons-Vigués et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of theCreative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly credited.

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Figure 1 The conceptual framework for the social determinants of health inequalities in cities of Europe [8].

consequence, urban health depends on many interactions [7].
Health inequalities can be tackled with appropriate
health and social policies cutting across sectors, involving all community groups and governments, from local
to global [4]. Governance has been defined as the relevant process by which governments and other social organizations and actors interact with citizens and makedecisions in a complex and globalized world [10]. Effective multilevel governance is clearly cross-sectoral andparticipative. Despite the diversity of countries’ regulations, local governments have the power to face healthinequalities. Municipal sectors such as urban planning,
culture, leisure, education, environment, health services,
social services, housing, etc. have a clear impact on thehealth of the citizens [7-9].
Socioeconomic inequalities in health have been recognized at least since the 1980s as being an important public health issue [11]. Europe was the only World HealthOrganization (WHO) Region to develop its own targets
for the Health For All (HFA) strategy in 1985, withTarget 1 of the 38 Targets focusing on the reduction of
inequalities in health [9,12].
However, only 1.7% of the documents published in the
PubMed database related to Epidemiology or Public
Health mention inequalities or determinants of health in
the title or abstract [13]. The majority of these health inequalities studies have been conducted to describe andanalyse inequalities and are not focused on policies orinterventions to reduce them in urban areas [14-17].
Although some countries are increasingly working toachieve health equity, there is little literature describing effective experiences and even less at the urban level. Given
that the majority of the world population lives in cities,
where health inequities are increasing [4] and that local
governments have widely ranging capacities to intervene
upon them, an updated review on published interventions
to reduce health inequalities in cities may be helpful for
future related actions. Therefore, the objective of thisstudy was to carry out a scoping review on social andhealth policies or interventions to tackle health inequalities in European cities published in scientific journals.

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The potential research questions revolve around what is
published, how this evolves, and what types of studies predominate in European cities. For this reason, evaluating
the effectiveness of interventions was not the principal
aim of this scoping review.
This study forms a part of the Ineq-Cities project: Socioeconomic inequalities in mortality – evidence andpolicies in cities of Europe (funded by DG-SANCO of
the European Union); for that reason, the review focusedon European cities. Hence, the project aims to study socioeconomic inequalities in mortality within European
cities, as well to identify social and health policies andinterventions implemented to address them.

Methods
Data sources

A scoping review [18,19] was carried out to select papers
on policies or interventions to tackle inequalities inhealth in European urban areas published in scientificjournals. We sought primarily to perform a mapping of
the published papers; therefore, the main objective was
not to assess the quality. Consequently, we opted for ascoping review which has been described as a process of
mapping the existing literature or evidence base, exploring it without describing findings in detail [18,19]. In
this complex topic, a scoping review is an important andnecessary first step before undertaking a more intensive
knowledge synthesis because it helps identify appropriate
parameters and potential scope [19].
A bibliographic search was done in the National Library of Medicine’s PubMed database and in the CSA

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Sociological Abstracts database. Biomedical and social
databases were chosen to cover different fields and disciplines related to the topic. In addition, a manual searchin the reference lists of the papers selected through these
two electronic databases was performed [20]. Thesesources were combined in order to capture as much
relevant information as possible. Table 1 illustrates thesearch strategies and the inclusion and exclusion criteria.
The search was limited to papers related to European
cities and published between January 1995 and March
2011. Additional requirements for papers were: 1) presentation of the execution and/or results directly related
to interventions or policies to reduce health inequalities(interventions had to state the reduction of health inequalities among their objectives), 2) written in English,
Spanish or French, and 3) published in peer-reviewed
journals. Theoretical papers and those only mentioning
health inequalities as a conclusion or recommendation
were excluded. As the research questions were what is
published, how this evolves and what types of studies
predominate, papers were not excluded due to the methodology used.
Study selection

Figure 2 represents the data extraction flow chart. The
searches in Pubmed and Sociological Abstracts were carried out on the 1st of April 2011, and identified 1162 papers (849 papers from Pubmed and 313 from Sociological
Abstracts). All these citations were systematically screened
and evaluated by one author to exclude publications irrelevant to the inclusion criteria. Therefore, according theTable 1 Search strategy applied in Pubmed and Sociological Abstracts databases
INCLUSION criteria

