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Siersbaek R, Kavanagh P, Ford J, Burke S, Parker S. How and why do financial incentives contribute to helping people stop smoking? A realist review. BMC Public Health 2024; 24:500. [PMID: 38365629 PMCID: PMC10873947 DOI: 10.1186/s12889-024-17967-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 02/03/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND Tobacco smoking remains a key cause of preventable illness and death globally. In response, many countries provide extensive services to help people to stop smoking by offering a variety of effective behavioural and pharmacological therapies. However, many people who wish to stop smoking do not have access to or use stop smoking supports, and new modes of support, including the use of financial incentives, are needed to address this issue. A realist review of published international literature was undertaken to understand how, why, for whom, and in which circumstances financial incentives contribute to success in stopping smoking for general population groups and among pregnant women. METHODS Systematic searches were undertaken from inception to February 2022 of five academic databases: MEDLINE (ovid), Embase.com, CIHAHL, Scopus and PsycINFO. Study selection was inclusive of all study designs. Twenty-two studies were included. Using Pawson and Tilley's iterative realist review approach, data collected were screened, selected, coded, analysed, and synthesised into a set of explanatory theoretical findings. RESULTS Data were synthesised into six Context-Mechanism-Outcome Configurations and one overarching programme theory after iterative rounds of analysis, team discussion, and expert panel feedback. Our programme theory shows that financial incentives are particularly useful to help people stop smoking if they have a financial need, are pregnant or recently post-partum, have a high threshold for behaviour change, and/or respond well to external rewards. The incentives work through a number of mechanisms including the role their direct monetary value can play in a person's life and through a process of reinforcement where they can help build confidence and self-esteem. CONCLUSION This is the first realist review to synthesise how, why, and for whom financial incentives work among those attempting to stop smoking, adding to the existing evidence demonstrating their efficacy. The findings will support the implementation of current knowledge into effective programmes which can enhance the impact of stop smoking care. PROSPERO REGISTRATION NUMBER CRD42022298941.
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Affiliation(s)
- Rikke Siersbaek
- Centre for Health Policy and Management, Trinity College Dublin, 3-4 Foster Place, Dublin, Ireland.
| | - Paul Kavanagh
- Health Intelligence, Strategic Planning and Transformation, 4th Floor, Jervis House, Jervis Street, Dublin, Ireland
| | - John Ford
- Wolfson Institute for Population Health, Queen Mary University, Charterhouse Square, EC1M 6BQ, London, UK
| | - Sara Burke
- Centre for Health Policy and Management, Trinity College Dublin, 3-4 Foster Place, Dublin, Ireland
| | - Sarah Parker
- Centre for Health Policy and Management, Trinity College Dublin, 3-4 Foster Place, Dublin, Ireland
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Tatton C, Lloyd J. Understanding for whom, under what conditions and how smoking cessation services for pregnant women in the United Kingdom work-a rapid realist review. BMC Public Health 2023; 23:2488. [PMID: 38087281 PMCID: PMC10717267 DOI: 10.1186/s12889-023-17378-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 11/30/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Maternal smoking in pregnancy is associated with several adverse maternal and infant health outcomes including increased risk of miscarriage, stillbirth, low birth weight, preterm birth, and asthma. Progress to reduce rates of smoking at time of delivery in England have been slow and over the last decade, less than half of pregnant women who accessed services went onto report having quit. This realist review was undertaken to improve the understanding of how smoking cessation services in pregnancy work and to understand the heterogeneity of outcomes observed. METHODS The initial programme theory was developed using the National Centre for Smoking Cession and Training Standard Treatment Programme for Pregnant Women and the National Institute for Health and Care Excellence guidance on treating tobacco dependency. A search strategy and inclusion criteria were developed. Four databases were searched to identify published papers and four websites were hand searched to identify any unpublished literature that could contribute to theory building. Realist logic was applied to the analysis of papers to identify the contexts in which the intended behaviour change mechanism(s) were triggered, or not, and towards what outcomes to develop context mechanism outcome configurations. RESULTS The review included 33 papers. The analysis produced 19 context mechanism outcome configurations structured under five closely interconnected domains (i) articulating harm, (ii) promoting support, (iii) managing cravings, (iv) maintaining commitment and (v) building self-efficacy. This review identifies two key processes involved in how services achieve their effects: how material resources are implemented and relationships. Of the two key processes identified, more existing literature was available evidencing how material resources are implemented. However, the review provides some evidence that non-judgemental and supportive relationships with healthcare workers where regular contact is provided can play an important role in interrupting the social cues and social practice of smoking, even where those around women continue to smoke. CONCLUSIONS This review clarifies the range of interconnected and bi-directional relationships between services and the personal and social factors in women's lives. It underscores the importance of aligning efforts across the models five domains to strengthen services' ability to achieve smoking cessation.
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Affiliation(s)
- Claire Tatton
- Faculty of Health and Life Sciences, Department of Health and Community Sciences, University of Exeter, Exeter, UK.
| | - Jenny Lloyd
- Faculty of Health and Life Sciences, Department of Health and Community Sciences, University of Exeter, Exeter, UK
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McCormack FC, Hopley RC, Boath EH, Parry SL, Roscoe SM, Stewart A, Birch VA. Exploring pregnant women's experiences of stopping smoking with an incentive scheme with 'enhanced' support: a qualitative study. Perspect Public Health 2023; 143:285-291. [PMID: 35787029 DOI: 10.1177/17579139221106842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM This study aims to understand pregnant women's experiences of smoking cessation with an incentive scheme in a deprived UK city. This is important because smoking cessation with pregnant women is one of the most crucial public health initiatives to promote, and is particularly challenging in deprived areas. While financial incentive schemes are controversial, there is a need to better understand pregnant women's experiences. The scheme combined quasi-financial incentives (shopping vouchers) for validated quits (carbon monoxide (CO) validated at < 10 ppm), enhanced support from smoking cessation advisors, the opportunity to identify a 'Significant Other Supporter' and nicotine replacement therapy. METHODS With the focus on understanding pregnant women's experiences, a qualitative design was adopted. Semi-structured interviews were completed with 12 pregnant women from the scheme, and the three advisors. All interviews were transcribed, and thematic analysis conducted. RESULTS Pregnant women reported various challenges to quitting, including long-established routines, and stress. Participants were aware of stigma around incentives but were all very positive about the scheme. The relationship with advisors was described as fundamental. The women valued their advice and support, while uptake of the 'Significant Other Supporter' appeared low. Participants viewed the CO monitoring as 'an incentive', while the vouchers were framed as a 'bonus'. Advisors perceived the vouchers as helping engage pregnant women and maintain quit status, and women appreciated the vouchers both as financial assistance and recognition of their accomplishments. CONCLUSION This study highlights the great value women placed on the support, advice and monitoring from specialist advisors. The distinction between vouchers as a welcomed bonus, rather than 'the incentive' to engage, is important. How smoking cessation and schemes to promote this are communicated to pregnant women and health professionals is important, particularly given the stigma and controversy involved.
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Affiliation(s)
- Fiona C McCormack
- Centre for Health and Development (CHAD), School of Health, Science and Wellbeing, Staffordshire University, Leek Road Campus, Stoke-on-Trent ST4 2DF, UK
| | - Rachel C Hopley
- Institute for Community Research and Development (ICRD), University of Wolverhampton, Wolverhampton, UK
| | - Elizabeth H Boath
- School of Health, Science and Wellbeing, Staffordshire University, Stoke-on-Trent, UK
| | - Sian L Parry
- Centre for Health and Development (CHAD), School of Health, Science and Wellbeing, Staffordshire University, Stoke-on-Trent, UK
| | - Suzie M Roscoe
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Antony Stewart
- School of Health, Science and Wellbeing, Staffordshire University, Stoke-on-Trent, UK
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Yoshino CA, Sidney-Annerstedt K, Wingfield T, Kirubi B, Viney K, Boccia D, Atkins S. Experiences of conditional and unconditional cash transfers intended for improving health outcomes and health service use: a qualitative evidence synthesis. Cochrane Database Syst Rev 2023; 3:CD013635. [PMID: 36999604 PMCID: PMC10064639 DOI: 10.1002/14651858.cd013635.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/01/2023]
Abstract
BACKGROUND It is well known that poverty is associated with ill health and that ill health can result in direct and indirect costs that can perpetuate poverty. Social protection, which includes policies and programmes intended to prevent and reduce poverty in times of ill health, could be one way to break this vicious cycle. Social protection, particularly cash transfers, also has the potential to promote healthier behaviours, including healthcare seeking. Although social protection, particularly conditional and unconditional cash transfers, has been widely studied, it is not well known how recipients experience social protection interventions, and what unintended effects such interventions can cause. OBJECTIVES: The aim of this review was to explore how conditional and unconditional cash transfer social protection interventions with a health outcome are experienced and perceived by their recipients. SEARCH METHODS: We searched Epistemonikos, MEDLINE, CINAHL, Social Services Abstracts, Global Index Medicus, Scopus, AnthroSource and EconLit from the start of the database to 5 June 2020. We combined this with reference checking, citation searching, grey literature and contact with authors to identify additional studies. We reran all strategies in July 2022, and the new studies are awaiting classification. SELECTION CRITERIA We included primary studies, using qualitative methods or mixed-methods studies with qualitative research reporting on recipients' experiences of cash transfer interventions where health outcomes were evaluated. Recipients could be adult patients of healthcare services, the general adult population as recipients of cash targeted at themselves or directed at children. Studies could be evaluated on any mental or physical health condition or cash transfer mechanism. Studies could come from any country and be in any language. Two authors independently selected studies. DATA COLLECTION AND ANALYSIS: We used a multi-step purposive sampling framework for selecting studies, starting with geographical representation, followed by health condition, and richness of data. Key data were extracted by the authors into Excel. Methodological limitations were assessed independently using the Critical Appraisal Skills Programme (CASP) criteria by two authors. Data were synthesised using meta-ethnography, and confidence in findings was assessed using the Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) approach. MAIN RESULTS: We included 127 studies in the review and sampled 41 of these studies for our analysis. Thirty-two further studies were found after the updated search on 5 July 2022 and are awaiting classification. The sampled studies were from 24 different countries: 17 studies were from the African region, seven were from the region of the Americas, seven were from the European region, six were from the South-East Asian region, three from the Western Pacific region and one study was multiregional, covering both the African and the Eastern Mediterranean regions. These studies primarily explored the views and experiences of cash transfer recipients with different health conditions, such as infectious diseases, disabilities and long-term illnesses, sexual and reproductive health, and maternal and child health. Our GRADE-CERQual assessment indicated we had mainly moderate- and high-confidence findings. We found that recipients perceived the cash transfers as necessary and helpful for immediate needs and, in some cases, helpful for longer-term benefits. However, across conditional and unconditional programmes, recipients often felt that the amount given was too little in relation to their total needs. They also felt that the cash alone was not enough to change their behaviour and, to change behaviour, additional types of support would be required. The cash transfer was reported to have important effects on empowerment, autonomy and agency, but also in some settings, recipients experienced pressure from family or programme staff on cash usage. The cash transfer was reported to improve social cohesion and reduce intrahousehold tension. However, in settings where some received the cash and others did not, the lack of an equal approach caused tension, suspicion and conflict. Recipients also reported stigma in terms of cash transfer programme assessment processes and eligibility, as well as inappropriate eligibility processes. Across settings, recipients experienced barriers in accessing the cash transfer programme, and some refused or were hesitant to receive the cash. Some recipients found cash transfer programmes more acceptable when they agreed with the programme's goals and processes. AUTHORS' CONCLUSIONS: Our findings highlight the impact of the sociocultural context on the functioning and interaction between the individual, family and cash transfer programmes. Even where the goals of a cash transfer programme are explicitly health-related, the outcomes may be far broader than health alone and may include, for example, reduced stigma, empowerment and increased agency of the individual. When measuring programme outcomes, therefore, these broader impacts could be considered for understanding the health and well-being benefits of cash transfers.
