Socioeconomic status and health behavior in children and adolescents: a systematic literature review

Socioeconomic status affects individuals’ health behaviors and contributes to a complex relationship between health and development. Due to this complexity, the relationship between SES and health behaviors is not yet fully understood. This literature review, therefore, aims to assess the association between socioeconomic status and health behaviors in childhood and adolescence. Preferred Reporting for Systematic Review and Meta-Analysis protocol guidelines were used to conduct a systematic literature review. The electronic online databases EBSCO Host, PubMed, Web of Science, and Science Direct were utilized to systematically search published articles. The Joanna Briggs Institute’s critical appeal tool was used to assess the quality of included studies. Eligibility criteria such as study context, study participants, study setting, outcome measures, and key findings were used to identify relevant literature that measured the association between socioeconomic status and health behaviors. Out of 2,391 studies, only 46 met the final eligibility criteria and were assessed in this study. Our review found that children and adolescents with low socioeconomic status face an elevated risk of unhealthy behaviors (e.g., early initiation of smoking, high-energy-dense food, low physical activity, and involvement in drug abuse), in contrast to their counterparts. Conversely, children and adolescents from higher socioeconomic backgrounds exhibit a higher prevalence of health-promoting behaviors, such as increased consumption of fruit and vegetables, dairy products, regular breakfast, adherence to a nutritious diet, and engagement in an active lifestyle. The findings of this study underscore the necessity of implementing specific intervention measures aimed at providing assistance to families from disadvantaged socioeconomic backgrounds to mitigate the substantial disparities in health behavior outcomes in children and adolescents.


