Evaluation of the Healthy Start Scheme: An Evidence Review

1. Introduction

Background and significance of the Welfare Food policies

1.1. The Scottish Government's commitment to improving health outcomes and reducing health inequalities is implemented through a variety of policies, guidelines, recommendations and campaigns which have been launched in Scotland and across the UK for the promotion of healthy lifestyles, balanced and sustainable diets, food standards and adequate nutrition (DH, 1991; NHS Scotland, 2015; PHE, 2014a; Scottish Government, 2010a; 2010b; 2011c). Consistently with this approach, a special preventative emphasis has been placed on women planning pregnancy, pregnant and breastfeeding women as well as infants and young children (Scottish Government, 2010b; 2011a, 2011b). This approach seeks to establish healthy diets and good nutrition early, as it recognizes how crucial they are for growth, development and health outcomes (both, immediate and long-term). One of the major difficulties faced when improving health outcomes is the extent of health inequalities: not only do significant differences exist in dietary patterns, nutritional intake and health outcomes between lower and higher socioeconomic groups (Nelson et al., 2007); but there is a clear effect of poorer nutrition and socio-economic disadvantage on health outcomes (Scottish Government, 2010b). The purpose of initiatives such as the Healthy Start Scheme is to target disadvantaged groups in order to support families from all backgrounds to give their children the best possible start.

1.2. The Welfare Foods policy is a national initiative comprised of: the Nursery Milk Scheme (NMS), Healthy Start Food Vouchers (HS Foods) and Healthy Start Vitamins (HS Vitamins). The Healthy Start Scheme (HS Scheme), consisting of the HS Foods and HS Vitamins, focuses on low-income pregnant and breastfeeding women and their children under 4 years of age at risk of nutritional insufficiency (Lucas et al., 2015). It provides them with vouchers and coupons restricted to certain purchases, i.e. cow's milk, fresh or frozen fruit and vegetables or infant formula milk and vitamins (Griffith et al., 2015). As such, it combines both welfare and public health policy domains, which face the additional challenge of integration between these areas and efficient collaboration by colleagues across agencies (Matchell, 2015). Nevertheless, an important role the HS policy also plays in improving food security should not be overlooked either, especially in the light of claims that the UK food aid system, in comparison with countries such as the US and Canada, is relatively undeveloped (Lambie-Mumford et al., 2014). Evidence suggests that only free nursery milk, free school meals and food vouchers contribute to reducing the negative impact of food (and nutrition) insecurity experienced by many low-income households across the UK (see Lambie-Mumford et al., 2014 for details).

Aims, scope and methods of the study

1.3. This study was conducted in response to the Scottish Government's commitment to improve the Welfare Foods Scheme to better meet Scotland's dietary and nutrition needs and to reduce - still significant - health inequalities (Scottish Government, 2010b; 2011b). It takes a form of evidence review that attempts to establish whether the Welfare Foods policy works effectively. In particular, this evidence review has three aims:

(i) to critically evaluate the effectiveness of the Healthy Start Scheme against its aims (discussed in detail in section 2.9), its impact on beneficiaries' diets and nutrition, dietary habits and health outcomes;

(ii) to engage in a wider discussion regarding healthy diets, dietary behaviours and nutrition pre - and during pregnancy and early years

and (iii) to contribute to the Scottish Government's action plan of how the Welfare Foods policy can be improved within the Scottish context over the next two years.

1.4. It needs to be highlighted, however, that it was decided amongst the supervisory team that the main focus should remain on the evaluation of the Healthy Start Scheme. Nevertheless, the review still attempts to situate the scheme within the broader context of the public health policy through e. g. addressing difficult questions about the competing evidence around specific intake recommendations for particular supplements (vitamin D and folic acid), the impact of inclusion of infant formula milk into the schemes or the benefits and challenges of providing free nursery milk.