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Affiliation(s)
- Clara A Yoshino
- World Health Organization Collaborating Centre on Tuberculosis and Social Medicine, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Kristi Sidney-Annerstedt
- World Health Organization Collaborating Centre on Tuberculosis and Social Medicine, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Tom Wingfield
- World Health Organization Collaborating Centre on Tuberculosis and Social Medicine, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Clinical Infection, Microbiology, and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
- Tropical and Infectious Disease Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Beatrice Kirubi
- World Health Organization Collaborating Centre on Tuberculosis and Social Medicine, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Centre for Public Health Research (CPHR), Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Kerri Viney
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Research School of Population Health, Australian National University, Canberra, Australia
- School of Public Health, University of Sydney, Sydney, Australia
| | - Delia Boccia
- Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, London, UK
| | - Salla Atkins
- World Health Organization Collaborating Centre on Tuberculosis and Social Medicine, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Global Health and Development, Health Sciences, Faculty of Social Sciences, Tampere University, Tampere, Finland
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McKell J, Harris FM, Sinclair L, Bauld L, Tappin DM, Hoddinott P. Usual care in a multicentre randomised controlled trial of financial incentives for smoking cessation in pregnancy: qualitative findings from a mixed-methods process evaluation. BMJ Open 2022; 12:e066494. [PMID: 36600364 PMCID: PMC9730354 DOI: 10.1136/bmjopen-2022-066494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 11/07/2022] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Financial incentives are recommended by the UK's National Institute for Health and Care Excellence to aid smoking cessation in pregnancy. However, little is known about how implementation contexts might impact on their effectiveness. Variations in smoking cessation support (usual care) for pregnant women who smoke were examined qualitatively as part of a prospective process evaluation of the Cessation in Pregnancy Incentives Trial (CPIT III). DESIGN Longitudinal case studies of five CPIT III trial sites informed by realist evaluation. SETTING A stop smoking service (SSS) serving a maternity hospital constituted each case study, located in three UK countries. PARTICIPANTS Data collection included semistructured interviews with trial participants (n=22), maternity (n=12) and SSS staff (n=17); and site observations and perspectives recorded in fieldnotes (n=85). RESULTS Cessation support (usual care) for pregnant women varied in amount, location, staff capacity, flexibility and content across sites. SSS staff capacity was important to avoid gaps in support. Colocation and good working relationships between maternity and SSS professionals enabled prioritisation and reinforced the importance of smoking cessation. Sites with limited use of carbon monoxide (CO) monitoring reduced opportunities to identify smokers while inconsistency around automatic referral processes prevented the offer of cessation support. SSS professionals colocated within antenatal clinics were available to women they could not otherwise reach. Flexibility around location, timing and tailoring of approaches for support, facilitated initial and sustained engagement and reduced the burden on women. CONCLUSIONS Trial sites faced varied barriers and facilitators to delivering cessation support, reflecting heterogeneity in usual care. If financial incentives are more effective with concurrent smoking cessation support, sites with fewer barriers and more facilitators regarding this support would be expected to have more promising trial outcomes. Future reporting of trial outcomes will assist in understanding incentives' generalisability across a wide range of usual care settings. TRIAL REGISTRATION NUMBER ISRCTN15236311.
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Affiliation(s)
- Jennifer McKell
- Institute for Social Marketing and Health, University of Stirling, Stirling, UK
| | - Fiona M Harris
- School of Health and Life Sciences, University of the West of Scotland, Paisley, UK
| | - Lesley Sinclair
- Department of Health Sciences, University of York, York, North Yorkshire, UK
| | - Linda Bauld
- Usher Institute of Population Health Sciences and Informatics, and SPECTRUM Research Consortium, University of Edinburgh, Edinburgh, UK
| | | | - Pat Hoddinott
- Nursing, Midwifery and Allied Health Professional Research Unit, University of Stirling, Stirling, UK
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Siersbaek R, Parker S, Kavanagh P, Ford JA, Burke S. How and why do financial incentives contribute to helping people stop smoking? A realist review protocol. BMJ Open 2022; 12:e060457. [PMID: 35705352 PMCID: PMC9204444 DOI: 10.1136/bmjopen-2021-060457] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Smoking is harmful to human health and programmes to help people stop smoking are key public health efforts that improve individual and population health outcomes. Research shows that financial incentives improve the success of stop smoking programmes. However, a better understanding of how they work is needed to better inform policy and to support building capability for implementation.The aims of this study: (1) To review the international literature to understand: How, why, in what circumstances and for whom financial incentives improve the success of stop smoking interventions among general population groups and among pregnant women. (2) To provide recommendations for how to best use financial incentives in efforts to promote smoking cessation. METHODS AND ANALYSIS A realist review of published international literature will be undertaken to understand how, why, for whom and in which circumstances financial incentives contribute to success in stopping smoking for general population groups and among pregnant women. Systematic searches were undertaken on 16 February 2022 of five academic databases: MEDLINE (ovid), Embase.com, CIHAHL, Scopus and PsycINFO. Iterative searching using citation tracking and of grey literature will be undertaken as needed. Using Pawson and Tilley's iterative realist review approach, data collected will be screened, selected, coded, analysed and synthesised into a set of explanatory theoretical findings. ETHICS AND DISSEMINATION Ethical approval is not required for this review as data sources to be included are previously published. The study will provide important findings for policy-makers and health system leaders to guide the development of stop smoking services which use incentives, for example, as part of the Health Service Executive's Tobacco Free Programme in Ireland. Understanding how contextual factors impact implementation and programmatic success is key to developing a more effective public health approach to stop smoking. Our dissemination strategy will be developed with our stakeholders. PROSPERO REGISTRATION NUMBER CRD42022298941.
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Affiliation(s)
- Rikke Siersbaek
- Centre for Health Policy and Management, Trinity College Dublin School of Medicine, Dublin 2, Ireland
| | - Sarah Parker
- Centre for Health Policy and Management, Trinity College Dublin School of Medicine, Dublin 2, Ireland
| | - Paul Kavanagh
- National Health Intelligence Unit, Strategy and Research, Jervis House, Jervis St, Health Service Executive, Dublin 1, Ireland
- Department of Public Health and Epidemiology, Centre for Population Health and Health Services Research, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Sara Burke
- Centre for Health Policy and Management, Trinity College Dublin School of Medicine, Dublin 2, Ireland
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Naledi T, Little F, Pike C, Edwards H, Robbertze D, Wagner C, London L, Bekker LG. Women of Worth: the impact of a cash plus intervention to enhance attendance and reduce sexual health risks for young women in Cape Town, South Africa. J Int AIDS Soc 2022; 25:e25938. [PMID: 35700052 PMCID: PMC9196891 DOI: 10.1002/jia2.25938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 05/12/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction Conditional cash transfers (CTs) augmented with other interventions are promising interventions for reducing HIV risk in adolescent girls and young women. Methods A multi‐phase, quasi‐experimental study assessed the impact of a CT (ZAR300; $22) conditional on attending a skills building intervention, Women of Worth (WoW), designed to improve sexual and reproductive health (SRH) outcomes in Cape Town, South Africa from May 2017 to December 2019. The intervention entailed 12 sessions with encouragement to attend adolescent and youth‐friendly health services. Women aged 19–24 years were randomized 1:1 to receive the intervention with a CT (“cash + care” or C+C) or without a CT (“care”). The study included a pilot phase followed by a post‐modification phase with improved uptake and retention without changing programme content or CT. Self‐reported HIV prevalence and SRH/HIV vulnerability were assessed via a self‐administered questionnaire at baseline, after 11 sessions, and 6–30 months’ post‐intervention for a subset. Mixed effect logistic regression models were fitted to estimate within‐subject changes in outcomes. Results Of 5116 participants, 904 (452 participants per arm) were in the pilot and 4212 (2039 “care” participants and 2173 “C+C” participants) were in the post modified phase. There were 1867 (85.9%) and 135 (6,6%) participants in the “C+C” group and the “Care,” respectively, that were WoW completers (≥ 11 sessions/retention). During the pilot phase, 194 (42.9%) and 18 (4.0%) participants in “C+C” and the “care” groups were retained. Receiving a CT sustained participation nearly 60‐fold (OR 60.37; 95% CI: 17.32; 210.50, p <0.001). Three‐hundred and thirty women were followed for a median of 15.0 months [IQR: 13.3; 17.8] to assess the durability of impact. Self‐reported new employment status increased more than three‐fold (p <0.001) at WoW completion and was sustained to the longer time point. Intimate partner violence indicators were reduced immediately after WoW, but this was not durable. Conclusions Participants receiving CT had sustained participation in an SRH/HIV prevention skills building with improvement in employment and some SRH outcomes. Layered, “young woman centred” programmes to address HIV and SRH risk in young women may be enhanced with CT.
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Affiliation(s)
- Tracey Naledi
- Desmond Tutu HIV Centre, UCT Health Sciences Faculty, University of Cape Town, Cape Town, South Africa.,Division of Public Health Medicine, University of Cape Town, Cape Town, South Africa
| | - Francesca Little
- Department of Statistical Sciences, University of Cape Town, Cape Town, South Africa
| | - Carey Pike
- Desmond Tutu HIV Centre, UCT Health Sciences Faculty, University of Cape Town, Cape Town, South Africa
| | - Harley Edwards
- Desmond Tutu HIV Centre, UCT Health Sciences Faculty, University of Cape Town, Cape Town, South Africa
| | - Dante Robbertze
- Desmond Tutu HIV Centre, UCT Health Sciences Faculty, University of Cape Town, Cape Town, South Africa
| | - Colleen Wagner
- Desmond Tutu HIV Centre, UCT Health Sciences Faculty, University of Cape Town, Cape Town, South Africa
| | - Leslie London
- Division of Public Health Medicine, University of Cape Town, Cape Town, South Africa
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, UCT Health Sciences Faculty, University of Cape Town, Cape Town, South Africa
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Paulo MS, Abdo NM, Bettencourt-Silva R, Al-Rifai RH. Gestational Diabetes Mellitus in Europe: A Systematic Review and Meta-Analysis of Prevalence Studies. Front Endocrinol (Lausanne) 2021; 12:691033. [PMID: 34956073 PMCID: PMC8698118 DOI: 10.3389/fendo.2021.691033] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 11/17/2021] [Indexed: 01/14/2023] Open
Abstract
Background Gestational Diabetes Mellitus (GDM) is defined as the type of hyperglycemia diagnosed for the first-time during pregnancy, presenting with intermediate glucose levels between normal levels for pregnancy and glucose levels diagnostic of diabetes in the non-pregnant state. We aimed to systematically review and meta-analyze studies of prevalence of GDM in European countries at regional and sub-regional levels, according to age, trimester, body weight, and GDM diagnostic criteria. Methods Systematic search was conducted in five databases to retrieve studies from 2014 to 2019 reporting the prevalence of GDM in Europe. Two authors have independently screened titles and abstracts and full text according to eligibility using Covidence software. A random-effects model was used to quantify weighted GDM prevalence estimates. The National Heart, Lung, and Blood Institute criteria was used to assess the risk of bias. Results From the searched databases, 133 research reports were deemed eligible and included in the meta-analysis. The research reports yielded 254 GDM-prevalence studies that tested 15,572,847 pregnant women between 2014 and 2019. The 133 research reports were from 24 countries in Northern Europe (44.4%), Southern Europe (27.1%), Western Europe (24.1%), and Eastern Europe (4.5%). The overall weighted GDM prevalence in the 24 European countries was estimated at 10.9% (95% CI: 10.0-11.8, I2 : 100%). The weighted GDM prevalence was highest in the Eastern Europe (31.5%, 95% CI: 19.8-44.6, I2 : 98.9%), followed by in Southern Europe (12.3%, 95% CI: 10.9-13.9, I2 : 99.6%), Western Europe (10.7%, 95% CI: 9.5-12.0, I2 : 99.9%), and Northern Europe (8.9%, 95% CI: 7.9-10.0, I2 : 100). GDM prevalence was 2.14-fold increased in pregnant women with maternal age ≥30 years (versus 15-29 years old), 1.47-fold if the diagnosis was made in the third trimester (versus second trimester), and 6.79- fold in obese and 2.29-fold in overweight women (versus normal weight). Conclusions In Europe, GDM is significant in pregnant women, around 11%, with the highest prevalence in pregnant women of Eastern European countries (31.5%). Findings have implications to guide vigilant public health awareness campaigns about the risk factors associated with developing GDM. Systematic Review Registration PROSPERO [https://www.crd.york.ac.uk/PROSPERO/], identifier CRD42020161857.
