title: Perspectives on financial incentives to health service providers for increasing breast feeding and smoking quit rates during pregnancy: a mixed methods study.
abstract: OBJECTIVE
  To explore the acceptability, mechanisms and consequences of provider incentives for smoking cessation and breast feeding as part of the Benefits of Incentives for Breastfeeding and Smoking cessation in pregnancy (BIBS) study.
  
  
  METHODS
  Cross-sectional survey and qualitative interviews.
  
  
  METHODS
  Scotland and North West England.
  
  
  METHODS
  Early years professionals: 497 survey respondents included 156 doctors; 197 health visitors/maternity staff; 144 other health staff. Qualitative interviews or focus groups were conducted with 68 pregnant/postnatal women/family members; 32 service providers; 22 experts/decision-makers; 63 conference attendees.
  
  
  METHODS
  Early years professionals were surveyed via email about the acceptability of payments to local health services for reaching smoking cessation in pregnancy and breastfeeding targets. Agreement was measured on a 5-point scale using multivariable ordered logit models. A framework approach was used to analyse free-text survey responses and qualitative data.
  
  
  RESULTS
  Health professional net agreement for provider incentives for smoking cessation targets was 52.9% (263/497); net disagreement was 28.6% (142/497). Health visitors/maternity staff were more likely than doctors to agree: OR 2.35 (95% CI 1.51 to 3.64; p<0.001). Net agreement for provider incentives for breastfeeding targets was 44.1% (219/497) and net disagreement was 38.6% (192/497). Agreement was more likely for women (compared with men): OR 1.81 (1.09 to 3.00; p=0.023) and health visitors/maternity staff (compared with doctors): OR 2.54 (95% CI 1.65 to 3.91; p<0.001). Key emergent themes were 'moral tensions around acceptability', 'need for incentives', 'goals', 'collective or divisive action' and 'monitoring and proof'. While provider incentives can focus action and resources, tensions around the impact on relationships raised concerns. Pressure, burden of proof, gaming, box-ticking bureaucracies and health inequalities were counterbalances to potential benefits.
  
  
  CONCLUSIONS
  Provider incentives are favoured by non-medical staff. Solutions which increase trust and collaboration towards shared goals, without negatively impacting on relationships or increasing bureaucracy are required.
authors.affiliation: Nursing, Midwifery and Allied Health Professions Research Unit, University of Stirling, Stirling, UK.
authors.forename: Pat
authors.identifier: http://orcid.org/0000-0002-4372-9681
authors.initials: P
authors.lastname: Hoddinott
authors.affiliation: Maternal and Infant Nutrition and Nurture Unit (MAINN), University of Central Lancashire, Preston, UK.
authors.forename: Gill
authors.initials: G
authors.lastname: Thomson
authors.affiliation: Health Services Research Unit, University of Aberdeen, Aberdeen, UK.
authors.forename: Heather
authors.initials: H
authors.lastname: Morgan
authors.affiliation: Maternal and Infant Nutrition and Nurture Unit (MAINN), University of Central Lancashire, Preston, UK.
authors.forename: Nicola
authors.initials: N
authors.lastname: Crossland
authors.affiliation: Health Services Research Unit, University of Aberdeen, Aberdeen, UK.
authors.forename: Graeme
authors.initials: G
authors.lastname: MacLennan
authors.affiliation: Maternal and Infant Nutrition and Nurture Unit (MAINN), University of Central Lancashire, Preston, UK.
authors.forename: Fiona
authors.initials: F
authors.lastname: Dykes
authors.affiliation: Health Services Research Unit, University of Aberdeen, Aberdeen, UK.
authors.forename: Fiona
authors.initials: F
authors.lastname: Stewart
authors.affiliation: Department of Health Policy and Social Marketing, University of Stirling, Stirling, UK.
authors.forename: Linda
authors.initials: L
authors.lastname: Bauld
authors.affiliation: Health Services Research Unit, University of Aberdeen, Aberdeen, UK.
authors.forename: Marion K
authors.initials: MK
authors.lastname: Campbell
mesh_terms: D000293:Adolescent; D000328:Adult; D001942:Breast Feeding / Q000191:economics*; D003430:Cross-Sectional Studies; D004739:England; D005260:Female; D017144:Focus Groups; D006282:Health Personnel; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008875:Middle Aged; D009042:Motivation; D011247:Pregnancy; D036301:Qualitative Research; D012201:Reward; D012606:Scotland; D016540:Smoking Cessation / Q000191:economics*; D011795:Surveys and Questionnaires; D055815:Young Adult
keywords: PREVENTIVE MEDICINE; PUBLIC HEALTH; QUALITATIVE RESEARCH