Cash Transfers Conditional on Breastfeeding: the UK NOSH Trial

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NOSH: Exploring the potential of direct cash transfers (financial incentives) to increase

breastfeeding rates in the UK

Clare ReltonSenior Research Fellow (Public Health section) Sheffield School of Health and Related Research (ScHARR), University of Sheffield, UK

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Thank you

• Funders: Medical Research Council – National Prevention Research Initiative (MR/J000434/1).

• Co-authors: – University of Sheffield: Barbara Whelan, Mark

Strong, Kate Thomas, Elaine Scott,– University of Dundee: Mary Renfrew, Heather

Whitford• Local women and healthcare providers

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Breastfeeding

• UK has one of the lowest rates in the world (duration & exclusivity)

• 6-8wk BF rates – routinely collected data • Wide variation (17%-92%)• Strongly socially patterned

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Negative financial incentives

• £3.10 a wk – milk, fruit & veg, infant formula

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Negative incentives

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Positive financial incentives

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Research Question

Does offering financial incentives to mums increase BF (prevalence and

duration) in areas with low breastfeeding rates?

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Methods

1. Developing the idea

2. Testing the feasibility of the intervention

3. Testing the effectiveness of the intervention

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Developing the idea

InterviewsFocus groups

Street intercept survey Stakeholder consensus meetings

• Whelan B et al. 2014. Healthcare providers’ views on the acceptability of financial incentives for breastfeeding: a qualitative study. BMC Pregnancy and Childbirth. 2014;14:355

• Whitford H, et al. 2014. A financial incentive scheme to encourage breastfeeding (NOSH) in areas of low breastfeeding: designing the scheme incorporating key stakeholders’ views. Accepted by Practicing Midwife

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Field test

Purpose• Acceptability and deliverability of the schemeMethods• NOSH Scheme offered in three areas with low

BF rates (<40%) (n=108 women)• Interviews (mums n= 19, HCPs n=36)• Focus groups & 2nd stakeholder consensus

meeting

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The launch

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Findings

• Half (58/108) of all eligible mums applied to join and a third (37/108) claimed vouchers for 6-8wk BF

• Scheme was deliverable and acceptable• Midwives & HVs informed mums and co-

signed application and claim forms• Satisfaction with the scheme was high• Verifying ……… was largely unproblematic

Health Visitor

Midwife

Community Nursery Nurse

Breast Feeding Peer Support

Family Nurse Partnership

Dr

Practice Nurse

Midwife Support Worker

Who signs claims

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Applicants Day 2 Day 10 6-8week 12week 26week0%

10%

20%

30%

40%

50%

60%

53%

44%42%

34%

25%

18%

Vouchers Claims

Mean Uptake across sites

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Mothers

“rewarded”, “valued”, “it’s like a praise”

“it’s a nice treat”

“you’re getting something good for doing something good”

“I would have breastfed anyway but it does help me

breastfeed longer”

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Midwives & Health Visitors“The fact that it involved payment felt a little bit

uncomfortable I guess … dissipated quite a lot cause I think we’ve seen how pleased the women have been …

how positive they’ve been about it” (Midwife)

“My lassy saw it as quite exciting that she were having a voucher signed and then it gave me the opportunity to

affirm her with what she’d done” (Health Visitor)

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Interpretation

• Scheme was deliverable and acceptable to mums and HCPs

• No changes made to the scheme• Scheme extended in all feasibility areas

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Cluster randomised controlled trial

Cluster (electoral ward) based randomised controlled trial testing the effectiveness of the scheme began Feb 2015 – will close Sept 2016

• 10,000+ mum/baby dyads in 92 clusters in 5 urban/rural areas in northern England.

• Protocol for the trial just published in BMJ Open

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Thank you

• Funders - Medical Research Council: National Prevention Research Initiative (MR/J000434/1).

• NOSH team- Barbara Whelan, Mark Strong, Kate Thomas, Heather Whitford, Elaine Scott, Patrice van Cleemput, Jess Welburn

• Public health, midwifery and health visitor teams

• Mothers

• Our collaborators Profs Mary Renfrew & Julia Fox-Rushby