Evaluation of the Healthy Start Scheme: An Evidence Review

4. Evaluation Of The Healthy Start Scheme

4.1. This chapter evaluates the operation of the Healthy Start Scheme. In particular, it examines its impact on diets, nutrition and health of pregnant and breastfeeding women and young children living in disadvantage and barriers to the scheme experienced by its beneficiaries. One should bear in mind, however, that not much research aiming to evaluate the Healthy Start Scheme has been conducted so far and majority of the evidence comes from the studies conducted in England only (see section 1.9 for details). This chapter also discusses the role of the nursery milk in young children's diet and health.

4.2. Following a discussion in the previous chapter on state's initiatives aiming to improve diets and nutrition in Scotland, one could ask where to position the Healthy Start Scheme within the public health policy realm. It is argued that its main focus is on influencing health, nutrition, diets and eating habits of low-income mothers and their children (individual motivational level factors). Yet, this is attempted through providing them with welfare benefits that contribute to cover the economic costs of healthy foods (environmental factors; Brug et al., 2008). As such, it can be argued that the Healthy Start Scheme combines elements of health promotion (e.g. by labelling it the Healthy Start) with the micro-level strategies that are supposed to facilitate healthy food choices amongst a targeted population. Nevertheless, the problem of how the Healthy Start scheme meets its aims and how effective it is in meeting low-income families' needs requires a closer examination.

4.3. In particular, evaluation of the scheme seems to be of great importance, especially in the light of claims that the authors of the Healthy Start policy had not fully taken into account the views, experiences and needs of its users (Matchell, 2015). As Matchell (2015) points out, development of the welfare foods initiative was driven by the need to develop "a 'policy package' that is appealing to visible actors" (Matchell, 2015:26). This rather short-term approach was marked by an initial budget which was restricted from the start and in consequence jeopardised the scheme's ability to fully meet its aims on the one hand and to reduce health inequalities on the other (Matchell, 2015). This criticism reinforces the need for improvements which are based on the views, knowledge and experiences of a range of scheme stakeholders, most importantly, which include those of its beneficiaries and potential users.

4.4. In order to achieve this goal, this chapter on evaluation of the Healthy Start Scheme's effectiveness will seek to answer (or at least contextualise and cast light on) following research questions:

1. How the Scheme operates, particularly:

• What works well from the stakeholders' perspective?
• What are the problems, challenges and barriers experienced by stakeholders?
• What is the impact (if any) of the Healthy Start Scheme on its beneficiaries' diets, dietary habits and health outcomes?

2. Does the Healthy Start Scheme meet its aims and aspirations (as defined in section 2.9)?

3. What can be improved and/or changed under the current legislation?

4.5. The next two subchapters will focus on the current operation of the Healthy Start Scheme and its impact on health, diets and health of low income populations. They will then attempt to evaluate the effectiveness of the scheme against its aims and objectives as defined in section 2.9. However, the subchapter on the Nursery Milk, due to lack of literature on the scheme, will only focus on two issues: whether the NMS is beneficial for young children's health and whether there is other alternative to provide young children with free milk. The recommendations chapter will attempt to link all the findings together while offering potential solutions to increase the Healthy Start Scheme's effectiveness in improving diets and nutrition of pregnant and breastfeeding women and young children from disadvantaged backgrounds.

Impact Of The Healthy Start Foods On Health, Diets And Nutrition Of Low-Income Families

I think they [food vouchers] are a good thing because you can only buy milk and fruit and veg, so they're really encouraging. (participant quoted by Khanom et al., 2015:9)

£3.10 a week when you are working doesn't feel like much but when you're not working and are on benefits it does make a difference, it's £3.10 a week you have of your money to spend on other things aside from milk, fruit and veg. (participant quoted by Lucas et al., 2015:462)

4.6. The literature demonstrates the importance of the Healthy Start Food Vouchers from the perspective of low-income families and health and social care practitioners (Khanom et al., 2015; Lucas et al., 2015; McFadden et al., 2013). Scottish professionals in the field of Child and Maternal Health and Nutrition hold the opinion that the Healthy Start Scheme has been reasonably successful and has shown the positive indicators of improved outcomes around increased access, uptake and awareness (Scottish Government, 2015b). Furthermore some health professionals see the scheme as playing an important role in improving the health outcomes of pregnant women and their children in low income families (although there is lack of research/evidence to support this perception, McFadden et al., 2013). More problematically, Lucas and colleagues (2013:39) report that "HS coordinators and frontline health and children's professionals have limited or no data on the impact of the scheme on families" and many of them perceive the scheme as having a limited impact on influencing the diets of low income families, with some even describing it as "a drop in the ocean."