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Affiliation(s)
- Marília Silva Paulo
- Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Noor Motea Abdo
- Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Rita Bettencourt-Silva
- Department of Endocrinology and Nutrition, Unidade Local de Saúde do Alto Minho, Viana do Castelo, Portugal
- Department of Endocrinology, Hospital Lusíadas Porto, Porto, Portugal
| | - Rami H. Al-Rifai
- Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
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Breen RJ, Ferguson SG, Palmer MA. Smokers' Perceptions of Incentivized Smoking Cessation Programs: Examining How Payment Thresholds Change With Income. Nicotine Tob Res 2021; 23:1567-1574. [PMID: 33621322 DOI: 10.1093/ntr/ntab031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 02/18/2021] [Indexed: 11/14/2022]
Abstract
INTRODUCTION Studies demonstrate that financial incentive programs increase smoking cessation. However, there is little guidance on which incentive magnitudes will ensure optimal enrollment and motivation levels. This study investigates current smokers' perceptions of varying incentive magnitudes to identify whether there is evidence for optimal amount(s) and whether perceptions differ by income group. METHODS Studies 1 (N = 56) and 2 (N = 147) were conducted online via Prolific.co. Current smokers were randomly shown multiple hypothetical incentive programs that differed only in the incentive amount offered. For each program, smokers rated its appeal and their likelihood of enrolling and predicted their motivation to quit if enrolled. Growth models were used to investigate the relationship between perspectives and the incentive amount. RESULTS An increasing quadratic trend in smokers' perceptions of programs as the incentive amount increased was identified. Incentive amounts beyond approximately £50-75 per week (£500-£750 total) did not significantly alter perceptions of programs. In Study 2, high-income smokers found programs significantly less appealing and motivating than low-income smokers, although no significant between-group differences were observed in the likelihood of enrollment. No significant differences were observed between low- and middle-income smokers. CONCLUSIONS Increasing the incentive amount increased smoker's perceptions of programs. This relationship was curvilinear, meaning there may be a point beyond which further increasing the amount will not improve enrollment or motivation levels. Incentives appear equally appealing to low- and middle-income smokers; the population among whom smoking is most prevalent. Future research could explore other elements of program design and whether findings hold under real-world conditions. IMPLICATIONS While acknowledging that they work, policymakers frequently request information about the monetary amount needed for incentive programs to be effective, and if this differs by income level. We investigated these questions using smokers' perceptions of hypothetical cessation programs that differed in the amount offered. An increasing quadratic trend in perceptions of programs by the amount and potential cut points was observed, suggesting a point may exist beyond which increasing the incentive will not improve perceptions of programs or enrollment levels. High-income smokers may not perceive incentives to be as appealing as other income groups, but appear equally willing to enroll.
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Affiliation(s)
- Rachel J Breen
- College of Health and Medicine, University of Tasmania, Launceston, TAS, Australia
| | - Stuart G Ferguson
- College of Health and Medicine, University of Tasmania, Launceston, TAS, Australia
| | - Matthew A Palmer
- College of Health and Medicine, University of Tasmania, Launceston, TAS, Australia
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van den Brand FA, Candel MJJM, Nagelhout GE, Winkens B, van Schayck CP. How Financial Incentives Increase Smoking Cessation: A Two-Level Path Analysis. Nicotine Tob Res 2021; 23:99-106. [PMID: 31993637 PMCID: PMC7789935 DOI: 10.1093/ntr/ntaa024] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 01/24/2020] [Indexed: 12/19/2022]
Abstract
Introduction Financial incentives effectively increase smoking cessation rates, but it is unclear via which psychological mechanisms incentives influence quit behavior. The current study examines how receiving financial incentives for smoking cessation leads to quitting smoking and investigates several mediators and moderators of that relationship. Aims and Methods The study sample consisted of 604 tobacco-smoking employees from 61 companies in the Netherlands who completed a baseline and follow-up questionnaire. The current study is a secondary analysis from a cluster randomized trial where employees received smoking cessation group counseling at the workplace. Participants in the intervention group additionally received financial incentives of €350 in total for 12-month continuous smoking abstinence. We used a two-level path analysis to test a model that assesses the effects of financial incentives through smoking cessation program evaluation, medication use, nicotine replacement use, attitudes, self-efficacy, and social influences on quit success. We additionally tested whether an individual’s reward responsiveness moderated the influence of incentives on quit success. Results The effect of financial incentives on quit success was mediated by a higher self-efficacy. Financial incentives were also associated with a higher use of cessation medication. A more positive program evaluation was related to higher self-efficacy, more social influence to quit, and more positive attitudes about quitting. The results did not differ significantly by individual reward responsiveness. Conclusions The results of the current study suggest that financial incentives may be used to increase medication use and self-efficacy for quitting smoking, which offers an indirect way to increase successful smoking cessation. Implications (1) This is the first study investigating via which psychological pathways financial incentives for quitting smoking can lead to long-term quit success. (2) The results showed a path between financial incentives and a higher likelihood of medication use. Incentives may encourage smokers to use medication in order to increase their chance of quitting smoking and receive the reward. (3) There was a path from financial incentives to quit success via a higher self-efficacy. (4) The effects of financial incentives did not depend on individual reward responsiveness.
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Affiliation(s)
- Floor A van den Brand
- Department of Family Medicine, Maastricht University (CAPHRI), Maastricht, The Netherlands
| | - Math J J M Candel
- Department of Methodology and Statistics, Maastricht University (CAPHRI), Maastricht, The Netherlands
| | - Gera E Nagelhout
- Department of Family Medicine, Maastricht University (CAPHRI), Maastricht, The Netherlands.,Department of Health Promotion, Maastricht University (CAPHRI), Maastricht, The Netherlands.,IVO Research Institute, The Hague, The Netherlands
| | - Bjorn Winkens
- Department of Methodology and Statistics, Maastricht University (CAPHRI), Maastricht, The Netherlands
| | - Constant P van Schayck
- Department of Family Medicine, Maastricht University (CAPHRI), Maastricht, The Netherlands
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11
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Bowker K, Ussher M, Cooper S, Orton S, Coleman T, Campbell KA. Addressing and Overcoming Barriers to E-Cigarette Use for Smoking Cessation in Pregnancy: A Qualitative Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17134823. [PMID: 32635510 PMCID: PMC7369696 DOI: 10.3390/ijerph17134823] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 06/29/2020] [Accepted: 07/01/2020] [Indexed: 12/21/2022]
Abstract
E-cigarettes may have a role in supporting pregnant women who would otherwise smoke to stop smoking. The study aimed to understand pregnant women’s vaping experiences, in particular how vaping to stop smoking is facilitated and how barriers to this are overcome. We conducted semi structured telephone interviews (n = 15) with pregnant or postpartum women who vaped during pregnancy, either exclusively (n = 10) or dual-used (n = 5) (smoked and vaped). Thematic analysis was used to analyse the interviews. Two themes emerged. First, ‘facilitating beliefs’: inherent beliefs that helped women overcome barriers to vaping. These included understanding the relative safety of vaping and economic gains compared with smoking and pregnancy being a motivator to stop smoking. Second, ‘becoming a confident vaper’: accumulating sufficient skill and confidence to comfortably vape. This included experimentation with e-cigarettes to ensure nicotine dependence and sensory needs were met. Seeking social support and employing strategies to address social stigma were also important. Positive beliefs about vaping and becoming proficient at vaping were viewed as ways to overcome barriers to vaping. The theoretical domain framework informed intervention recommendations to assist pregnant smokers who have tried but cannot stop smoking to switch to vaping.
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Affiliation(s)
- Katharine Bowker
- Division of Primary Care, School of Medicine, University of Nottingham, Nottingham NG7 2RD, UK; (S.C.); (S.O.); (T.C.); (K.A.C.)
- Correspondence: ; Tel.: +44-0115-748-4040
| | - Michael Ussher
- Population Health Research Institute, St George’s, University of London, London SW17 0RE, UK;
- Institute for Social Marketing and Health, University of Stirling, Stirling FK9 4LA, UK
| | - Sue Cooper
- Division of Primary Care, School of Medicine, University of Nottingham, Nottingham NG7 2RD, UK; (S.C.); (S.O.); (T.C.); (K.A.C.)
| | - Sophie Orton
- Division of Primary Care, School of Medicine, University of Nottingham, Nottingham NG7 2RD, UK; (S.C.); (S.O.); (T.C.); (K.A.C.)
| | - Tim Coleman
- Division of Primary Care, School of Medicine, University of Nottingham, Nottingham NG7 2RD, UK; (S.C.); (S.O.); (T.C.); (K.A.C.)
| | - Katarzyna Anna Campbell
- Division of Primary Care, School of Medicine, University of Nottingham, Nottingham NG7 2RD, UK; (S.C.); (S.O.); (T.C.); (K.A.C.)
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12
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Campbell K, Coleman-Haynes T, Bowker K, Cooper SE, Connelly S, Coleman T. Factors influencing the uptake and use of nicotine replacement therapy and e-cigarettes in pregnant women who smoke: a qualitative evidence synthesis. Cochrane Database Syst Rev 2020; 5:CD013629. [PMID: 32441810 PMCID: PMC7387757 DOI: 10.1002/14651858.cd013629] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Nicotine replacement therapy (NRT) delivers nicotine without the toxic chemicals present in tobacco smoke. It is an effective smoking cessation aid in non-pregnant smokers, but there is less evidence of effectiveness in pregnancy. Systematic review evidence suggests that pregnant women do not adhere to NRT as prescribed, which might undermine effectiveness. Electronic cigarettes (e-cigarettes) have grown in popularity, but effectiveness and safety in pregnancy are not yet established. The determinants of uptake and use of NRT and e-cigarettes in pregnancy are unknown. OBJECTIVES To explore factors affecting uptake and use of NRT and e-cigarettes in pregnancy. SEARCH METHODS We searched MEDLINE(R), CINAHL and PsycINFO on 1 February 2019. We manually searched OpenGrey database and screened references of included studies and relevant reviews. We also conducted forward citation searches of included studies. SELECTION CRITERIA We selected studies that used qualitative methods of data collection and analysis, included women who had smoked in pregnancy, and elicited participants' views about using NRT/e-cigarettes for smoking cessation or harm reduction (i.e. to smoke fewer cigarettes) during pregnancy. DATA COLLECTION AND ANALYSIS We identified determinants of uptake and use of NRT/e-cigarettes in pregnancy using a thematic synthesis approach. Two review authors assessed the quality of included studies with the Wallace tool. Two review authors used the CERQual approach to assess confidence in review findings. The contexts of studies from this review and the relevant Cochrane effectiveness review were not similar enough to fully integrate findings; however, we created a matrix to juxtapose findings from this review with the descriptions of behavioural support from trials in the effectiveness review. MAIN RESULTS We included 21 studies: 15 focused on NRT, 3 on e-cigarettes, and 3 on both. Studies took place in five high-income countries. Most studies contributed few relevant data; substantially fewer data were available on determinants of e-cigarettes. Many studies focused predominantly on issues relating to smoking cessation, and determinants of NRT/e-cigarette use was often presented as one of the themes. We identified six descriptive themes and 18 findings within those themes; from these we developed three overarching analytical themes representing key determinants of uptake and adherence to NRT and/or e-cigarettes in pregnancy. The analytical themes show that women's desire to protect their unborn babies from harm is one of the main reasons they use these products. Furthermore, women consider advice from health professionals when deciding whether to use NRT or e-cigarettes; when health professionals tell women that NRT or e-cigarettes are safer than smoking and that it is okay for them to use these in pregnancy, women report feeling more confident about using them. Conversely, women who are told that NRT or e-cigarettes are as dangerous or more dangerous than smoking and that they should not use them during pregnancy feel less confident about using them. Women's past experiences with NRT can also affect their willingness to use NRT in pregnancy; women who feel that NRT had worked for them (or someone they know) in the past were more confident about using it again. However, women who had negative experiences were more reluctant to use NRT. No trials on e-cigarette use in pregnancy were included in the Cochrane effectiveness review, so we considered only NRT findings when integrating results from this review and the effectiveness review. No qualitative studies were conducted alongside trials, making full integration of the findings challenging. Women enrolled in trials would have agreed to being allocated to NRT or control group and would have received standardised information on NRT at the start of the trial. Overall, the findings of this synthesis are less relevant to women's decisions about starting NRT in trials and more likely to help explain trial participants' adherence to NRT after starting it. We considered most findings to be of moderate certainty; we assessed findings on NRT use as being of higher certainty than those on e-cigarette use. This was mainly due to the limited data from fewer studies (only in the UK and USA) that contributed to e-cigarette findings. Overall, we judged studies to be of acceptable quality with only minor methodological issues. AUTHORS' CONCLUSIONS Consistent messages from health professionals, based on high-quality evidence and clearly explaining the safety of NRT and e-cigarettes compared to smoking in pregnancy, could help women use NRT and e-cigarettes more consistently/as recommended. This may improve their attitudes towards NRT or e-cigarettes, increase their willingness to use these in their attempt to quit, and subsequently encourage them to stay smoke-free.