1.5. The study was carried out over a 3 months period, ruling out the scope for a more systematic review. Literature contributing to this study was selected based on purposive and strategic sampling criteria. A range of academic databases across social and medical sciences and various key search-words were used in order to identify relevant literature on the HS scheme on the one hand and health, healthy diets and nutrition pre- and during pregnancy and early years on the other. Moreover, additional research and evidence shared by health, social care and welfare organizations involved in the monitoring, feedback and implementation of the Healthy Start Scheme at both national and local levels was included in this report. As a consequence of such sampling decisions, this study incorporates the most recent and relevant literature, both published and unpublished, between 2010 and 2015 (with some important exceptions published before 2010) and presents a small scale evidence-review.

1.6. The evidence used in this review comes from a broad range of literature sources, including academic publications, recommendations and guidelines from different health advisory bodies, the Scottish Government's and other stakeholders' reports and initiatives. Their findings were evaluated and relevant data was extracted and organised under key themes discussed in the following chapters: The Healthy Start - setting the scene; Nutrition, Diet and Dietary Patterns in Scotland , Evaluation of the Healthy Start Scheme and Recommendations. The draft and a final report were then reviewed by a supervisory team before publication.

Caveats and limitations

1.7. While the study analyses the most up-to date recommendations and guidance on healthy diets and nutrition and addresses the evidentiary problems contained therein, it does not presume to evaluate the evidence of the scientific quality previously reviewed and collated by health professional agencies/advisory bodies, such as the National Institute for Care and Excellence (NICE), Scientific Advisory Committee on Nutrition (SACN), First Steps Nutrition Trust, and the British Medical Association (BMA). Rather, research results have been summarised and analysed in reference to the Healthy Start Scheme's aims and their possible impact on health outcomes of pregnant and breastfeeding women and young children and potential improvements to the scheme.

1.8. Furthermore, this review narrows its scope to certain aspects of public health policy: healthy diets, nutrition and dietary patterns of women pre- and during pregnancy and breastfeeding and of young children under 5. The review acknowledges a wide range of (interconnected) strategies and initiatives aimed at improving health outcomes for this demographic, such as the promotion of breastfeeding, the importance of physical activity, early prevention of maternal and childhood obesity, antenatal care etc. As these are extensively covered elsewhere (Scottish Government, 2010a; 2011a; 2011b) they have been excluded from this analysis.

1.9. Moreover, it is important to note that the Healthy Start is a relatively new scheme and is only just starting to produce data and results for monitoring and evaluation purposes. The existing literature is therefore somewhat scarce (McFadden et al., 2013). Furthermore, much of the existing research was conducted solely in England (e.g. Attree, 2006; Jessiman et al., 2013; Lucas et al., 2013 & 2015; McFadden et al., 2013; 2014 & 2015). Whilst these results can undoubtedly provide a useful framework for the evaluation of the Healthy Start scheme for the Scottish Government, one should be cautious of their transferability into the Scottish context. In order to counter this, we have also made use of responses to the Scottish Government consultation amongst a range of Healthy Start stakeholders across Scotland. At the time of writing this review, a report on the impact of the Welfare Food programme containing insights from health, social care and welfare professionals in the field of maternal and child health and nutrition has just been drafted and its preliminary findings have been included in this review (Scottish Government, 2015b). However, consultation with the Healthy Start scheme users in Scotland is yet to be sought. Similarly, a comprehensive evaluation project of the Healthy Start Scheme in Scotland based on secondary analysis of the data from Growing Up in Scotland Survey and Infant Feeding Survey, is currently being carried on and is due in 2017 (for details see: National Institute for Health Research website)^[1].

1.10. With these caveats and limitations in mind, this report attempts to evaluate the effectiveness of the Healthy Start Scheme and the role of the Nursery Milk Scheme in diets of young children as well as offers some recommendations for improvements. The next chapter provides a contextual background for the key public health and Welfare Foods policies in Scotland.