Introduction
Health behavior constitutes a fundamental facet of individuals' holistic well-being, exerting a substantial influence on their physical health, mental well-being, and overall longevity (1)(2)(3)(4)(5).Over the past decades, considerable attention has been directed toward comprehending health behaviors and cultivating healthy lifestyles (6)(7)(8)(9).However, socioeconomic status (SES) (e.g., income, education, occupation, social position) pose a significant obstacle to achieving these objectives (10).Thus, people from low-SES backgrounds are more likely to exhibit a higher rate of smoking tobacco, drinking alcohol, excess weight gain, and a sedentary lifestyle, which has been consistently identified as a pivotal determinant of premature and preventable morbidity and mortality compared to their counterparts (11)(12)(13).
The literature reveals that children and adolescents' health and health behaviors primarily depend on their parental SES backgrounds (14)(15)(16)(17)(18).It is well documented that children and adolescents from high parental SES backgrounds have more access to education, housing, food, clothing, health services, and social services (19)(20)(21)(22)(23).These advantageous services enhance self-confidence, self-esteem, and self-efficacy, which promotes a healthy lifestyle and reduces the risk of stress in youngsters (14,15,17).In contrast, parental support, healthy parental lifestyle, medical services, and social networks are less open to children and adolescents with low parental SES (21,(24)(25)(26)(27). Hence, poor availability of goods and services increases the likelihood of physical and mental health issues and encourages them to adopt risky behaviors (e.g., smoking, drinking alcohol, illicit drug use, gambling) to deal with their concerns (28)(29)(30)(31)(32)(33).Therefore, parental social, cultural, and economic status are fundamental determinants of health and health behaviors in children and adolescents, which are apparent from the early stages of life and persist into adolescence (34,35).
Globally, millions of children, particularly those with low socioeconomic profiles, do not start their lives in a healthy state (36,37).This could be due to insufficient goods and services, which are the primary causes of impairment in children's neuro-biological development, resulting in poor social, emotional, psychological, and physiological outcomes (38,39).Thus, focusing on improving support for deprived and underserved populations is a powerful strategy to establish the roots of healthy behaviors in childhood and adolescent development (40).Therefore, it is recommended that every government adopt a health and health equity policy program to promote positive health behaviors among its population (41)(42)(43)(44).
Numerous studies have been documented in the international literature to determine (45), analyze (46), and explored (47,48) the relationship between SES and health behaviors in children and adolescents.For example, in a study conducted by Liu et al. (49), adolescents hailing from families with lower parental SES exhibited a significantly higher likelihood of [OR = 2.12, 95% CI, 1.49-3.01]cigarette smoking than those from middle and high SES backgrounds.Melotti et al. (50) explored the association between parental SES and alcohol consumption among adolescents.They discovered an inverse association, revealing that adolescents with low SES had higher odds (OR: 1.26, 95% CI, 1.05-1.52) of consuming alcohol compared to those with high SES backgrounds.Furthermore, a seminal study by Krist et al. (51) investigated the impact of parental SES on physical activity levels in children and adolescents.The results indicated that those from lower parental SES backgrounds were less likely to engage in regular physical activity (OR = 0.90, 95% CI 0.63-1.29) in comparison to their peers from higher SES backgrounds.Collectively, this extensive body of evidence underscores the pivotal role played by parental SES in shaping the multifaceted landscape of health behaviors among children and adolescents.These disparities in health behaviors often contribute to adverse health outcomes, including a heightened prevalence of chronic diseases such as obesity, diabetes, and cardiovascular diseases (52).
Given the evidence above, examining the association between parental SES and health behaviors of children and adolescents holds profound scientific significance and societal consequences.Thus, a good understanding of how parental SES influences health behaviors among young individuals enables the identification of vulnerable populations at an early stage, allowing for targeted interventions and preventive measures to combat socioeconomic comorbidities and their consequences during childhood and adolescence.However, to the best of our knowledge, the existing body of literature examining the association between SES and health behaviors (e.g., protective health behaviors and damaging health behaviors) among children and adolescents remains limited (45-47, 53, 54).To address this gap in the literature, this review comprehensively examines the association between SES and health behaviors in children and adolescents aged 3-18 years, utilizing the literature on SES and health behaviors.In this review, health behaviors were examined in two ways: (i) protecting health behaviors and (ii) impairing health behaviors among children and adolescents.Protecting health behaviors is defined as the consumption of fruit vegetables, consumption of dairy products, regular breakfast, and involvement in physical activity during leisure time (55).Consumption of high-fatty foods (e.g., chips, noodles), high sugary drinks (e.g., fruit juice, Coco Cola, cordial) and engagement in smoking (i.e., tobacco, cannabis), illicit drugs, alcohol consumption, and sedentary activities during their leisure time are defined as unhealthy behaviors exhibited by children and adularescent (56).In this review study, we were particularly interested to examining two important research questions: (i) Does low socioeconomic status influence risky or impair health behavior patterns among children and adolescents compared to their counterparts?(ii) What is the association between SES and health behaviors in children and adolescents?Through an exploration of these research questions, this study will help to better understand the relationship between SES and health behaviors in children and adolescents.By doing so, this study seeks to provide valuable insights that can inform potential policy interventions aims at enhancing the health behavior outcomes of children and adolescents, particularly those who come from underserved and disadvantaged socioeconomic backgrounds.

Methods
This review article followed the Preferred Reporting for Systematic Review and Meta-Analysis Protocol (PRISMA-P) guidelines in order to identify studies that were screened, included and excluded in this review (57).PRISMA-P helps to provide a guideline for development of protocol for systematic review, and meta-analysis in order to

Criteria of excluded studies
Based on predefined eligibility criteria, we evaluated the titles and abstracts of the identified studies.In cases where the studies were found relevant to our review, we thoroughly assessed the full text.However, if the studies were not relevant to our study, such as national income inequalities and health behavior or national per-capita income inequalities and health behaviors in childhood and adolescence, we excluded such studies.Additionally, if the study did not meet the eligibility criteria such as population, comparator, outcome, and study design, we excluded the paper from this study.For example, review articles, pilot studies, reports, dissertations, books, symposia, supplementary, prospective, or intervention studies, and articles published in other languages.Articles published before 2000 were also excluded from this study, primarily because their full-text versions were not readily accessible.Furthermore, articles with a sample size of less than 500 were excluded from the analysis.The decision to exclude studies with a sample size less than 500 was driven by a combination of methodological constraints.Two articles had sample sizes of 246 and 310, respectively; however, these studies found no association between SES and health behaviors in adolescents.Therefore, we decided to exclude them from the final analysis.