4.7. At the same time, women registered for the scheme reported that it made them think more about health and diets (McFadden et al., 2013) or even contributed to them making healthier dietary choices (Khanom et al., 2015). The "nudge"-effect of the policy (intending to influence dietary behaviours of targeted population) has been clearly visible in these women's accounts - at least in relation to the choices made within the scheme. Yet, it remains difficult to assess what impact the scheme has had on other dietary choices since objections have been raised that the vouchers may displace the amount of money reserved for healthy choices, making it available for the purchase of unhealthy food products (McFadden et al., 2013).

4.8. Nevertheless, low-income women declared that the availability of the food vouchers increased not only the quantity but also the variety of fruit and vegetables they purchased (McFadden et al., 2014); or that they were able to experiment with different fruits and vegetables for their children - which they would normally not be able to afford. At the same time, food vouchers seemed to have a greater impact on the food choices and eating habits of breastfeeding women as they spent the vouchers on fruit/vegetables/cow's milk.

4.9. Women using formula milk reported to spend the vouchers on formula (and reported that it was not enough to cover its costs, McFadden et al., 2014). Furthermore, the main item acquired with the use of the food vouchers, according to Infant Feeding Survey, has been formula milk (McAndrew et al., 2012). That being said, some critics argue that barriers to breastfeeding are amongst factors that limit the potential of the Healthy Start to improve maternal nutrition and diets (McAndrew et al., 2012). Additionally, there is a lack of consensus amongst health professionals about whether formula milk should be a part of the scheme. By some the inclusion of formula milk under the label 'the Healthy Start' is perceived as conflicting with the promotion of breastfeeding and - in a broader sense - of healthy choices and good health outcomes in the future (McFadden et al., 2015; Scottish Government, 2015b). Moreover, it remains unclear whether including the formula in the scheme may have an adverse impact on breastfeeding rates amongst mothers from less affluent backgrounds (McAndrew et al., 2012). For example, women in receipt of the vouchers are reported to be less likely to breastfeed not only than average but also than women who are eligible for the HS but not registered or women who have never been in employment (McAndrew et al., 2012). However, this correlation remains unclear and may interact with other factors, such as socio-economic disadvantage, lower educational attainment and age with mothers eligible for the scheme being younger than average (McFadden et al., 2013). On the other hand, others argued that low income families should have access to resources to feed their children and recognised access to formula milk through the scheme provides a nutritional safety net for infants growing up in disadvantaged communities (McFadden et al., 2013). They also pointed out that the vouchers value should cover the whole costs of the formula milk (McFadden et al., 2014).

4.10. It should also be highlighted that food vouchers were perceived to be a financial safety net that helps with the costs of food products and to some extent improves low-income households' food security (Lucas et al., 2013). In particular, some women pointed out that the food vouchers have been an important part of their food budgets, describing it as: "a 'big relief' or as making a 'big difference'" (Lucas et al., 2015:462). As such, for some beneficiaries food vouchers serve as resources that are actually secured for food, and this kind of security has been highly appreciated (Lucas et al., 2015). Yet, the Healthy Start scheme alone remains an insufficient food managing strategy in times of austerity. As Dowler and Lambie-Mumford (2015) argue, in order to improve food security, the state should guarantee an income which is sufficient to secure food against other expenses as well as economic and physical access to affordable healthy foods that also meet cultural needs. Currently, the Healthy Start scheme itself, even when combined with a range of other public health strategies, is argued to be "insufficient to outweigh the negative effects of poverty on nutrition" (Attree, 2006:75).

