title: Unintended consequences of incentive provision for behaviour change and maintenance around childbirth.
abstract: Financial (positive or negative) and non-financial incentives or rewards are increasingly used in attempts to influence health behaviours. While unintended consequences of incentive provision are discussed in the literature, evidence syntheses did not identify any primary research with the aim of investigating unintended consequences of incentive interventions for lifestyle behaviour change. Our objective was to investigate perceived positive and negative unintended consequences of incentive provision for a shortlist of seven promising incentive strategies for smoking cessation in pregnancy and breastfeeding. A multi-disciplinary, mixed-methods approach included involving two service-user mother and baby groups from disadvantaged areas with experience of the target behaviours as study co-investigators. Systematic reviews informed the shortlist of incentive strategies. Qualitative semi-structured interviews and a web-based survey of health professionals asked open questions on positive and negative consequences of incentives. The participants from three UK regions were a diverse sample with and without direct experience of incentive interventions: 88 pregnant women/recent mothers/partners/family members; 53 service providers; 24 experts/decision makers and interactive discussions with 63 conference attendees. Maternity and early years health professionals (n = 497) including doctors, midwives, health visitors, public health and related staff participated in the survey. Qualitative analysis identified ethical, political, cultural, social and psychological implications of incentive delivery at population and individual levels. Four key themes emerged: how incentives can address or create inequalities; enhance or diminish intrinsic motivation and wellbeing; have a positive or negative effect on relationships with others within personal networks or health providers; and can impact on health systems and resources by raising awareness and directing service delivery, but may be detrimental to other health care areas. Financial incentives are controversial and generated emotive and oppositional responses. The planning, design and delivery of future incentive interventions should evaluate unexpected consequences to inform the evidence for effectiveness, cost-effectiveness and future implementation.
authors.affiliation: Maternal and Infant Nutrition & Nurture Unit (MAINN), School of Health, University of Central Lancashire, Preston, Lancashire, England.
authors.forename: Gill
authors.initials: G
authors.lastname: Thomson
authors.affiliation: Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland.
authors.forename: Heather
authors.initials: H
authors.lastname: Morgan
authors.affiliation: Maternal and Infant Nutrition & Nurture Unit (MAINN), School of Health, University of Central Lancashire, Preston, Lancashire, England.
authors.forename: Nicola
authors.initials: N
authors.lastname: Crossland
authors.affiliation: Nursing, Midwifery and Allied Health Professions Research Unit, University of Stirling, Stirling, Scotland.
authors.forename: Linda
authors.initials: L
authors.lastname: Bauld
authors.affiliation: Maternal and Infant Nutrition & Nurture Unit (MAINN), School of Health, University of Central Lancashire, Preston, Lancashire, England.
authors.forename: Fiona
authors.initials: F
authors.lastname: Dykes
authors.affiliation: Nursing, Midwifery and Allied Health Professions Research Unit, University of Stirling, Stirling, Scotland.
authors.forename: Pat
authors.initials: P
authors.lastname: Hoddinott
authors.forename: Stephan
authors.initials: S
authors.lastname: Dombrowski
authors.forename: Graeme
authors.initials: G
authors.lastname: MacLennan
authors.forename: Kieran
authors.initials: K
authors.lastname: Rothnie
authors.forename: Fiona
authors.initials: F
authors.lastname: Stewart
authors.forename: Shelley
authors.initials: S
authors.lastname: Farrar
authors.forename: Deokhee
authors.initials: D
authors.lastname: Yi
authors.forename: Jenni
authors.initials: J
authors.lastname: Hislop
authors.forename: Anne
authors.initials: A
authors.lastname: Ludbrook
authors.forename: Marion
authors.initials: M
authors.lastname: Campbell
authors.forename: Victoria Hall
authors.initials: VH
authors.lastname: Moran
authors.forename: Falko
authors.initials: F
authors.lastname: Sniehotta
authors.forename: David
authors.initials: D
authors.lastname: Tappin
mesh_terms: D000293:Adolescent; D000328:Adult; D005260:Female; D017144:Focus Groups; D015438:Health Behavior; D006282:Health Personnel; D006306:Health Surveys / Q000191:economics; D054625:Healthcare Disparities / Q000191:economics; D006801:Humans; D007398:Interpersonal Relations; D007407:Interviews as Topic; D008297:Male; D008875:Middle Aged; D009035:Mothers; D009042:Motivation; D036801:Parturition / Q000502:physiology*; D011247:Pregnancy; D011795:Surveys and Questionnaires; D055815:Young Adult