Data extraction
The data extraction was done by two independent reviewers using a data extraction table.The data extraction was based on the Joanna Briggs Institute (JBI) checklist (e.g., country, study setting/context, participant characteristics, outcome measures, and key findings).The final data extraction was based on the phase two screening of studies (i.e., 46 studies) by NG following the PRISMA guidelines (57), while GD, MMR, and RK approved data extraction.

Quality assessment of study
The Joanna Briggs Institute (JBI) and System for the Unified Management of the Assessment and Review of Information (SUMARI) is an appraisal tools assist in evaluation of the trustworthiness outcomes of the included studies (62)(63)(64).For the cross-sectional studies, JBI SUMARI apprise as follows: (i) inclusion criteria were clearly defined for the study population; (ii) study subject and study setting were clearly explained; (iii) exposures were scientifically measured; (iv) standard criteria and objectives were used to assess the measurement of the study; (v) confounding factors were identified; (vi) a strategic plan was developed to address the confounding factors; (vii) the results of the studies were reliable and valid; (viii) an appropriate statistical method was used to analyze the study.On the other hand, cohort studies were evaluated as follows: (i) the sample was recruited from the study population; (ii) exposures were measured equally between the exposed and unexposed groups; (iii) exposures were measured in a valid and reliable way; (iv) confounding factors were identified; (v) the statistical plan was used to address the confounding factors; (vi) at the beginning of the study, the sampled population was free from exposures; (vii) outcomes of the study were measured in a valid and reliable way; (viii) follow-up time was sufficiently reported; (ix) follow-up was completed, and if not, reasons were well explained; (x) plans were explored to address the issue of those in the sample lost to follow-up; (xi) the standard statistical method to analyze the study was used.To establish the credibility of our findings, every included study was apprised using the JBI SUMARI and provided the score for each study by two independent reviewers.Studies were included in this review if they had gained a score of 60 percent or above, while studies with a score of less than 60 percent were excluded.However, in the context of this study appraisal, none of the papers met the criteria for a score below 60 percent.As a result, it was not necessary to exclude any studies through the application of the JBI SUMARI appraisal tools (see Supplementary Table S4).In alignment with these principles, our review study also employed the JBI SUMARI to contribute to the overall reliability and quality of the review findings (65, 66).Furthermore, the risk of bias in the included studies was evaluated using the 10-item grading scale for prevalence studies developed by Hoy et al. (67).The study methodology, case definition, prevalence periods, sampling, data collection, reliability, and validity of the investigations were thoroughly scrutinized.Each study was categorized as exhibiting either a low risk of bias (shown by affirmative replies to domain questions) or a high risk of bias (indicated by negative responses to domain questions).In each study, a binary scoring system was used to assign a value of 1 (indicating presence) or 0 (indicating absence) to each domain.The cumulative sum of these domain values was used to derive the overall study quality score.The assessment of bias risk was performed by calculating the total number of high-risk biases in each study.Studies were categorized as having a low risk of bias if they had two or fewer high-risk biases, moderate risk of bias if they had three or four high-risk biases, and high risk of bias if they had five or more high-risk biases.To resolve discrepancies among the reviewers, a consensus-based approach was employed for the final categorization of the risk of bias (see Supplementary Table S5).

Outcome measurement of the study
The outcomes of this study were health behaviors, either through health-protective behaviors (e.g., consumption of fruit and vegetables, consumption of a healthy diet, physical exercise) or impairing health behaviors (e.g., smoking, drinking alcohol, high sedentary lifestyle and illicit drug use), in children and adolescents (68).Childhood and adolescence are two distinct stages of life that are characterized by diverse features in the respective age groups (e.g., physical and psychological) (69,70).Childhood is a time of rapid and remarkable development, encompassing significant strides in the physical, cognitive, social, and emotional dimensions that outpace the progress seen in other life stages.During this period, children's innate intellectual curiosity flourishes, driving them to explore the world around them and actively engage in interactive experiences (71,72).On the other hand, adolescence is widely acknowledged as a transformative phase known as the "storm and stress" period, characterized by profound changes in biological, cognitive, psychosocial, and emotional realms (73).These transformative shifts often give rise to a range of adjustment challenges, including mood swings, propensity for risk-taking behaviors, and conflicts with both parental figures and peers (73).Thus, considering the relationship between health behaviors in childhood and adolescence is pivotal, therefore, this review study examined the association between parental SES and health behaviors in children and adolescents separately.

