The push me, pull you of financial incentives and health inequalities: a mixed methods study investigating smoking cessation in pregnancy and breastfeeding

Background Financial incentives are increasingly considered to address socially patterned behaviours like smoking in pregnancy and breastfeeding. We investigated their mechanisms of action in relation to health inequalities to inform incentive intervention design. Methods The evidence syntheses we undertook were incentive effectiveness, delivery processes, barriers and facilitators to smoking cessation in pregnancy and also breastfeeding; and incentives for lifestyle behaviours. We searched Medline, Embase, CINAHL, PsycINFO, Web of Science, the Cochrane Library (all sections), MIDIRS, ASSIA, and the Trials Register of Promoting Health Interventions for studies published in English between Jan 1, 1990, and March 31, 2012, using a range of natural language, MeSH, and other index terms. Surveys were done with 1144 respondents from the general public and with 497 maternity and early-years health professionals. Qualitative interviews and focus groups were conducted with pregnant women, recent mothers, and partners in three UK settings (n=88); and with 53 service providers, 24 experts and decision makers, and 63 conference attendees. A discrete choice experiment (DCE) was conducted with 320 female current or ex-smokers. Findings Systematic reviews raised concerns about the reach of incentives, particularly to marginalised groups. Baseline characteristics for people who were eligible, approached, and recruited to studies were under-reported. Sample sizes were mostly small. Surveys revealed mixed acceptability. Less educated, white British, and women general public respondents disagreed (odds ratios [OR] 0·5≤OR<1·0) particularly with smoking cessation incentives. Universal incentives (55% net agreement) were preferred to targeting low income women (49% net agreement). DCE results showed that incentives, a quitting pal, and initial text or telephone support were statistically significant in increasing the reported likelihood that women would quit. Conflicting narratives of women's emotional, social and material environments and the push and pull of incentives were voiced. For some, unrestricted shopping vouchers offered rare opportunities for choice, reward for effort, and feeling valued amidst adversity. Women struggle on their own, even concealing behaviour, especially when people in personal networks smoke or formula feed. However layers of autonomy were revealed, with varying levels of resistance to the nanny state, and feeling judged, pressure, and stigma. How incentive interventions fit with life's challenges were incorporated into a logic model. Interpretation Financial incentives can help some women, but whether they will address inequalities is unclear because of concerns about reach and resistance to being pushed and pulled. Funding The project was funded by the Health Technology Assessment programme (10/31/02) and will be published in full in Health Technology Assessment. The Chief Scientist Office of the Scottish Government Health and Social Care Directorates funds the Nursing Midwifery and Allied Health Professional Research Unit, University of Stirling; and the Health Services Research Unit and the Health Economics Research Unit, University of Aberdeen. Contributors All authors contributed to the conduct and writing involved in this study. PH was the chief investigator who led the study. PH, HM, GT, NC, SF, JH, VHM, GM, SUD, KR, FS, LB, AL, FD, FFS, DT, and MKC contributed to reviewing the evidence in the systematic reviews. PH, HM, GT, NC, LB, GM, DY, AL, and MKC contributed to the primary survey research. PH, HM, GT, NC, SUD, LB, and FD contributed to the primary qualitative research. HM and GT co-led service user involvement. SF, DY, and AL provided health economic expertise and conducted the DCE. GM and MKC provided statistical and methods advice. SUD and FS provided psychology expertise in behaviour change. FS developed and ran the search strategies, and managed information and references. LB and DT oversaw the transfer of the Cessation in Pregnancy Incentives Trial (CPIT) qualitative transcripts for incorporation into the study. Declaration of interests LB and DT declare that they co-led the CPIT trial, and declare no other competing interests. FFS is a grant holder for another National Institute for Health Research study investigating incentives, and declares no other competing interests. All other authors declare no competing interests. Correspondence to: Prof Pat Hoddinott, Nursing Midwifery and Allied Health Professional Research Unit, Unit 13 Scion House, Stirling University Innovation Park, Stirling FK9 4NF, UK Copyright © 2014 Elsevier Ltd. All rights reserved.