Mitigating child health inequalities through equity, diversity, inclusion, and accessibility school practices in Canada

Abstract

Unhealthy lifestyle behaviours and mental disorders disproportionately affect children living in deprived neighbourhoods. In Canada, schools are encouraged to adopt equity, diversity, inclusion, and accessibility (EDIA) practices to tackle these inequalities. We examined whether integrating EDIA school practices into curriculum and programming mitigates the impact of neighbourhood deprivation on children’s lifestyle behaviours and mental health. In 2023/2024, we surveyed 1970 students in grades 4–6 (aged 9–12) from 28 elementary schools in Alberta. Students self-reported diet, physical activity, screen time, and mental health and wellbeing. School principals reported on the extent (full vs. partial) of integrating EDIA school practices into curriculum and programming. The Canadian Index of Multiple Deprivation (i.e. residential instability, economic dependency, ethno-cultural composition, situational vulnerability) was used to capture neighbourhood deprivation. Over half (54%) of schools had fully integrated EDIA school practices into curriculum and programming, and were located primarily in areas with greater residential instability (50%), ethno-cultural diversity (57%), economic dependency and situational vulnerability (46%). In highly deprived neighbourhoods, students attending schools with fully integrated EDIA practices were less likely to have poor diets (0.9 vs. 1.6) and consume excessive intake of free sugar (1.3 vs. 1.8) and saturated fat (0.6 vs. 0.8). EDIA school practices did not appear to moderate the relationship of neighbourhood deprivation with physical activity, screen time, or mental health and wellbeing. These findings suggest that integrating EDIA school practices into curriculum and programming may help buffer some adverse effects of neighbourhood deprivation on children’s health and diets in particular.

Contribution to Health Promotion.

• More schools located in deprived neighbourhoods integrate school practices targeting equity, diversity, inclusion, and accessibility (EDIA) into curriculum and programming.

• Integrating five EDIA practices into curriculum and programming can help mitigate the adverse effects of neighbourhood deprivation on children’s diet.

• EDIA practices did not moderate the relationship of neighbourhood deprivation with physical activity, screen time, or mental health and wellbeing.

• EDIA practices must be complemented by other strategies to address inequalities in other lifestyle behaviours and mental health and wellbeing.

INTRODUCTION

Neighbourhood deprivation in childhood—defined broadly by Townsend (1987) as not only economic poverty but also limited access to education, housing, and social support—is one of the crucial social determinants of child health (van Vuuren et al. 2014, Christian et al. 2015, Minh et al. 2017). Children living in deprived neighbourhoods are more likely to engage in unhealthy behaviours (Jenkin et al. 2015, Noonan et al. 2016, Egli et al. 2020) and experience poorer physical and mental health outcomes (van Vuuren et al. 2014, Christian et al. 2015, Minh et al. 2017, Visser et al. 2021). These effects can persist into adulthood, contributing to increased risk of chronic illness, substance use, disability, and early mortality (Jivraj et al. 2020, Jakobsen 2023). While much research has focused on residential neighbourhood deprivation, children spend most of their waking hours in and around schools. Therefore, school neighbourhood deprivation may offer a critical (and potentially underutilized) leverage point for population health interventions (Huang et al. 2013).

Schools are uniquely positioned to promote lifelong healthy behaviours and can either amplify or buffer the effects of school neighbourhood deprivation (World Health Organization 2021). Fostering an inclusive school environment has shown promise in improving dietary and physical activity outcomes (Patton et al. 2006, Vander Ploeg et al. 2014, Bastian et al. 2015), highlighting the potential of embedding principles of Equity, Diversity, Inclusion, and Accessibility (EDIA) into school policies and practices as an important health promotion tool. In Canada’s increasingly diverse society, where immigrants account for 23% of the population (Statistics Canada 2022a, 2022b), and over 10% of youth identify as 2SLGBTQ+ (Statistics Canada 2024a) integrating EDIA school practices into curriculum and programming is critical to ensuring equitable access to education and support for all students. However, integrating EDIA policies and practices is a complex process that often relies on commitment from principals, teachers, parents/guardians, and the broader school community (Gerdin et al. 2021, Kalubi et al. 2023), and may require a broad range of activities (e.g. curriculum adaptation, culturally sensitive teaching methods, inclusive language use, and resource allocation according to local priorities) (OECD 2023). It typically occurs in stages, from partial integration, where schools assess the fit and feasibility of new policies and practices, to full integration, where these policies and practices are fully integrated within the school environment (Fixsen et al. 2009). When fully integrated, EDIA practices can help ensure that all students, regardless of their socioeconomic circumstances, ethnicity, race, culture, beliefs, age, sex or gender identity and expression, sexual orientation, nationality, language, and special needs, benefit from supportive and equitable learning environments (OECD , Veugelers et al. 2023).