European Cities
Papers published between January 1995-March 2011
Papers published in peer-reviewed journals
Papers on policies or interventions to reduce health inequalities
Papers in English, Spanish or French

EXCLUSION criteria

Theoretical papers on policies or interventions to reduce health inequalities
Papers that only talk about reducing inequalities in the conclusions or recommendations

Pubmed search(health equit* [Title/Abstract] OR health inequalit* [Title/Abstract] OR health inequit* [Title/Abstract] OR disparit*[Title/Abstract] OR depriv* [Title/Abstract] OR social justice* [Mesh]) AND (policy [Mesh] OR policy making [Mesh] OR
health policy [Mesh] OR organizational policy [Mesh] OR health plan implementation [Mesh] OR community healthplanning [Mesh] OR government program [Mesh] OR program evaluation [Mesh] OR intervention* [Title/Abstract] OR
policy* [Title/Abstract] OR policies [Title/Abstract] OR plan [Title/Abstract] OR action [Title/Abstract]) AND (Urban
renewal [Mesh] OR Urban Health [Mesh] OR urban regeneration [Title/Abstract] OR Cities [Mesh] OR city planning[Mesh] OR urban area [Title/Abstract] OR city* [Title/Abstract] OR cities [Title/Abstract] OR healthy city* [Title/Abstract]
OR municipal* [Title/Abstract] OR town [Title/Abstract])

CSA Sociological abstracts ((TI = ((health inequit*) or (health inequalit*) or (health inequit*)) or TI = (disparit* or depriv*)) or (AB = ((healthsearchinequit*) or (health inequalit*) or (health inequit*)) or AB = (disparit* or depriv*)) or (DE = (social justice*))) and((DE = (policy or (policy making) or (health policy)) or DE = ((organizational policy) or (health plan implementation) or(community health planning)) or DE = ((government program) or (program evaluation))) or (TI = (intervention* orpolicy* or policies) or TI = plan) or (AB = (intervention* or policy* or policies) or AB = plan)) and ((DE = ((urban
renewal) or (urban health) or cities) or DE = (city planning)) or (TI = ((urban area) or city* or cities) or TI = ((health city*)or municipal* or town)) or (AB = ((urban area) or city* or cities) or AB = ((health city*) or municipal* or town)))Pons-Vigués et al. BMC Public Health 2014, 14:198
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Search in Pubmed database849 papers

Search in Sociological Abstract
313 papers

1 person reviewed thesetting, the publication
date and the journal

231 papers published in the
study period and related toEuropean cities

1 person reviewed
the journal of thepapers165 papers were retrieved
from peer-reviewed journals
1 person reviewed
the setting and the
publication date

Two reviewers
screened independently
the abstracts

81 papers to review

20 papers to review

Two reviewers
screened independently
the full documents

46 papers were selected

Two reviewers
screened independently
the full documents

2 papers were selected

Review of the title of the references of the 48 selected
papers (1400 references aprox)
Two reviewers screened independently
81 papers to review the abstract
Two reviewers screened independently
6 papers were selected

After all the process, 54 papers were selected

Figure 2 Literature review and data abstraction flow chart.

Pubmed search, 231 papers related to European cities had
been published in the study period. Two reviewers independently screened these 231 abstracts, and 81 papers
were selected to be completely reviewed. Finally, 46 ofthese papers were included in the study.
With reference to the Sociological Abstracts search,
165 papers were retrieved from peer-reviewed journals.
Nevertheless, only 20 of them were related to European
cities and published in the study period. Two reviewers
independently screened these 20 papers and two of themwere included in the study. In both searches, the disagreement between the reviewers about 22 documents
was resolved by a third reviewer.
The titles of the documents referenced in the 48 papers selected were screened to exclude obviously irrelevant or duplicate documents. After that, their abstracts
were screened independently by two reviewers (MP, JM)
who had previously screened the papers in order tofind additional ones to be included. The same criteria
formerly used were applied. This manual search in theselected papers’ reference lists led to the identification of
6 new papers. In consequence, the entire review process
resulted in the selection of 54 papers.

Data extraction, variables and data analysis

The following data were extracted from each publication: authors, year of publication, goal of the paper, study
design, city and year of the intervention, target population of the intervention, intervention description, evaluation of the intervention and results or health outcomesof the paper. This information for each paper was captured in a table displayed in the annex of this review(see Additional file 1: Tables S1-S5), and in a database.
Five researchers participated independently in the study
selection and the data extraction.

