Low-income groups and behaviour change interventions: a ......Low-income groups and behaviour change...

doi:10.1136/jech.2008.078725 Apr 2009;

2009;63;610-622; originally published online 21J Epidemiol Community Health S Michie, K Jochelson, W A Markham and C Bridle

effectiveness and theoretical frameworksinterventions: a review of intervention content, Low-income groups and behaviour change

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Low-income groups and behaviour changeinterventions: a review of intervention content,effectiveness and theoretical frameworks

S Michie,1 K Jochelson,2 W A Markham,3 C Bridle4

1 Research Department ofClinical, Education and HealthPsychology, University CollegeLondon, London, UK; 2 Equalityand Human Rights Commission,London, UK; 3 School of Healthand Social Studies, University ofWarwick, Coventry, UK;4 Clinical Trials Unit, WarwickMedical School, University ofWarwick, Coventry, UK

Correspondence to:Professor S Michie, ResearchDepartment of Clinical,Education and HealthPsychology, University CollegeLondon, 1–19 Torrington Place,London WC1E 7HB, UK;[email protected]

Accepted 2 March 2009

ABSTRACTBackground: Interventions to change health-relatedbehaviours have potential to increase health inequalities.Methods: This review investigated the effectiveness ofinterventions targeting low-income groups to reducesmoking or increase physical activity and/or healthy eating.Of 9766 papers identified by the search strategy, 13 met theinclusion criteria. Intervention content was coded intocomponent technique and theoretical basis, and examinedas a potential source of effect heterogeneity.Results: Interventions were heterogeneous, comprising4–19 techniques. Nine interventions had positive effects,seven resulted in no change and one had an adverseeffect. Effective interventions had a tendency to havefewer techniques than ineffective interventions, with noevidence for any technique being generally effective orineffective. Only six studies cited theory relative tointervention development, with little information abouthow theory was used and no obvious association withintervention content or effect.Conclusion: This review shows that behaviour changeinterventions, particularly those with fewer techniques,can be effective in low-income groups, but highlights thelack of evidence to draw on in informing the design ofinterventions for disadvantaged groups.

Chronic diseases, such as cardiovascular disease,diabetes, cancer and respiratory disease, are a majorcause of death and disability worldwide. There isconsiderable evidence showing that quitting smok-ing, eating a healthier diet, not consuming exces-sive amounts of alcohol and exercising regularlycan have a major impact on reducing rates ofchronic illness1 2 Lower socioeconomic status (SES)and lower social status is associated with poorerhealth outcomes and less healthy behaviours.3–6 Forexample, in Great Britain, although smokingprevalence has declined across all socioeconomicgroups, 15% of managerial and professional groupssmoked compared with 29% of manual occupa-tional groups in 2006.7 While 30% of adults inmanagerial and professional groups eat the recom-mended five portions of fruit and vegetable a day,just 18% of adults in the routine and manualgroups do so.8 Only 25% of people in lowersocioeconomic groups participate in sports andexercise compared with about 50% of highersocioeconomic groups (although when occupa-tional activity is controlled for, activity levels aresimilar).8 9 The adult routine and manual group isestimated at about 15 million people; about 4.3million smoke, 12.3 million eat less than five fruitand vegetable portions a day, and 7.5 million are

not physically active.10 Even a small percentagechange in behaviour in lower socioeconomic groupscould have a large impact on the health profile ofthe general population and on health costs.

The health promotion literature offers manytheories and techniques on behaviour change, butthus far there has been little research analysing theeffectiveness of particular component techniques,or of the effectiveness of techniques acrossdifferent groups. Literature reviews of particularhealth behaviours point to the paucity of data onthe impact of health promotion programmes onbehaviour change in poor and socially excludedgroups.11–13 Recent reviews also noted the lack ofinformation at review or meta-review level on thevariable effects of interventions on different socio-economic groups and on the impact of interven-tions on reducing health inequalities14–16 Albarracinet al show that the impact of interventions iscontingent on gender, age, ethnicity and otherpopulation-specific factors, suggesting that genericinterventions cannot be applied across populationswith confidence that they will be effective.16

There is clear evidence that people from dis-advantaged backgrounds are less successful inachieving behaviour change following participationin formal programmes such as smokers’ clinics.17 18

However, this does not necessarily mean thatthose programmes were less effective; it may bethat those from disadvantaged backgrounds beganwith a lower chance of success because of theirstarting levels of behaviour, and their physical and/or social environments undermine attempts atchange. There is consistent evidence that smokersin low socioeconomic groups are significantly morelikely to fail to quit smoking compared withsmokers in higher socioeconomic groups.19

Community-based programmes promoting healthyeating and physical activity have more difficultyrecruiting participants from low socioeconomicgroups20 and find higher attrition rates amonglow-income participants.21

Reducing health inequalities depends on devel-oping interventions to increase healthy behavioursthat are differentially effective in favour of thosefrom disadvantaged backgrounds or that targetsocially disadvantaged groups. A recent review onbehaviour change drew attention to the lack ofreviews and primary studies investigating differ-ential effectiveness among social groups and thelack of research on the cost-effectiveness ofbehaviour change interventions.15 The few studiesthat have investigated the effectiveness of inter-ventions across socioeconomic groups have tended

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to do this as post hoc comparisons and are underpowered to dothis, leading to equivocal results.