The urgency to advance integration of such practices has been underscored by the COVID-19 pandemic, which has contributed to widening health inequalities among children, especially in deprived neighbourhoods (Saulle et al. 2022, Maximova et al. 2023). By promoting social justice and fostering positive learning environments (Gerdin et al. 2021, OECD 2023), EDIA practices may help mitigate the effects of school neighbourhood deprivation on children’s health and wellbeing. However, to date, no studies have examined whether EDIA school practices moderate this relationship. This evidence is essential for informing effective, equity-driven education and health policies and practices. This study aimed to assess whether the integration of EDIA school practices into curriculum and programming moderates the relationship between school neighbourhood deprivation and children's lifestyle behaviours and mental health and wellbeing.

MATERIALS AND METHODS

Study design and participants

In spring 2023 and 2024, all Grades 4 to 6 students (aged 9 to 12 years) in 28 schools in socioeconomically deprived neighbourhoods in Alberta, Canada, were invited to participate in the study. The participating schools are part of APPLE Schools (A Project Promoting Healthy Living for Everyone in Schools), which is a health promotion initiative shown to improve healthy eating, physical activity, and mental health habits of students (Fung et al. 2012, Vander Ploeg et al. 2014, Bastian et al. 2015, Maximova et al. 2023). Of 3319 students invited to participate, 1970 (59.4%) completed a one-hour survey during regular class time and reported on their demographic characteristics, lifestyle behaviours, and mental health and wellbeing. Principals completed an online survey about their schools’ practices and policies. School postal codes were linked to area-based indices of deprivation. All study procedures were approved by the Health Research Ethics Board of the University of Alberta (Pro00119951), the Unity Health Toronto Research Ethics Board (REB# 22-118), and participating school boards.

Integration of equity, diversity, inclusion, and accessibility school practices into curriculum and programming

Principals in each participating school were asked to complete an online survey about school practices and policies. As part of it, principals were asked the following: (i) ‘Does your school or school district have policies or guidelines related to offering EDIA-relevant curriculum and programmes?’ (ii) ‘Does your school support professional development of teachers related to offering EDIA-relevant curriculum and programmes (e.g. Circle of Courage)?’ (iii) ‘Does your school communicate with staff regarding EDIA-relevant curriculum and programmes (e.g. agenda items at staff meetings)?’ (iv) ‘Does your school communicate with families regarding EDIA-relevant curriculum and programmes (e.g. newsletters, announcements, parent information nights)?’ and (v) ‘Does your school have a specific committee to address EDIA-relevant curriculum and programmes?’ Principals who were new to their school were encouraged to consult with other school administrators when completing the online survey to ensure the accuracy of responses. Responses were scored 1 for ‘yes’ and 0 for ‘no’ or ‘unsure’, and summed to create a composite score (range: 0–5), with higher scores indicating greater integration of EDIA school practices. For analysis and ease of interpretation, scores ≤4 and 5 were categorized as partial and full integration of EDIA school practices, respectively.

School neighbourhood deprivation

School neighbourhood deprivation was assessed using the Statistics Canada’s 2021 Canadian Index of Multiple Deprivation (CIMD) (Matheson et al. 2012, Statistics Canada 2024b), which is a composite index based on the 2021 Census that quantifies four dimensions of neighbourhood deprivation at the smallest census geographic unit, the dissemination area (DA), usually comprised of 400–700 people living in one or more adjacent dissemination blocks (Statistics Canada 2021a). The four CIMD dimensions are: (i) residential instability representing the fluctuation of the neighbourhood population in a given area over time; (ii) economic dependency reflecting a neighbourhood population’s reliance on the workforce and income sources other than employment income; (iii) ethno-cultural composition capturing the ethnic diversity of a neighbourhood immigrant and visible minority populations; and (iv) situational vulnerability measuring the sociodemographic conditions related to education and housing, while accounting for demographic characteristics (e.g. Indigenous status). We used a subset of 6010 DAs from the Prairie Region CIMD (Statistics Canada 2024b) to create an Alberta-specific index (Supplementary File). Scores for each dimension of deprivation were divided into tertiles (rather than quintiles, given n = 28 schools), with tertile 1 representing ‘low deprivation’, tertile 2 ‘middle deprivation’, and tertile 3 ‘high deprivation’. For ethno-cultural composition, these tertiles correspond to low, middle, and high diversity, respectively. School postal codes were then linked by DA to tertiles of deprivation across four dimensions of the Alberta-specific CIMD, which served as proxies for school neighbourhood deprivation experienced by students.