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The main characteristics of the documents were classified and are summarized in Tables 2 and 3, taking into
account the following variables:– Type of intervention to reduce health inequalities: 1)
Promotion of health behaviours, 2) Healthy settings(where people actively use and shape theenvironment; as for example, school, workplace,neighbourhood and community), 3) Socioeconomic
context (economic factors, employment and working
conditions, public services and social transfers), 4)
Physical context (climate, built-up environment andenvironmental characteristics) and 5) Combined
approach. This taxonomy was based on the IneqCities
project conceptual framework [8,21], (Figure 1),
adapted from the one proposed by the WHO Hidden
Cities Report [4] and from Vlahov [5].
– Study design of the paper: documents were classified
according to the design type of the research
conducted. The categories were: experimental
studies, quasi-experimental studies, observational
studies, qualitative studies, reviews, health impact
assessment studies and mixed-methods (studies
combining two or more designs).
– Country of city intervention: this variable described
the cities where interventions were developed
according to the home country. An extra category
was added when the intervention took place
simultaneously in different cities in different
European countries.
– Setting of the intervention: this variable indicateswhere the intervention was performed and it was
categorised as: the entire city, a neighbourhood orarea, a healthcare or social center, school, or a
specific community group.
– Target population of the intervention: a variableconsisting of three categories according to the age ofthe participants: children, adult and all ages.
– Focus of the intervention: a dichotomous variableindicating whether the intervention was universal
or selective (intervention was addressed to a partof the population with some risk or vulnerable
features).
– Evaluation of the intervention: this variable collects
information from the paper about whether theintervention had been evaluated, and the type of
result (positive, negative or partially positivenegative). Some interventions could have been
evaluated but if this had not been indicated in thepaper it was not stated. It includes different types of
evaluation: efficiency, effectiveness, impact, monitoring,satisfaction, etc.
– Year of publication categorized in three groups:
1995-2000, 2001-2005 and 2006-2011.

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Results
The entire review process led to the selection of 54 papers. The main characteristics are presented in Table 2
and 3 summarizes the objective according to the type ofintervention, the setting and the target population.
Although publication of interventions tackling health inequalities has increased considerably over the last 15 years,
the number of documents is still very small. Between 1995
and 2000, six papers were published, whereas in the past 6
years (2006 - April 2011), 26 papers had been published(48.2% of the documents of this review). Nineteen of thepapers reviewed (35.2%) used an experimental design suchas randomised controlled trials, followed by 13 quasiexperimental studies (24.1%). 16.7% of the documents(9 papers) were observational studies whereas 9.2% werereview (5 papers) and qualitative studies (5 papers).
Forty of the 54 studies (74.1%) were carried out in cities of the United Kingdom. The 18 remaining papers
were divided between cities in Spain (5 studies, 9.2%),
the Netherlands (4 studies, 7.4%), Germany (2 studies,3.7%), France (1 study, 1.9%) and other European countries (2 multicentric studies, 3.7%). The setting of theintervention is more evenly distributed. The setting of
15 papers was the whole city (27.8%), in 13 it was a deprived neighbourhood (24.1%) and in 12 a healthcare orsocial center (22.2%).
The majority of the interventions targeted both adultand child populations (23 studies, 42.6%). Half of themused a universal approach, and the other half a selective
one. The majority of the interventions were evaluated(46 interventions, 79.3%) and 29 of them had positive
results (53.7%). The rest of the evaluation showed that
8 interventions (14.8%) were not effective, 7 (13.0%)
showed both positive results and negative results, and 2interventions (3.7%) did not mention the results of theirevaluation. Not all of the evaluated interventions used
health indicators as outcome measures. Further detailsof the evaluation of each intervention or policy are available in the supplementary data.
Almost half of the interventions promoted healthy behaviours (24 documents, 44.5%), for example to promoteoral health programmes, increase physical activity, decrease cardiovascular risk factors, etc.; 10 interventions(18.5%) promoted healthy settings, for example to improve road safety, redesign a playground, etc.; 6 interventions (11.1%) targeted the socioeconomic context, forexample: transport policy, food services, etc.; 4 interventions were focused on the physical context (7.4%), forexample: neighbourhood renewal, etc.; and 10 interventions (18.5%) used a combined approach, for example:
environmental and educational interventions to promotewater consumption. Further details of the documents
employing these five approaches are available in the supplementary data.

