Barbara Whelan

Healthcare providers’ views on the acceptability of financial incentives for breastfeeding: a qualitative study

BackgroundDespite a gradual increase in breastfeeding rates, overall in the UK there are wide variations, with a trend towards breastfeeding rates at 6–8 weeks remaining below 40% in less affluent areas. While financial incentives have been used with varying success to encourage positive health related behaviour change, there is little research on their use in encouraging breastfeeding. In this paper, we report on healthcare providers’ views around whether using financial incentives in areas with low breastfeeding rates would be acceptable in principle. This research was part of a larger project looking at the development and feasibility testing of a financial incentive scheme for breastfeeding in preparation for a cluster randomised controlled trial.MethodsFifty–three healthcare providers were interviewed about their views on financial incentives for breastfeeding. Participants were purposively sampled to include a wide range of experience and roles associated with supporting mothers with infant feeding. Semi-structured individual and group interviews were conducted. Data were analysed thematically drawing on the principles of Framework Analysis.ResultsThe key theme emerging from healthcare providers’ views on the acceptability of financial incentives for breastfeeding was their possible impact on ‘facilitating or impeding relationships’. Within this theme several additional aspects were discussed: the mother’s relationship with her healthcare provider and services, with her baby and her family, and with the wider community. In addition, a key priority for healthcare providers was that an incentive scheme should not impact negatively on their professional integrity and responsibility towards women.ConclusionHealthcare providers believe that financial incentives could have both positive and negative impacts on a mother’s relationship with her family, baby and healthcare provider. When designing a financial incentive scheme we must take care to minimise the potential negative impacts that have been highlighted, while at the same time recognising the potential positive impacts for women in areas where breastfeeding rates are low.

Are financial incentives for breastfeeding feasible in the UK? A mixed methods field study

Abstract Background The UK has one of the lowest breastfeeding rates (duration and exclusivity) in the world. Moreover, breastfeeding is strongly socially patterned, with young women in areas of high deprivation being less likely to breastfeed than women in areas of low deprivation. This study tested the feasibility of a financial incentive intervention to increase breastfeeding in areas with 6–8 week breastfeeding rates of 40% or less. Methods The intervention was the offer of a structured financial incentive scheme to women with babies aged up to 6 months old. If women were breastfeeding their baby, they could claim vouchers, at five different timepoints—ie, when their baby reached 2 days, 10 days, 6 weeks, 3 months, and 6 months old. Breastfeeding was verified by signed statements from the mother and health-care professional. Vouchers were for supermarkets and high street shops, to the value of £40, up to a maximum of £200. Starting in November, 2013, the scheme was offered to women with babies born during a 16-week period resident in three neighbourhoods in Derbyshire and South Yorkshire, UK, all of whom had historically persistent low 6–8 week breastfeeding rates, ranging from 21% to 29%. The feasibility (acceptability and deliverability) of the incentive scheme and the study design to key stakeholder groups was assessed with quantitative and qualitative methods, in advance of undertaking a full randomised controlled trial. 36 health-care providers and 18 women gave semi-structured interviews. Findings Relevant approvals for the study were obtained. Women learnt about the scheme from their midwife or the media (print, radio, social media), or both. Of a total of 108 women eligible for the scheme, 58 (53·7%) joined the scheme, 48 (44·4%) claimed 2-day vouchers, 45 (41·7%) claimed 10-day vouchers, and 37 (34·3%) claimed 6–8 week vouchers. 3-month and 6-month data are still accruing. 53 health-care providers cosigned claim forms. Satisfaction with the scheme (including the method used to verify breastfeeding) was high among both mothers and health-care staff participating in the scheme. Interpretation The scheme was both deliverable and acceptable to mothers and health-care staff in this field study. The scheme was extended (and will continue until at least December, 2014) in all three areas. A randomised controlled trial testing the effectiveness of the scheme is now planned. Funding Medical Research Council National Prevention Research Initiative (MR/J000434/1).

Cluster randomised controlled trial of a financial incentive for mothers to improve breast feeding in areas with low breastfeeding rates: the NOSH study protocol