Measure of socioeconomic status (SES)
SES is a multidimensional construct and is measured objectively by income, education, and occupation, or subjectively by prestige, place of residence, ethnic origin, or religious background, covering both objective and subjective measures of SES (74-76).The stratification of SES into subgroups (e.g., low SES and high SES) was predicted based on goods and materials consumed by the individual in a household, including durable goods such as televisions, bicycles, and vehicles, as well as housing-related attributes such as access to drinking water, food, bathroom facilities, and agricultural and flooring materials (77).Households that possessed adequate provision of food, water, hand-washing materials, agricultural products, fields for production, and other consumer items for a duration of merely 6 months were categorized as having low-income or low-SES backgrounds.On the other hand, families that possessed an ample supply of food and other products, including consumer goods, to sustain themselves for a period of 12 months or more were classified as affluent or wealthy or high SES backgrounds (77,78).Based on previous literature (21,22,77,79,80), our study defined low SES and high SES backgrounds and examined the association between SES and health behaviors in children and adolescents.

Description of the study
In this systematic literature review, 2,391 articles were initially retrieved, and 585 duplicates were removed before entering the first phase of screening.A total of 1806 articles were assessed in the first phase of screening based on their titles and abstracts.Thus, in the first screening phase, we retained only 146 articles and rejected 1,660 articles.Consequently, in phase two of the screening, we assessed 146 papers based on their full text.Of these, only 46 articles met the inclusion criteria for further evaluation.Hence, these 46 articles were eligible in our final review, which is shown in Figure 1.

Parental socioeconomic status and smoking among children
From a total of 46 studies, 18 studies (25, 47, 49, 50, 53, 79, 81, 84, 86-88, 93, 96, 97, 104, 105, 107, 109) showed an association between SES and smoking behavior in children and adolescents.Out of 18 studies, five reported a positive association between low SES and smoking behavior in children, implying that children with low SES had a greater risk of exposure to early smoking, and experimenting with smoking, compared to those who were from a high SES background (25,49,53,104,105).

Parental socioeconomic status and smoking among adolescents
From a total of 18 studies, 12 studies showed a positive association between low SES and smoking behaviors in adolescents, indicating  108,115) assessed the association between SES and drinking alcohol.Of them, seven studies reported a positive association between high SES and drinking alcohol in children (25,53,83,102,104,105,115).This implies that younger children from higher SES backgrounds are more likely to experiment with drinking alcohol compared with their counterparts.One study found a negative association between drinking alcohol and high SES (100).

Parental socioeconomic status and drinking alcohol among adolescents
With regard to SES and drinking alcohol by adolescents, from 18 studies, six reported a negative association between drinking alcohol and high SES (50,85,91,101,107,108).Conversely, three studies reported a positive association between drinking alcohol and high SES (47,79,97).This positive association indicates that adolescents from a high SES background were found to have a higher chance of drinking alcohol than their counterparts.Moreover, a study by Richter et al. (84) reported that adolescents from Western, Northern, Southern (except Spain), Central and Eastern (except Latvia) Europe, and from a low SES background, were found to have a lower chance of drinking alcohol   Frontiers in Public Health 08 frontiersin.orgcompared to their counterparts; however, adolescents from Scotland, Wales, Norway, Finland, Denmark, Greece, Italy, Malta, Hungary, Russia, and Ukraine were only statistically significant.In summary, out of 18 studies, children (seven studies, or 38.88%) and adolescents (three studies, or 16.66%) from a high SES background had a higher chance of drinking alcohol than those from a low SES background, while six studies (33.33%) found a negative association between a high SES background and drinking alcohol in adolescents (Table 2).We identified 15 studies (25,48,51,53,81,89,92,94,97,98,104,105,110,113,117) that examined the association between SES and PA.From a total of 15 studies, seven found a positive  association between high SES and PA in children (25,48,51,98,104,110,117); however, two reported a negative association between high SES and PA (53,105).This negative association implies that those children from a high SES background had a lower chance of being physically active compared to their counterparts.

