Benefits of Incentives for Breastfeeding and Smoking cessation in pregnancy (BIBS): a mixed-methods study to inform trial design

Abstract

BackgroundSmoking in pregnancy and/or not breastfeeding have considerable negative health outcomes for mother and baby.AimTo understand incentive mechanisms of action for smoking cessation in pregnancy and breastfeeding, develop a taxonomy and identify promising, acceptable and feasible interventions to inform trial design.DesignEvidence syntheses, primary qualitative survey, and discrete choice experiment (DCE) research using multidisciplinary, mixed methods. Two mother-and-baby groups in disadvantaged areas collaborated throughout.SettingUK.ParticipantsThe qualitative study included 88 pregnant women/recent mothers/partners, 53 service providers, 24 experts/decision-makers and 63 conference attendees. The surveys included 1144 members of the general public and 497 health professionals. The DCE study included 320 women with a history of smoking.Methods(1) Evidence syntheses: incentive effectiveness (including meta-analysis and effect size estimates), delivery processes, barriers to and facilitators of smoking cessation in pregnancy and/or breastfeeding, scoping review of incentives for lifestyle behaviours; (2) qualitative research: grounded theory to understand incentive mechanisms of action and a framework approach for trial design; (3) survey: multivariable ordered logit models; (4) DCE: conditional logit regression and the log-likelihood ratio test.ResultsOut of 1469 smoking cessation and 5408 breastfeeding multicomponent studies identified, 23 smoking cessation and 19 breastfeeding studies were included in the review. Vouchers contingent on biochemically proven smoking cessation in pregnancy were effective, with a relative risk of 2.58 (95% confidence interval 1.63 to 4.07) compared with non-contingent incentives for participation (four studies, 344 participants). Effects continued until 3 months post partum. Inconclusive effects were found for breastfeeding incentives compared with no/smaller incentives (13 studies) but provider commitment contracts for breastfeeding show promise. Intervention intensity is a possible confounder. The acceptability of seven promising incentives was mixed. Women (for vouchers) and those with a lower level of education (except for breastfeeding incentives) were more likely to disagree. Those aged ≤ 44 years and ethnic minority groups were more likely to agree. Agreement was greatest for a free breast pump and least for vouchers for breastfeeding. Universal incentives were preferred to those targeting low-income women. Initial daily text/telephone support, a quitting pal, vouchers for > £20.00 per month and values up to £80.00 increase the likelihood of smoking cessation. Doctors disagreed with provider incentives. A ‘ladder’ logic model emerged through data synthesis and had face validity with service users. It combined an incentive typology and behaviour change taxonomy. Autonomy and well-being matter. Personal difficulties, emotions, socialising and attitudes of others are challenges to climbing a metaphorical ‘ladder’ towards smoking cessation and breastfeeding. Incentive interventions provide opportunity ‘rungs’ to help, including regular skilled flexible support, a pal, setting goals, monitoring and outcome verification. Individually tailored and non-judgemental continuity of care can bolster women’s capabilities to succeed. Rigid, prescriptive interventions placing the onus on women to behave ‘healthily’ risk them feeling pressurised and failing. To avoid ‘losing face’, women may disengage.LimitationsIncluded studies were heterogeneous and of variable quality, limiting the assessment of incentive effectiveness. No cost-effectiveness data were reported. In surveys, selection bias and confounding are possible. The validity and utility of the ladder logic model requires evaluation with more diverse samples of the target population.ConclusionsIncentives provided with other tailored components show promise but reach is a concern. Formal evaluation is recommended. Collaborative service-user involvement is important.Study registrationThis study is registered as PROSPERO CRD42012001980.FundingThe National Institute for Health Research Health Technology Assessment programme.

Public acceptability of financial incentives for smoking cessation in pregnancy and breast feeding: a survey of the British public

“…This data add to reports of poor reach of incentive interventions, particularly to the most marginalised individuals 12 13. Universal incentives were preferred to incentives targeted at low-income women, with concerns about unintended consequences such as stigma and value judgements raised in linked qualitative data 16. Differential uptake across educational groups and the potential for health inequalities to increase is a concern, as noted for lifestyle behaviour change interventions 22.…”

“…Methodological research indicates that high-quality, well-controlled quota sampling in survey design has a negligible impact on the bias and precision of estimates compared with that in a simple random sample 18. Our multidisciplinary mixed methods approach to survey design and investigating two behaviours concurrently, with an innovative participatory approach to incorporating service user perspectives through coapplicant mother and baby groups located in disadvantaged areas, is novel 16 19. Important limitations relate to the unknown generalisability to other countries; non-responder and selection biases and other potential confounders.…”

“…This research was commissioned to investigate two behaviours concurrently, and this may be considered as either a strength or a limitation. There is a tradition of researching lifestyle behaviours separately, but from an individual and a social network perspective, they are often complexly inter-related 7 16. In addition, smoking cessation and breast feeding are associated and may confound each other, as women who stop smoking are more likely to breast feed than those who continue to smoke 20 21.…”

“…Incentives provided for preparatory behaviours, for example, attending a support group or one-to-one session, and unpredictable incentives like raffles, were also considered. A justification for our selected shortlist is described in detail elsewhere 16. In the survey (see Web 1, p1–4), acceptability of the shortlisted interventions was measured on a five-point Likert style scale from strongly agree to strongly disagree.…”

The Community IntraVenous Antibiotic Study (CIVAS): a mixed-methods evaluation of patient preferences for and cost-effectiveness of different service models for delivering outpatient parenteral antimicrobial therapy

“…This chapter describes a DCE which seeks to understand patient preferences for OPAT services. DCEs (also known as stated choice) are being increasingly used in health care to elicit preferences for a range of health-care services, 115 for example, smoking cessation in pregnancy 116 and communication therapy following stroke. 117 The DCE was developed using the findings from the systematic review and interview data (see Chapter 4).…”