This review focuses on interventions specifically targeted atlow-income populations, one index of disadvantage. It includedthree targeted behaviours related to health: smoking, healthyeating and physical activity. These were selected as they arehighly associated with illness and death, eg, they constituted70% of the modifiable behaviours found to be associated withdeath in the United States in 2000.22 This review analysesintervention content into its component techniques; such adetailed description is necessary for evaluating effectiveness andfor understanding mechanisms of change.23 24 Interventions aredescribed using a reliable taxonomy of behaviour changetechniques.25

The increasing recognition that interventions to changebehaviour should draw on theories of behaviour and behaviourchange in their development26 is for three main reasons.24 First,interventions are likely to be more effective if they target causaldeterminants of behaviour and behaviour change. Second,theory-based interventions facilitate an understanding of whyparticular interventions work and thus provide a basis fordeveloping better interventions across different contexts,populations and behaviours. Third, theory can be advancedonly if interventions and evaluations are theoreticallyinformed.24 25 However, many studies do not make the linkbetween theoretical models, expected outcomes and the processof change explicit.

The aim of this review is to identify evidence for theeffectiveness of health behaviour interventions that target low-income groups, with the aim of reducing smoking andunhealthy eating or increasing physical activity. It focuses onthe component techniques of the interventions, the theoriesused to develop the interventions, and considers associationsbetween theory and intervention content, and between inter-vention content and effect. It should be stressed that thisapproach is unable to comment on differential effectivenessacross social groups, only on whether there was any evidence ofeffect in interventions targeting low-income groups.

METHOD

Search strategyWe searched 21 electronic databases (January 1995 to September2006) using search terms related to a low-income population(eg, socioeconomic status, deprivation, disadvantaged, income)and three behaviours related to health: smoking cessation,healthy eating and physical activity (see Appendix A fordatabases and Appendix B for example search strategies). Inaddition, we approached 24 experts in the health inequalitiesfield enquiring about potential studies missed by our electronicsearch strategy, and we checked the bibliographies of allincluded studies.

ScreeningTitles and abstracts were screened against the inclusion criteriaby one reviewer, and a second reviewer independently checked arandom 10% of the search results. Full-text papers of referencesthat could not be excluded were ordered, and divided equallyamong two reviewers for assessment against the inclusioncriteria. For each reviewer, all papers initially selected forinclusion, and a random 10% of papers initially excluded, wereindependently assessed by the other reviewer. Inter-rateragreement was very good, kappa = 0.81.

Eligibility criteriaThe eligibility criteria for inclusion in this study were:1. Population: non-clinical, general population adults

(18+ years) from a low-income group.

2. Interventions: any interventions promoting smokingcessation, healthy eating and/or physical activity targetedat low-income groups.

3. Outcomes: behavioural outcomes relevant to the interven-tion target, ie, smoking cessation and increased healthyeating and physical activity.

4. Date: published after January 1995.

5. Language: published in the English language.

6. Methodological criteria: concurrent control, with or with-out random allocation. This therefore excludes reviews.

Data extractionA reviewer extracted data from the primary studies and asecond reviewer checked all papers for accuracy; discrepancieswere resolved through discussion. The interventions were codedby study design, country, target behaviour, type of participant,type of theory cited by the authors as informing theintervention, type of intervention and intervention effect.Intervention content was analysed into component techniques,using a reliable published taxonomy of 26 techniques,35 but twoadditional techniques were also identified. When interventionstargeted more than one behaviour, the techniques and resultswere recorded for each behaviour.

Data analysisOwing to the heterogeneity in intervention content and design,and the small sample, meta-analysis was not appropriate. Thenumber of techniques in effective and ineffective interventionswere tested statistically using independent t-tests.

RESULTS

Available evidenceAs figure 1 illustrates, the search strategy identified 9766references to potentially relevant studies, of which 1468 wereduplicates. We screened 8298 distinct references, excluding 8025primarily because the study populations were not of lowincome. We ordered full-text copies of the remaining 273references, and assessed 264 (nine could not be obtained, seeAppendix C), of which 238 were excluded primarily for failingto satisfy the population criterion. A total of 13 studies,

Figure 1 Flow of study papers through the review.

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reporting 17 comparisons of interest, were included in thereview (see table 1).