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Table 2 Descriptive characteristics of the 54 papers obtained classified by type of intervention
Type of intervention

Total

Promote healthy
behaviours

Promote healthy
settings

Socio-economic
context

Physicalcontext

Combined
approach(N = 24 - 44.5%)(N = 10 – 18.5%)(N = 6 – 11.1%)(N = 4 – 7.4%)(N = 10 – 18.5%)

Experimental

11

3

2

0

Quasi-experimental

5

5

0

1

Observational

5

1

2

Qualitative

1

1

0

Review

1

0

Health impact assessment

00Mixed methods

1

0

N

%

3

19

35.2

2

13

24.1

1

0

9

16.7

0

3

5

9.2

0

2

2

5

9.2

2

0

0

2

3.7

0

0

0

1

1.9

Study design

Country
United Kingdom

19

9

4

4

4

40

74.1

Spain

0

0

2

0

3

5

9.2

Netherlands

4

0

0

0

0

4

7.4

Germany

0

0

0

0

2

2

3.7

France

1

0

0

0

0

1

1.9

Different European countries

0

1

0

0

1

2

3.7

City

3

2

4

3

3

15

27.8

Neighbourhood

6

3

1

1

2

13

24.1

Healthcare center

11

0

0

0

1

12

22.2

School

2

4

1

0

2

9

16.7

Community group

2

1

0

0

2

5

9.2

14

1

1

0

2

18

33.3

Setting

Target population
AdultsChildren

4

6

0

1

2

13

24.1

Adults and Children

6

3

5

3

6

23

42.6

Universal

10

6

3

3

5

27

50.0

Selective

14

4

3

1

5

27

50.0

Focus

Evaluation of the intervention
Yes, positive result

13

6

3

1

6

29

53.7

Yes, negative result

5

1

0

0

2

8

14.8

Yes, positive and negative results

2

1

1

3

0

7

13.0

Yes, missing result

0

2

0

0

0

2

3.7

No

1

0

1

0

0

2

3.7

Missing

3

0

1

0

2

6

11.1

2006–2011

14

6

2

0

4

26

48.2

2001–2005

7

1

4

4

4

20

37.0

1995-2000

3

3

0

0

2

8

14.8

Year of publication

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Table 3 Interventions classified according to type of intervention, setting and target population
Type ofintervention

Setting

Promotehealthy
behaviours

City

Target population
Adult

Children

Physical and cognitive training programme
Different activities to promote healthy eating

Neighbourhoodor area

A weight management programme

Healthcare orsocial center

A web-based intervention to support selfmanagement in patients with coronary heartdiseasePhysical exercise program

Adult & Children
Health check tests and aposter campaign

Reduce teenage pregnancy Introduction of health brokers
to promote health
Dietary health education
programIntensive home-visiting
program
Oral health promotion
programAssessing CVD risk in pharmacies

Interventions to prevent
mother-to-child transmissionof HIV
Introduction of asthma
specialist nurses

Preventive care of patients with high CV risk

Individual asthma education
programme

Cultural approach to CV risk prevention program
Behavioural counselling on fruit and vegetables
consumption
Health shop in community centre
Cognitive Behaviour Theraphy for smokers
SchoolCommunity
group

Promotehealthysettings

Teacher-supervised
toothbrushing

Oral health promotion
programIntervention for diabetes support and education
Health education and physical exercise
programme

City

Domestic water
fluoridation

Neighbourhoodor area

Receiving pasteurised
cows’ milk by 6 months ofageFree smoke alarms and fire
safety information
Improved physical access tohigh-quality ‘healthy’ foods
Installation of central heating

Healthcare orsocial center
SchoolRoad safety program
Free healthy school meals
Playground redesignintervention

Socioeconomic
context

Communitygroup

Impact of English smoke-free legislation

City

Food services and insertion for the homelessPrimary care reform
Transport strategy

Neighbourhoodor area

Early Years Centers provide
high quality day care

Healthcare orsocial center
SchoolCommunity
group

Providing daycare facilities foryoung children

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Table 3 Interventions classified according to type of intervention, setting and target population (Continued)
Physicalcontext

City

Traffic calming

Urban regeneration programs
Interventions to improve
housing

Neighbourhoodor area

Neighbourhood renewal

Healthcare orsocial center
SchoolCommunity
group
Combined
approach

City

Healthy cities
Strategies to reduce healthinequalities

Neighbourhoodor area

Family Support Services

Healthcare orsocial center

Postnatal Support Health
VisitorSocial and health maternal andchild intervention

SchoolCommunity
group

Environmental andeducational intervention
Race equality policies
Social care and health follow-up programme
targeting homeless tuberculosis patients

CVD: Cardiovascular diseases.
CV: Cardiovascular.
HIV: Human Immunodeficiency Virus.

