Best Start Foods - evaluation: annex B - qualitative research

Executive summary

Introduction

The Scottish Government commissioned ScotCen Social Research in October 2021 to conduct qualitative research to contribute to the overall evaluation of Best Start Foods (BSFs). The research sought to understand the experience of families who had received BSFs in the first two years of the benefit from the perspective of BSFs clients and healthcare professionals. The research also sought to explore the experiences of participating retailers on administering the scheme. BSFs provides eligible pregnant women, parents and carers with a weekly payment which can be used to buy selected nutritious food and drink items from certain participating retailers. BSFs payments are loaded onto and then used via a debit card.The qualitative interviews explored clients' experiences of the application process, use of BSFs, impact of BSFs and participants' views on how BSFs could be improved in the future. Thirty-three BSFs clients, nine retailers and five healthcare professionals were interviewed between 13th December 2021 and 23rd February 2022 for the evaluation.

Applying for Best Start Foods

• BSFs clients learned about BSFs from a range of sources, including: healthcare professionals (e.g., midwives, family nurses, health visitors), other professionals (e.g., benefits advisors, case workers), word-of-mouth (family and friends), advertisements (online, posters, TV adverts) and directly from Social Security Scotland if they had previously received Healthy Start Vouchers (HSVs).
• Overall, BSFs clients said the application process was straightforward and quick to complete because the questions were clear and they could choose how to apply (e.g., by phone, online or via paper application form).
• There were clients who received support from Social Security Scotland, family nurses, case workers or family and friends to complete the application form which made the application process easier. They required support because they did not speak English or lacked confidence with filling out forms due to poor literacy, limited IT skills or other reasons.
• The main challenges experienced during the application process were related to communication. The time from application completion to communication of a decision varied from two weeks to 12 weeks. BSFs clients and healthcare professionals also commented that they struggled to get hold of Social Security Scotland by phone to enquire about their application. Some participants reported receiving multiple requests from Social Security Scotland for the same information which led to delays in receiving BSFs and was stressful for applicants.

Knowledge and understanding of Best Start Foods

• Knowledge and understanding of BSFs varied across BSFs clients, healthcare professionals and retailers.
• Overall, BSFs clients and healthcare professionals were aware that BSFs could be used to buy cow's milk, formula milk and fresh fruit and vegetables. Awareness that BSFs could also be used to buy frozen or tinned fruit and vegetables (without added sugar) and pulses was not as commonly understood. Not all retailers had heard of BSFs but assumed that the items that could be bought would be the same as HSVs (e.g. milk, fruit and vegetables).
• Awareness of the BSFs payment amount, and that it changed depending on the age of the child, was mixed among BSFs clients.

Use of Best Start Foods

• Overall, BSFs clients were positive about the guidance they received on how to use the BSFs card. They thought it was clear, easy to understand and covered information on activating the card, checking the balance, replacing a lost card, what the card could be used to buy and where it could be used. However, clients who did not speak and/or read English reported having to rely on others to understand the guidance as it was not offered in other languages.
• Once they started using the BSFs card, there were some gaps in BSFs clients' knowledge. For example: a PIN must be entered when using the BSFs card for the first time (contactless payment won't work for first use); which shops the BSFs card can and cannot be used in and why; the BSFs card can be used online for food shopping; and the card balance can be checked at an ATM as well as online/by phone.
• Overall, BSFs clients reported positive experiences of using the BSFs card, despite some experiencing challenges the first time they used the card. Clients liked that the BSFs card was like a debit card so they could use chip and PIN or contactless to make payments in store, enabling them to use self-checkout. They also thought that it was straightforward to check the card balance by phone or using an ATM. Clients perceived that the BSFs card could be used in a greater range of stores to buy a larger range of foods than the previous HSVs.
• Overall, BSFs clients, healthcare professionals and retailers thought that a card payment system was an improvement on vouchers. BSFs clients found a card more discreet and they found it easier to use. Vouchers had expiry dates, required exact payments or you could lose some of the value, could be easily lost or did not scan properly. Retailers said a card system was easier for them as they did not have to collate vouchers and send them away to claim the payment.
• The main challenge experienced by BSFs clients using the BSFs card was it not being accepted in store. Reasons for this included that the card had not been activated (due to not reading or understanding the guidance) and the card could only be used in shops with certain merchant codes. BSFs clients reported feeling embarrassed when the card did not work and as a result only went to certain shops where they knew the card would be accepted, even if these shops were not as convenient or were more expensive.