Of the 13 studies included in the review, three wereconducted in the United Kingdom,31 38 39 one in Canada,34 eightin the USA,27–30 32 33 40–43 and one in the Netherlands.44 In total,seven, six and four studies developed interventions to promotesmoking cessation, healthy eating and physical activity,respectively, with three studies targeting more than onebehaviour.32–34

Eight studies were randomised controlled trials(RCTs),28 30–32 38 39 42 43 and five studies evaluated interventionsamong a non-randomised cohort with concurrent con-trol.33 34 40 41 44 Sample sizes ranged from 15 to more than 2000,although most were between 200 and 1000, with an averageapproaching 500. Effect data were extracted for the final follow-up, which ranged from less than 6 months28 to between 6 and12 months,30 32 33 39 42 43 to 12 months or more.31 34 38 40 41 44 Noneof the studies investigated cost-effectiveness.

Intervention techniquesInterventions were very heterogeneous, incorporating anythingfrom 4 to 19 techniques. Figure 2 shows the number ofinterventions incorporating each technique (multiple beha-viours targeted by one study intervention are counted asseparate interventions). Those used most frequently (in at least9 of the 17 interventions) were: providing general information;providing information about the consequences of a particularbehaviour; helping to form an intention to change a behaviour;setting specific goals; identifying barriers to changing behaviour;planning social support or social change; and providing rewardscontingent on performing the behaviour.

Intervention content and effectsOverall, nine interventions had positive effects, seven resulted inno detectable change and one had an adverse effect. Forsmoking, four studies reported a positive effect,28 39–41 and threereported no effects.34 42 43 For healthy eating, four studiesreported positive effects30 32 38 44 and two reported no effects.33 34

For physical activity, one study reported a positive effect,31 two

no effects32 33 and one an adverse effect.34 Overall, five of thenine positive intervention effects were obtained from RCTsaimed at promoting healthy eating,30 32 38 physical activity31 andsmoking cessation,39 three of which were conducted in theUK.31 38 39 Differing sample sizes do not appear to explaindifferences in effectiveness, as there was no difference betweensample sizes for effective interventions (M = 665, SD = 812) andthose having no effect (M = 613, SD = 443; t(11) = 0.12,p = 0.91).

Effective interventions had a tendency to have fewertechniques on average than ineffective interventions; anindependent t-test demonstrated that this reached marginalstatistical significance (8.22 vs 12.75; t(15) = 21.95, p = 0.07;95% CI for mean difference 29.48 to 0.43) (fig 3). Figure 4compares the frequency with which techniques are included ineffective and ineffective interventions. The most commonlyused techniques were providing information (the first threetechniques in figure 4) and facilitating goal setting (the secondtwo techniques in fig 4). Visual inspection suggests that all thetechniques have potential merit, with none appearing to beoverwhelmingly effective or ineffective.

Effects over timeThe effects of behaviour change interventions may ameliorateover time, such that significant intervention effects are lesslikely to be observed in studies with longer follow-ups. In thisreview, however, there is no evidence of a time-dilution effect,but evidence suggests the reverse. Of the nine positive effectsreported among the included studies, four were obtained instudies with follow-up ,12 months, and five in studies with>12 month follow-ups. Indeed, with only one exception,34

studies with long-term follow-up reported only positiveintervention effects, with non-significant effects thereforeclustered among studies with shorter term follow-up. Ofcourse, results based on indirect comparison must be interpretedwith caution. Nevertheless, it is plausible to speculate that theeffects of interventions targeting low-income groups may takelonger to emerge, and/or have effects that may be more durableor sustainable over time. Resolving these issues may have

Figure 2 Technique type and frequency.

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profound effects on intervention development, research designand, ultimately, reducing health inequalities among low-incomegroups.

Theoretical base of interventionsTheories were cited in 6 of the 13 included studies, incorporat-ing 10 of the 17 comparisons, four studies drawing on morethan one theory. Five studies cited the stages of change/transtheoretical model, four studies cited social cognitivetheory, and five theories were cited only once: the theory ofreasoned action, the precaution adoption model, the precede–proceed model, behaviour modification principles and organisa-tional theory. There was thus a plethora of theories used inthese few studies. None of the papers reported how the statedtheories were used as a basis for selecting the techniquescomprising the intervention, and none drew conclusions abouttheory from the evaluation data. There were no obviousdifferences in intervention content (ie, the techniques usedwithin the intervention) between those studies that explicitlyused theory and those that did not. There was also no obviousassociation between reported use of theory and whether or notthe intervention was effective.

DISCUSSIONThere is evidence that behaviour change interventions can beeffective in low-income groups. Of the 17 interventionevaluations that targeted low-income groups, we found thatnine were effective, seven were not statistically different andone suggested adverse effects. That nine statistically significantpositive results were obtained purely by chance seems unlikely.However, the small number of studies means that the resultsshould be treated with caution.