4.11. There is a lack of evidence on the HS scheme's impact on improving health outcomes or reducing health inequalities amongst those eligible (McFadden et al., 2014). It is anticipated that we will need to await the publication of an on-going research project investigating the impact of the HS scheme on maternal and children health outcomes with the use of secondary data from Growing Up in Scotland Survey and the Infant Feeding Survey in order to obtain such evidence.

4.12. Furthermore, a significant number of barriers to the scheme including awareness, eligibility, application process, access to registered retailers or low value of food vouchers, discussed in detail below, has also been reported that will need to be addressed if the scheme is to work more effectively.

Awareness:

4.13. There are relatively low levels of awareness about the scheme amongst the general population as well as amongst some subgroups entitled to the scheme (McFadden et al., 2014). In particular, non-English speakers, those with low literacy levels, working families on low income and families with changing incomes were often not aware of the scheme. One reason for this may be that some health professionals provide the information on the HS only to the families they consider to be eligible (McFadden et al., 2013; 2014), therefore some eligible families are being missed (Lucas et al., 2015). On the other hand, those who were informed about the HS scheme during their first antenatal visit often reported being overloaded with information, often missing out details concerning the HS scheme (Barbour et al., 2012; McFadden et al., 2014).

Eligibility criteria:

4.14. Although welfare eligibility criteria were reported to be quite straightforward and understandable, criteria regarding tax credits were found to be complex and confusing (McFadden et al., 2014). Household income threshold for families in receipt of tax credits was reported to be definitely too low. In particular, women slightly over the income threshold reported their frustration of not being eligible for the scheme as they believed it would be very useful for them. In other words, low-income families felt the scheme definitely should continue but the eligibility income threshold should be increased (Khanom et al., 2015). The rigidity of the eligibility criteria was also problematic for families in low paid work or with fluctuating incomes as their circumstances often change, leaving them in and out of their entitlement.

4.15. Furthermore, eligibility criteria were also unclear for women under 18 as their entitlement changes from universal into means-tested after the child's birth or upon the mother's eighteenth birthday, and they were often not aware of such changes (Lucas et al., 2015). Following the birth, registering the baby with the HS Issuing Unit was also found problematic with some parents not being aware of such obligation (Lucas et al., 2015). The subgroups that would benefit the most from the scheme, particularly those who are nutritionally and financially vulnerable such as asylum seekers, low-income families with fluctuating income, remain excluded from the scheme (McFadden et al., 2013, Scottish Government, 2015b).

Application process:

4.16. Most of participants of Lucas and colleagues' study (2015) found the application process easy. In particular, parents reported that their application was processed quickly (received vouchers within 2-4 weeks from applying, unlike other benefits). However, in case of delays or rejection, they rarely understood the reasons why the vouchers stopped, while phoning a helpline was reported to be too expensive (Lucas et al., 2013). Completing the application form was reported to be time-consuming, complex and sometimes difficult to fill in for some of the beneficiaries (Scottish Government, 2015b). The requirement of needing to have the form counter-signed by a health professional was seen as impeding access to the scheme against its intention to actually initiate the early contact with the health professionals that would provide women with information about healthy diets, nutrition and vitamins supplementation during pregnancy (McFadden et al., 2013).

Other:

4.17. Access to registered retailers was found to be problematic at times, particularly in rural areas or for women from ethnic minorities who reported that they often don't have access to culturally appropriate fruit and vegetables in supermarkets while small shops are often not registered for the scheme (McFadden et al., 2013). Lucas and colleagues (2013) reported that users are more likely to spend their vouchers in supermarkets due to factors such as: convenience, greater availability of foods, lower prices and greater anonymity.

4.18. Some negative experiences of using the food vouchers were reported, but they were rather rare (Lucas et al., 2015). Feelings of shame or stigma attached to using the vouchers were rarely reported either, which may be due to beneficiaries' increased efforts to avoid embarrassment through using a range of strategies, for example by using self-checkouts or the shops known for accepting the vouchers (Lucas et al., 2015).

4.19. Most importantly, perhaps, impact of the scheme on access to healthy foods and improving diets has been undermined by the rising prices of food and costs of living in relation to the voucher value which has not been increased since 2009 (and it has stood at £3.10; Lucas et al., 2015). Moreover, proposals to include the food vouchers under Universal Credit may also threaten low-income families to secure the money for healthy (or sometimes any) food against other household expenses (Lucas et al., 2015).

