Evaluation of the Healthy Start Scheme: An Evidence Review

2. Healthy Start - Setting The Scene

2.1. This chapter identifies the key public health policies in Scotland, directed at general population and in particular at women planning pregnancy, pregnant and breastfeeding women and young children - of whom some are beneficiaries of the Healthy Start Scheme. It then positions the Welfare Foods policy (consisting of the Healthy Start Scheme and the Nursery Milk Scheme) within this broader public health agenda, identifies the main aims of the scheme and outlines the key areas for improvements.

Key public health policies

2.2. The promotion of a healthy, balanced and sustainable diet (NHS Health Scotland, 2015; PHE, 2014a) as well as overall good nutrition (DH, 1991) remains a key public health objective in Scotland and across the UK, alongside a range of other health strategies, such as: promoting healthy lifestyles, physical activity and healthy weight or obesity-prevention (Scottish Government, 2010a & 2011c). The main and primary aims of these combined, complex and often interwoven strategies are to achieve better health outcomes for all citizens on the one hand and to reduce and eradicate health inequalities between members of different social classes on the other (Attree, 2006; Scottish Government, 2010b).

2.3. Preconception and pregnancy, as well as infancy and early years have been long recognized to be especially important and critical periods of human development which have tremendous impact on health outcomes in later stages of life (BMA, 2009; SACN, 2011). In the light of well-established clinical literature, good nutrition and healthy diets are important for achieving good health outcomes amongst pregnant and breastfeeding women and for normal growth and healthy development of young children (Baskin et al., 2015; Westland and Crawley, 2012). In particular, an emerging body of evidence has linked maternal nutrition with infant cognitive development (Emmett et al., 2015; McInerny, 2014), maternal mental health (Baskin et al., 2015; Emmett et al., 2015), infant birthweight (Wen et al., 2013) as well as with risk of birth defects and negative health outcomes in mothers and their children (Kaiser & Campbell, 2014). For example, unhealthy dietary habits during pregnancy have been adversely associated with high infant birthweight (over 4 kilos) which consequently carries increased risks of obesity in childhood and adolescence (Wen et al., 2013).

2.4. Furthermore, there is a wide range of clinical evidence establishing the connection between poor early nutrition and an increased risk of chronic disease in later periods of life (BMA, 2009; SACN, 2011). While evidence comes from numerous sources (such as observational studies in humans and experimental in humans and animals), it varies in quality and remains inconclusive (e.g. due to other risk factors affecting humans health and occurring at different stages of life - genetic, environmental and behavioural; SACN, 2011). Despite there still being many unanswered questions about the precise interactions between genetic, environmental and behavioural impacts, SACN (2011:115) concluded that the evidence collected is sufficient "for concern about the later health consequences of compromised or excessive nutrient supply during early growth and development". What is more, the evidence from the emerging field of epigenetics links maternal (and also paternal) diet and nutrition with a child's "epigenetic programming of health and the response to diet itself" (Haggarty, 2013:364). Such nutrition programming "suggests that an under- or oversupply of a particular nutrient or nutrients at a critical or sensitive period of development may have long-term effects on the structure or function of specific organs or systems in the offspring" (Emmet et al., 2015:154). For more information on epigenetic nutrition programming consult Cambridge Journals website^[2].

2.5. Therefore, a variety of recommendations and strategies (concerning nutrition, food standards, healthy and sustainable diets) directed at all women planning pregnancy, pregnant and breastfeeding women as well as at young children have been widely implemented, both in Scotland and across the UK (e.g. DH, 2010; NICE, 2008b; Scottish Government, 2011b; NHS Health Scotland, 2015). However, as significant differences exist in dietary patterns and nutritional intake between lower and higher socioeconomic groups, similarly as negative health outcomes remain unequally distributed (Nelson et al., 2007; Scottish Government, 2010b), some of the Government's initiatives, the Healthy Start Scheme in particular, are directed specifically at disadvantaged populations.

Welfare Foods policies

2.6. 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 Nursery Milk Scheme and the Healthy Start Vouchers and Vitamins have been enacted under the power in section 13 of the Social Security Act (1988) and they are both governed by legislation (Healthy Start Scheme and Welfare Food (Amendment) Regulations 2005; Welfare Food Regulations 1996). The Healthy Start and NMS operate as a single Welfare Food Scheme across the whole UK and is a matter reserved to the UK Government. It is currently under debate whether this provision will remain reserved or will be devolved as part of the on-going process resulting from the Smith Commission.

2.7. The local delivery of the scheme is currently run by the Department of Health (DH) for England, but funding from Scottish Government budgets is provided for Scottish applicants. Moreover, Scottish Health Boards are responsible for distribution of the Healthy Start Vitamins to beneficiaries - directly or by sub-contracting vitamins provision to other suppliers (Healthy Start Scheme and Welfare Food (Amendment) Regulations 2005). For example, Scotland (unlike other UK state members) made the Healthy Start Vitamins available through the community pharmacies' route between April 2013 and May 2015 (Scottish Government, 2015a). Furthermore, Scottish Ministers hold the powers to alter the prescription of foods and vitamins under the Healthy Start Regulations, and may have more decision-making powers over the scheme's scope, administration and implementation when the Scotland Bill 2015-16, devolving new powers to the Scottish Parliament and the Scottish Government, is enacted. How the Healthy Start Scheme may be affected by the most recent welfare policy changes in the UK also remains unclear (Matchell, 2015). Despite all the uncertainty encompassing the future of the scheme, at the time of writing this report development of Welfare Food policies in Scotland continues under the current legislative framework.