More than half of the interventions promoting healthbehaviour had adults as the target population (14 papers), 14 papers used a selective approach, 13 papers
were evaluated and found positive results. Eleven ofthese 24 interventions were set in healthcare centers. Examples of interventions developed in health centres andaimed at the adult population are behavioural counselling on fruit and vegetables consumption [22], and setting up a health shop in a community centre [23].
Six of the 10 interventions promoting healthy settings
targeted children, had a universal approach, were evaluated and showed positive results. Four of these interventions were developed at schools, for example, playgroundredesign interventions [24,25].
Five of the 6 papers about interventions related to socioeconomic context and material resources were addressed to the whole population, three papers took auniversal approach, four papers addressed the whole
city and 4 papers were evaluated and found positive
results. Primary health care reform [26] was an example
of intervention aimed at the entire population of thecity.
The physical context was the focus of only 4 interventions. Three of them targeted the whole population,
were evaluated and obtained both positive and negative
results.

More than half of the interventions using a combination approach targeted the whole population (6 papers),
used a universal approach (5 papers), were evaluatedand obtained positive results (6 papers). Three of theseinterventions addressed the whole city, for example interventions related to the healthy cities strategy [27].
During the review process some protocols of design,
implementation or interventions evaluation were identified. Although they were out of the scope of this study,
we considered that they provided interesting information. For that reason, these 4 studies are cited in thispaper [28-31].

Discussion
This project identified 54 papers published in scientificjournals related to social and health policies or interventions to tackle health inequalities in European cities. A
third of the studies used an experimental design, most ofthem were carried out in the United Kingdom, a quarterhad either the whole city as the setting or a deprived
neighbourhood and half of them promoted healthy behaviours. The majority of the interventions targeted both
adults and children, half of them used a universal approach and the other half a selective one. Half of the interventions were evaluated and had positive results.

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Although the volume of publications in this field has
increased over the years, there are still relatively few papers published in scientific journals related to policies
and interventions focussed on real experiences to tackle
health inequalities. Different factors may contribute tothis fact. As the literature shows, searching for studies
on the social determinants of health or health inequalities is difficult and time-consuming [16]. Although the
combination of heterogeneous sources of data were included in order to include as much relevant informationas possible, there are probably many documents describing interventions to reduce social inequalities in healthwhich have not been collected in this review because they
are in the grey literature (for example, European Portal for
Action on Health Inequalities [32]) or because there is noevidence of this purpose in the objective or in the summary of the paper. This has already been identified as areal gap in a review paper on the wider social determinants of health [16]. As we had a more specific aim, it isprobable that there is even less available scientific literature. Although some useful interventions have been published in grey literature and reports or in presentations[12], it would be interesting to publish them in scientificjournals as this is the best way to reach scholars and improve evidence based scientific knowledge.
In addition, we were looking for policies and interventions at the local level. The reduction of health inequalities cannot be done only with policies undertaken inurban areas; there are many health determinants which
are the responsibility of the national or regional government [3,15]. Some important universal policies withgreat potential effect on health inequalities, implemented
on a national level, may therefore be overlooked (e.g.
maternal and child health services). However, local governments have certain competences in a number of sectors from which they can contribute in the reduction ofsocio-economic health inequalities [33]. As cities are an
important setting for intervention governance, it is necessary to show what is being done at this level. In thehealth policy documents of some cities or counties, it ispossible to see that certain strategies are planned [34],but often these strategies do not end up being describedto the scientific community. This may be due to the heavy
workload of people responsible for such interventions, butalso because it is very difficult to publish them as local experiences are not as attractive to scientific journals as
national or international strategies. As social health inequalities are an important public health issue, it might beinteresting to promote publishing of strategies carried out,
or at least to increase the number of published interventions in scientific journals. Health inequalities are present
in all countries; therefore, the experience of interventions
carried out in other cities to tackle them might prove tobe very interesting and helpful.

