Interventions to Promote Healthy Eating, Physical Activity and Smoking in Low-Income Groups: a Systematic Review with Meta-Analysis of Behavior Change Techniques and Delivery/Context

Eleanor R Bull, Nicola McCleary, Xinru Li, Stephan U Dombrowski, Elise Dusseldorp, Marie Johnston, Eleanor R Bull, Nicola McCleary, Xinru Li, Stephan U Dombrowski, Elise Dusseldorp, Marie Johnston

Abstract

Purpose: Healthy eating, physical activity and smoking interventions for low-income groups may have small, positive effects. Identifying effective intervention components could guide intervention development. This study investigated which content and delivery components of interventions were associated with increased healthy behavior in randomised controlled trials (RCTs) for low-income adults.

Method: Data from a review showing intervention effects in 35 RCTs containing 45 interventions with 17,000 participants were analysed to assess associations with behavior change techniques (BCTs) and delivery/context components from the template for intervention description and replication (TIDieR) checklist. The associations of 46 BCTs and 14 delivery/context components with behavior change (measures of healthy eating, physical activity and smoking cessation) were examined using random effects subgroup meta-analyses. Synergistic effects of components were examined using classification and regression trees (meta-CART) analyses based on both fixed and random effects assumptions.

Results: For healthy eating, self-monitoring, delivery through personal contact, and targeting multiple behaviors were associated with increased effectiveness. Providing feedback, information about emotional consequences, or using prompts and cues were associated with reduced effectiveness. In synergistic analyses, interventions were most effective without feedback, or with self-monitoring excluding feedback. More effective physical activity interventions included behavioral practice/rehearsal or instruction, focussed solely on physical activity or took place in home/community settings. Information about antecedents was associated with reduced effectiveness. In synergistic analyses, interventions were most effective in home/community settings with instruction. No associations were identified for smoking.

Conclusion: This study identified BCTs and delivery/context components, individually and synergistically, linked to increased and reduced effectiveness of healthy eating and physical activity interventions. The identified components should be subject to further experimental study to help inform the development effective behavior change interventions for low-income groups to reduce health inequalities.

Keywords: Behavior change techniques; Healthy eating; Low-income populations; Meta-analysis; Physical activity; Smoking cessation.

Conflict of interest statement

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical Approval

No primary data was collected in this study so ethical approval was not required.

Figures

Fig. 1
Fig. 1
Fourteen delivery/context components based on the TIDieR checklist
Fig. 2
Fig. 2
Diagram representing univariate moderator analyses for healthy eating. BCTs are presented with their original labels and number from BCTv1 [14]. In Figs. 2, 3, 4, 5, and 6, ğ represents effect size and 95% CIs statistical significance. Figure 2 indicates that healthy eating interventions were significantly more effective where they did include the BCT 2.3 Self-monitoring of behavior, or if there were multiple behavioral targets or a face-to-face component, or did not include BCTs 2.2 Feedback on behavior, 7.1 Prompts and cues or 5.6 Information about emotional consequences
Fig. 3
Fig. 3
Results from random effects meta-CART meta-analysis for healthy eating (k = 16). Figure 3 indicates random effects meta-CART analysis of effective combinations of the four BCTs and two delivery/context components identified as individually significant moderators in Fig. 2. Healthy eating interventions were more effective if they did not include the BCT 2.2 Feedback on behavior, but if they did, then those with a Face-to-face delivery component were more effective than those without
Fig. 4
Fig. 4
Results from fixed effects meta-CART meta-analysis for healthy eating (k = 16). Figure 4 indicates fixed effects meta-CART analysis of effective combinations of the four BCTs and two delivery/context components identified as individually significant moderators in Fig. 2. Results were similar to Fig. 3, but also indicated that interventions excluding the BCT 2.2 Feedback on behavior but including 2.3 Self-monitoring of behavior were most effective
Fig. 5
Fig. 5
Diagram representing univariate moderator analyses for physical activity. Figure 5 indicates that physical activity interventions were significantly more effective where they did include the BCTs 8.1 Behavioral practice/rehearsal or 4.1 Instruction on how to perform the behavior, or had a sole focus on physical activity, or were delivered in a community or home (rather than health) setting, or did not include the BCT 4.2 Information about antecedents
Fig. 6
Fig. 6
Results from fixed effects meta-CART meta-analysis for physical activity (k = 12). Figure 6 indicates fixed effects meta-CART analysis of effective combinations of the three BCTs and two delivery/context components identified as individually significant moderators in Fig. 5. Physical activity interventions were more effective if they were delivered in a community setting or at home and included the BCT 4.1 Instruction on how to perform the behavior, and were least effective if delivered in a health setting

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