{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,14]],"date-time":"2026-09-14T02:02:54Z","timestamp":1789351374479,"version":"build-2803163510"},"reference-count":38,"publisher":"Oxford University Press (OUP)","issue":"5","license":[{"start":{"date-parts":[[2026,8,13]],"date-time":"2026-08-13T00:00:00Z","timestamp":1786579200000},"content-version":"vor","delay-in-days":9,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,8,4]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:p>While Holistic Health Promotion is mandated in Hungary, little is known about its school-level implementation, especially in small schools. We analyzed national data of 2883 elementary schools, and (i) compared the implementation between small (10\u201399 students) and not-small schools, and (ii) conducted county-level socioeconomic comparisons within the subsample of small schools. Health promotion activities were implemented inconsistently across schools. Small schools (N\u2009=\u2009320) reported fewer structured working groups (9.7%) and lower engagement of school health staff in program development (doctors: 3.1%, nurses: 6.9%, psychologists: 0.9%). Participation in national food schemes was markedly higher in low socioeconomic status (SES) areas than in high SES small schools (Milk Scheme: 83.5% vs. 46.5; Fruit &amp; Vegs Scheme: 86.9% vs. 67.3%). Menu planning was aligned with the Public Catering Act in two-thirds of all schools (68.9%), which falls short of full adherence. Coverage of nutrition education was high (95.5%). Experiential learning tools like school gardens (31.7%) and educational kitchens (18.8%) were predominantly found in high SES context. After-school physical activity opportunities were significantly limited in small schools. The availability of bullying (32.2%) and digital addictions (52.2%) prevention measures was limited in low SES context. Parental health literacy programs showed moderate integration across all groups (average score: 6 out of 10). This study provides the first nationwide school-level evidence on variation in the implementation of health promotion policies. Findings highlight modest differences by size and SES, and underscore the need for targeted actions to support small and disadvantaged schools.<\/jats:p>","DOI":"10.1093\/eurpub\/ckag143","type":"journal-article","created":{"date-parts":[[2026,7,27]],"date-time":"2026-07-27T13:42:21Z","timestamp":1785159741000},"source":"Crossref","is-referenced-by-count":0,"title":["Disparities in practice: implementation of health promotion policies in 2883 Hungarian schools with a focus on small-sized institutions"],"prefix":"10.1093","volume":"36","author":[{"given":"Zsuzsa","family":"R\u00e1kosy","sequence":"first","affiliation":[{"name":"Department of Public Health Medicine, Medical School, University of P\u00e9cs , P\u00e9cs,","place":["Hungary"]},{"name":"Bethesda Children\u2019s Hospital Directorate of Prevention, , Budapest,","place":["Hungary"]},{"name":"MTA-PTE Innovative Health Pedagogy Research Group , P\u00e9cs,","place":["Hungary"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dorottya","family":"\u00c1rva","sequence":"additional","affiliation":[{"name":"MTA-PTE Innovative Health Pedagogy Research Group , P\u00e9cs,","place":["Hungary"]},{"name":"Institute of Preventive Medicine and Public Health, Faculty of Medicine, Semmelweis University , Budapest,","place":["Hungary"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0741-7880","authenticated-orcid":false,"given":"Vikt\u00f3ria Anna","family":"Kov\u00e1cs","sequence":"additional","affiliation":[{"name":"Bethesda Children\u2019s Hospital Directorate of Prevention, , Budapest,","place":["Hungary"]},{"name":"Institute of Health Sciences, K\u00e1roli G\u00e1sp\u00e1r University of the Reformed Church , Budapest,","place":["Hungary"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2026,8,13]]},"reference":[{"key":"2026091321115813300_ckag143-B1","doi-asserted-by":"publisher","DOI":"10.1787\/8d398062-en","volume-title":"Hungary: Country Health Profile 2023, State of Health in the EU","author":"OECD\/European Observatory on Health Systems and Policies","year":"2023"},{"key":"2026091321115813300_ckag143-B2","volume-title":"Health Behaviour in School-Aged Children International Report from the 2021\/2022 Survey","author":"Raki\u0107","year":"2024"},{"key":"2026091321115813300_ckag143-B3","volume-title":"Making Every School a Health-Promoting School: Global Standards and Indicators for Health-Promoting Schools and Systems","year":"2021"},{"key":"2026091321115813300_ckag143-B4","doi-asserted-by":"publisher","first-page":"61","DOI":"10.18458\/KB.2016.4.61","article-title":"Teljesk\u00f6r\u0171 iskolai eg\u00e9szs\u00e9gfejleszt\u00e9s (TIE): jelen helyzet. [Holistic health promotion (HHP): current situation]","volume":"2","author":"Somhegyi","year":"2016","journal-title":"K\u00fcl\u00f6nleges B\u00e1n\u00e1sm\u00f3d"},{"key":"2026091321115813300_ckag143-B5","doi-asserted-by":"publisher","first-page":"177","DOI":"10.1093\/heapro\/dax001","article-title":"Health promoting schools-a complex approach and a major means to health improvement","volume":"32","author":"Turunen","year":"2017","journal-title":"Health Promot Int"},{"key":"2026091321115813300_ckag143-B6","author":"Ministry of Human Capacities"},{"key":"2026091321115813300_ckag143-B7","first-page":"11","article-title":"A teljesk\u00f6r\u0171 int\u00e9zm\u00e9nyi eg\u00e9szs\u00e9gfejleszt\u00e9s (TIE) m\u00faltja, jelene \u00e9s j\u00f6v\u0151je. [Holistic health promotion (HHP) in educational institutions: past, present and future]","volume":"100","author":"Somhegyi","year":"2023","journal-title":"N\u00e9peg\u00e9szs\u00e9g\u00fcgy"},{"key":"2026091321115813300_ckag143-B8","doi-asserted-by":"publisher","first-page":"130","DOI":"10.1186\/s12889-015-1360-y","article-title":"The world health organization\u2019s health promoting schools framework: a Cochrane systematic review and meta-analysis","volume":"15","author":"Langford","year":"2015","journal-title":"BMC Public Health"},{"key":"2026091321115813300_ckag143-B9","doi-asserted-by":"publisher","first-page":"116","DOI":"10.1016\/j.puhe.2020.02.006","article-title":"The impact of the world health organization health promoting schools framework approach on diet and physical activity behaviours of adolescents in secondary schools: a systematic review","volume":"182","author":"McHugh","year":"2020","journal-title":"Public Health"},{"key":"2026091321115813300_ckag143-B10","doi-asserted-by":"publisher","first-page":"149","DOI":"10.1186\/s13012-015-0338-6","article-title":"Implementing health promotion programmes in schools: a realist systematic review of research and experience in the United Kingdom","volume":"10","author":"Pearson","year":"2015","journal-title":"Implement Sci"},{"key":"2026091321115813300_ckag143-B11","doi-asserted-by":"publisher","first-page":"2623","DOI":"10.3390\/ijerph18052623","article-title":"Health promoting schools in Germany. Mapping the implementation of holistic strategies to tackle NCDs and promote health","volume":"18","author":"Dadaczynski","year":"2021","journal-title":"Int J Environ Res Public Health"},{"key":"2026091321115813300_ckag143-B12","doi-asserted-by":"publisher","first-page":"50","DOI":"10.1016\/j.evalprogplan.2016.04.005","article-title":"An evaluation of factors which can affect the implementation of a health promotion programme under the schools for health in Europe framework","volume":"57","author":"Bennett","year":"2016","journal-title":"Eval Program