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In children and in adults, interventions are mainly focussed on the lifestyle drift and on promoting healthy
behaviours [35]. As Bambra [36] reported, policy has
had a tendency to focus on healthy behaviour interventions rather than tackling upstream, distal causes such as
poor living conditions. This approach contrasts with evidence which suggests that health inequalities tend to
persist between socioeconomic groups even if lifestylefactors are equalized [36]. This poor progress is probably
attributable to the fact that studying the impact on
health inequalities of interventions in upstream structural determinants is more difficult due to the complex
pathways between these determinants and health inequalities. However, the recent WHO review of social
determinants suggests that addressing the “causes of thecauses” is the right way to proceed on these, ensuringthat people have the skills and control over their lives tobe able to change behaviour [37].
Although many cities are making efforts to tackle inequalities in health [12], it is necessary to move from a
traditional health education focus on lifestyle determinants
to more strategic interventions on structural determinants(as many of those presented in Figure 1). The challenge ofreducing health inequalities requires policies and interventions in all sectors of society, because their causes are complex [6,7,9]. That is to say that health inequities challenge
the traditional division of societies and their governments
into sectors for organizational purposes [35]. Many policies
aiming to address social determinants require intersectoral
action [38] and community participation, two principles ofaction proposed by the Commission on Social Determinants of Health [15]. This is especially relevant in cities,
according to statements by Healthy Cities [39]. A recent
paper suggests that intersectoral approaches to healthequity are feasible in a variety of social, economic and political systems [38]. In consequence, the intersectoral approach is essential to improve the health, wellbeing andquality of life of citizens. All community sectors are essential in addressing health policy [40]. Unfortunately, these
aspects are not too clear or evident in many of papers inthis review. Achieving community participation and working intersectorally is not an easy task, even though it is considered important [40]. Evidence shows that intersectoral
action is more effective than tackling health inequalities
from the health sector only [41]. A useful tool to promote
effective work in this sense is the Urban Health Equity
Assesment and Response Tool (Urban Heart), a clear guidefor policy makers at local and national levels to address
health inequalities in cities [42]. Moreover, intersectoral action facilitates the WHO policy Health in All Policies,
which takes into account the impact on health of all policies, such as education, environment, economic policies,
housing, or transport mobility [43]. In addition, current experience shows that health impact assessment could playPons-Vigués et al. BMC Public Health 2014, 14:198
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an important role in the development of the Health in All
Policies strategy. Health impact assessment is an important
methodology to support decisions in policy-making [44].
The United Kingdom (UK) is one of the countries witha longer historical background of working on health inequalities [45,46] and, for example, London has a specific strategy to tackle health inequalities [34] which has
been supported by different governments. This fact iscorroborated in this paper because the UK is the country
where most published interventions were found. In
addition, English people might have more facilities topublish because of the language. We found more papers
in Pubmed than in the Sociological Abstracts databaseprobably because the latter tends to focus on international
literature in sociology and disciplines traditionally more
related to the social and behavioural sciences rather thanto health. However, social and economic factors are being
considered more and more as determinants of healthinequalities so we consider that this trend may change. In
consequence, this issue may deserve further research.
There is still little experience of evaluating the impact ofinterventions to reduce health inequalities [27,47,48].
Most of the evaluations reviewed in this study concerned
healthy behaviours and proximal outcomes. Evaluating upstream interventions presents additional methodologicalchallenges. Evidence is especially needed from evaluationsof universal polices [35]. That is particularly important to
inform the debate on the most efficient and effective useof scarce resources in financial crisis situations, such as
the present global one. In addition, it is necessary because
it can happen that some interventions may increase inequalities in the population if they are of greater benefit toadvantaged (lower-risk) groups than to disadvantaged(higher-risk) groups [49]. Despite the fact that the aim of
this scoping review was not to evaluate the effectivenessor quality of the interventions included [18,19], this is asubject which warrants further study. Note that 54% of theinterventions were evaluated and had positive results.
However, not all reported results in terms of health indicators. Even in the UK which has such a long history of tackling social determinants of health, evaluation is sorely
lacking [50]. About 35% of the papers used an experimental design to evaluate the intervention. Overall, the evaluation of effects is the aspect most commonly published inscientific journals rather than accounts of real experiences,which are probably explained to other audiences.
Strengths and limitations of the study