Student lifestyle behaviours and mental health and wellbeing

Students completed a validated web-based food behaviour questionnaire that employed a multiple-pass approach to gathering data on all foods and beverages consumed in the past 24 h and their serving sizes (Hanning et al. 2009). Dietary outcomes included daily intake of sodium, free sugars, and saturated fat. Based on Canada’s Dietary Guidelines (Health Canada 2019), excessive intake was defined as ≥2300 mg sodium/day and ≥10% of daily energy from free sugars or saturated fat. To assess the diet quality, we calculated the Healthy Eating Food Index 2019 (HEFI-2019) (Brassard et al. 2022), which ranges from 0 to 80, with higher scores indicating better alignment with the 2019 Canada’s Food Guide (Health Canada 2021). HEFI-2019 scores were dichotomized into higher (≥40) and lower diet quality (<40).

Students completed the Physical Activity Questionnaire for Older Children (PAQ-C) scale (Kowalski et al. 2004), with scores ranging from 1 to 5 and higher scores indicating higher physical activity. Physical activity levels were classified as higher (PAQ-C ≥ 2.5) and lower (<2.5). Students also reported the number of hours per day they spend (i) watching videos, (ii) playing video games, and (iii) chatting using any type of electronic device (e.g. cellphones, iPads, computers, game consoles, TVs) on weekdays and weekends. Response options ranged from ‘0 h’ to ‘more than 8 h a day’. The average daily screen time for each of these activities was calculated using the formula [(time on weekdays * 5 + time on weekends * 2)/7 days]; then they were summed and averaged to obtain the total daily screen time. Based on the Canadian 24-Hour Movement Guidelines for Children and Youth (Tremblay et al. 2016), total daily screen time was categorized as adequate (≤2 h/day) or excessive (>2 h/day).

Using an instrument derived from population-based surveys (Rosenberg 1965, Marsh and O’Neill 1984, Harter 1985, Statistics Canada 1995), students were asked to rate 12 statements related to their feelings, including 7 positively worded items (‘My future looks good to me’, ‘I like the way I look’, ‘I like myself’, ‘I feel like I belong at school’, ‘I do well in my school work’, ‘I feel like I have many friends’, ‘If I have problems, there is someone I trust to go to for advice’) and 5 negatively worded ones (‘I feel unhappy or sad’, ‘I worry a lot’, ‘I am in trouble with my teacher[s]’, ‘I have trouble paying attention’, ‘I have trouble enjoying myself’). Response options ‘never or almost never’, ‘sometimes’, and ‘often or almost always’ were assigned scores of 1, 2, and 3, respectively, for positively worded items. Responses were reverse-coded for negatively worded items. Scores were summed to create a cumulative score for mental health and wellbeing, ranging from 12 to 36, with higher scores indicating better mental health and wellbeing. Scores were dichotomized into good (≥24) and poor mental health and wellbeing (<24).

Student and school sociodemographic characteristics

Students reported their gender (girl, boy, other, or prefer not to answer), grade (4, 5, and 6), and family affluence by responding to the following six questions: (i) ‘Do you have your own bedroom for yourself?’; (ii) ‘How many computers does your family own (including laptops and tablets, not including game consoles and cellphones)?’; (iii) ‘How many bathrooms (room with a bath/shower or both) are in your home?’; (iv) ‘Does your family have a dishwasher at home?’; (v) ‘Does your family own a car, van or truck?’; and (vi) ‘How many times did you and your family travel to another province or country for a holiday/vacation in 2022?’. Responses to these six questions were summed to create the Family Affluence Scale III (FAS-III) index, a validated indicator of child and adolescent perceived socioeconomic status (Torsheim et al. 2016), which ranges from 0 to 13, with higher scores indicating higher family affluence. Finally, using school postal codes, the population centre of each school was classified as rural (<1000 inhabitants), small (1000–29 999), medium (30 000–99 999), or large (>100 000) according to Statistics Canada classification (Statistics Canada 2021b).

Statistical analysis

Distributions of student lifestyle and mental health indicators across the four deprivation dimensions in schools with partial vs. full EDIA integration were compared using Pearson χ² tests. Multivariable logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals for associations between school neighbourhood deprivation and student lifestyle behaviours and mental health and wellbeing. Given the low intra-class correlation (<0.02), standard logistic regression models (as opposed to mixed effect models) were run. Models were incrementally adjusted for gender, grade, and FAS-III, and since there were no substantial differences in estimates, only the results of the models adjusted for all three sociodemographic indicators are reported. Next, to assess effect modification by the extent of EDIA integration, interaction terms of EDIA integration (full vs. partial) with tertiles of school neighbourhood deprivation were included. Results are presented separately for schools with partial vs. full EDIA integration. Dietary data were provided by 1525 students, and 95 students who reported unrealistic daily energy intake (<500 or >5000 kilocalories) were excluded from analyses, as per existing recommendations (Willett 2012). Dietary data of 1430 students were included in analyses. Statistical significance was set at P < 0.05. Analyses were conducted in Stata/SE 18 (StataCorp n.d.).