The most frequently used intervention techniques wereproviding information (eg, about the consequences of thebehaviour) and prompting people to form intentions and setgoals. No clear patterns between the purported theoretical basis,intervention content and the effect were evident, although thedataset was too small for formal analysis. In addition, the lackof reported detail as to how theory was used in designinginterventions precludes the possibility of explaining a lack ofassociation. It may be that particular theories were not usefulfor intervention development, or that useful theories werepoorly applied.

There are two suggestive findings from this review. The firstis that more focused interventions involving a small set oftechniques may be more effective than interventions combininga large number of different techniques. There may be morevariation in the quality of intervention delivery as the numberof component techniques increases, both within and betweenproviders, increasing the likelihood of inconsistent effects. Thishighlights the need to monitor the fidelity of interventiondelivery,45 46 an important practice that is rarely observed. Moreresearch based on larger datasets is required to clarify theseissues.

The second suggestive finding is that the most commontechniques—providing information, facilitating goal setting andprompting barrier identification—may be helpful for low-income groups. These sets of techniques may be workingadditively, in that providing information about the benefits ofchanging behaviour may increase people’s motivation tochange, while helping people to form specific, realistic goals,identify barriers and draw on social support may help people totranslate motivation into action. This has some parallels with afinding from Coulter and Ellins’ systematic review of patient-focused interventions.47 They found that providing information,on its own, had little effect on people’s knowledge about theirown health. However, combined with professional consultation

Figure 3 Number of techniques used in effective and ineffectiveinterventions.

Figure 4 Number of effective andineffective interventions using eachtechnique.

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or advice, it could improve knowledge and recall, especiallywhere the information was personalised. Disadvantaged popu-lations benefited more than other groups, possibly because theirknowledge base was smaller, and so they had more to gain fromhealth information. It is also consistent with a meta-analysis ofinterventions to increase HIV preventive behaviours.16 Providinginformation changed behaviour only when accompanied byactive, behavioural strategies such as teaching self-managementtechniques.

Goal setting is a key behaviour change technique in evidence-based theories of behaviour change, most notably socialcognitive theory48 and self-regulation (control) theory.49

Setting goals that are realistic and achievable helps people tofeel more confident about being able to change their behaviour.Setting goals may also help people to be more aware of theircurrent behaviour and to take steps when they notice theirbehaviour is falling short of their targets. Breaking down large,long-term goals into smaller, short-term goals allows people tobuild on small successes, leading to greater feelings of control or‘‘mastery’’. This may be especially important for those indisadvantaged situations, who often experience a lack of controland therefore feel powerless to bring about change. Emergingresearch findings suggest that adults with a low income or ahigh school education or less score poorly on the ‘‘patientactivation measure’’. This measures an individual’s confidence,knowledge and skills to take action to improve their health andstay the course even under stress.50 Goal setting is a relativelysimple technique that can be successfully taught to a wide rangeof people varying in educational and social background, butdisadvantaged groups may have more to gain, if their confidenceand skill base is lower.51–54

Our scoping review is, by definition, not exhaustive. Giventhat only three of the 13 interventions were conducted in theUK and nine were from North America, caution needs to beexercised about the generalisability of the findings. In addition,the scope of the review did not extend to consider studies thatdirectly compared the effectiveness of an intervention in low-income groups versus more affluent groups. It is therefore notclear whether interventions to change these behaviours aredifferentially effective across socioeconomic groups. Tworeviews have used a similar taxonomy of techniques forinvestigating intervention techniques in populations notselected by socioeconomic status and were able to use meta-regression in much larger datasets.12 55 They identified self-monitoring of behaviour as the most effective technique.However, within-study comparisons are needed to answer thequestion as to whether different techniques, or different modesof delivery, tailored so as to be more relevant or attractive, areneeded to promote health among lower income groups.

However, this review shows that there is a widespreadpaucity of evidence about the effectiveness and cost-effective-ness of changing health behaviours in disadvantaged groups. Tobuild evidence about ‘‘what works for whom’’, it is essentialthat the same intervention be compared across different groups,and that different interventions be compared in the samegroups. As this review demonstrates, such work is in its infancy.

For those with responsibility for commissioning or conduct-ing systematic reviews in this or related areas, there is a need toconsider carefully methods for maximising the inclusion ofrelevant evidence. First, reviews may need to include otherstudy designs that adequately balance methodological reliabilityand contextual relevance. Second, future reviews may need toconsider evidence obtained from a wider range of individuals.For example, our review focused on evidence that reportedTa

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outcomes in adults, excluding evidence that targeted low SESadults but reported outcomes only in their children. Third,future reviews should consider the implications of usingdifferent indicators of social disadvantage. For example, in ourreview, the population of interest was defined as low income,but that meant the review excluded ‘‘culturally sensitive/targeted’’ interventions that were not explicitly indexed underterms related to SES.