Impact of Best Start Foods

• BSFs clients and healthcare professionals reported that receiving BSFs had a number of positive impacts on families.
• While BSFs did not alter the way every family shops, some reported that receiving BSFs enabled them to buy and eat more fruit and vegetables, a greater variety of fruit and vegetables, and better quality fruit and vegetables than they had been able to without BSFs.
• Being able to buy more and a greater variety of fruit and vegetables had a number of health and wellbeing impacts on BSFs clients and their families. Parents perceived that it was positive knowing that they could afford to buy healthy food which would provide their child(ren) with the nutrients they needed, not having to limit the amount of fruit, vegetables and milk their child(ren) had access to, and being able to meet dietary requirements (as a result of intolerances) of their family. BSFs also positively impacted parents' mental health. The use of a prepaid card helped reduce anxiety when in shops and clients that experienced mental health issues appreciated the option of using the card online. Additionally, seeing their child(ren) enjoying healthy food lifted parents' moods and inspired them to try new recipes. Children enjoyed being involved in choosing what fruit and vegetables to buy which was reported as resulting in them eating more fruit and vegetables than they did previously and in general, eating a more healthy diet.
• BSFs had a positive impact on the household finances of families, though the extent of this impact varied. Receiving BSFs relieved the burden on overall household budgets by reducing food expenses. This enabled some families to save a little money for the first time which they could put towards other costs (e.g., clothes, child classes). For others, BSFs was a safety net for them towards the end of the month, ensuring that there was always money for healthy food for the children. There were clients that were also more reliant on the BSFs payments. In cases where clients were dealing with a particular financially constrained month, BSFs was considered a "lifesaver" in terms of having extra money for food.
• BSFs clients and healthcare professionals mentioned a number of other positive impacts of BSFs. These included: that the BSFs card was more discreet than HSVs and therefore there was less stigma associated with it and clients felt more comfortable using the card; and BSFs enabled families to introduce budgeting to child(ren).

Suggested improvements of Best Start Foods

While participants were positive about the use of the BSFs card, healthcare professionals, BSFs clients and retailers made suggestions as to how to improve BSFs.

• Clients, healthcare professionals and retailers raised concerns that awareness of BSFs was low and therefore eligible families may not be applying. There were clients who thought the best way to ensure that those eligible for BSFs apply for it, was for the government to make direct contact with those who meet the eligibility criteria. Others went further and suggested that data from other sources could be used to automatically register people for BSFs.
• All participant groups agreed that the promotion of BSFs could be improved. To address the lack of awareness of BSFs, participants suggested both a wider public marketing campaign and targeted advertisement and promotion to retailers and healthcare professionals. Targeted marketing included: providing relevant healthcare professionals and retailers with promotional materials about BSFs to share with families and customers; providing retailers with promotional materials to use in shops; and using representatives to visit retailers to raise awareness of BSFs. Retailers also suggested providing a designated contact at Social Security Scotland for retailers to foster opportunities to work together on campaigns, promotions and innovative solutions to barriers and challenges.
• While there were clients who were very postive about the communication and support they received from Social Security Scotland, there were others who experienced challenges and saw room for improvement. Suggestions included: providing a clear explanation for a rejected application in decision letters; sending a letter/email to clients in advance of their final payment to inform them of the payment date so they can prepare financially; implementing staff training to ensure they are kept up to date with any changes to UK or Scottish social security benefits.
• Overall clients felt that the guidance leaflet received with the card was useful and comprehensive. However, once clients started using the card, gaps in their knowledge were identified. To address these gaps, clients called for information in the guidance to cover a fuller list of retailers where the BSFs card can, and cannot, be used, and information on how to use the BSFs card online.
• Clients would like to see some improvements to the accessibility of support and communication provided by Social Security Scotland. This included: communication provided in languages other than English; the provision of interpreters or translators to clients who do not speak English to support the application process; and allowing clients to nominate a proxy to make contact with Social Security Scotland on their behalf. It is important to note that interpreter and translation services are available through Social Security Scotland even though clients were not aware of this.
• Participants would like to see the length of time between application and receiving the BSFs card shortened and suggested a range of ways that could help achieve this. Suggestions included: enabling applicants to submit evidence at the time of application; increasing the number of staff working on the helpline and reviewing applications; and allowing emails informing clients of their application decision.
• BSFs clients and healthcare professionals suggested changes that could improve the experience and impact of using the BSFs card. These included: expanding the list of healthy foods that can be bought using BSFs to further encourage healthy eating; extending eligibility of BSFs to when a child starts school to ensure children have access to nutritious food from age 3 to 5 years; introducing a flat rate of payment regardless of a child's age; introducing an app for card management so people can choose how to access information and support; and allowing some essential non-food items to be bought using BSFs.

Conclusions

All of the participant types, clients, health professionals and retailers reported very positive views of BSFs in this study. The general consensus was that the BSFs application process was relatively easy and uncomplicated, the use of the BSFs card was mostly straightforward and was viewed as decreasing stigma and the benefit itself had led to more healthy dietary practices and reduced financial burden and concerns within low-income households. As was the case with the Best Start Grant (BSG), BSFs was perceived as having these positive outcomes on low income families at a key time in the early years of their children's lives. The adoption of a card for clients to access BSFs is also important as not only does it decrease feelings of stigma which were associated with using vouchers, but it also added to the view that BSFs is an entitlement, and not a donation or 'hand-me-down'. The monitoring of funds on the card also increased the clients' budgeting skills, and increased their confidence and feelings of self-worth as parents and carers. Health professionals also reported positive impacts on clients and their families in terms of dietary intake and mental wellbeing.