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Affiliation(s)
| | | | - Katharine Bowker
- Division of Primary Care, University of Nottingham, Nottingham, UK
| | - Sue E Cooper
- Division of Primary Care, University of Nottingham, Nottingham, UK
| | - Sarah Connelly
- Division of Primary Care, University of Nottingham, Nottingham, UK
| | - Tim Coleman
- Division of Primary Care, University of Nottingham, Nottingham, UK
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13
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Linn BK, Stasiewicz PR, Fillo J, Bradizza CM. The Great Disrupter: Relationship of Alexithymia to Emotion Regulation Processes and Smoking among Pregnant Women. Subst Use Misuse 2020; 55:1113-1121. [PMID: 32153230 PMCID: PMC7401085 DOI: 10.1080/10826084.2020.1729198] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Background: Many women continue to smoke during pregnancy, despite known risks, often in response to negative affect. Recent scholarship has begun to examine factors that decrease the success of behavioral treatments for smoking cessation in pregnancy, which are the preferred interventions. Alexithymia is one factor that may interfere with smoking cessation interventions. Alexithymia restricts access to emotional information and increases propensity toward maladaptive behaviors, including smoking. However, mechanisms underlying such effects are largely unknown. Objectives: Using data from a longitudinal treatment study, the present research examined difficulties with emotion regulation as a potential mechanism linking alexithymia and smoking. Pregnant smokers (n = 73; mean age = 24.78; SD = 4.50) completed measures related to alexithymia, smoking, emotion regulation, depression, anxiety, and anger at baseline and then again following eight sessions of Cognitive-Behavioral Smoking Cessation Treatment. Results: Nearly 40% of the sample met the criteria for alexithymia. The alexithymia group reported higher depression, anxiety, and anger. They also reported more difficulties with emotion regulation. In a path analysis, baseline alexithymia had a significant positive indirect effect on number of cigarettes smoked at the end of treatment through difficulties with emotion regulation. Conclusions/Importance: Similar to other studies, alexithymia limits the understanding of emotional information necessary for selection and implementation of adaptive coping responses. Our results extend the literature by suggesting that smoking may be an attempt to manage undifferentiated and unpleasant sensations created by alexithymia.
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Affiliation(s)
- Braden K Linn
- Clinical and Research Institute on Addictions, University at Buffalo, Buffalo, New York, USA
| | - Paul R Stasiewicz
- School of Social Work, University at Buffalo, Buffalo, New York, USA
| | - Jennifer Fillo
- Clinical and Research Institute on Addictions, University at Buffalo, Buffalo, New York, USA
| | - Clara M Bradizza
- School of Social Work, University at Buffalo, Buffalo, New York, USA
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14
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Small S, Porr C, Swab M, Murray C. Experiences and cessation needs of Indigenous women who smoke during pregnancy: a systematic review of qualitative evidence. ACTA ACUST UNITED AC 2019; 16:385-452. [PMID: 29419622 DOI: 10.11124/jbisrir-2017-003377] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVES The aim of this review was to identify and synthesize the best available evidence to address two questions: i) what is the experience of smoking during pregnancy for Indigenous women? and ii) what are the smoking cessation needs of Indigenous women who smoke during pregnancy? INTRODUCTION Smoking during pregnancy not only affects pregnant women's general health but also causes such serious problems as pre-term delivery, low birth weight, and sudden infant death. Rates of smoking during pregnancy are particularly high among Indigenous women. Learning about Indigenous women's experiences of smoking during pregnancy and associated smoking cessation needs is important to providing informed health care to them. INCLUSION CRITERIA The participants of interest were Indigenous women who smoked during a current or past pregnancy. The phenomena of interest were the experiences of smoking during pregnancy for Indigenous women and the smoking cessation needs of Indigenous women during pregnancy. The context was any community worldwide where pregnant Indigenous women live. Studies considered for this review were those in which qualitative data were gathered and analysed on the phenomena of interest, including mixed methods research. METHODS A comprehensive search was conducted for published studies in academic databases (i.e. PubMed, CINAHL, PsycINFO, Embase, Sociological Abstracts, SocINDEX, and Web of Science), unpublished studies in sources of gray literature (i.e. ProQuest Dissertations and Theses, OAIster, LILACS, MedNar, Google, Google Scholar, OpenGrey and relevant websites), and any additional studies in reference lists. Language and date limiters were not applied. The searches included all studies globally and were carried out on October 31, 2016. Studies that met the inclusion criteria were assessed for methodological quality by two reviewers independently, using the criteria of the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Qualitative Research. Descriptive details of each study accepted for this review were extracted in accordance with the elements of the JBI Data Extraction Form for Qualitative Research. The research findings that were relevant to the phenomena of interest and had participant voice were extracted from each included study and synthesized using the JBI meta-aggregative approach. The synthesized findings were assigned confidence scores in accordance with the JBI ConQual approach. RESULTS Thirteen studies were included in this review following careful consideration of the methodological quality of each study. The studies yielded a total of 116 research findings, which were grouped into 19 categories and then aggregated to form five synthesized findings. Confidence in the findings was determined to be low to very low (see ConQual Summary of Findings). CONCLUSION There is a small body of research evidence on Indigenous women's experiences of smoking during pregnancy and their smoking cessation needs. Confidence in the synthesized findings is constrained due to methodological limitations in many of the primary studies included in this review, along with mixed credibility of the research findings from across primary studies.
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Affiliation(s)
- Sandra Small
- School of Nursing, Memorial University of Newfoundland, St. John's, Canada.,Memorial University School of Nursing Collaboration for Evidence-Based Nursing and Primary Health Care: A Joanna Briggs Institute Affiliated Group
| | - Caroline Porr
- School of Nursing, Memorial University of Newfoundland, St. John's, Canada.,Memorial University School of Nursing Collaboration for Evidence-Based Nursing and Primary Health Care: A Joanna Briggs Institute Affiliated Group
| | - Michelle Swab
- Health Sciences Library, Memorial University of Newfoundland, St. John's, Canada.,Memorial University School of Nursing Collaboration for Evidence-Based Nursing and Primary Health Care: A Joanna Briggs Institute Affiliated Group
| | - Cynthia Murray
- School of Nursing, Memorial University of Newfoundland, St. John's, Canada.,Memorial University School of Nursing Collaboration for Evidence-Based Nursing and Primary Health Care: A Joanna Briggs Institute Affiliated Group
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15
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Vlaev I, King D, Darzi A, Dolan P. Changing health behaviors using financial incentives: a review from behavioral economics. BMC Public Health 2019; 19:1059. [PMID: 31391010 PMCID: PMC6686221 DOI: 10.1186/s12889-019-7407-8] [Citation(s) in RCA: 120] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 07/31/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Incentives are central to economics and are used across the public and private sectors to influence behavior. Recent interest has been shown in using financial incentives to promote desirable health behaviors and discourage unhealthy ones. MAIN TEXT If we are going to use incentive schemes to influence health behaviors, then it is important that we give them the best chance of working. Behavioral economics integrates insights from psychology with the laws of economics and provides a number of robust psychological phenomena that help to better explain human behavior. Individuals' decisions in relation to incentives may be shaped by more subtle features - such as loss aversion, overweighting of small probabilities, hyperbolic discounting, increasing payoffs, reference points - many of which have been identified through research in behavioral economics. If incentives are shown to be a useful strategy to influence health behavior, a wider discussion will need to be had about the ethical dimensions of incentives before their wider implementation in different health programmes. CONCLUSIONS Policy makers across the world are increasingly taking note of lessons from behavioral economics and this paper explores how key principles could help public health practitioners design effective interventions both in relation to incentive designs and more widely.
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Affiliation(s)
- Ivo Vlaev
- Warwick Business School, University of Warwick, Coventry, UK.
| | - Dominic King
- Centre for Health Policy, Imperial College London, London, UK.
| | - Ara Darzi
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Paul Dolan
- Department of Psychological and Behavioural Science, London School of Economics, London, UK
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16
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Notley C, Gentry S, Livingstone‐Banks J, Bauld L, Perera R, Hartmann‐Boyce J. Incentives for smoking cessation. Cochrane Database Syst Rev 2019; 7:CD004307. [PMID: 31313293 PMCID: PMC6635501 DOI: 10.1002/14651858.cd004307.pub6] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Financial incentives, monetary or vouchers, are widely used in an attempt to precipitate, reinforce and sustain behaviour change, including smoking cessation. They have been used in workplaces, in clinics and hospitals, and within community programmes. OBJECTIVES To determine the long-term effect of incentives and contingency management programmes for smoking cessation. SEARCH METHODS For this update, we searched the Cochrane Tobacco Addiction Group Specialised Register, clinicaltrials.gov, and the International Clinical Trials Registry Platform (ICTRP). The most recent searches were conducted in July 2018. SELECTION CRITERIA We considered only randomised controlled trials, allocating individuals, workplaces, groups within workplaces, or communities to smoking cessation incentive schemes or control conditions. We included studies in a mixed-population setting (e.g. community, work-, clinic- or institution-based), and also studies in pregnant smokers. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. The primary outcome measure in the mixed-population studies was abstinence from smoking at longest follow-up (at least six months from the start of the intervention). In the trials of pregnant women we used abstinence measured at the longest follow-up, and at least to the end of the pregnancy. Where available, we pooled outcome data using a Mantel-Haenzel random-effects model, with results reported as risk ratios (RRs) and 95% confidence intervals (CIs), using adjusted estimates for cluster-randomised trials. We analysed studies carried out in mixed populations separately from those carried out in pregnant populations. MAIN RESULTS Thirty-three mixed-population studies met our inclusion criteria, covering more than 21,600 participants; 16 of these are new to this version of the review. Studies were set in varying locations, including community settings, clinics or health centres, workplaces, and outpatient drug clinics. We judged eight studies to be at low risk of bias, and 10 to be at high risk of bias, with the rest at unclear risk. Twenty-four of the trials were run in the USA, two in Thailand and one in the Phillipines. The rest were European. Incentives offered included cash payments or vouchers for goods and groceries, offered directly or collected and redeemable online. The pooled RR for quitting with incentives at longest follow-up (six months or more) compared with controls was 1.49 (95% CI 1.28 to 1.73; 31 RCTs, adjusted N = 20,097; I2 = 33%). Results were not sensitive to the exclusion of six studies where an incentive for cessation was offered at long-term follow up (result excluding those studies: RR 1.40, 95% CI 1.16 to 1.69; 25 RCTs; adjusted N = 17,058; I2 = 36%), suggesting the impact of incentives continues for at least some time after incentives cease.Although not always clearly reported, the total financial amount of incentives varied considerably between trials, from zero (self-deposits), to a range of between USD 45 and USD 1185. There was no clear direction of effect between trials offering low or high total value of incentives, nor those encouraging redeemable self-deposits.We included 10 studies of 2571 pregnant women. We judged two studies to be at low risk of bias, one at high risk of bias, and seven at unclear risk. When pooled, the nine trials with usable data (eight conducted in the USA and one in the UK), delivered an RR at longest follow-up (up to 24 weeks post-partum) of 2.38 (95% CI 1.54 to 3.69; N = 2273; I2 = 41%), in favour of incentives. AUTHORS' CONCLUSIONS Overall there is high-certainty evidence that incentives improve smoking cessation rates at long-term follow-up in mixed population studies. The effectiveness of incentives appears to be sustained even when the last follow-up occurs after the withdrawal of incentives. There is also moderate-certainty evidence, limited by some concerns about risks of bias, that incentive schemes conducted among pregnant smokers improve smoking cessation rates, both at the end of pregnancy and post-partum. Current and future research might explore more precisely differences between trials offering low or high cash incentives and self-incentives (deposits), within a variety of smoking populations.