RESULTS

Of 28 participating schools, most were located in large population centres (75.0%), and about half were in neighbourhoods of high residential instability (50.0%), ethno-cultural composition (57.1%), and situational vulnerability (46.4%) deprivation, but in the middle tertile of economic dependency deprivation (46.4%) (Table 1). About half (53.6%) of schools had fully integrated EDIA school practices. Schools with fully integrated EDIA practices were located in more deprived neighbourhoods, regardless of the dimension of deprivation (Fig. 1).

Table 1.

Characteristics of 1970 Grade 4–6 students from 28 elementary schools in Alberta, Canada.^a

Student-level	n = 1970	School-level	n = 28
Socio-demographics		Population centreb, %
Gender, %		Rural/small	14.2
Girls	48.5	Medium	10.7
Boys	47.3	Large	75.0
Otherc	4.3	No. EDIA school practices integrated, %
Grade, %		1	3.6
4	34.9	2	7.1
5	33.8	3	14.3
6	31.3	4	21.4
FAS-IIId, median (IQR)	10 (8–11)	5	53.6
		Residential instability, %
Lifestyle behaviours		Low	14.3
Sodium intakee, %		Middle	35.7
≥2300 mg	58.7	High	50.0
Free sugars intakee, %		Economic dependency, %
≥10%E	45.1	Low	14.3
Saturated fat intakee, %		Middle	46.4
≥10%E	65.3	High	39.3
Diet qualitye, %		Ethno-cultural composition, %
HEFI-2019 < 40	61.0	Low	21.4
Physical activity, %		Middle	21.4
PAQ-C < 2.5	25.7	High	57.1
Screen time, %		Situational vulnerability, %
>2 hours/day	42.6	Low	32.1
Mental health and wellbeing, %		Middle	21.4
MHW score <24	12.1	High	46.4

E, total energy intake in kilocalories; EDIA, equity, diversity, inclusion, accessibility; FAS-III, Family Affluence Scale III; HEFI-2019, Healthy Eating Food Index 2019; IQR, Interquartile range; MHW, Mental health and wellbeing; PAQ-C, Physical Activity Questionnaire for Children.

^aPercentages may not total 100% due to missing data.

^bRural or remote community: <1000 people; Small population centre: 1000–29 999 people; Medium population centre: 30 000–99 999 people; Large population centre: >100 000 people.

^cStudents reporting their gender as ‘other’ or ‘prefer not to answer’.

^dFAS-III was used as a self-reported measure of socioeconomic status. The FAS-III is a composite scale comprised of 6 items related to family household and resources, with scores ranging from 0 (lowest affluence) to 13 (highest affluence).

^ePercentages for dietary behaviours are based on the available data (n = 1430, with the daily energy intake between 500 and 5000 kcal).

Figure 1.

Integration of EDIA school practices across the four dimensions of school neighbourhood deprivation in 28 elementary schools in Alberta, Canada.

Among 1430 students who provided dietary data, almost half reported excessive free sugar consumption (45.1%), and more than half reported excessive sodium (58.7%) and saturated fat (65.3%) intakes, with almost two-thirds having low diet quality (HEFI-2019 scores <40) (61.0%) (Table 1). More than a quarter of students (25.7%) reported inadequate physical activity, 42.6% reported excessive screen time, with 12.1% reporting poor mental health and wellbeing. Compared to students attending schools with partial EDIA integration, more students in schools with fully integrated EDIA practices reported screen time >2 h/day (46% vs. 40.3%) and worse mental health and wellbeing (14.7% vs. 9.6%), while the prevalence of excessive intake of sodium, free sugars, and saturated fats, as well as lower diet quality and inadequate physical activity, was comparable among students in schools with full and partial EDIA integration (Table 2). When stratified by tertiles of deprivation, fewer students attending schools with full EDIA integration in the low (18.6% vs. 28.9%) and middle (20.3% vs. 27.9%) tertiles of residential instability, and in the middle tertiles of economic dependency (23.2% vs. 34.1%) and ethno-cultural composition (34.3% vs. 12.0%), reported inadequate physical activity. With respect to screen time, more students in fully integrated EDIA schools reported excessive screen time, with differences particularly pronounced in the high tertile of economic dependency (44.9% vs. 37.7%). Moreover, these students reported worse mental health and wellbeing scores, regardless of the deprivation domain or tertile of deprivation.

Table 2.