Parental socioeconomic status and physical activity (PA) among adolescents
Five studies found a positive association between high-SES and physical activity in adolescents (89,92,94,97,113).These findings implied that the adolescents from high parental SES backgrounds were more physically active compared to their counterparts, while one study found a negative association between high SES and PA (81).In summary, children from high-SES backgrounds in seven studies (46.66%) and adolescents in five studies (33.33%) had a higher chance of being more physically active than those from low-SES backgrounds (Table 3).
3.5.Parental socioeconomic status and fruits/vegetables  111,118) were identified that examined the association between SES and fruit and vegetable consumption.Ten of these studies found a positive link between high SES and children's consumption of fruits and vegetables (48, 53,82,84,95,99,106,110,111,118), which implies that children from a high SES background had a higher chance of consuming high amounts of fruits and vegetables compared to those from low SES backgrounds.

Parental socioeconomic status and fruits/ vegetables among adolescents
From 14 studies that examined the association between SES and the consumption of fruits and vegetables, four studies found a positive association between high SES and the consumption of fruit and vegetables in adolescents (79,81,89,90).A study by Vereecken et al. (82) reported that adolescents from Europe (West, South, North, Central, East), North America, and Asia with low SES were less likely to consume fruits and vegetables than those from high-SES backgrounds.Adolescents from low-SES families in Western Europe, Northern Europe, Southern Europe, North-Eastern Europe (except Estonia, Hungary, Latvia, Russia, and Ukraine), North America, and Asia were less likely to consume vegetables than their counterparts.Overall, high SES was associated with greater rates of fruit and vegetable consumption among children (10 studies or 71.42%) and adolescents (4 studies or 28.57%) compared to low SES (see Table 4).

Parental socioeconomic status and dietary habits among adolescents
Out of 18 studies that examined the association between SES and dietary habits, five studies reported a positive association between high SES and consumption of healthy dietary food in adolescents (79,81,90,97,112), implying that adolescents with high parental SES had a higher probability of consuming a high proportion of dairy products, a regular breakfast, a healthy or nutritious diet, a balanced diet, and a low proportion of high-fat diet than those with low SES (see Table 5).In summary, six (33.33%) and five studies (27.77%) were positively associated with high SES and healthy dietary habits in childhood and adolescence, respectively.

Parental socioeconomic status and cannabis, marijuana, and illicit drug use by adolescents
In this literature review, we assessed three studies (47,101,103) out of 46 that examined the relationship between SES and cannabis use and illicit drugs.Of these, one study reported a negative association between high SES and cannabis use (47), while another found a negative relationship between high SES and marijuana consumption (101).Similarly, two other studies found a negative association between high SES and illicit drugs used by adolescents (101, 103).This indicates that adolescents with low SES were found to consume cannabis, marijuana, and illicit drugs more frequently than adolescents from high SES backgrounds.In summary, 66.66%, or two studies, reported a negative association between high SES and illicit drug used in adolescents (see Table 6).