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Affiliation(s)
- Caitlin Notley
- University of East AngliaNorwich Medical SchoolNorwichUK
| | - Sarah Gentry
- University of East AngliaNorwich Medical SchoolNorwichUK
| | | | - Linda Bauld
- University of EdinburghUsher Institute, College of Medicine and Veterinary MedicineEdinburghUK
| | - Rafael Perera
- University of OxfordNuffield Department of Primary Care Health SciencesOxfordUK
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17
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Van den Brand FA, Dohmen LME, Van Schayck OCP, Nagelhout GE. 'Secretly, it's a competition': a qualitative study investigating what helped employees quit smoking during a workplace smoking cessation group training programme with incentives. BMJ Open 2018; 8:e023917. [PMID: 30478122 PMCID: PMC6254401 DOI: 10.1136/bmjopen-2018-023917] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Smoking cessation programmes in combination with financial incentives have shown to increase quit rates in smokers, but it is not clear which elements of this intervention help smokers to succeed in their quit attempt. The aim of this study was to explore the view of successful and unsuccessful quitters about which factors had affected their ability to quit smoking. DESIGN Semistructured qualitative interviews were conducted and analysed using the Framework method. SETTING Interviews were conducted in 2017 with employees from nine different Dutch companies. PARTICIPANTS 24 successful and unsuccessful quitters from the intervention group of a cluster randomised controlled trial (RCT) who participated in a workplace smoking cessation group training programme in which smoking abstinence was rewarded with financial incentives. RESULTS Themes that emerged were the workplace setting, quitting with colleagues, motivation, family support, strategies and the financial incentives. The interviewees reported that the smoking cessation programme was appreciated in general, was convenient, lowered the threshold to sign up, stimulated peer support and competition and provided strategies to resist smoking. Personal motivation and a mind set to never smoke again were regarded as important factors for quit success. The financial incentives were not considered as a main motivator to quit smoking, which contradicts the results from the RCT. The financial incentives were considered as more attractive to smokers with a low income. CONCLUSIONS According to participants, contributors to quitting smoking were the workplace cessation programme, personal motivation and peer support, but not the incentives. More research is needed on the contradiction between the perceived effects of financial incentives on quit success and the actual difference in quit rates. TRIAL REGISTRATION NUMBER NTR5657.
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Affiliation(s)
- Floor A Van den Brand
- Department of Family Medicine, Maastricht University (CAPHRI), Maastricht, The Netherlands
| | - Lisa M E Dohmen
- Department of Family Medicine, Maastricht University (CAPHRI), Maastricht, The Netherlands
| | - Onno C P Van Schayck
- Department of Family Medicine, Maastricht University (CAPHRI), Maastricht, The Netherlands
| | - Gera E Nagelhout
- Department of Family Medicine, Maastricht University (CAPHRI), Maastricht, The Netherlands
- Department of Health Promotion, Maastricht University (CAPHRI), Maastricht, The Netherlands
- IVO Addiction Research Institute, The Hague, The Netherlands
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18
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Tombor I, Shahab L, Brown J, Crane D, Michie S, West R. Development of SmokeFree Baby: a smoking cessation smartphone app for pregnant smokers. Transl Behav Med 2017; 6:533-545. [PMID: 27699682 PMCID: PMC5110502 DOI: 10.1007/s13142-016-0438-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Pregnant smokers may benefit from digital smoking cessation interventions, but few have been designed for this population. The aim was to transparently report the development of a smartphone app designed to aid smoking cessation during pregnancy. The development of a smartphone app (‘SmokeFree Baby’) to help pregnant women stop smoking was guided by frameworks for developing complex interventions, including the Medical Research Council (MRC), Multiphase Optimization Strategy (MOST) and Behaviour Change Wheel (BCW). Two integrative behaviour change theories provided the theoretical base. Evidence from the scientific literature and behaviour change techniques (BCTs) from the BCT Taxonomy v1 informed the intervention content. The app was developed around five core modules, each with a distinct intervention target (identity change, stress management, health information, promoting use of face-to-face support and behavioural substitution) and available in a ‘control’ or ‘full’ version. SmokeFree Baby has been developed as part of a multiphase intervention optimization to identify the optimum combination of intervention components to include in smartphone apps to help pregnant smokers stop smoking.
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Affiliation(s)
- Ildiko Tombor
- Cancer Research UK Health Behaviour Research Centre, University College London, WC1E 6BT, London, UK.
| | - Lion Shahab
- Department of Epidemiology and Public Health, University College London, WC1E 6BT, London, UK
| | - Jamie Brown
- Cancer Research UK Health Behaviour Research Centre, University College London, WC1E 6BT, London, UK
| | - David Crane
- Department of Clinical, Educational and Health Psychology, University College London, WC1E 6BT, London, UK
| | - Susan Michie
- Department of Clinical, Educational and Health Psychology, University College London, WC1E 6BT, London, UK
| | - Robert West
- Cancer Research UK Health Behaviour Research Centre, University College London, WC1E 6BT, London, UK
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19
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Chamberlain C, O'Mara‐Eves A, Porter J, Coleman T, Perlen SM, Thomas J, McKenzie JE. Psychosocial interventions for supporting women to stop smoking in pregnancy. Cochrane Database Syst Rev 2017; 2:CD001055. [PMID: 28196405 PMCID: PMC6472671 DOI: 10.1002/14651858.cd001055.pub5] [Citation(s) in RCA: 180] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Tobacco smoking remains one of the few preventable factors associated with complications in pregnancy, and has serious long-term implications for women and babies. Smoking in pregnancy is decreasing in high-income countries, but is strongly associated with poverty and is increasing in low- to middle-income countries. OBJECTIVES To assess the effects of smoking cessation interventions during pregnancy on smoking behaviour and perinatal health outcomes. SEARCH METHODS In this sixth update, we searched the Cochrane Pregnancy and Childbirth Group's Trials Register (13 November 2015), checked reference lists of retrieved studies and contacted trial authors. SELECTION CRITERIA Randomised controlled trials, cluster-randomised trials, and quasi-randomised controlled trials of psychosocial smoking cessation interventions during pregnancy. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and trial quality, and extracted data. Direct comparisons were conducted in RevMan, with meta-regression conducted in STATA 14. MAIN RESULTS The overall quality of evidence was moderate to high, with reductions in confidence due to imprecision and heterogeneity for some outcomes. One hundred and two trials with 120 intervention arms (studies) were included, with 88 trials (involving over 28,000 women) providing data on smoking abstinence in late pregnancy. Interventions were categorised as counselling, health education, feedback, incentives, social support, exercise and dissemination.In separate comparisons, there is high-quality evidence that counselling increased smoking cessation in late pregnancy compared with usual care (30 studies; average risk ratio (RR) 1.44, 95% confidence interval (CI) 1.19 to 1.73) and less intensive interventions (18 studies; average RR 1.25, 95% CI 1.07 to 1.47). There was uncertainty whether counselling increased the chance of smoking cessation when provided as one component of a broader maternal health intervention or comparing one type of counselling with another. In studies comparing counselling and usual care (largest comparison), it was unclear whether interventions prevented smoking relapse among women who had stopped smoking spontaneously in early pregnancy. However, a clear effect was seen in smoking abstinence at zero to five months postpartum (11 studies; average RR 1.59, 95% CI 1.26 to 2.01) and 12 to 17 months (two studies, average RR 2.20, 95% CI 1.23 to 3.96), with a borderline effect at six to 11 months (six studies; average RR 1.33, 95% CI 1.00 to 1.77). In other comparisons, the effect was unclear for most secondary outcomes, but sample sizes were small.Evidence suggests a borderline effect of health education compared with usual care (five studies; average RR 1.59, 95% CI 0.99 to 2.55), but the quality was downgraded to moderate as the effect was unclear when compared with less intensive interventions (four studies; average RR 1.20, 95% CI 0.85 to 1.70), alternative interventions (one study; RR 1.88, 95% CI 0.19 to 18.60), or when smoking cessation health education was provided as one component of a broader maternal health intervention.There was evidence feedback increased smoking cessation when compared with usual care and provided in conjunction with other strategies, such as counselling (average RR 4.39, 95% CI 1.89 to 10.21), but the confidence in the quality of evidence was downgraded to moderate as this was based on only two studies and the effect was uncertain when feedback was compared to less intensive interventions (three studies; average RR 1.29, 95% CI 0.75 to 2.20).High-quality evidence suggests incentive-based interventions are effective when compared with an alternative (non-contingent incentive) intervention (four studies; RR 2.36, 95% CI 1.36 to 4.09). However pooled effects were not calculable for comparisons with usual care or less intensive interventions (substantial heterogeneity, I2 = 93%).High-quality evidence suggests the effect is unclear in social support interventions provided by peers (six studies; average RR 1.42, 95% CI 0.98 to 2.07), in a single trial of support provided by partners, or when social support for smoking cessation was provided as part of a broader intervention to improve maternal health.The effect was unclear in single interventions of exercise compared to usual care (RR 1.20, 95% CI 0.72 to 2.01) and dissemination of counselling (RR 1.63, 95% CI 0.62 to 4.32).Importantly, high-quality evidence from pooled results demonstrated that women who received psychosocial interventions had a 17% reduction in infants born with low birthweight, a significantly higher mean birthweight (mean difference (MD) 55.60 g, 95% CI 29.82 to 81.38 g higher) and a 22% reduction in neonatal intensive care admissions. However the difference in preterm births and stillbirths was unclear. There did not appear to be adverse psychological effects from the interventions.The intensity of support women received in both the intervention and comparison groups has increased over time, with higher-intensity interventions more likely to have higher-intensity comparisons, potentially explaining why no clear differences were seen with increasing intervention intensity in meta-regression analyses. Among meta-regression analyses: studies classified as having 'unclear' implementation and unequal baseline characteristics were less effective than other studies. There was no clear difference between trials implemented by researchers (efficacy studies), and those implemented by routine pregnancy staff (effectiveness studies), however there was uncertainty in the effectiveness of counselling in four dissemination trials where the focus on the intervention was at an organisational level. The pooled effects were similar in interventions provided for women classified as having predominantly low socio-economic status, compared to other women. The effect was significant in interventions among women from ethnic minority groups; however not among indigenous women. There were similar effect sizes in trials with biochemically validated smoking abstinence and those with self-reported abstinence. It was unclear whether incorporating use of self-help manuals or telephone support increased the effectiveness of interventions. AUTHORS' CONCLUSIONS Psychosocial interventions to support women to stop smoking in pregnancy can increase the proportion of women who stop smoking in late pregnancy and the proportion of infants born low birthweight. Counselling, feedback and incentives appear to be effective, however the characteristics and context of the interventions should be carefully considered. The effect of health education and social support is less clear. New trials have been published during the preparation of this review and will be included in the next update.