A dedicated stream of research funding for research intointerventions targeting health behaviour change among low SESgroups would thus seem to be timely and warranted. For suchinvestment to maximise its potential to improve populationhealth, the study of interventions to change behaviour should beinformed by methods for analysing interventions by theircomponent techniques and underlying theories of behaviourchange. This will facilitate building evidence about, not just‘‘what works’’ but how interventions work, evidence that iscrucial for the future development of more effective interventions.

Funding: This review was funded by the King’s Fund.

Competing interests: None.

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nutrition, physical activity and the prevention of cancer: a global perspective.Washington DC: Institute of Cancer Research, 2007.

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11. Hillsdon M, Foster C, Caill N, et al. The effectiveness of public health interventions forincreasing physical activity among adults: a review of reviews, 2nd edn. London:Health Development Agency, 2005.

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13. Naidoo B, Warm D, Quigley R, et al. Smoking and public health: a review of reviewsof interventions to increase smoking cessation, reduce smoking initiation and preventfurther uptake of smoking. London: Health Development Agency, 2004.

14. Blaxter M. Evidence for the effect on inequalities in health of interventions designedto change behaviour. http://www.nice.org.uk/nicemedia/pdf/EvidencefortheeffectonInequalitiesdesignedtochangebehavior.pdf. 2007 (accessed 19Feb 2008).

15. National Institute for Health and Clinical Excellence. Behaviour change atpopulation, community and individual levels. Public health programme guidance 6.London: National Institute of Health and Clinical Excellence, 2007.

16. Albarracin D, Gillette JC, Earl AN, et al. A test of major assumptions aboutbehaviour change: a comprehensive look at the effects of passive and active HIV-prevention interventions since the beginning of the epidemic. Psychol Bull2005;131:856–97.

17. Kidd KE, Altman DG. Adherence in social context. Controlled Clin Trials2000;21:694–6.

18. Ferguson J, Bauld L, Chesterman J, et al. The English smoking treatment services:one-year outcomes. Addiction 2005;100:59–69.

19. Bell K, McCullough L, Greaves L. The effectiveness of National Health Serviceintensive treatments for smoking cessation in England: a systematic review. London:National Institute for Clinical and Health Excellence, 2006.

20. Bernal G, Sharron-del-Rio MR. Are empirically supported treatments valid for ethnicminorities? Toward an alternative approach for treatment research. Cult DiversityEthnic Minority Psychol 2001;7:328–42.

21. Yancey AK, Ortega AN, Kumanyika SK. Effective recruitment and retention ofminority research participants. Annu Rev Public Health 2006;27:1–28.

22. Mokdad AH, Marks JS, Stroup DF, et al. Actual causes of death in the UnitedStates, 2000 (vol. 291, pp. 1238, 2004). J Am Med Assoc 2004;293:293–4.

23. Michie S. Designing and implementing ‘‘behaviour change’’ interventions to improvepopulation health. J Health Serv Res Policy 2008;13:64–9.

24. Michie S, Johnston M, Francis J, et al. From theory to intervention: mappingtheoretically derived behavioural determinants to behaviour change techniques. ApplPsychol Int Rev 2008;57:660–80.

25. Michie S, Abraham C. Identifying techniques that promote health behaviour change:evidence based or evidence inspired? Psychol Health 2004;19:29–49.

26. Campbell M, Fitzpatrick R, Haines A, et al. Framework for design and evaluation ofcomplex interventions to improve health. BMJ 2000;321:694–6.

27. Andrews JO, Bentley DNP, Crawford CHW, et al. Using community-basedparticipatory research to develop a culturally sensitive smoking cessation interventionwith public housing neighbours. Ethnicity Disease 2007;17:331–7.

28. Andrews JO, Felton G, Wewers ME, et al. Sister to sister: a pilot study to assistAfrican American women in subsidized housing to quit smoking. SouthernOnline J Nursing Res 2005;6:23–31.

29. Auslander W, Haire-Joshu D, Houston C, et al. The short term impact of a healthpromotion program for low-income African American women. Res Social Work Pract2000;10:78–97.

30. Auslander W, Haire-Joshu D, Houston C, et al. A controlled evaluation of stagingdietary patterns to reduce the risk of diabetes in African-American women. DiabetesCare 2002;25:809–14.

31. Lowther M, Mutrie N, Scott EM. Promoting physical activity in a socially andeconomically deprived community: a 12-month randomized control trial of fitnessassessment and exercise consultation. J Sport Sci 2002;20:577–88.

32. Emmons KM, Stoddard AM, Fletcher R, et al. Cancer prevention among workingclass, multiethnic adults: results of the healthy directions-health centers study.Am J Public Health 2005;95:1200–5.