Healthy Start Vitamins - A 'Missed Opportunity'?

4.20. Evidence suggests that precise targeting of low income women and young children by the scheme is failing to meet its objectives, although there are some examples of good practice (Lucas et al., 2013; Scottish Government, 2015b). Unfortunately, the Healthy Start Vitamins remain rather a 'missed opportunity' due to a very low uptake of the vitamin supplements and consequently - an increased risk of birth defects and negative health outcomes associated with certain vitamin-insufficiency before and during pregnancy and early years (McFadden et al., 2015).

4.21. Evaluative studies have focused on the causes of these low uptake-rates for vitamin supplements as well as of the barriers faced by low-income families, those eligible, but also those already registered for the scheme, in accessing the HS vitamins (Barbour et al., 2012; Jessiman et al., 2013; McFadden et al., 2015; Moonan et al., 2012; Scottish Government, 2015b). Based on both, beneficiaries' experiences, and on the knowledge and expertise of health and social care professionals, those additional obstacles to vitamin-uptake and the shortcomings of the HS Vitamins component of the scheme can be divided into four categories, namely: barriers experienced by families, challenges experienced by health professionals, eligibility and application process factors, and factors within the operation of the scheme (adapted from MacKenzie, the Healthy Start Leads meeting, September 8, 2015). Furthermore, identifying and addressing barriers to the HS Vitamins scheme will potentially allow us to improve vitamins supplements availability, accessibility and awareness of their importance for women and children's health and well-being.

Barriers experienced by families influencing the effectiveness of the Vitamin Scheme include:

1. Low awareness of the need for and importance of vitamin-supplementation during pregnancy and early years amongst women (Jessiman et al., 2013; Moonan et al., 2012).

2. Information overload during the first prenatal visit, harming the processing or memorising of information received about the importance of vitamin-supplementation (Barbour et al.; 2012).

3. Information about nutrition and vitamin supplements in pregnancy often provided not early enough.

4. Low motivation to use vitamin supplements before and during pregnancy and breastfeeding and/or in early years (Jessiman et al., 2013) due to:

• Beliefs that vitamins are not necessary if having healthy diets;
• Good child health outcomes in previous pregnancies without the use of vitamin supplements quoted as support for not using vitamin supplements;
• A dislike of taking tablets or administering drops;
• Concern that the vitamins might cause health problems in children;
• Confusion amongst parents and some professionals about when to start vitamins supplementation in early years (whether to start at 1 month or 6 months after birth, to stop if a child exceeds 500 ml of formula milk, or whether to restart when the child moves to cow's milk at the age of one);
• Difficulties measuring the correct dosage of liquid drops;
• Not seeking nutritional or medical information from health professionals.

Challenges experienced by health professionals influencing the scheme's success include:

1. Lack of awareness of the importance of and the current recommendations on the vitamin supplements pre- and during pregnancy as well as early years amongst some health practitioners (Barbour et al., 2012; Jessiman et al., 2013; Moonan et al., 2012; Scottish Government, 2015b), such as:

• scepticism/negative attitudes towards vitamin supplements;
• limited knowledge about the current recommendations regarding vitamin intake for pregnant/breastfeeding women and young children; for example, Lockyer and Porcellato (2011) indicate that the level of awareness of risks associated with vitamin D deficiency and of groups being at risk of deficiency amongst health professionals in the UK varies considerably, with only half of the respondents being aware of the UK recommendations for vitamins supplementation;
• lack of trust in vitamins suppliers.

2. Lack of awareness of the Healthy Start Scheme amongst some health professionals (e.g. GPs, midwives, health visitors) or about some aspects of the scheme (e.g. who is responsible for vitamins distribution, where vitamins can be collected by eligible women) etc.

3. Low promotion of the scheme by health professionals (due to low awareness amongst them about vitamin-supplementation as well as about the HS scheme, attitudes towards vitamin-supplementation as well as workload and/or low frequency of appointments).