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Affiliation(s)
- Catherine Chamberlain
- La Trobe UniversityJudith Lumley Centre251 Faraday StreetMelbourneVicAustralia3000
- University of MelbourneMelbourne School of Population and Global HealthMelbourneAustralia
- Monash UniversitySchool of Public Health & Preventive MedicineMelbourneAustralia
- Murdoch Childrens Research InstituteHealthy Mothers Healthy Families Research GroupMelbourneVictoriaAustralia3052
| | - Alison O'Mara‐Eves
- University College LondonEPPI‐Centre, Social Science Research Unit, UCL Institute of Education18 Woburn SquareLondonUKWC1H 0NR
| | - Jessie Porter
- University of MelbourneMelbourne School of Population and Global HealthMelbourneAustralia
| | - Tim Coleman
- University of NottinghamDivision of Primary CareD1411, Medical SchoolQueen's Medical CentreNottinghamUKNG7 2UH
| | - Susan M Perlen
- Murdoch Childrens Research InstituteHealthy Mothers Healthy Families Research GroupMelbourneVictoriaAustralia3052
| | - James Thomas
- University College LondonEPPI‐Centre, Social Science Research Unit, UCL Institute of Education18 Woburn SquareLondonUKWC1H 0NR
| | - Joanne E McKenzie
- Monash UniversitySchool of Public Health & Preventive MedicineMelbourneAustralia
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Morgan H, Hoddinott P, Thomson G, Crossland N, Farrar S, Yi D, Hislop J, Moran VH, MacLennan G, Dombrowski SU, Rothnie K, Stewart F, Bauld L, Ludbrook A, Dykes F, Sniehotta FF, Tappin D, Campbell M. Benefits of Incentives for Breastfeeding and Smoking cessation in pregnancy (BIBS): a mixed-methods study to inform trial design. Health Technol Assess 2016; 19:1-522, vii-viii. [PMID: 25897655 DOI: 10.3310/hta19300] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Smoking in pregnancy and/or not breastfeeding have considerable negative health outcomes for mother and baby. AIM 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. DESIGN 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. SETTING UK. PARTICIPANTS 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. LIMITATIONS 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. STUDY REGISTRATION This study is registered as PROSPERO CRD42012001980. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Heather Morgan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Pat Hoddinott
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Gill Thomson
- Maternal and Infant Nutrition and Nurture Unit, University of Central Lancashire, Preston, UK
| | - Nicola Crossland
- Maternal and Infant Nutrition and Nurture Unit, University of Central Lancashire, Preston, UK
| | - Shelley Farrar
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Deokhee Yi
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Jenni Hislop
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Victoria Hall Moran
- Maternal and Infant Nutrition and Nurture Unit, University of Central Lancashire, Preston, UK
| | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Kieran Rothnie
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Fiona Stewart
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Linda Bauld
- The Institute of Social Marketing, University of Stirling, Stirling, UK
| | - Anne Ludbrook
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Fiona Dykes
- Maternal and Infant Nutrition and Nurture Unit, University of Central Lancashire, Preston, UK
| | - Falko F Sniehotta
- Institute of Health and Society, University of Newcastle, Newcastle, UK
| | - David Tappin
- Perinatal Epidemiology and Child Health Unit, School of Medicine, University of Glasgow, Glasgow, UK
| | - Marion Campbell
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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Abstract
BACKGROUND Material or financial incentives are widely used in an attempt to precipitate or reinforce behaviour change, including smoking cessation. They operate in workplaces, in clinics and hospitals, and to a lesser extent within community programmes. In this third update of our review we now include trials conducted in pregnant women, to reflect the increasing activity and resources now targeting this high-risk group of smokers. OBJECTIVES To determine whether incentives and contingency management programmes lead to higher long-term quit rates. SEARCH METHODS We searched the Cochrane Tobacco Addiction Group Specialised Register, with additional searches of MEDLINE, EMBASE, CINAHL and PsycINFO. The most recent searches were in December 2014, although we also include two trials published in 2015. SELECTION CRITERIA We considered randomised controlled trials, allocating individuals, workplaces, groups within workplaces, or communities to experimental or control conditions. We also considered controlled studies with baseline and post-intervention measures. We include studies in a mixed-population setting (e.g. community-, work-, institution-based), and also, for this update, trials in pregnant smokers. DATA COLLECTION AND ANALYSIS One author (KC) extracted data and a second (JH-B) checked them. We contacted study authors for additional data where necessary. The main outcome measure in the mixed-population studies was abstinence from smoking at longest follow-up, and at least six months from the start of the intervention. In the trials of pregnant smokers abstinence was measured at the longest follow-up, and at least to the end of the pregnancy. MAIN RESULTS Twenty-one mixed-population studies met our inclusion criteria, covering more than 8400 participants. Ten studies were set in clinics or health centres, one in Thai villages served by community health workers, two in academic institutions, and the rest in worksites. All but six of the trials were run in the USA. The incentives included lottery tickets or prize draws, cash payments, vouchers for goods and groceries, and in six trials the recovery of money deposited by those taking part. The odds ratio (OR) for quitting with incentives at longest follow-up (six months or more) compared with controls was 1.42 (95% confidence interval (CI) 1.19 to 1.69; 17 trials, [20 comparisons], 7715 participants). Only three studies demonstrated significantly higher quit rates for the incentives group than for the control group at or beyond the six-month assessment: One five-arm USA trial compared rewards- and deposit-based interventions at individual and group level, with incentives available up to USD 800 per quitter, and demonstrated a quit rate in the rewards groups of 8.1% at 12 months, compared with 4.7% in the deposits groups. A direct comparison between the rewards-based and the deposit-based groups found a benefit for the rewards arms, with an OR at 12 months of 1.76 (95% CI 1.22 to 2.53; 2070 participants). Although more people in this trial accepted the rewards programmes than the deposit programmes, the proportion of quitters in each group favoured the deposit-refund programme. Another USA study rewarded both participation and quitting up to USD 750, and achieved sustained quit rates of 9.4% in the incentives group compared with 3.6% for the controls. A deposit-refund trial in Thailand also achieved significantly higher quit rates in the intervention group (44.2%) compared with the control group (18.8%), but uptake was relatively low, at 10.5%. In the remaining trials, there was no clear evidence that participants who committed their own money to the programme did better than those who did not, or that contingent rewards enhanced success rates over fixed payment schedules. We rated the overall quality of the older studies as low, but with later trials (post-2000) more likely to meet current standards of methodology and reporting.Eight of nine trials with usable data in pregnant smokers (seven conducted in the USA and one in the UK) delivered an adjusted OR at longest follow-up (up to 24 weeks post-partum) of 3.60 (95% CI 2.39 to 5.43; 1295 participants, moderate-quality studies) in favour of incentives. Three of the trials demonstrated a clear benefit for contingent rewards; one delivered monthly vouchers to confirmed quitters and to their designated 'significant other supporter', achieving a quit rate in the intervention group of 21.4% at two months post-partum, compared with 5.9% among the controls. Another trial offered a scaled programme of rewards for the percentage of smoking reduction achieved over the course of the 12-week intervention, and achieved an intervention quit rate of 31% at six weeks post-partum, compared with no quitters in the control group. The largest (UK-based) trial provided intervention quitters with up to GBP 400-worth of vouchers, and achieved a quit rate of 15.4% at longest follow-up, compared to the control quit rate of 4%. Four trials confirmed that payments made to reward a successful quit attempt (i.e. contingent), compared to fixed payments for attending the antenatal appointment (non-contingent), resulted in higher quit rates. Front-loading of rewards to counteract early withdrawal symptoms made little difference to quit rates. AUTHORS' CONCLUSIONS Incentives appear to boost cessation rates while they are in place. The two trials recruiting from work sites that achieved sustained success rates beyond the reward schedule concentrated their resources into substantial cash payments for abstinence. Such an approach may only be feasible where independently-funded smoking cessation programmes are already available, and within a relatively affluent and educated population. Deposit-refund trials can suffer from relatively low rates of uptake, but those who do sign up and contribute their own money may achieve higher quit rates than reward-only participants. Incentive schemes conducted among pregnant smokers improved the cessation rates, both at the end-of-pregnancy and post-partum assessments. Current and future research might continue to explore the scale, loading and longevity of possible cash or voucher reward schedules, within a variety of smoking populations.
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Affiliation(s)
- Kate Cahill
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, UK, OX2 6GG
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22
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Giles EL, Robalino S, Sniehotta FF, Adams J, McColl E. Acceptability of financial incentives for encouraging uptake of healthy behaviours: A critical review using systematic methods. Prev Med 2015; 73:145-58. [PMID: 25600881 DOI: 10.1016/j.ypmed.2014.12.029] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 11/28/2014] [Accepted: 12/26/2014] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Financial incentives are effective in encouraging healthy behaviours, yet concerns about acceptability remain. We conducted a systematic review exploring acceptability of financial incentives for encouraging healthy behaviours. METHODS Database, reference, and citation searches were conducted from the earliest available date to October 2014, to identify empirical studies and scholarly writing that: had an English language title, were published in a peer-reviewed journal, and explored acceptability of financial incentives for healthy behaviours in members of the public, potential recipients, potential practitioners or policy makers. Data was analysed using thematic analysis. RESULTS Eighty one papers were included: 59 pieces of scholarly writing and 22 empirical studies, primarily exploring acceptability to the public. Five themes were identified: fair exchange, design and delivery, effectiveness and cost-effectiveness, recipients, and impact on individuals and wider society. Although there was consensus that if financial incentives are effective and cost effective they are likely to be considered acceptable, a number of other factors also influenced acceptability. CONCLUSIONS Financial incentives tend to be acceptable to the public when they are effective and cost-effective. Programmes that benefit recipients and wider society; are considered fair; and are delivered to individuals deemed appropriate are likely to be considered more acceptable.
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Affiliation(s)
- Emma L Giles
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Newcastle upon Tyne, Tyne and Wear NE2 4AX, UK.
| | - Shannon Robalino
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Newcastle upon Tyne, Tyne and Wear NE2 4AX, UK.
| | - Falko F Sniehotta
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Newcastle upon Tyne, Tyne and Wear NE2 4AX, UK.
| | - Jean Adams
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Newcastle upon Tyne, Tyne and Wear NE2 4AX, UK.
| | - Elaine McColl
- Newcastle Clinical Trials Unit, Institute of Health and Society, Newcastle University, 4th Floor William Leech Building, The Medical School, Framlington Place, Newcastle upon Tyne, Tyne and Wear NE2 4HH, UK.
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Moran VH, Morgan H, Rothnie K, MacLennan G, Stewart F, Thomson G, Crossland N, Tappin D, Campbell M, Hoddinott P. Incentives to promote breastfeeding: a systematic review. Pediatrics 2015; 135:e687-702. [PMID: 25647672 DOI: 10.1542/peds.2014-2221] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Few women in industrialized countries achieve the World Health Organization's recommendation to breastfeed exclusively for 6 months. Governments are increasingly seeking new interventions to address this problem, including the use of incentives. The goal of this study was to assess the evidence regarding the effectiveness of incentive interventions, delivered within or outside of health care settings, to individuals and/or their families seeking to increase and sustain breastfeeding in the first 6 months after birth. METHODS Searches of electronic databases, reference lists, and grey literature were conducted to identify relevant reports of published, unpublished, and ongoing studies. All study designs published in English, which met our definition of incentives and that were from a developed country, were eligible for inclusion. Abstract and full-text article review with sequential data extraction were conducted by 2 independent authors. RESULTS Sixteen full reports were included in the review. The majority evaluated multicomponent interventions of varying frequency, intensity, and duration. Incentives involved providing access to breast pumps, gifts, vouchers, money, food packages, and help with household tasks, but little consensus in findings was revealed. The lack of high-quality, randomized controlled trials identified by this review and the multicomponent nature of the interventions prohibited meta-analysis. CONCLUSIONS This review found that the overall effect of providing incentives for breastfeeding compared with no incentives is unclear due to study heterogeneity and the variation in study quality. Further evidence on breastfeeding incentives offered to women is required to understand the possible effects of these interventions.