Plann"},{"key":"2026091321115813300_ckag143-B13","author":"Bartelink","year":"2020"},{"key":"2026091321115813300_ckag143-B14","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1108\/HE-12-2021-0149","article-title":"Exploring the implementation dynamics of the Health Promoting School approach in Europe: a qualitative study among school health representatives","volume":"123","author":"Driessen-Willems","year":"2023","journal-title":"Health Educ"},{"key":"2026091321115813300_ckag143-B15","author":"Vila\u00e7a","year":"2019"},{"key":"2026091321115813300_ckag143-B16","first-page":"265","volume-title":"A Nevel\u00e9studom\u00e1ny V\u00e1laszai a J\u00f6v\u0151 Kih\u00edv\u00e1saira. XXI. Orsz\u00e1gos Nevel\u00e9studom\u00e1nyi Konferencia. Program, El\u0151ad\u00e1s-\u00d6sszefoglal\u00f3k","author":"Lipt\u00e1k","year":"2021"},{"key":"2026091321115813300_ckag143-B17","doi-asserted-by":"publisher","first-page":"41","DOI":"10.1016\/j.edurev.2006.03.001","article-title":"Does secondary school size make a difference?: a systematic review","volume":"1","author":"Newman","year":"2006","journal-title":"Edu Research Rev"},{"key":"2026091321115813300_ckag143-B18","author":"McRobbie","year":"2001"},{"key":"2026091321115813300_ckag143-B19","doi-asserted-by":"publisher","first-page":"4382","DOI":"10.1002\/pits.70006","article-title":"From marginalization to inclusion: how alternative education supports sexuality and gender diverse youth","volume":"62","author":"Ireland","year":"2025","journal-title":"Psychol Schools"},{"key":"2026091321115813300_ckag143-B20","doi-asserted-by":"publisher","first-page":"243","DOI":"10.1111\/j.1746-1561.2005.00032.x","article-title":"The small schools movement: implications for health education","volume":"75","author":"Cleary","year":"2005","journal-title":"J Sch Health"},{"key":"2026091321115813300_ckag143-B21","doi-asserted-by":"publisher","first-page":"93","DOI":"10.1186\/s12889-015-1440-z","article-title":"Health promotion in primary and secondary schools in Denmark: time trends and associations with schools\u2019 and students\u2019 characteristics","volume":"15","author":"Nabe-Nielsen","year":"2015","journal-title":"BMC Public Health"},{"key":"2026091321115813300_ckag143-B22","doi-asserted-by":"publisher","first-page":"1661","DOI":"10.1016\/S0140-6736(08)61690-6","article-title":"Closing the gap in a generation: health equity through action on the social determinants of health","volume":"372","author":"Marmot","year":"2008","journal-title":"Lancet"},{"key":"2026091321115813300_ckag143-B23","doi-asserted-by":"publisher","first-page":"381","DOI":"10.1146\/annurev-publhealth-031210-101218","article-title":"The social determinants of health: coming of age","volume":"32","author":"Braveman","year":"2011","journal-title":"Annu Rev Public Health"},{"key":"2026091321115813300_ckag143-B24","doi-asserted-by":"publisher","first-page":"111","DOI":"10.1136\/jech.55.2.111","article-title":"Multilevel analyses of neighbourhood socioeconomic context and health outcomes: a critical review","volume":"55","author":"Pickett","year":"2001","journal-title":"J Epidemiol Community Health"},{"key":"2026091321115813300_ckag143-B25","doi-asserted-by":"publisher","first-page":"1783","DOI":"10.2105\/ajph.91.11.1783","article-title":"Investigating neighborhood and area effects on health","volume":"91","author":"Diez Roux","year":"2001","journal-title":"Am J Public Health"},{"key":"2026091321115813300_ckag143-B26","author":"Inchley","year":"2020"},{"key":"2026091321115813300_ckag143-B27","doi-asserted-by":"publisher","first-page":"1240909","DOI":"10.3389\/feduc.2023.1240909","article-title":"The influence of institutional characteristics on implementing school-based universal addiction prevention: a Hungarian mixed-methods nationwide study on the state of implementation, barriers, and facilitators","volume":"8","author":"\u00c1rva","year":"2024","journal-title":"Front