3 The social gradient in health is predicted to steepen further2 despite policy efforts aimed at maximising equality.3–5 Behaviours linked to health, particularly healthy eating, physical activity and smoking, show a similar social gradient to health outcomes. Consumption of tobacco, a poor diet and a lack of physical activity are major risks to premature morbidity and etc mortality.6 7 People of lower socioeconomic status are more likely to smoke,5 be sedentary8 and eat a poor diet9 compared with those

of higher socioeconomic status. These behaviours have been suggested as mediators of the link between social position and health outcomes.10–12 Changing health behaviours Given the potential improvements that changes in behaviour can bring to health, health research and clinical practice devotes considerable time and effort to behavioural interventions. For instance, stopping smoking increases life

expectancy at any age and halves the risk of cardiovascular disease within 1 year.13 Experts agree that major improvements in public health will be brought about through behaviour changes in the population.7 14 15 Targeting behaviour change efforts at people at the lower end of the income spectrum is seen as a major means to reducing health inequalities. Gruer et al (ref 12, p.5) for instance argued that “the scope for reducing health inequalities related to social position […] is limited unless many smokers in lower social positions can be enabled to stop smoking.” Health behaviour change in low-income populations Existing behaviour change support for those disadvantaged by income may not be fit for purpose.14 Evidence suggests that people from low-income groups are more difficult to identify and successfully recruit to general population interventions.16–18 Moreover, it has been suggested that low-income populations may achieve poorer behaviour change outcomes following interventions compared with more affluent participants, resulting in poorer health outcomes19–21 and potentially leading to intervention-generated

inequalities.22 In studies targeted at the whole population rather than specific Dacomitinib subgroups, Michie et al23 have argued that observed differences in outcomes between socioeconomic groups may reflect baseline differences in health behaviours, and that the interventions themselves may be effective across the socioeconomic spectrum. In their review of interventions targeted specifically at those disadvantaged by income, examining controlled studies (with or without random allocation) published between 1995 and 2006, they found 13 relevant studies with 17 available comparisons. Approximately half of interventions were reported as effective relative to controls, but no meta-analysis was performed to estimate an overall effect size.