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Affiliation(s)
- Victoria Hall Moran
- Maternal and Infant Nutrition and Nurture Unit, University of Central Lancashire, Preston, United Kingdom;
| | - Heather Morgan
- Health Services Research Unit, University of Aberdeen, United Kingdom
| | - Kieran Rothnie
- Health Services Research Unit, University of Aberdeen, United Kingdom
| | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, United Kingdom
| | - Fiona Stewart
- Health Services Research Unit, University of Aberdeen, United Kingdom
| | - Gillian Thomson
- Maternal and Infant Nutrition and Nurture Unit, University of Central Lancashire, Preston, United Kingdom
| | - Nicola Crossland
- Maternal and Infant Nutrition and Nurture Unit, University of Central Lancashire, Preston, United Kingdom
| | - David Tappin
- David Tappin, School of Medicine, University of Glasgow, United Kingdom; and
| | - Marion Campbell
- Health Services Research Unit, University of Aberdeen, United Kingdom
| | - Pat Hoddinott
- Nursing, Midwifery and Allied Health Professions Research Unit, University of Stirling, United Kingdom
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Crossland N, Thomson G, Morgan H, Dombrowski SU, Hoddinott P. Incentives for breastfeeding and for smoking cessation in pregnancy: An exploration of types and meanings. Soc Sci Med 2015; 128:10-7. [DOI: 10.1016/j.socscimed.2014.12.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Mantzari E, Vogt F, Marteau TM. Financial incentives for increasing uptake of HPV vaccinations: a randomized controlled trial. Health Psychol 2015; 34:160-71. [PMID: 25133822 PMCID: PMC4312136 DOI: 10.1037/hea0000088] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Revised: 12/31/2013] [Accepted: 02/09/2014] [Indexed: 12/03/2022]
Abstract
OBJECTIVE Uptake of human papillomavirus (HPV) vaccinations by 17- to 18-year-old girls in England is below (<35%) target (80%). This trial assesses (a) the impact of financial incentives on uptake and completion of an HPV vaccination program, and (b) whether impacts are moderated by participants' deprivation level. It also assesses the impact of incentives on decision quality to get vaccinated, as measured by attitudes toward the vaccination and knowledge of its consequences. METHOD One thousand 16- to 18-year-old girls were invited to participate in an HPV vaccination program: 500 previously uninvited, and 500 unresponsive to previous invitations. Girls randomly received either a standard invitation letter or a letter including the offer of vouchers worth £ 45 (€ 56; $73) for undergoing 3 vaccinations. Girls attending their first vaccination appointment completed a questionnaire assessing decision quality to be vaccinated. Outcomes were uptake of the first and third vaccinations and decision quality. RESULTS The intervention increased uptake of the first (first-time invitees: 28.4% vs. 19.6%, odds ratio [OR] = 1.63, 95% confidence interval [CI; 1.08, 2.47]; previous nonattenders: 23.6% vs. 10.4%, OR = 2.65, 95% CI [1.61, 4.38]) and third (first-time invitees: 22.4% vs. 12%, OR = 2.15, 95% CI [1.32, 3.50]; previous nonattenders: 12.4% vs. 3%, OR = 4.28, 95% CI [1.92, 9.55]) vaccinations. Impacts were not moderated by deprivation level. Decision quality was unaffected by the intervention. CONCLUSIONS Although the intervention increased completion of HPV vaccinations, uptake remained lower than the national target, which, in addition to cost effectiveness and acceptability issues, necessitates consideration of other ways of achieving it.
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Affiliation(s)
| | - Florian Vogt
- Institute of Pharmaceutical Science, King's College London
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Ormston R, van der Pol M, Ludbrook A, McConville S, Amos A. quit4u: the effectiveness of combining behavioural support, pharmacotherapy and financial incentives to support smoking cessation. HEALTH EDUCATION RESEARCH 2015; 30:121-133. [PMID: 24848555 DOI: 10.1093/her/cyu024] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The 'quit4u' stop smoking service (SSS) was developed by National Health Service (NHS) Tayside for smokers in deprived areas of Dundee (UK). quit4u combined behavioural support and pharmacotherapy with financial incentives for each week that participants remained quit. A quasi-experimental study was undertaken with smokers using quit4u between 2009 and 2011 compared with smokers using SSSs in the rest of Scotland. The outcome measures were: number of quit attempts; quit rates at 1, 3 and 12 months; cost-effectiveness. Mechanisms of change were explored through quantitative and qualitative research that explored the views and experiences of service users and professionals involved in quit4u. The number of quit attempts made using SSSs in deprived areas of NHS Tayside increased by 44% between 2007 and 2010. quit4u had significantly higher quit rates at 1 month (49.9% versus 33.7%), 3 months (30.7% versus 14.2%) and 12 months (9.3% versus 6.5%) compared with similar smokers using other SSSs. The incremental cost per quitter was £2296. A combination of elements kept clients engaged and supported quit attempts: carbon monoxide (CO) tests, financial incentives, high-quality pharmacy support, rolling groups and greater varenicline use. quit4u may provide an effective and cost-effective model for engaging and supporting smokers in deprived areas to quit.
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Affiliation(s)
- R Ormston
- ScotCen Social Research, Edinburgh, UK, Health Economics Research Unit, University of Aberdeen, Aberdeen, UK and UK Centre for Tobacco and Alcohol Studies, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - M van der Pol
- ScotCen Social Research, Edinburgh, UK, Health Economics Research Unit, University of Aberdeen, Aberdeen, UK and UK Centre for Tobacco and Alcohol Studies, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - A Ludbrook
- ScotCen Social Research, Edinburgh, UK, Health Economics Research Unit, University of Aberdeen, Aberdeen, UK and UK Centre for Tobacco and Alcohol Studies, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - S McConville
- ScotCen Social Research, Edinburgh, UK, Health Economics Research Unit, University of Aberdeen, Aberdeen, UK and UK Centre for Tobacco and Alcohol Studies, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - A Amos
- ScotCen Social Research, Edinburgh, UK, Health Economics Research Unit, University of Aberdeen, Aberdeen, UK and UK Centre for Tobacco and Alcohol Studies, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
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Giles EL, Sniehotta FF, McColl E, Adams J. Acceptability of financial incentives and penalties for encouraging uptake of healthy behaviours: focus groups. BMC Public Health 2015; 15:58. [PMID: 25636330 PMCID: PMC4318173 DOI: 10.1186/s12889-015-1409-y] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 01/13/2015] [Indexed: 11/21/2022] Open
Abstract
Background There is evidence that financial incentive interventions, which include both financial rewards and also penalties, are effective in encouraging healthy behaviours. However, concerns about the acceptability of such interventions remain. We report on focus groups with a cross-section of adults from North East England exploring their acceptance of financial incentive interventions for encouraging healthy behaviours amongst adults. Such information should help guide the design and development of acceptable, and effective, financial incentive interventions. Methods Eight focus groups with a total of 74 adults were conducted between November 2013 and January 2014 in Newcastle upon Tyne, UK. Focus groups lasted approximately 60 minutes and explored factors that made financial incentives acceptable and unacceptable to participants, together with discussions on preferred formats for financial incentives. Verbatim transcripts were thematically coded and analysed in Nvivo 10. Results Participants largely distrusted health promoting financial incentives, with a concern that individuals may abuse such schemes. There was, however, evidence that health promoting financial incentives may be more acceptable if they are fair to all recipients and members of the public; if they are closely monitored and evaluated; if they are shown to be effective and cost-effective; and if clear health education is provided alongside health promoting financial incentives. There was also a preference for positive rewards rather than negative penalties, and for shopping vouchers rather than cash incentives. Conclusions This qualitative empirical research has highlighted clear suggestions on how to design health promoting financial incentives to maximise acceptability to the general public. It will also be important to determine the acceptability of health promoting financial incentives in a range of stakeholders, and in particular, those who fund such schemes, and policy-makers who are likely to be involved with the design, implementation and evaluation of health promoting financial incentive schemes. Electronic supplementary material The online version of this article (doi:10.1186/s12889-015-1409-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Emma L Giles
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Newcastle upon Tyne, Tyne and Wear, NE2 4AX, UK.
| | - Falko F Sniehotta
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Newcastle upon Tyne, Tyne and Wear, NE2 4AX, UK.
| | - Elaine McColl
- Newcastle Clinical Trials Unit, 4th Floor William Leech Building, The Medical School, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK.
| | - Jean Adams
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Newcastle upon Tyne, Tyne and Wear, NE2 4AX, UK. .,Centre for Diet & Activity Research, MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Box 285 Institute of Metabolic Science, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK.
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Wadge H, Bicknell C, Vlaev I. Perceived ethical acceptability of financial incentives to improve diabetic eye screening attendance. BMJ Open Diabetes Res Care 2015; 3:e000118. [PMID: 26635964 PMCID: PMC4663372 DOI: 10.1136/bmjdrc-2015-000118] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 07/28/2015] [Accepted: 08/04/2015] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To test the ethical acceptability of using financial incentives to increase diabetic retinopathy screening attendance. BACKGROUND Financial incentives could be an effective way to increase attendance at screening for diabetic retinopathy, although there can be ethical concerns about this approach. DESIGN Survey of people with diabetes in North West London. Those who were due to attend a screening appointment were invited to complete a questionnaire. Key demographic variables included age, gender, and deprivation. SETTING AND PARTICIPANTS A questionnaire was issued to those invited to attend screening in North West London and those who run the screening service. The questionnaire captured views on aspects of the ethical problem and different incentive types. MAIN VARIABLES STUDIED It captured views on the different dimensions of the ethical problem and different types of incentive. In order to understand how views might vary within a population, demographic variables were used to analyze the results. RESULTS AND CONCLUSIONS Vouchers were found to be the most acceptable form of incentive, significantly more so than cash payments. Most rejected the notion of targeting those who need incentivizing, preferring equality. Age was an important factor, with those aged between 40 and 64 the most optimistic about the potential benefits. Higher levels of deprivation were linked to increased acceptability scores. While some ethical concerns are strongly held among certain groups, there is also much support for the principle of incentivizing positive behaviors. This paves the way for future research into the effectiveness of incentivizing diabetic retinopathy screening attendance.
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Affiliation(s)
- Hester Wadge
- Division of Surgery, Department of Surgery and Cancer , St Mary's Hospital , London , UK
| | - Colin Bicknell
- Division of Surgery, Department of Surgery and Cancer , St Mary's Hospital , London , UK
| | - Ivo Vlaev
- Division of Surgery, Department of Surgery and Cancer , St Mary's Hospital , London , UK
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Glover M, Kira A, Walker N, Bauld L. Using Incentives to Encourage Smoking Abstinence Among Pregnant Indigenous Women? A Feasibility Study. Matern Child Health J 2014; 19:1393-9. [DOI: 10.1007/s10995-014-1645-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Whelan B, Thomas KJ, Van Cleemput P, Whitford H, Strong M, Renfrew MJ, Scott E, Relton C. Healthcare providers' views on the acceptability of financial incentives for breastfeeding: a qualitative study. BMC Pregnancy Childbirth 2014; 14:355. [PMID: 25296687 PMCID: PMC4288621 DOI: 10.1186/1471-2393-14-355] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 09/22/2014] [Indexed: 11/17/2022] Open
Abstract
Background Despite 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. Methods Fifty–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. Results The 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. Conclusion Healthcare 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.
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Affiliation(s)
- Barbara Whelan
- Section of Public Health, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield S1 4DA, UK.