Distribution of student lifestyle behaviours and mental health and wellbeing by school neighbourhood deprivation and level of integration of EDIA school practices.^a

	EDIA	Overall	Residential instability			Economic dependency			Ethno-cultural composition			Situational vulnerability
			Low	Middle	High	Low	Middle	High	Low	Middle	High	Low	Middle	High
Sodium ≥2300 mg	Partiala	58.1	57.9	56.7	59.5	58.6	59.2	55.5	57.0	59.6	57.1	58.1	57.6	57.6
	Full	57.9	51.1	62.1	57.3	b	58.1	57.7	52.8	69.7	57.0	61.4	55.9	57.4
Free sugars ≥10%E	Partial	45.4	44.0	41.5	52.4	47.7	43.2	46.3	38.7	40.5	51.1	41.9	48.8	53.5
	Full	44.6	37.5	48.4	44.6	b	43.9	45.1	39.3	50.6	44.5	38.6	40.7	47.2
Saturated fat ≥10%E	Partial	66.2	62.9	66.5	68.5	71.3	64.3	62.8	66.7	68.5	64.3	67.0	64.0	65.7
	Full	65.1	65.2	65.7	64.4	b	66.7	63.7	77.5	70.8	62.7	74.7	75.9	59.7
HEFI-2019 < 40	Partial	61.3	58.5	56.3	70.2	66.7	60.1	56.7	57.0	58.4	64.3	56.9	68.0	66.7
	Full	59.1	52.7	60.9	60.7	b	60.4	58.1	58.4	64.0	58.6	59.5	60.7	58.6
PAQ-C < 2.5	Partial	27.6	28.9	27.9	25.5	23.3	34.1	23.8	28.5	34.3	23.6	28.2	25.7	27.6
	Full	25.0	18.6	20.3	31.3	b	23.3	26.1	24.1	12.0	27.2	22.3	32.5	23.3
Screen time >2 hours/day	Partial	40.3	33.8	39.8	48.5	40.9	42.5	37.7	44.0	34.9	41.4	36.5	49.3	45.0
	Full	46.0	34.0	46.5	50.1	b	47.6	44.9	42.0	41.8	47.3	41.2	45.0	47.3
MHW score <24	Partial	9.6	9.7	7.1	13.5	11.7	7.8	10.0	5.5	8.7	12.1	8.7	6.1	17.7
	Full	14.7	14.0	15.0	14.8	b	12.9	15.9	15.7	16.7	14.3	14.1	15.5	14.6

E, total energy intake in kilocalories; EDIA, equity, diversity, inclusion, accessibility; HEFI-2019, Healthy Eating Food Index 2019; MHW, mental health and wellbeing; PAQ-C, Physical Activity Questionnaire for Children.

^aPartial EDIA: integration of ≤4 school practices, Full EDIA: integration of five school practices.

^bThere were no observations of student lifestyle behaviours and mental health and wellbeing in low deprivation neighbourhoods with full integration of EDIA school practices.

Results in bold indicate statistically significant differences (P < 0.05) based on Pearson χ² tests.

Students were less likely to report excessive intake of free sugars when attending schools with full vs. partial integration of EDIA school practices located in neighbourhoods with high residential instability (1.1, 95% CI 0.8–1.5 vs. 1.5, 95% CI 1.1–2.1), ethno-cultural composition (1.3, 95% CI 0.9–1.8 vs. 1.8, 95% CI 1.2–2.7) and situational vulnerability (1.3, 95% CI 1.0–1.7 vs. 1.7, 95% CI 1.1–2.6) (Table 3). Students were less likely to report excessive intake of saturated fats when attending schools with full vs. partial integration of EDIA school practices located in neighbourhoods with high ethno-cultural composition (0.6, 95% CI 0.4–0.9 vs. 0.8, 95% CI 0.5–1.2) and situation vulnerability (0.7, 95% CI 0.6–0.9 vs. 1.0, 95% CI 0.6–1.6). Students were also less likely to consume diets of poor quality when attending schools with full integration of EDIA school practices, with differences being particularly pronounced in highly deprived neighbourhoods across all four dimensions of deprivation, and were particularly noticeable for residential instability (1.2, 95% CI 0.9–1.6 vs. 1.8, 95% CI 1.2–2.5) and ethno-cultural composition (0.9, 95% CI 0.6–1.2 vs. 1.6, 95% CI 1.0–2.4). However, these students were more likely to consume excess sodium when attending schools with medium deprivation for residential instability (1.6, 95% CI 1.2–2.1 vs. 1.2, 95% CI 0.8–1.7) and ethno-cultural composition (1.9, 95% CI 1.1–3.2 vs. 1.1, 95% CI 0.7–1.16), and had higher likelihood of inadequate physical activity when attending schools with high residential instability (1.8, 95% CI 1.2–2.7 vs. 0.7, 95% CI 0.5–1.1) and of spending >2 h/day on screens when attending schools with medium residential instability (1.7, 95% CI 1.2–2.2 vs. 1.3, 95% CI 1.0–1.9). Although more students reported worse mental health in schools with full integration of EDIA practices (Table 2), the likelihood of reporting poor mental health and wellbeing was generally comparable between students attending schools with full vs. partial EDIA integration across all deprivation domains, except in the middle tertile of ethno-cultural composition. In this tertile, students in schools with full integration of EDIA practices were twice as likely to report worse mental health (2.0, 95% CI 1.1–3.7) compared to those in partial EDIA schools (1.1, 95% CI 0.6–1.9).