Introduction Breast feeding can promote positive long-term and short-term health outcomes in infant and mother. The UK has one of the lowest breastfeeding rates (duration and exclusivity) in the world, resulting in preventable morbidities and associated healthcare costs. Breastfeeding rates are also socially patterned, thereby potentially contributing to health inequalities. Financial incentives have been shown to have a positive effect on health behaviours in previously published studies. Methods and analysis Based on data from earlier development and feasibility stages, a cluster (electoral ward) randomised trial with mixed-method process and content evaluation was designed. The ‘Nourishing Start for Health’ (NOSH) intervention comprises a financial incentive programme of up to 6 months duration, delivered by front-line healthcare professionals, in addition to existing breastfeeding support. The intervention aims to increase the prevalence and duration of breast feeding in wards with low breastfeeding rates. The comparator is usual care (no offer of NOSH intervention). Routine data on breastfeeding rates at 6–8 weeks will be collected for 92 clusters (electoral wards) on an estimated 10 833 births. This sample is calculated to provide 80% power in determining a 4% point difference in breastfeeding rates between groups. Content and process evaluation will include interviews with mothers, healthcare providers, funders and commissioners of infant feeding services. The economic analyses, using a healthcare providers perspective, will be twofold, including a within-trial cost-effectiveness analysis and beyond-trial modelling of longer term expectations for cost-effectiveness. Results of economic analyses will be expressed as cost per percentage point change in cluster level in breastfeeding rates between trial arms. In addition, we will present difference in resource use impacts for a range of acute conditions in babies aged 0–6 months. Ethics and dissemination Participating organisations Research and Governance departments approved the study. Results will be published in peer-reviewed journals and at conference presentations. Trial registration number ISRCTN44898617; Pre-results.

Effect of Financial Incentives on Breastfeeding: A Cluster Randomized Clinical Trial

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 Participants The 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

Views on the acceptability of financial incentives for breastfeeding: a qualitative study

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 Measures The 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. Results In 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 6 to 8 weeks. This was measured using routinely collected data. Trial Registration International Standard Randomized Controlled Trial Registry: ISRCTN44898617.

Valuing breastfeeding: Health care professionals’ experiences of delivering a conditional cash transfer scheme for breastfeeding in areas with low breastfeeding rates

Abstract Background Breastfeeding is good for both baby and mother, and the associated health benefits persist. However, in many communities breastfeeding is not the norm. Financial incentives are a potentially powerful method to achieve health-related behaviour change, and these incentives have been used with varying success in a range of settings. The use of financial incentives to promote breastfeeding is controversial, and there has been little research in this area. A street intercept survey with women from areas of low breastfeeding rates showed that financial incentives were acceptable to 80% (95% CI 67–88; n=54) of those sampled. In this study, we aimed to investigate in depth the acceptability of financial incentives for breastfeeding both in principle and in practice among a range of key stakeholders. Our research is part of a wider study to develop and trial a financial incentive scheme for breastfeeding in areas with 6–8-week rates below 40%. Methods We undertook semistructured individual interviews (n=54) and focus groups (n=8) with two stakeholder groups based in south Yorkshire and north Derbyshire: mothers who had breastfed or formula fed, or both (n=38) and health-care staff with infant feeding roles (n=53). A sampling frame was developed to purposively sample for maximum variation in the range of infant feeding preferences and experiences in different age groups. Stakeholders were recruited from childrens centres, breastfeeding support groups, parent and toddler groups, and community or hospital maternity services. Health-care staff were midwives, health visitors, breastfeeding peer support workers, childrens centre managers, charity or voluntary sector workers, public health leads, and commissioners. Interviews were analysed by thematic analysis, drawing on the principles of framework analysis. NVivo was used to support the analytical process. Interviewer bias was minimised by use of inter-rater reliability, peer debriefing, and reflexivity. Ethics approval for the study was obtained from ScHARR Research Ethics Committee, NHS RD ethical concerns about financial incentives for breastfeeding; potential negative effects; and concerns about the practical implementation of a scheme. Many interviewees felt that financial incentives might encourage more women to attempt breastfeeding. Health-care staff, particularly, felt that a financial incentive might help to normalise breastfeeding in communities with low breastfeeding rates. Some viewed the incentive as being a reward for breastfeeding and that breastfeeding would be perceived as valuable and good. Both groups were concerned about moral implications, perception of incentives as bribery, penalising those unable to breastfeed, and how such interventions would be policed. Many considered the moral implications of how a financial incentive would be spent and whether the incentive should be cash or vouchers. Further, financial incentives could affect women negatively—in particular, if it reduced the intrinsic motivation to breastfeed. Additionally, an incentive could add pressure on the woman to breastfeed and might not help if she ran into difficulties. Both groups made suggestions for the practical implementation of the scheme that would make it more acceptable. There was low acceptability for verification methods that required the mother to perform in order to prove that she was breastfeeding. Interpretation There was difficulty in recruiting primiparous women to the study, which limits the generalisability of these results. Although a wide range of views were expressed within and between stakeholder groups, financial incentives for key stakeholders were broadly acceptable, in principle. Issues were identified that need consideration when implementing a financial incentive scheme in practice. Funding Medical Research Council—National Prevention Research Initiative (MR/J000434/1).

What primary health professionals need to promote breastfeeding

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.