IMPORTANCE Although breastfeeding has a positive effect on an infant's health and development, the prevalence is low in many communities. The effect of financial incentives to improve breastfeeding prevalence is unknown.OBJECTIVE To assess the effect of an area-level financial incentive for breastfeeding on breastfeeding prevalence at 6 to 8 weeks post partum. DESIGN, SETTING, AND PARTICIPANTSThe Nourishing Start for Health (NOSH) trial, a cluster randomized trial with 6 to 8 weeks follow-up, was conducted between April 1, 2015, and March 31, 2016, in 92 electoral ward areas in England with baseline breastfeeding prevalence at 6 to 8 weeks post partum less than 40%. A total of 10 010 mother-infant dyads resident in the 92 study electoral ward areas where the infant's estimated or actual birth date fell between February 18, 2015, and February 17, 2016, were included. Areas were randomized to the incentive plus usual care (n = 46) (5398 mother-infant dyads) or to usual care alone (n = 46) (4612 mother-infant dyads).INTERVENTIONS Usual care was delivered by clinicians (mainly midwives, health visitors) in a variety of maternity, neonatal, and infant feeding services, all of which were implementing the UNICEF UK Baby Friendly Initiative standards. Shopping vouchers worth £40 (US$50) were offered to mothers 5 times based on infant age (2 days, 10 days, 6-8 weeks, 3 months, 6 months), conditional on the infant receiving any breast milk. MAIN OUTCOMES AND MEASURESThe primary outcome was electoral ward area-level 6-to 8-week breastfeeding period prevalence, as assessed by clinicians at the routine 6-to 8-week postnatal check visit. Secondary outcomes were area-level period prevalence for breastfeeding initiation and for exclusive breastfeeding at 6 to 8 weeks. RESULTSIn the intervention (5398 mother-infant dyads) and control (4612 mother-infant dyads) group, the median (interquartile range) percentage of women aged 16 to 44 years was 36.2% (3.0%) and 37.4% (3.6%) years, respectively. After adjusting for baseline breastfeeding prevalence and local government area and weighting to reflect unequal cluster-level breastfeeding prevalence variances, a difference in mean 6-to 8-week breastfeeding prevalence of 5.7 percentage points (37.9% vs 31.7%; 95% CI for adjusted difference, 2.7% to 8.6%; P < .001) in favor of the intervention vs usual care was observed. No significant differences were observed for the mean prevalence of breastfeeding initiation (61.9% vs 57.5%; adjusted mean difference, 2.9 percentage points; 95%, CI, −0.4 to 6.2; P = .08) or the mean prevalence of exclusive breastfeeding at 6 to 8 weeks (27.0% vs 24.1%; adjusted mean difference, 2.3 percentage points; 95% CI, −0.2 to 4.8; P = .07).CONCLUSIONS AND RELEVANCE Financial incentives may improve breastfeeding rates in areas with low baseline prevalence. Offering a financial incentive to women in areas of England with breastfeeding rates below 40% compared with usual care resulted in a modest but statistically significant increase in breastfeeding prevalence at ...
Using the naturally-occurring data of official UK Parliamentary transcripts for the development of a new high speed rail project, this paper takes one characteristic of the design process, the use of precedent, to explore how problems and solutions are framed during discussion. In contrast to accounts of reframing that describe one big insight changing the design process we show how one particular precedent allows a series of attempts at reframing to take place in discussion. We conclude by arguing that precedents enable adiffusionof semi-objective meaning in discussion, similar to a prototype in a more conventional design process. This contrasts with other types of discourse elements, such as storytelling, that function through the subjectiveaccumulationof meaning
Alongside a randomized controlled trial testing the effectiveness of offering a cash transfer scheme (shopping vouchers) to mothers in areas with low breastfeeding rates, qualitative interviews were conducted with health care professionals delivering the scheme to explore their experiences. Health care professionals (n = 34; mainly midwives and health visitors) were interviewed in depth. Transcripts from recorded interviews were analyzed using a Framework Analysis approach. There was widespread acceptance of the scheme by health care professionals, with prior concerns regarding bribery and coercion being quickly allayed. Health care professionals reported that the scheme fitted in well with their routine ways of promoting and endorsing breastfeeding. They described their experiences of women's positive reaction toward the scheme and how the scheme encouraged breastfeeding and gave breastfeeding higher value. Health care professionals reported that the incentives helped them engage women and promote and support breastfeeding in areas with low breastfeeding rates.
Background The UK has one of the lowest breastfeeding rates in the world. The NOurishing Start for Health (NOSH) cluster-randomised trial was a trial of a financial incentive scheme that aimed to increase breastfeeding in UK areas where breastfeeding was not the norm (South Yorkshire, Derbyshire, and Nottinghamshire). The announcement of the initial field test of the Vouchers for Breastfeeding scheme generated a substantial amount of (mainly negative) media and social media coverage. Given the media interest and scrutiny in public health research and action (especially where financial incentives are concerned), we aimed to understand negative responses, and the underlying values they represent, to inform future public health research into financial incentives.Methods A researcher (DU) external to the project and the research area led a discourse analysis of the research project archive, drawing upon more than 500 documents that included team briefs, scholarly articles, publicity material, media reports, and online responses. The purpose of the analysis was to identify where conflicting values were apparent, particularly those at critical transition points in the project, which facilitated further content and visual analysis of relevant documents.Findings The analysis exposed fundamental, opposing, and apparently intractable views on the use of financial incentives to increase breastfeeding in the UK. These conflicting positions were apparent from the early stages of the research project and recurred at critical points during the development and delivery of the scheme. In contrast to local stakeholder views, media and social media commentators tended to marginalise the research question and focus instead on discussing why offering incentives for breastfeeding should not be national policy. The analysis also revealed how the project researchers used extensive stakeholder consultation, deployed sensitive language in all public engagements, and adapted well-established visual representations of financial incentives, to navigate through the inherent controversy.Interpretation Projects that challenge societal behavioural norms should anticipate strong and sometimes hostile reactions when planning and progressing their research. Also, researchers should not assume that media and social media reactions represent the considered views of stakeholders directly affected by the research, which in this case were mothers (and their health-care providers) in the areas where the scheme was being trialled. Funding Medical Research Council (MR/J000434/1) via the National Prevention Research Initiative Phase 4 awards. ContributorsCR and DU conceived the idea for the discourse analysis. DU conducted the analysis and wrote the first draft. CR, MS, KT, and MJR contributed to subsequent drafts. CR led the revision of the final version of the abstract. All authors have seen and approved the final version for publication. Declaration of interestsWe declare no competing interests.
Design continues to look beyond the confines of the studio as both practitioners and researchers engage with wider social and political contexts. This paper takes design into the Parliamentary debating chamber where a country raises and debates problems and proposes and explores solutions. There is an increasing amount of work that explores the use of design in policy-making processes but little that explores design as an interpretation of the Parliamentary process. This paper draws on one characteristic of the design process, the use of precedent, and examines how this appears and functions in Parliamentary debate. The paper argues that this 'design analysis' gives insight into debate as a design process and into the debate transcript as a naturally occurring source of design data. This contributes to the scope of design studies and suggests that the UK Parliament could be considered one of the most influential design studios in a country.
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