Table 3.

Effects of school neighbourhood deprivation and student lifestyle behaviours and mental health and wellbeing according to levels of integration of EDIA school practices.

		Residential instability (Low = Ref.)				Economic dependency (Low = Ref.)				Ethno-cultural composition (Low = Ref.)				Situational vulnerability (Low = Ref.)
		Middle		High		Middle		High		Middle		High		Middle		High
	EDIA	OR	95% CI	OR	95% CI	OR	95% CI	OR	95% CI	OR	95% CI	OR	95% CI	OR	95% CI	OR	95% CI
Sodium ≥ 2300 mg	Partiala	1.2	0.8, 1.7	1.2	0.9, 1.7	1.0	0.8, 1.6	0.8	0.5, 1.3	1.1	0.7, 1.6	1.1	0.7, 1.6	0.9	0.7, 1.4	1.1	0.7, 1.6
	Full	1.6	1.2, 2.1	1.3	1.0, 1.8	b	b	b	b	1.9	1.1, 3.2	1.2	0.8, 1.6	0.9	0.7, 1.4	1.1	0.9, 1.4
Free sugars ≥10%E	Partial	1.0	0.7, 1.5	1.5	1.1, 2.1	0.8	0.5, 1.2	1.0	0.6, 1.5	1.2	0.8, 1.7	1.8	1.2, 2.7	1.4	0.9, 2.1	1.7	1.1, 2.6
	Full	1.4	1.0, 1.9	1.1	0.8, 1.5	b	b	b	b	1.6	0.9, 2.7	1.3	0.9, 1.8	1	0.7, 1.5	1.3	1.0, 1.7
Saturated fat ≥10%E	Partial	1.2	0.8, 1.9	1.2	0.8, 1.7	0.8	0.5, 1.2	0.7	0.4, 1.1	0.6	0.4, 0.9	0.8	0.5, 1.2	0.9	0.6, 1.4	1.0	0.6, 1.6
	Full	1.2	0.9, 1.7	1.1	0.8, 1.5	b	b	b	b	0.9	0.5, 1.6	0.6	0.4, 0.9	1.4	0.9, 2.1	0.7	0.6, 0.9
HEFI-2019 < 40	Partial	1.1	0.8, 1.6	1.8	1.2, 2.5	0.8	0.5, 1.2	0.8	0.5, 1.2	0.9	0.7, 1.4	1.6	1.0, 2.4	1.6	1.0, 2.4	1.4	0.9, 2.3
	Full	1.3	0.9, 1.7	1.2	0.9, 1.6	b	b	b	b	1.2	0.7, 2.0	0.9	0.6, 1.2	1.1	0.8, 1.6	0.9	0.7, 1.2
PAQ-C < 2.5	Partial	0.9	0.6, 1.6	0.7	0.5, 1.1	1.5	0.9, 2.2	1.0	0.6, 1.5	1.6	1.0, 2.5	0.8	0.5, 1.2	0.8	0.5, 1.2	0.7	0.4, 1.1
	Full	1.0	0.6, 1.6	1.8	1.2, 2.7	b	b	b	b	0.4	0.2, 0.9	1.1	0.7, 1.6	1.6	1.0, 2.5	0.9	0.6, 1.4
Screen time >2 hours/day	Partial	1.3	1.0, 1.9	1.7	1.2, 2.3	1.0	0.7, 1.5	0.8	0.6, 1.2	0.8	0.6, 1.2	0.9	0.7, 1.3	1.5	1.0, 2.2	1.2	0.8, 1.9
	Full	1.7	1.2, 2.2	1.8	1.4, 2.4	b	b	b	b	1.0	0.7, 1.5	1.2	0.9, 1.5	1.2	0.9, 1.7	1.4	1.1, 1.8
MHW score <24	Partial	0.7	0.4, 1.2	0.8	0.5, 1.3	0.6	0.3, 1.1	0.8	0.4, 1.4	1.1	0.6, 1.9	1.3	0.8, 2.2	0.5	0.3, 1.1	1.5	0.9, 2.7
	Full	1.1	0.7, 1.7	1	0.7, 1.6	b	b	b	b	2.0	1.1, 3.7	1.4	0.9, 2.1	1.4	0.9, 2.2	1.3	0.9, 1.9

Logistic regressions were adjusted for gender, grade, and Family Affluence Scale III.

Bolded results are statistically significant (P < 0.05).