33. Rosamond WD, Ammerman AS, Holliday JL, et al. Cardiovascular disease risk factorintervention in low-income women: the North Carolina WISEWOMAN project. PrevMed 2000;31:370–9.

34. O’Loughlin J, Paradis G, Gray-Donald K, et al. The impact of a community-basedheart disease prevention program in a low-income, inner-city neighborhood.Am J Public Health 1999;89:1819–26.

35. Abraham C, Michie S. A taxonomy of behavior change techniques used ininterventions. Health Psychol 2008;27:379–87.

36. Loughlan C, Mutrie N. Conducting an exercise consultation: guidelines for healthprofessionals. J Inst Health Educ 1995;33:78–82.

37. Paradis G, O’Loughlin J, Elliott M, et al. A heart health promotion programme in alow income, low education neighbourhood in Montreal, Canada: theoretical modeland early field experience. J Epidemiol Community Health 1995;49:503–12.

38. Steptoe AL, Perkins-Porras EA, McKay C, et al. Behavioural counselling to increaseconsumption of fruit and vegetables in low income adults: randomised trial. BMJ2003;326:855–8.

39. Sykes CM, Marks DF. Effectiveness of a cognitive behaviour therapy self-helpprogramme for smokers in London, UK. Health Promotion Int 2001;16:255–60.

40. Fisher EB, Auslander WF, Munro JF, et al. Neighbors for a smoke free north side:evaluation of a community organization approach to promoting smoking cessationamong African Americans. Am J Public Health 1998;88:1658–63.

41. Hahn EJ, Rayens MK, Chirila C, et al. Effectiveness of a quit and win contest with alow-income population. Prev Med 2004;39:543–50.

42. Solomon LJ, Scharoun GM, Flynn BS, et al. Free nicotine patches plus proactivetelephone peer support to help low-income women stop smoking. Prev Med2000;31:68–74.

43. Solomon LJ, Marcy TW, Howe KD, et al. Does extended proactive telephonesupport increase smoking cessation among low-income women using nicotinepatches? Prev Med 2005;40:306–13.

What this study adds

c There are few well-conducted evaluations of interventions tochange health behaviours targeted at low-income groups.

c An innovative method of specifying intervention content usinga reliable taxonomy of techniques.

c The most frequently used techniques included goal setting,planning social support/change and providing rewards.

c Such interventions can be effective for low-income groups.c There was no difference in intervention content or outcome

between studies that said they used theory and those that didnot.

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44. Bemelmans WJ, Broer J, Vries JH, et al. Impact of Mediterranean diet educationversus posted leaflet on dietary habits and serum cholesterol in high risk populationfor cardiovascular disease. Public Health Nutr 2000;3:273–83.

45. Bellg AJ, Borrelli B, Resnick B, et al. Enhancing treatment fidelity in health behaviorchange studies: best practice and recommendations from the Behavior ChangeConsortium. Health Psychol 2004;23:443–51.

46. Hardeman W, Michie S, Fanshawe T, et al. Fidelity of delivery of a physical activityintervention: predictors and consequences. Psychol Health 2008;23:11–24.

47. Coulter A, Ellins J. Effectiveness of strategies for informing, educating and involvingpatients. BMJ 2007;335:24–7.

48. Bandura A. Social foundations of thought and action: a social cognitive theory.Englewood Cliffs, NJ, USA: Prentice Hall, 1986.

49. Carver CS, Scheier MF. Themes and issues in the self-regulation of behavior. In:Wyer RS, ed. Perspectives on behavioral self-regulation. London: Lawrence ErlbaumAssociates, 1999:1–105.

50. Hibbard JH, Stockard J, Mahoney ER, et al. Development of the Patient ActivationMeasure (PAM): conceptualising and measuring activation in patients andconsumers. Health Service Res 2004;39:1005–26.

51. Heneman K, Block-Joy A, Zidenberg-Cherr S, et al. A ‘‘contract for change’’increases produce consumption in low income women: a pilot study. J Am DieteticAssoc 2005;105:1793–6.

52. Mayer JA, Jermanovich A, Wight BL, et al. Changes in the health behaviours ofolder adults: the San Diego Medicare Preventive Health Project. Prev Med1994;23:127–33.

53. Kelley K, Abraham C. RCT of a theory-based intervention promoting healthy eatingand physical activity amongst out-patients older than 65 years. Soc Sci Med2004;59:787–97.

54. Glasgow RE, Toobert DJ, Hampson SE, et al. Implementation, generalization andlong-term results of the ‘‘choosing well’’ of diabetes self-management intervention.Patient Educ Counselling 2002;48:115–22.

55. Dombrowski S, Sniehotta FF, Avenel A, et al. Identifying active ingredients incomplex behavioural interventions for obese adults with additional risk factors: asystematic review. Under review.

