title: Benefits of Incentives for Breastfeeding and Smoking cessation in pregnancy (BIBS): a mixed-methods study to inform trial design.
abstract: BACKGROUND
  Smoking in pregnancy and/or not breastfeeding have considerable negative health outcomes for mother and baby.
  
  
  OBJECTIVE
  To 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.
  
  
  METHODS
  Evidence syntheses, primary qualitative survey, and discrete choice experiment (DCE) research using multidisciplinary, mixed methods. Two mother-and-baby groups in disadvantaged areas collaborated throughout.
  
  
  METHODS
  UK.
  
  
  METHODS
  The 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.
  
  
  RESULTS
  Out 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.
  
  
  CONCLUSIONS
  Included 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.
  
  
  CONCLUSIONS
  Incentives provided with other tailored components show promise but reach is a concern. Formal evaluation is recommended. Collaborative service-user involvement is important.
  
  
  BACKGROUND
  This study is registered as PROSPERO CRD42012001980.
  
  
  BACKGROUND
  The National Institute for Health Research Health Technology Assessment programme.
authors.affiliation: Health Services Research Unit, University of Aberdeen, Aberdeen, UK.
authors.forename: Heather
authors.initials: H
authors.lastname: Morgan
authors.affiliation: Health Services Research Unit, University of Aberdeen, Aberdeen, UK.
authors.forename: Pat
authors.initials: P
authors.lastname: Hoddinott
authors.affiliation: Maternal and Infant Nutrition and Nurture Unit, University of Central Lancashire, Preston, UK.
authors.forename: Gill
authors.initials: G
authors.lastname: Thomson
authors.affiliation: Maternal and Infant Nutrition and Nurture Unit, University of Central Lancashire, Preston, UK.
authors.forename: Nicola
authors.initials: N
authors.lastname: Crossland
authors.affiliation: Health Economics Research Unit, University of Aberdeen, Aberdeen, UK.
authors.forename: Shelley
authors.initials: S
authors.lastname: Farrar
authors.affiliation: Health Economics Research Unit, University of Aberdeen, Aberdeen, UK.
authors.forename: Deokhee
authors.initials: D
authors.lastname: Yi
authors.affiliation: Health Services Research Unit, University of Aberdeen, Aberdeen, UK.
authors.forename: Jenni
authors.initials: J
authors.lastname: Hislop
authors.affiliation: Maternal and Infant Nutrition and Nurture Unit, University of Central Lancashire, Preston, UK.
authors.forename: Victoria Hall
authors.initials: VH
authors.lastname: Moran
authors.affiliation: Health Services Research Unit, University of Aberdeen, Aberdeen, UK.
authors.forename: Graeme
authors.initials: G
authors.lastname: MacLennan
authors.affiliation: Institute of Health and Society, University of Newcastle, Newcastle, UK.
authors.forename: Stephan U
authors.initials: SU
authors.lastname: Dombrowski
authors.affiliation: Health Services Research Unit, University of Aberdeen, Aberdeen, UK.
authors.forename: Kieran
authors.initials: K
authors.lastname: Rothnie
authors.affiliation: Health Services Research Unit, University of Aberdeen, Aberdeen, UK.
authors.forename: Fiona
authors.initials: F
authors.lastname: Stewart
authors.affiliation: The Institute of Social Marketing, University of Stirling, Stirling, UK.
authors.forename: Linda
authors.initials: L
authors.lastname: Bauld
authors.affiliation: Health Economics Research Unit, University of Aberdeen, Aberdeen, UK.
authors.forename: Anne
authors.initials: A
authors.lastname: Ludbrook
authors.affiliation: Maternal and Infant Nutrition and Nurture Unit, University of Central Lancashire, Preston, UK.
authors.forename: Fiona
authors.initials: F
authors.lastname: Dykes
authors.affiliation: Institute of Health and Society, University of Newcastle, Newcastle, UK.
authors.forename: Falko F
authors.initials: FF
authors.lastname: Sniehotta
authors.affiliation: Perinatal Epidemiology and Child Health Unit, School of Medicine, University of Glasgow, Glasgow, UK.
authors.forename: David
authors.initials: D
authors.lastname: Tappin
authors.affiliation: Health Services Research Unit, University of Aberdeen, Aberdeen, UK.
authors.forename: Marion
authors.initials: M
authors.lastname: Campbell
mesh_terms: D000328:Adult; D001942:Breast Feeding; D005260:Female; D017144:Focus Groups; D006801:Humans; D007407:Interviews as Topic; D009042:Motivation; D011247:Pregnancy; D036301:Qualitative Research; D012107:Research Design; D016540:Smoking Cessation; D055815:Young Adult