CI, confidence interval; E, total energy intake in kilocalories; EDIA, equity, diversity, inclusion, accessibility; HEFI-2019, Healthy Eating Food Index 2019; MHW, mental health and wellbeing; OR, odds ratio; PAQ-C, Physical Activity Questionnaire for Children.

^aPartial EDIA: integration of ≤4 school practices, Full EDIA: integration of five school practices.

^bSince there are no full EDIA schools in the low tertile of economic dependency (i.e. the reference category is empty), the corresponding estimates have been suppressed.

DISCUSSION

This study examined whether the extent of integration of EDIA practices in schools moderates the association between school neighbourhood deprivation and student lifestyle behaviours and mental health and wellbeing. Schools that integrated all five EDIA practices into curriculum and school programming (i.e. providing curriculum and programmes relevant to EDIA; facilitating professional development in EDIA curriculum and programmes; maintaining ongoing communication about EDIA curriculum and practices with both staff and families; establishing a committee to focus on EDIA-related curriculum and programmes) were more frequently located in more deprived neighbourhoods, with more students in these neighbourhoods reporting screen time >2 h/day and poorer mental health and wellbeing. Full integration of EDIA school practices appeared to play a protective role for several key dietary outcomes (i.e. daily intake of free sugars and saturated fat, and diet quality), particularly in more deprived neighbourhoods, thus pointing to EDIA practices as an important strategy to support healthier lifestyle behaviours and address diet-related inequalities among children and youth.

We hypothesize that, since school leadership is a key determinant of successful integration of health promotion initiatives (Betschart et al. 2022, Adams et al. 2023), full integration of EDIA practices in schools may reflect stronger leadership and a more proactive uptake of new policies, including equity-focused ones, which have been in the spotlight since the start of the COVID-19 pandemic (Mullin et al. 2021). Stronger leadership goes beyond the readiness to implement policies and might result in a greater uptake of other health-promoting programmes, including those targeting food insecurity and nutrition education. Furthermore, given that most schools that integrated all five EDIA practices are located in more deprived areas, it is possible that administrators in these schools are more attuned to structural barriers and actively work to expand the reach and effectiveness of health promotion efforts by leveraging targeted funding streams, which are often allocated to schools serving students from lower socioeconomic backgrounds. Elucidating the potential mechanisms underlying the moderating role of EDIA school practices requires future research to examine why some schools are able to fully integrate these practices into curriculum and programming while others are not.

However, while we observed encouraging results for several dietary outcomes, our study showed that in schools with full integration of EDIA practices students reported inadequate physical activity and excessive screen time, with some estimates indicating that (contrary to our expectations) full integration was associated with higher odds of being physically inactive (in the high tertile of residential instability and middle tertile of situational vulnerability) and engaging in >2 h/day of screen time (in the middle and high tertiles of residential instability and high tertile of situational vulnerability). However, these results might not reflect on the lack of potential of EDIA policies to improve these outcomes but rather the salience of other factors, such as those related to the physical environment (e.g. lack of access to well-maintained playgrounds, accessible parks, walkable streets, and recreational facilities) (Veugelers et al. 2008, Davidson et al. 2010, Shearer et al. 2012, An et al. 2017), that might have bigger impacts on these behaviours. Therefore, to improve these behaviours EDIA school practices on their own may not be sufficient and need to be complemented by broader community-level interventions that target environmental barriers to physical activity in deprived neighbourhoods, as well as family-level interventions that would help increase parental social interactions and engagement in family activities (as opposed to screen time).

Similarly, full integration of EDIA practices did not appear to be associated with better mental health and wellbeing, despite this outcome being one of the drivers for the EDIA practices integration in schools. Canada’s ethno-cultural landscape is rapidly changing (Statistics Canada 2022b), with Statistics Canada projecting that by 2041 immigrants and their Canadian-born children will comprise over half of the population (Statistics Canada 2022c). Moreover, immigrant children and those born into immigrant families are particularly vulnerable to health inequalities (Salami et al. 2022), which have been further widened by the COVID-19 pandemic (Maximova et al. 2023). Schools in more deprived areas may more readily adopt EDIA practices in response to mental health and wellbeing challenges affecting their student populations. In fact, our data showed that 14.6% of students attending schools with full integration of EDIA policies reported poor mental health and wellbeing, compared to 9.6% in schools with partial EDIA integration. Hence, these issues might motivate school administrators to adopt EDIA policies as an attempt to improve students’ mental health and wellbeing. Given that this study used cross-sectional data, future research employing longitudinal designs and other epidemiological methods is needed to discern the impact of EDIA policies on student mental health and wellbeing.