Discussion
Our study produced evidence, mostly from cross-sectional and longitudinal studies, that consistently demonstrates a strong relationship between SES and health behaviors.SES plays a major and well-documented influence in the onset and progression of chronic diseases in children and adolescents.Lower-income children and adolescents may have less access to frequent check-ups, preventative care, and early disease identification, increasing their risk of acquiring chronic disorders.Furthermore, SES influences the availability and cost of healthy food.Low-income families may struggle to offer adequate diets, which can contribute to poor eating habits, obesity, and linked chronic illnesses such as type 2 diabetes (52, 119, 120).Childhood and adolescence are regarded as pivotal stages in the development of life foundations in the general population.Focusing on younger ages is important because health behaviors can be learned and consolidated during these ages, affecting an individual's health for the rest of their life.Therefore, this review study aims to examine the association between SES and health behaviors in children and adolescents.
The findings of this review demonstrate that children and adolescents from low SES backgrounds are more likely to engaged in unhealthy behaviors, such as smoking, alcohol consumption, physical inactivity, poor dietary choices, and drug use, when compared to their peers from higher SES backgrounds.These disparities in multiple health behaviors among children and adolescents may In the context of SES and smoking behavior among children and adolescents, the results of this review study reported that children and adolescents with low parental SES backgrounds had heightened vulnerability to early exposure to smoking during childhood and early initiation of smoking during adolescence.This susceptibility may be attributed to a confluence of factors, including pervasive tobacco advertising, normalization of smoking within their social environments, easy access to cigarettes, limited social support for smoking cessation, heightened nicotine dependence, and the burden of stressful life circumstances.These findings substantiate the existing body of literature, which consistently demonstrates an elevated prevalence of smoking within lower SES strata, often attributed to factors such as a paucity of robust social support networks and the presence of stress-inducing lifestyles.Furthermore, children from low SES backgrounds are approximately 6.6 times more likely to be exposed to secondhand smoke within their parental residences compared to their counterparts in high-SES households (125)(126)(127).This discrepancy underscores the urgent need for targeted interventions to mitigate the adverse consequences of smoking in vulnerable populations, particularly during the critical period of life.
On the other hand, alcohol consumption was significantly higher among adolescents with high SES.These findings align with those of previous research, reinforcing the robust association between SES and adolescent alcohol consumption.Specifically, adolescents from high parental SES backgrounds exhibit increased odds of alcohol use (OR = 1.4,95% CI = 1.19-1.78)(128).Recent research by Torchyan et al. (129) further substantiates this phenomenon, indicating a heightened likelihood of weekly alcohol consumption (OR = 1.24, 95% CI = 1.16-1.32)among high-SES adolescents when compared to their counterparts (129).This persistent pattern has been confirmed in other studies, indicating that high-SES adolescents are more likely to consume alcohol under parental supervision than their counterparts, (130).This could be explained through social and cultural activities (business meetings, and, party celebrations), the availability of alcohol at home, and the availability of pocket money to purchase alcohol (131).This review underlines early alcohol initiation among children with high SES, which is often influenced by parental drinking behavior (132).Thus, parental discretion in alcohol consumption around children is pivotal in preventing negative alcohol-related behavior (133).Therefore, this study suggests that parents should take care while drinking alcohol in front of their children to prevent them from developing bad alcohol-related behavior.
In addition, our review study found that children and adolescents with high SES were more likely to be engaged in physical exercise.These findings are consistent with previous studies and led to the conclusion that parental SES (OR = 95% CI = 2.18, 3.42) were significantly (p < 0.05) associated with participation in indoor and outdoor physical activities by children and adolescents (134,135).If parents had a good family income, there would be a higher chance of availability of goods and material resources at home (136).This availability of materials would make it possible to be more engaged in physical activity rather than spending more time watching television or  being inactive (137).However, children and adolescents from lower parental SES backgrounds were found to participate less often in physical activity but were more often involved in sedentary behaviors.Previous studies have found that poor parental SES backgrounds were significantly associated with poor physical activity, high sedentary activity, and high screen time in children and adolescents (113,138,139).Moreover, there was ample evidence to suggest that more children and adolescents from deprived SES were more likely to spend more time inside the home due to a lack of a secure neighborhood, lack of green areas for sports and recreational activities, and the cost associated with physical activity (140, 141).In relation to SES and diet (e.g., dairy products, fruit, vegetables, breakfast, soft drinks, and high-fat diet), we found that higher SES was positively associated with the consumption of breakfast, dairy products, fruit, vegetables, and a balanced diet, but negatively associated with consumption of sugar, sugar items, high-fat diet, and soft drinks.The findings of this review study are consistent with those of other studies that show that parental SES has a strong influence on children's diet (142).These findings show that children and adolescents from high-SES families consume a healthy proportion of calories (β = 1.86,SE = 0.76) rather than high-energy foods (143).Children and adolescents from low-SES families may have few food options and may even face food insecurity and scarcity at home (144).Therefore, low parental SES may lead to low price food, high-fat diet, high-salt food, energy-dense food, and low intake of regular breakfast, dairy products, fruits, and vegetables during childhood and adolescence (144)(145)(146)(147).
Moreover, in the context of SES and cannabis and illicit drug abuse in adolescents, there was a correlation between the consumption of cannabis and illicit drug abuse and low parental SES, poor schooling, unsafe neighborhoods, and stressful daily life events.Thus, it is important to consider how parental SES particularly affects an adolescent's health behaviors.This review study revealed that 66.66% of the adolescents had consumed illicit drugs.These conditions increase the risk of physical, psychological, social, and emotional competence in adolescents.These findings could help to provide information about how low parental SES affects children and adolescents, and thus motivate authorities to carry out preventative activities and appropriate rules, regulations, and policies to promote healthy lifestyles in children and adolescents (148).Overall, risky health behaviors were found to be a major concern, particularly in children and adolescents with low parental SES.These conditions may increase the risk of poor health and development in childhood and adolescence.Therefore, to control these issues, an appropriate strategy helps to protect and prevent risky health behaviors in children and adolescents and gives them equal rights, services, and facilities to fight against inequalities.Hence, this study indicated that parental SES play a significant role in developing social and emotional competence and positive health outcomes in children and adolescents.Therefore, authorities and government bodies should pay more attention to the health and health behaviors of every individual, including children and adolescents, and provide support to children and adolescents, especially those with low parental SES.