APPENDICES

A. Databases searchedThe following databases were searched from January 1995 to September 2006:c ASSIA (Applied Social Sciences Index and Abstracts)c BiblioMapc CCTR (Cochrane Controlled Trials Register)c CDP (Chronic Disease Prevention)c CDSR (Cochrane Database of Systematic Reviews)c CHID (Combined Health Information Database)c CINAHL (Cumulative Index for Nursing and Allied Health Literature)c DARE (Database of Abstracts of Reviews of Effectiveness)c Dissertation Abstractsc Econlit (Economic Literature)c EMBASEc GreyLit (British Library grey literature collection)c HealthStarc HMIC (Healthcare Management Information Consortium)c MEDLINEc NHS EED (NHS Economic Evaluation Database)c Popline (Population Health and Family Planning)c PsychInfoc Social Science Citation Indexc Social Policy and Practicec Sociofile

B. Example search strategiesASSIA 220906Query(CSA) ((KW = (socioeconomic or socio-economic) and KW = (status or factor*))OR (KW = ((low income) or poverty or disadvantage*) or KW = deprive*)) AND(KW = (lifestyle* or activit* or inactivit*) or KW = ((weight gain) or overweight orobes*) or KW = ((food habit*) or (poor diet*))) AND ((KW = ((healthy eating) or fruit*or vegetable*) or KW = (exercis* or (health behaviour*) or (Health behavior*))) OR(KW = (interven* or Intervention*)))

Cinahl (Ovid) 2209061. socioeconomic factor$.ti,ab.2. exp Socioeconomic Status/3. socioeconomic status.ti,ab.4. (disadvantage$ or depriv$ or poverty or low income).ti,ab.5. (SES and status and low).ti,ab.6. or/1–57. exp LIFESTYLE/

8. lifestyle$.ti,ab.9. (activit$ or inactivit$).ti,ab.10. ((weight and gain) or overweight).ti,ab.11. exp OBESITY/12. obesity.ti,ab.13. food habit$.ti,ab.14. poor diet.ti,ab.15. or/7–1416. healthy eating.ti,ab.17. (fruit or vegetable$ or exercise$).ti,ab.18. exp Health Behavior/19. health behavior.ti,ab.20. health behaviour.ti,ab.21. health behaviour.ti,ab.22. (intervene$ or intervention$).ti,ab.23. or/16–2224. 6 and 15 and 2325. limit 24 to (english language and yr = ‘‘1996–2007’’)

Embase 2209061. socioeconomic factor$.ti,ab.2. exp Socioeconomic Status/3. socioeconomic status.ti,ab.4. (disadvantage$ or depriv$ or poverty or low income).ti,ab.5. (SES and status and low).ti,ab.6. or/1–57. exp LIFESTYLE/8. lifestyle$.ti,ab.9. (activit$ or inactivit$).ti,ab.10. ((weight and gain) or overweight).ti,ab.11. exp OBESITY/12. obesity.ti,ab.13. food habit$.ti,ab.14. poor diet.ti,ab.15. or/7–1416. healthy eating.ti,ab.17. (fruit or vegetable$ or exercise$).ti,ab.18. exp Health Behavior/19. health behavior.ti,ab.20. health behaviour.ti,ab.21. health behaviour.ti,ab.22. (intervene$ or intervention$).ti,ab.23. or/16–2224. 6 and 15 and 2325. limit 24 to (english language and yr = ‘‘1996–2007’’)

Medline (Ovid) 2209061. socioeconomic factor$.ti,ab.2. exp Socioeconomic Status/3. socioeconomic status.ti,ab.4. (disadvantage$ or depriv$ or poverty or low income).ti,ab.5. (SES and status and low).ti,ab.6. or/1–57. exp LIFESTYLE/8. lifestyle$.ti,ab.9. (activit$ or inactivit$).ti,ab.10. ((weight and gain) or overweight).ti,ab.11. exp OBESITY/12. obesity.ti,ab.13. food habit$.ti,ab.14. poor diet.ti,ab.15. or/7–1416. healthy eating.ti,ab.17. (fruit or vegetable$ or exercise$).ti,ab.18. exp Health Behavior/19. health behavior.ti,ab.20. health behaviour.ti,ab.21. health behaviour.ti,ab.22. (intervene$ or intervention$).ti,ab.23. or/16–2224. 6 and 15 and 2325. limit 24 to (english language and yr = ‘‘1996–2007’’)

PsycInfo (Ovid) 2209061. socioeconomic factor$.ti,ab.2. exp Socioeconomic Status/3. socioeconomic status.ti,ab.

