Best Start Foods - evaluation: annex B - qualitative research

4. Discussion

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 aim of this research was to explore and understand the experiences of families who had received BSFs and the impact receiving the benefit had on recipients and their families. The research also aimed to provide insight into the perceptions of health professionals and retailers on the impact, scope and administration of the benefit.

The discussion will seek to review the extent to which the BSFs has made progress towards achieving its aims. It will also summarise key findings, propose potential modifications to BSFs, describe the strengths and limitations of the study before the conclusions and implications of the study are considered.

Summary

Application process

According to the participants, the administration of the BSFs card had worked well. Overall, the application process was straightforward, quick and easy to complete because the questions were clear and clients could choose to apply online, by phone or complete a paper form. Where required, clients were able to access support from Social Security Scotland, health professionals, case workers, family and friends. However, there was acknowledgement that not all eligible families may have access to such support. Challenges experienced during the application process related to language barriers, accessing timely support from Social Security Scotland and delays in receiving a decision. Where challenges were identified, practical solutions were suggested, including access to translated materials and interpreters, increased staff resources and improved staff training. It should be noted that interpreter and translation services are available through Social Security Scotland even though clients were not aware of this.

Knowledge and understanding

BSFs clients learned about BSFs from a range of sources, including: health professionals, other professionals, word-of-mouth, advertisements, and directly from Social Security Scotland if they had previously received Healthy Start Vouchers (HSVs). However, all participant types thoughts that awareness of BSFs was relatively low and therefore eligible families may not be applying.

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 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 with HSVs. Awareness of the BSFs payment amount, and that it changed depending on the age of the child, was mixed among BSFs clients, though this did not seem to create major problems for the benefit recipients and their families.

Use of the Best Start Foods card

Clients found using the BSFs card to be a positive experience and a vast improvement on HSVs. The card simplified food shopping for clients. Unlike vouchers, with the BSFs card, exact payments are not necessary and any unspent money is carried over to the next month. Clients also found that a card is much more discreet as it works like any other payment card. The main challenge clients experienced when using the card was that on rare occasions the card was rejected. However, this was often due to a lack of awareness about which shops the card could and could not be used in and the procedures for using the card for the first time.

Impact of Best Start Foods

In the first two years of BSFs, progress has been made towards achieving its aims to:

• Enable low income families to meet the costs of nutritious food
• Encourage healthier diets and food choices during pregnancy through to the child turning 3
• Contribute to better general health and wellbeing of low income families
• Ease the burden on household expenses and stress related to financial insecurity

BSFs was also reported to have a number of other impacts, such as inspiring families to try news foods and recipes, inspiring conversations with children about money and reduced stigma associated with the former voucher system.

Healthier diets and food choices

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. However, while clients felt BSFs helped to provide nutritious food for their children from pregnancy up until age 3, some low income families reported that they could not sustain this after their BSFs entitlement ended. This was, despite the provision of milk and a free nutritious meal as part of local authorities' statutory Early Learning and Childcare (ELC) provision to all children aged 3 to 5^[19], a National Standard committed to in the Scottish Government's diet and healthy weight delivery plan^[20]. As a consequence, these participants called for BSFs to be extended until their child(ren) started school.

Improved general health and wellbeing

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 of their family. BSFs also positively impacted on parents' mental health. The use of a prepaid card helped reduce anxiety when in shops and clients experiencing 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 to buy which was reported in resulting in them eating more fruit and vegetables than they did previously and in general, eating a healthier diet.

Ease the burden on household expenses

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 family costs. 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.

Suggested improvements to Best Start Foods

Overall, BSFs was very positively received by the research participants. On the whole, clients perceived the application process to be straightforward, the guidance on using the card was sufficient, the card format was easier to use and less stigmatising that the previous voucher system, and BSFs had a positive impact on the ability of low income families to provide nutritious food for their children. There was a general consensus that BSFs was already working well within and across respondent types, and hence proposed changes to improve BSFs tended to be relatively minor.

Research participants provided suggestions for the Scottish Government to consider in any future developments of the benefit. These included:

• Targeted promotion of BSFs to ensure that eligible families, healthcare professionals and relevant retailers are aware of BSFs, as there was evidence that there was a lack of awareness amongst all three groups.
• Improving aspects of communication from Social Security Scotland to applicants and clients. Including: providing explanations for unsuccessful applications in decision letters; notifying clients when BSFs payments are coming to an end; improving the accessibility of communication and support for those who do not speak English by providing translated communication materials and interpreters.
• Implementing improvements to the application process to increase the speed of application decisions being made. Improvements might include: 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.
• Improving the experience and impact of using the BSFs card by: 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; introducing a flat rate of payment regardless of a child's age; introducing an app for card management so people can choose how they prefer to access information and support; and allowing some essential non-food items to be bought using BSFs.

Strengths and limitations

There were a number of strengths and limitations associated with this evaluation. The key ones were:

Sampling/recruitment

• BSFs clients were recruited via Social Security Scotland's Client Panel. Those interested in participating in the research were asked to contact ScotCen directly. Everyone who expressed an interest was asked to complete screening questions. This enabled the research team to sample on a number of different criteria and resulted in the successful recruitment of a wide range of clients in terms of age, family size, household composition, SIMD, geographical area and employment status.
• Despite inviting over 800 BSFs clients to participate in the research, only three of the 33 clients that participated in the research were male. However, this is in line with Scottish Social Security data which shows that the vast majority of BSFs claimants are female.
• Even with the support of the Scottish Government a relatively low number of healthcare professionals were recruited to participate in the research. With the ongoing Covid-19 pandemic the NHS is under significant pressures and the Scottish Government did not want to overburden health boards with research requests. Therefore recruitment was targeted at four health boards. The healthcare professionals that took part in the research gave in depth feedback on their experiences which added value to the other overall evaluation.
• Only two of the larger supermarket chains participated in the research, with others opting-out. However, the research also elicited responses from retailers managing and working in shops and interacting with customers. Combined, they provided useful insight into the experiences of retailers.
• It is possible that those who choose to participate in the research are more likely to have had a positive experience of BSFs. However, it could also be argued that those with more polarised views are more likely to participate. The research findings demonstrated a range of positive and negative feedback on the application process. If it had been possible to interview claimants whose applications had been unsuccessful this may have allowed a different perspective on the BSFs application process. The evaluation focused on those who had applied for and used BSFs in order to assess the experience and impacts of payments.

Findings

• The research provides insight into the views of a range of clients, healthcare professionals and retailers in relation to BSFs including: its promotion, application process, use, perceived impact and ways it might be improved in the future. However, it is unable to demonstrate how prevalent these views are across Scotland, which would require a nationally representative quantitative survey (which in turn could not elicit the depth of response of qualitative interviews). As such, it is unwise to generalise the findings from this evaluation to the whole BSFs client base.