2.8. The Healthy Start Scheme targets low-income pregnant and breastfeeding women and children under 4 years of age at risk of nutritional insufficiency (Lucas et al., 2015) and provides them with coupons for free vitamins and vouchers for certain healthy foods (milk, fruit and vegetables, and infant formula milk). Most of the beneficiaries are means tested except for pregnant women under the age of 18. For more information on the Healthy Start Scheme, eligibility criteria, application process, foods and vitamin supplements prescribed by the scheme etc. consult the Healthy Start website^[3].

2.9. The Healthy Start Scheme undoubtedly combines elements of public health and welfare areas of the state's interests and interventions (Machell, 2015), as it provides a financial facilitator to opt for healthier dietary choices and enables access to free vitamin supplements. As such, the literature suggests that the scheme was implemented in order to meet certain aims, in particular:

1. To provide a nutritional and financial safety net for low-income families and to improve access to healthy and nutrition-rich foods and vitamin supplements through the use of vouchers and coupons;

2. To influence the dietary choices of pregnant and breastfeeding women and young children ("nudge"effect) with ring-fenced food vouchers;

3. To improve nutrition, diets and the health outcomes of pregnant and breastfeeding women and young children (no data on the latter);

4. To tackle vitamin-defficiency preconceptually, during pregnancy, breastfeeding and early years (HS Vitamins);

5. To promote breastfeeding, healthy diets and health information through accessing health services early in pregnancy (Griffith et al., 2015; Lucas et al., 2013; McFadden et al., 2015).

2.10. Moreover, it could be argued that, in view of its strategic aims, the Healthy Start Scheme could also be positioned within the broader public health agenda that attempts to reduce health inequalities across the UK. Similarly, the role it plays in improving low-income families' food security should also be highlighted, especially in light of claims that the UK food aid-system remains under-developed, while "more and more households are facing food poverty, or what is more often understood as food insecurity" in the UK (Dowler & Lambie-Mumford, 2015:417). As such, this report suggests that the role of the Healthy Start scheme may be and perhaps should be understood in various ways. For example, Lucas and colleagues (2015) have reported that their study's participants - the beneficiaries of the scheme - perceived it as a form of welfare support or as a health strategy that aims to encourage healthy diets, or as both.

2.11. The NMS is another Welfare Foods initiative, yet its design differs from the Healthy Start rather significantly. Unlike the Healthy Start that is a means tested strategy, the NMS entitles all children under five (regardless of their background), who spend more than two hours a day in childcare, to receive a free daily portion of milk (1/3 pint or 189 ml). However, it remains under childcare providers' control whether to enter the scheme and claim the reimbursement for milk they provide. Currently, the uptake of the NMS stands at approximately 50% (for details see: The NMS website^[4]).

Need for action, need for improvements

2.12. The Scottish Government is currently reviewing how the Welfare Food Schemes could be improved to better meet Scotland's needs. The overall uptake of the Healthy Start Scheme in Scotland is relatively high (approximately 74% of women eligible use the scheme; however the uptake rates vary significantly when broken down regionally, with uptake rates as low as 45% in some areas and as high as 90% in others), suggesting a need for increasing eligible users' awareness of the scheme in certain geographical areas. Voucher redemption stands at 88% in Scotland in comparison to 90% in England (MacKenzie, the Healthy Start Leads meeting, September 8, 2015; Scottish Government, 2015a).

2.13. The evaluation of the scheme conducted in England showed that Healthy Start is an important source of support for low income families, and is recognized as such by health and social care practitioners (McFadden et al., 2013). That being said, a significant number of barriers and shortcomings have also been reported. For example, despite the wide range of evidence emphasising the importance of vitamins intake amongst pregnant and breastfeeding women as well their children as crucial for their health and development, the uptake of the HS vitamins has been very low amongst eligible women in the UK (overall - below 10%; Jessiman et al., 2013; while some report an uptake as low as below 3%; Moonan et al. 2012). Introduction of the Scottish national trial scheme involving community pharmacies in distribution of vitamins (between April 2013 and May 2015) has not improved the uptake rates even though the role of pharmacies as a distribution route has increased (Scottish Government, 2015a). Therefore, the Scottish Government still has more work to do to increase the awareness, accessibility and consequently the uptake of the Healthy Start Scheme, in particular of the vitamin supplements, in Scotland. While the focus is mostly on the improvements under the current system, also other possible actions (if the Welfare Foods policy is to be a devolved power) will be explored under this review in the recommendations section. However, before engaging with evaluation of the Healthy Start Scheme itself and offering some recommendations for improvements, this report will first discuss the evidence on the role of nutrition, diet and eating habits in achieving good health outcomes amongst pregnant and breastfeeding women and for normal growth and healthy development of young children.