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4. (disadvantage$ or depriv$ or poverty or low income).ti,ab.5. (SES and status and low).ti,ab.6. or/1–57. exp LIFESTYLE/8. lifestyle$.ti,ab.9. (activit$ or inactivit$).ti,ab.10. ((weight and gain) or overweight).ti,ab.11. exp OBESITY/12. obesity.ti,ab.13. food habit$.ti,ab.14. poor diet.ti,ab.15. or/7–1416. healthy eating.ti,ab.17. (fruit or vegetable$ or exercise$).ti,ab.18. exp Health Behavior/19. health behavior.ti,ab.20. health behaviour.ti,ab.21. health behaviour.ti,ab.22. (intervene$ or intervention$).ti,ab.23. or/16–2224. 6 and 15 and 2325. limit 24 to (english language and yr = ‘‘1995–2007’’)

C. Previously unobtained full-text papers (n = 21)Full copies now obtained—all independently screened andexcluded (n = 6)1. Croghan IT, O’Hara MR, Schroeder DR, et al. A community-wide smoking

cessation program: quit and win 1998 in Olmsted County. Prev Med2001;33:229–38.

2. Fernandez E, Schiaffino A, Borrell C, et al. Social class, education, and smokingcessation: long-term follow-up of patients treated at a smoking cessation unit.Nicotine Tob Res 2006;8:29–36.

3. Freels SA, Warnecke RB, Parsons JA, et al. Characteristics associated withexposure to and participation in a televised smoking cessation intervention programfor women with high school or less education. Prev Med 1999;28:579–88.

4. Lazev AB, Vidrine DJ, Arduino RC, et al. Increasing access to smoking cessationtreatment in a low-income, HIV-positive population: the feasibility of usingcellular telephones. Nicotine Tob Res 2004;6:281–6.

5. Swinburn BA, Caterson I, Seidell JC, et al. Diet, nutrition and the prevention ofexcess weight gain and obesity. Public Health Nutr 2004;7:123–46.

6. Widga AC, Lewis NM, Fada RD. Defined, in-home, pre-natal nutritionintervention for low-income women. J Am Diet Assoc 1999;99:1058–62.

Unable to obtain full-text copies (n = 9)1. Cason KL, Scholl JF, et al. A comparison of program delivery methods for low

income nutrition audiences. Topics Clin Nutr 2002;17:63–73.

2. Finkelstein EA, Troped PJ, et al. Cost-effectiveness of a cardiovascular diseaserisk reduction program aimed at financially vulnerable women: theMassachusetts WISEWOMAN Project. J Women’s Health Gender-Based Med2002;11:519–26.

3. Foley RM, and Pollard CM. Food Cent$—implementing and evaluating anutrition education project focusing on value for money. Aust NZ J Public Health1998;22:494–501.

4. Freudenberg N, Silver D, et al. Health promotion in the city: a structured reviewof the literature on interventions to prevent heart disease, substance abuse,violence and HIV infection in US metropolitan areas, 1980–1995. J UrbanHealth 2000;77:443–57.

5. Kisioglu AN, Aslan B, et al. Improving control of high blood pressure amongmiddle-aged Turkish women of low socio-economic status through public healthtraining. Croatian Med J 2004;45:477–82.

6. Palmer TA, and Jaworski CA. Exercise prescription for underprivilegedminorities. Curr Sports Med Rep 2004;3:344–8.

7. Shi L. Sociodemographic characteristics and individual health behaviors.Southern Med J 1998;91:933–41.

8. Walcott-McQuigg JA. Psychological factors influencing cardiovascular riskreduction behavior in low and middle income African-American women. J NatlBlack Nurses’ Assoc 2000;11:27–35.

9. Will JC, Massoudi B, et al. Reducing risk for cardiovascular disease in uninsuredwomen: combined results from two WISEWOMAN projects. J Am MedWomens Assoc 2001;56:161–5.

Dissertations—excluded (n = 6)1. Davies SL. Using the transtheoretical model of change as a framework for

understanding smoking behavior in a sample of low-income, hospitalized,African-American smokers. Dissertation Abstracts International: Section B: TheSciences and Engineering 1997;58(5-B).

2. De Vogli R. Socioeconomic determinants of healthy lifestyles: does psychosocialstress matter? Dissertation Abstracts International: Section B: The Sciencesand Engineering 2004;65(2-B).

3. Dutton GR. Effects of a primary care weight management intervention onphysical activity in low-income African American women. DissertationAbstracts International: Section B: The Sciences and Engineering 2006;66(7-B).

4. Rounds TJ. Evaluation of a community-based home visiting program for lowincome families. Dissertation Abstracts International Section A: Humanities andSocial Sciences 1997;57(8-A).

5. Roundtree WJ. An analysis of parental scaffolding among three African-American mother–child dyads participating in the home instruction program forpreschool youngsters (HIPPY). Dissertation Abstracts International Section A:Humanities and Social Sciences 2000;61(6-A).

6. Springer J. Health behavior change as it relates to the adoption of andadherence to a program of physical activity. Dissertation AbstractsInternational: Section B: The Sciences and Engineering 2005;65(7-B).

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