Strength and limitations
This study comprehensively examined the association between SES and health behaviors, including protecting and impairing health behaviors in children and adolescents across the world.Moreover, this study used multiple databases and followed a structural research process that provided transparent, unbiased, and reliable information on SES and health behaviors.In summary, this study's strengths lie in its comprehensive approach, use of multiple databases, adherence to a structured research process, and commitment to providing unbiased information.However, this study had certain limitations.The heterogeneity of the studies makes Meta-Analysis not possible.Another limitation is no risk of bias and no registration in "PROSPERO, " was remedied by that two researchers have independently assessed each article, and that a Quality Score was provided (Supplementary Table S4) as well as a "PRISMA" approach (Supplementary Table S3).

Conclusion
The current study revealed a robust association between low parental SES and a myriad of unhealthy behaviors (high smoking behavior, low physical exercise, illicit drug use, low consumption of fruit and vegetables, and unhealthy diet) in children and adolescents.However, alcohol consumption was more common in adolescents with a high parental SES.Based on these significant findings, this study underscores the urgent need for an appropriate intervention program that caters to the unique needs of children and adolescents from low-SES families.By implementing measures such as free all-day schools with complementary meals, free after-school activities, and supervised homework sessions, we can bridge the gaps in opportunities, capabilities, and productivity, thereby fostering healthier and more promising futures for these individuals.

8 (
, South, Central, and East regions) with low SES and parental occupation were more likely to smoke compared to those with high or middle SES.Similarly, adolescents in Canada and the USA with low SES had a higher likelihood of smoking than their high or middlelacking education, lower social class, or low family income had higher odds of ever smoking (OR: 1.14, 95% CI 0.95-1.38;OR: 1.15, 95% CI 0.81-1.60;OR: 1.17, slightly higher chance of smoking (OR: 1.027, 95% CI 0.929-1.136)compared to those from high parental SES.Economic instability and stressful events contribute to an increased probability of engaging in smoking behavior.However, the study has some methodological constraints.Continued) 10.3389/fpubh.2023.1228632

3. 4 .
Parental socioeconomic status and physical activity (PA) 3.4.1.Parental socioeconomic status and physical activity (PA) among children free time and fewer constructive ways to spend it, potentially leading to alcohol use.However, data was collected using self-report measures and utilized a crosssectional research design.So, it cannot establish a causal association and there might be a chance of biases in the findings.7

TABLE 2
Studies examining the association between parental SES and alcohol consumption.

TABLE 3
Studies examining the association between parental SES and physical activity (PA).

TABLE 4
Studies examining the association between SES and fruits and vegetables consumption.

TABLE 5
Studies examining the association between parental SES and diet habits.

TABLE 6
Studies examining the association between SES and cannabis, and illicit drug use.