To our knowledge, this is the first scientific review ofthe social and health policies or interventions to tackle
health inequalities in European cities. Previous papers
have reviewed health inequalities interventions at the national level or at the urban level but in the American
context (USA and Canada) [33,36]. For that reason, thisPage 10 of 12

study can contribute to advancing knowledge in the reduction of socioeconomic health inequalities. At the national level, Bambra et al. combined a rapid review with aDelphi distillation, producing a shortlist of evidence-based
recommendations. According to these authors, extensive,
specific and robust evidence is urgently needed to guidepolicy and programmes [36]. Besides, Collins and Hayes
demonstrated a pervasiveness of ‘behavioural’ and ‘biomedical’ perspectives, and a lack of consideration afforded
to the roles and responsibilities of municipal governments,
among the health inequities scholarly community [33].
The rigorous procedures used have ensured the validityof the data abstraction. However, the review is not exhaustive because we have not been able to identify all relevant evidence and we did not search in the grey literature.
We tried to identify all possible papers published in scientific journals by searching in two different databases, oneof which is not medical, in order to capture policies or interventions from other sectors. The combination of heterogeneous sources of data adds value to the results. As
one of the additional requirements for inclusion was that
papers were written in English, Spanish or French, we believe it has brought a significant change in the results since
we only had to exclude two documents.
We must also take into account that the fact that thesepolicies and interventions have been published does notnecessarily mean they are still functioning or effective.
Furthermore, given the heterogeneity of the objectives ofthe papers it has not been possible to summarize theirmain results or conclusions. The articles varied with regard to the richness of information included to describe
different aspects of these interventions or policies.

Conclusions
The volume of publications in this field has increased over
the years, however, there are still relatively few papers
published in scientific journals related to policies and interventions focussed on real experiences to tackle healthinequalities. In addition, although health behaviours are
not the main determinants of health inequalities [15], themajority of the documents published in scientific journals
were based on interventions focusing on them. In order toincrease the policy evidence, to support people working ininterventions and to contribute to the incorporation ofhealth in all policies [15], examples of local policies and interventions to reduce inequalities should be published in
the scientific literature.
Additional file
Additional file 1: Table S1. Promotion health behaviours interventions.
Table S2. Healthy settings interventions. Table S3. Socioeconomic
context interventions. Table S4. Physical context interventions. Table S5.
Combined approach interventions. List of the 54 papers selected in thisstudy.

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Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
MPV, ED, JM and CB are the principal investigators responsible for theconception of the project. In addition, MPV, ED, JM and CB were involved indata collection, analysis of the data and writing the manuscript. SSN, RH, BB
and JPD have made substantial contributions to interpretation of data; havebeen involved in drafting the manuscript or revising it critically for important
intellectual content. All authors participated in the discussion of the analysis,
the editing of the drafts and read and agreed on the final version of thismanuscript. All authors have participated sufficiently in the work to takepublic responsibility for appropriate portions of the content. All authors readand approved the final manuscript.
Acknowledgements
We would like to express our thanks to Edwin Ng for his collaboration in thedesign of the Sociological Abstracts search strategy, and to all those
INEQ-CITIES researchers who contributed ideas included in this paper.
This article has been partially funded by the project INEQ-CITIES,“Socioeconomic inequalities in mortality: evidence and policies of cities ofEurope”; project funded by the Executive Agency for Health and Consumers(Commission of the European Union), project n°2008 12 13.
Author details
1
Agència de Salut Pública de Barcelona, Barcelona, Spain. 2CIBER
Epidemiología y Salud Pública (CIBERESP), Madrid, Spain. 3Institut Universitarid’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona,
Spain. 4Institut d’Investigació Biomèdica (IIB Sant Pau), Barcelona, Spain.
5
Department of Epidemiology and Public Health, University College London,
London, UK. 6Erasmus Medical Center, Rotterdam, Netherlands. 7Departmentof Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
8
Department of Community & Occupational Health, University Medical
Center Groningen, Groningen, Netherlands. 9Graduate School Kosice Institutefor Society and Health, Safarik University, Kosice, Slovakia. 10Universitat
Pompeu Fabra, Barcelona, Spain.
Received: 29 July 2013 Accepted: 4 February 2014
Published: 24 February 2014
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doi:10.1186/1471-2458-14-198
Cite this article as: Pons-Vigués et al.: Social and health policies orinterventions to tackle health inequalities in European cities: a scoping
review. BMC Public Health 2014 14:198.

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