In Canada, most jurisdictions have already introduced school policies to support EDIA integration (UNESCO 2023). In Alberta, the Ministry of Education developed inclusion and diversity policies for K-12 schools (Government of Alberta n.d.). Our findings underscore the need for EDIA practices nationwide and show that some schools, particularly those in deprived neighbourhoods, have already begun integration. However, it is important to recognize integration of EDIA practices as a complex, multi-step process involving exploration, installation, partial and full integration, and sustainment (Fixsen et al. 2009) that requires significant shifts in school environment to meet students’ evolving needs (Gerdin et al. 2021, OECD 2023). Adding to the challenge, schools in more deprived areas often struggle to secure stakeholder buy-in, which is essential for the successful integration and sustainment of EDIA practices. For example, a cross-sectional study of 161 schools in Quebec, Canada, revealed that schools in more socially deprived areas reported lower teacher commitment to student health and reduced parent and community engagement (Kalubi et al. 2023).

To help secure buy-in within school communities, Veugelers et al. (2023) recommended tailoring EDIA practices to each school's unique needs, priorities, culture, resources, and social contexts. This approach aligns with evidence showing that school-based interventions promoting social inclusion reduce health inequalities among children (Vander Ploeg et al. 2014, Bastian et al. 2015). For example, Vander Ploeg et al. (2014) found such interventions effective in reducing health inequalities by improving physical activity and thus preventing childhood obesity. Similarly, another Canadian study found that inclusion-focused school-based initiatives in low-income neighbourhoods helped equalize physical activity levels between children in low- and middle-income-neighbourhood schools (Bastian et al. 2015). By adapting practices to local contexts, schools can foster equitable environments that support the health and wellbeing of all students, regardless of background or identity.

This study has several strengths and limitations. It is the first one, to our knowledge, to explore the role of EDIA practices in mitigating the negative effects of school neighbourhood deprivation on student lifestyle behaviours and mental health and wellbeing. We gathered data on a range of lifestyle behaviours and mental health and wellbeing from a large sample of grade 4–6 students attending 28 elementary schools located in socioeconomically deprived areas. Moreover, we considered multiple dimensions of neighbourhood deprivation. However, some limitations should be noted. The cross-sectional nature of the study captures EDIA integration and student lifestyle behaviours at a single point in time, limiting our ability to infer causality and account for changes to EDIA practices and/or their implementation that might have occurred over time. Moreover, we could not account for the timing of EDIA practices integration and did not explore factors that exist at the organizational and individual levels that would explain why some schools integrated EDIA practices fully, while others did not. Also, schools likely varied in their integration stages, which may have influenced these policies’ ability to impact student outcomes. Additionally, as we mentioned earlier in this discussion, schools in more deprived neighbourhoods are more likely to fully integrate EDIA school practices because of overtly worse student lifestyle behaviours and mental health and wellbeing; thus confounding by indication cannot be excluded. Finally, principals were asked to self-report on the EDIA practices, and self-reported data may be subject to recall and social desirability bias, while missing dietary data and dichotomization of continuous outcomes may have affected precision. These limitations highlight the need for future research to better assess how EDIA practices are integrated into school culture (e.g. via direct observation, document review of school policies) and how this integration unfolds over time and the use of causal inference approaches (e.g. difference-in-difference) to better understand the impact of EDIA integration on student health.

CONCLUSION

This study found that schools in more deprived neighbourhoods were more likely to fully integrate EDIA practices into curriculum and school programming. While full integration of these practices offered some protection for student diets, it did not appear to offset the negative effects of neighbourhood deprivation on other lifestyle behaviours (i.e. physical activity, sedentary behaviour) and mental health and wellbeing. These findings highlight the need for tailored EDIA strategies that reflect the unique context of each school community and that actively engage teachers and families to enhance effectiveness, particularly in high-need settings.

Author contributions

K.M.: Conceptualization, Funding acquisition, Methodology, Resources, Supervision, Writing—review & editing. C.H.: Conceptualization, Investigation, Methodology, Formal analysis, Visualization, Writing—original draft. F.M.: Methodology, Supervision, Writing—review & editing. J.D.: Data curation, Project administration, Writing—review & editing. P.J.V.: Conceptualization, Funding acquisition, Methodology, Resources, Supervision, Writing—original draft, Writing—review & editing.

Supplementary data

Supplementary data is available at Health Promotion International online.

Conflict of interest

None declared.

Funding

This work was supported by operating funds from the Canadian Institutes for Health Research (grant #179953 to K.M. and P.J.V.). K.M. holds the Murphy Family Foundation Chair in Early Life Interventions. F.I.M. holds the Unity Health Toronto Chair in Homelessness, Housing and Health.

Ethical approval

All study procedures were approved by the Health Research Ethics Board of the University of Alberta (Pro00119951), Unity Health Toronto Research Ethics Board (REB# 22-118), and participating school boards.

Data availability

The data that support the findings of this study are available from the corresponding author, upon reasonable request.