Educ"},{"key":"2026091321115813300_ckag143-B28","author":"Hungarian Central Statistical Office","year":"2025"},{"key":"2026091321115813300_ckag143-B29","author":"Hungarian Academy of Sciences, Centre for Economic and Regional Studies, Institute of Economics","year":"2017"},{"key":"2026091321115813300_ckag143-B30","author":"Economx","year":"2024"},{"key":"2026091321115813300_ckag143-B31","doi-asserted-by":"publisher","first-page":"1297970","DOI":"10.3389\/fpubh.2023.1297970","article-title":"The importance of school leaders in school health promotion. A European call for systematic integration of health in professional development","volume":"11","author":"Leksy","year":"2024","journal-title":"Front Public Health"},{"key":"2026091321115813300_ckag143-B32","doi-asserted-by":"publisher","first-page":"519","DOI":"10.1080\/02640410701624549","article-title":"Evaluation of an extra-curricular school sport programme promoting lifestyle and lifetime activity for adolescents","volume":"26","author":"Lubans","year":"2008","journal-title":"J Sports Sci"},{"key":"2026091321115813300_ckag143-B33","doi-asserted-by":"publisher","author":"Echazarra","year":"2019","DOI":"10.1787\/8b1a5cb9-en"},{"key":"2026091321115813300_ckag143-B34","doi-asserted-by":"publisher","first-page":"6794","DOI":"10.3390\/ijerph20186794","article-title":"Enhancing food literacy and food security through school gardening in rural and regional communities","volume":"20","author":"Holloway","year":"2023","journal-title":"Int J Environ Res Public Health"},{"key":"2026091321115813300_ckag143-B35","doi-asserted-by":"publisher","first-page":"514","DOI":"10.3122\/jabfm.2018.04.170261","article-title":"Socioeconomic status and other factors associated with childhood obesity","volume":"31","author":"Williams","year":"2018","journal-title":"J Am Board Fam Med"},{"key":"2026091321115813300_ckag143-B36","doi-asserted-by":"publisher","first-page":"105833","DOI":"10.1016\/j.chiabu.2022.105833","article-title":"Association between weight status and bullying experiences among children and adolescents in schools: an updated meta-analysis","volume":"134","author":"Cheng","year":"2022","journal-title":"Child Abuse Negl"},{"key":"2026091321115813300_ckag143-B37","doi-asserted-by":"publisher","first-page":"255","DOI":"10.1080\/13548506.2011.608806","article-title":"Physical activity, sedentary behavior, and childhood obesity: a review of cross-sectional studies","volume":"17","author":"Prentice-Dunn","year":"2012","journal-title":"Psychol Health Med"},{"key":"2026091321115813300_ckag143-B38","doi-asserted-by":"publisher","first-page":"e023389","DOI":"10.1136\/bmjopen-2018-023389","article-title":"Social deprivation, gender and obesity: multiple stigma? Results of a population survey from Germany","volume":"9","author":"Makowski","year":"2019","journal-title":"BMJ Open"}],"container-title":["European Journal of Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/eurpub\/article-pdf\/36\/5\/ckag143\/70635962\/ckag143.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/eurpub\/article-pdf\/36\/5\/ckag143\/70635962\/ckag143.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,14]],"date-time":"2026-09-14T01:12:02Z","timestamp":1789348322000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/eurpub\/article\/doi\/10.1093\/eurpub\/ckag143\/8761272"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,4]]},"references-count":38,"journal-issue":{"issue":"5","published-print":{"date-parts":[[2026,8,4]]}},"URL":"https:\/\/doi.org\/10.1093\/eurpub\/ckag143","relation":{},"ISSN":["1101-1262","1464-360X"],"issn-type":[{"value":"1101-1262","type":"print"},{"value":"1464-360X","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2026,10]]},"published":{"date-parts":[[2026,8,4]]},"article-number":"ckag143"}}