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Chamberlain C, O’Mara-Eves A, Oliver S, Caird JR, Perlen SM, Eades SJ, Thomas J. Psychosocial interventions for supporting women to stop smoking in pregnancy. Cochrane Database Syst Rev 2013; 10:CD001055. [PMID: 24154953 PMCID: PMC4022453 DOI: 10.1002/14651858.cd001055.pub4] [Citation(s) in RCA: 178] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Tobacco smoking in pregnancy remains one of the few preventable factors associated with complications in pregnancy, stillbirth, low birthweight and preterm birth and has serious long-term implications for women and babies. Smoking in pregnancy is decreasing in high-income countries, but is strongly associated with poverty and increasing in low- to middle-income countries. OBJECTIVES To assess the effects of smoking cessation interventions during pregnancy on smoking behaviour and perinatal health outcomes. SEARCH METHODS In this fifth update, we searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 March 2013), checked reference lists of retrieved studies and contacted trial authors to locate additional unpublished data. SELECTION CRITERIA Randomised controlled trials, cluster-randomised trials, randomised cross-over trials, and quasi-randomised controlled trials (with allocation by maternal birth date or hospital record number) of psychosocial smoking cessation interventions during pregnancy. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and trial quality, and extracted data. Direct comparisons were conducted in RevMan, and subgroup analyses and sensitivity analysis were conducted in SPSS. MAIN RESULTS Eighty-six trials were included in this updated review, with 77 trials (involving over 29,000 women) providing data on smoking abstinence in late pregnancy.In separate comparisons, counselling interventions demonstrated a significant effect compared with usual care (27 studies; average risk ratio (RR) 1.44, 95% confidence interval (CI) 1.19 to 1.75), and a borderline effect compared with less intensive interventions (16 studies; average RR 1.35, 95% CI 1.00 to 1.82). However, a significant effect was only seen in subsets where counselling was provided in conjunction with other strategies. It was unclear whether any type of counselling strategy is more effective than others (one study; RR 1.15, 95% CI 0.86 to 1.53). In studies comparing counselling and usual care (the largest comparison), it was unclear whether interventions prevented smoking relapse among women who had stopped smoking spontaneously in early pregnancy (eight studies; average RR 1.06, 95% CI 0.93 to 1.21). However, a clear effect was seen in smoking abstinence at zero to five months postpartum (10 studies; average RR 1.76, 95% CI 1.05 to 2.95), a borderline effect at six to 11 months (six studies; average RR 1.33, 95% CI 1.00 to 1.77), and a significant effect at 12 to 17 months (two studies, average RR 2.20, 95% CI 1.23 to 3.96), but not in the longer term. In other comparisons, the effect was not significantly different from the null effect for most secondary outcomes, but sample sizes were small.Incentive-based interventions had the largest effect size compared with a less intensive intervention (one study; RR 3.64, 95% CI 1.84 to 7.23) and an alternative intervention (one study; RR 4.05, 95% CI 1.48 to 11.11).Feedback interventions demonstrated a significant effect only when compared with usual care and provided in conjunction with other strategies, such as counselling (two studies; average RR 4.39, 95% CI 1.89 to 10.21), but the effect was unclear when compared with a less intensive intervention (two studies; average RR 1.19, 95% CI 0.45 to 3.12).The effect of health education was unclear when compared with usual care (three studies; average RR 1.51, 95% CI 0.64 to 3.59) or less intensive interventions (two studies; average RR 1.50, 95% CI 0.97 to 2.31).Social support interventions appeared effective when provided by peers (five studies; average RR 1.49, 95% CI 1.01 to 2.19), but the effect was unclear in a single trial of support provided by partners.The effects were mixed where the smoking interventions were provided as part of broader interventions to improve maternal health, rather than targeted smoking cessation interventions.Subgroup analyses on primary outcome for all studies showed the intensity of interventions and comparisons has increased over time, with higher intensity interventions more likely to have higher intensity comparisons. While there was no significant difference, trials where the comparison group received usual care had the largest pooled effect size (37 studies; average RR 1.34, 95% CI 1.25 to 1.44), with lower effect sizes when the comparison group received less intensive interventions (30 studies; average RR 1.20, 95% CI 1.08 to 1.31), or alternative interventions (two studies; average RR 1.26, 95% CI 0.98 to 1.53). More recent studies included in this update had a lower effect size (20 studies; average RR 1.26, 95% CI 1.00 to 1.59), I(2)= 3%, compared to those in the previous version of the review (50 studies; average RR 1.50, 95% CI 1.30 to 1.73). There were similar effect sizes in trials with biochemically validated smoking abstinence (49 studies; average RR 1.43, 95% CI 1.22 to 1.67) and those with self-reported abstinence (20 studies; average RR 1.48, 95% CI 1.17 to 1.87). There was no significant difference between trials implemented by researchers (efficacy studies), and those implemented by routine pregnancy staff (effectiveness studies), however the effect was unclear in three dissemination trials of counselling interventions where the focus on the intervention was at an organisational level (average RR 0.96, 95% CI 0.37 to 2.50). The pooled effects were similar in interventions provided for women with predominantly low socio-economic status (44 studies; average RR 1.41, 95% CI 1.19 to 1.66), compared to other women (26 studies; average RR 1.47, 95% CI 1.21 to 1.79); though the effect was unclear in interventions among women from ethnic minority groups (five studies; average RR 1.08, 95% CI 0.83 to 1.40) and aboriginal women (two studies; average RR 0.40, 95% CI 0.06 to 2.67). Importantly, pooled results demonstrated that women who received psychosocial interventions had an 18% reduction in preterm births (14 studies; average RR 0.82, 95% CI 0.70 to 0.96), and infants born with low birthweight (14 studies; average RR 0.82, 95% CI 0.71 to 0.94). There did not appear to be any adverse effects from the psychosocial interventions, and three studies measured an improvement in women's psychological wellbeing. AUTHORS' CONCLUSIONS Psychosocial interventions to support women to stop smoking in pregnancy can increase the proportion of women who stop smoking in late pregnancy, and reduce low birthweight and preterm births.
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Affiliation(s)
- Catherine Chamberlain
- Global Health and Society Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Alison O’Mara-Eves
- EPPI-Centre, Social Science Research Unit, Institute of Education, University of London, London, UK
| | - Sandy Oliver
- EPPI-Centre, Social Science Research Unit, Institute of Education, University of London, London, UK
| | - Jenny R Caird
- EPPI-Centre, Social Science Research Unit, Institute of Education, University of London, London, UK
| | - Susan M Perlen
- Healthy Mothers Healthy Families Research Group, Murdoch Childrens Research Institute, Melbourne, Australia
| | - Sandra J Eades
- School of Public Health, Sydney School of Medicine, University of Sydney, Sydney, Australia
| | - James Thomas
- EPPI-Centre, Social Science Research Unit, Institute of Education, University of London, London, UK
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Promberger M, Marteau TM. When do financial incentives reduce intrinsic motivation? comparing behaviors studied in psychological and economic literatures. Health Psychol 2013; 32:950-7. [PMID: 24001245 PMCID: PMC3906839 DOI: 10.1037/a0032727] [Citation(s) in RCA: 151] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Revised: 01/11/2013] [Accepted: 01/24/2013] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To review existing evidence on the potential of incentives to undermine or "crowd out" intrinsic motivation, in order to establish whether and when it predicts financial incentives to crowd out motivation for health-related behaviors. METHOD We conducted a conceptual analysis to compare definitions and operationalizations of the effect, and reviewed existing evidence to identify potential moderators of the effect. RESULTS In the psychological literature, we find strong evidence for an undermining effect of tangible rewards on intrinsic motivation for simple tasks when motivation manifest in behavior is initially high. In the economic literature, evidence for undermining effects exists for a broader variety of behaviors, in settings that involve a conflict of interest between parties. By contrast, for health related behaviors, baseline levels of incentivized behaviors are usually low, and only a subset involve an interpersonal conflict of interest. Correspondingly, we find no evidence for crowding out of incentivized health behaviors. CONCLUSION The existing evidence does not warrant a priori predictions that an undermining effect would be found for health-related behaviors. Health-related behaviors and incentives schemes differ greatly in moderating characteristics, which should be the focus of future research.
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Affiliation(s)
- Marianne Promberger
- Centre for the Study of Incentives in Health and Department of Psychology, King’s College London, United Kingdom.
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Marteau TM, Thorne J, Aveyard P, Hirst J, Sokal R. Financial incentives for smoking cessation in pregnancy: protocol for a single arm intervention study. BMC Pregnancy Childbirth 2013; 13:66. [PMID: 23497294 PMCID: PMC3605251 DOI: 10.1186/1471-2393-13-66] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Accepted: 03/05/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Smoking during pregnancy and in the postnatal period is a major cause of low birth weight and a range of adverse infant health outcomes. Stop smoking services can double quit rates, but only 17% of pregnant women smoking at the time they book for antenatal care use these services. In a recent Cochrane review on the effectiveness of smoking cessation interventions in pregnancy, financial incentives were found to be the single most effective intervention. We describe a single arm intervention study offering participation in a financial incentive scheme for smoking cessation to all pregnant smokers receiving antenatal care in one area in England. The aim of the study is to assess the potential effectiveness of using financial incentives to achieve smoking cessation in pregnant women who smoke, to inform the use of financial incentive schemes in routine clinical practice as well as the interpretation of existing trials and the design of future studies. METHOD/DESIGN 500 consecutive pregnant smokers are offered participation in the scheme, which involves attending for up to 32 assessments until six months post-partum, to verify smoking cessation by self report and a negative exhaled carbon monoxide measurement. At each visit when cessation is verified, participants receive a shopping voucher starting at a value of £8 and increasing by £1 at each consecutive successful visit. Assessments decline in frequency, occurring most frequently during the first two weeks after quitting and the first two weeks after delivery. The maximum cumulative total that can be earned through the scheme is £752. DISCUSSION The results of this study will inform the use of financial incentive schemes in routine clinical practice as well as the interpretation of existing trials and the design of future studies. The main results are (a) an estimate of the proportion of pregnant smokers who enrol in the scheme; (b) estimates of the proportion of pregnant smokers who participate in the scheme and who achieve prolonged abstinence at: i. delivery and ii. six months postpartum; (c) predictors of i. participation in the scheme, and ii. smoking cessation; and (d) estimates of the adverse effects of using incentives to achieve quitting as indexed by: i. the delay in quitting smoking to enrol in an incentive scheme and, ii. false reporting of smoking status, either to gain entry into the scheme or to gain an incentive.
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Affiliation(s)
| | | | - Paul Aveyard
- Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Julie Hirst
- NHS Derbyshire County, Newholme Hospital, Bakewell, UK
| | - Rachel Sokal
- NHS Derbyshire County, Scarsdale, Chesterfield, UK
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Howard LM, Bekele D, Rowe M, Demilew J, Bewley S, Marteau TM. Smoking cessation in pregnant women with mental disorders: a cohort and nested qualitative study. BJOG 2013; 120:362-70. [PMID: 23167511 PMCID: PMC3638317 DOI: 10.1111/1471-0528.12059] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2012] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To investigate whether 1) pregnant smokers with mental disorders are less likely to accept referrals to smoking cessation services compared with pregnant smokers without disorders; 2) they experience specific barriers to smoking cessation. DESIGN Cohort study supplemented by cross-sectional survey and nested qualitative study. SETTING Three maternity services, London, UK. POPULATION Pregnant smokers with and without mental disorders. METHODS Case notes were examined on a cohort of 400 consecutive pregnant smokers; data were triangulated with routinely collected data on 845 pregnant smokers at two other sites; 27 pregnant smokers were interviewed using qualitative methods. MAIN OUTCOME MEASURES Acceptance of referral to smoking cessation services; perceived barriers to quitting. RESULTS Pregnant smokers with a mental disorder recorded by midwives were one-quarter of the cohort (97, 23%), were more likely to accept referral to smoking cessation services (69% versus 56%, adjusted odds ratio 1.70, 95% confidence interval 1.03-2.79), but more likely to still smoke at delivery (69% versus 56%, adjusted odds ratio 2.63, 95% confidence interval 1.41-4.92). Discussion about smoking was documented in 7.7% of subsequent antenatal visits in women with or without mental disorders. Pregnant smokers with diagnosed mental disorders reported that they and health practitioners did not prioritise smoking advice because of concern about adversely impacting mental health. CONCLUSIONS Pregnant women with mental disorders appear more motivated, yet find it more difficult, to stop smoking. Prioritisation of mental health over smoking may therefore lead to increasing health inequality for this group. Research into effective smoking cessation interventions is required for those with mental disorders.
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Affiliation(s)
- L M Howard
- PO31 Institute of Psychiatry, King's College London, London, UK.
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