The influence of eligibility criteria and the difficulty of the application process on the scheme's take-up and success ranges:

1. From complicated or limiting eligibility criteria (Lucas et al., 2015; McFadden et al., 2013) such as:

• Women and children who would benefit from the scheme are not entitled (e.g. asylum seekers, pregnant women in prison, low income families exceeding income threshold);
• Eligible pregnant women are entitled to free vitamins from the 10th week of gestation even though folic acid supplementation is recommended before and during first 12 weeks of pregnancy in order to prevent neural tube defects in infants;
• Free vitamins are only available for eligible children under 4 even though supplement-recommendations include children until their fifth birthday (such as: DH, 2012).

2. To a difficult application process (Jessiman et al., 2013; Lucas et al., 2015; McFadden et al., 2013; Scottish Government, 2015b) involving or complicated by:

• Completing a reportedly time-consuming and inaccessible or difficult application form;
• Changes in family financial circumstances which may act as a barrier - e.g. fluctuating income, experiences of homelessness, moving in and out of employment may cause some groups of beneficiaries to lose their entitlement;
• The need to re-register for the HS Scheme after the child's birth or after reaching 18 years old is a requirement eligible families are often not aware of and which acts as a barrier for access to the scheme.

Factors affecting the operation of the Healthy Start Vitamins Scheme are:

1. The administration of the scheme by Welfare provisions has been criticized as undermining public health initiatives directed at all pregnant and breastfeeding women as well young children for sending the wrong message about vitamins insufficiency (especially vitamin D and folate) being linked with poor diets and poverty. On the other hand, access to the scheme through the health system may exclude women who get involved with the health services irregularly (McFadden et al., 2015); e.g. contact with NHS services often decrease when children get older (Scottish Government, 2015b).

2. The complex distribution, ordering and reimbursement system creates:

• Difficulties in finding an accessible and effective location for suitable distribution (Moonan et al., 2012), e.g. due to the size and geographic spread of the populations under certain NHS Boards (Scottish Government, 2015a:9);
• Difficulties in supplying the necessary vitamins: national and local supply chains remain "logistically complex, requiring the time, resources and creative thinking of a range of local and regional practitioners" (McFadden et al., 2015:6). Moreover, as distribution arrangements are agreed locally, health professionals may not be aware of the location or even existence of access points. In consequence, "the current targeted approach is reaching very few of those eligible for Healthy Start or who are at risk of vitamin deficiency" (McFadden et al., 2015:6).
• Difficulties with finding funding to order vitamins (McFadden et al., 2015);
• Difficulties in keeping record of how many vitamin supplements were provided to eligible families and then simultaneously claiming reimbursement from the Department of Health while providing the coupons as proof (McFadden et al., 2015);
• Difficulties with availability and accessibility of vitamins generated by: vitamins short shelf lives (e.g. vitamins going out of date before being distributed to eligible families, no available stock when necessary); financial strain on low-income families due to the helpline being too expensive to call; confusion around the use of the vitamin coupons amongst eligible families; limited access to distribution points (e.g. in some localities availability was restricted to one centre at a limited time only or local distribution points were too far away for some eligible families to access them; Lucas et al., 2015; McFadden et al., 2015; Scottish Government, 2015a).

Do We Need Nursery Milk?

4.22. The Nursery Milk Scheme, alongside the Healthy Start Scheme, constitutes the Welfare Foods policy in the UK. While two previous subchapters focused extensively on evaluation of the Healthy Start Scheme, this subchapter, due to lack of literature on the NMS, will only discuss two issues: whether it is beneficial for young children's health and whether there is other alternative to provide young children with free milk.

4.23. Evidence suggests that in developed countries such as the UK, children's diets remain nutrient-sufficient for the majority of micronutrients (Scottish Government, 2013a; Westland and Crawley; 2012). However, it has also been widely reported that iron, zinc, vitamin D, iodine, folate and vitamin B12 insufficiency still may occur quite commonly (Agostoni et al., 2013; Decsi and Lohner, 2014; Shergill-Bonner, 2013).

4.24. Cow's milk and other dairy products remain the main dietary sources of calcium, vitamin D (but only if fortified, e.g. in the US but not in the UK) and iodine (Pearce et al., 2004). Cow's milk is also an important source of other vitamins and minerals, especially: protein, vitamin B and B12 (for more information about their role in the human body please consult the British Nutrition Foundation website^[11]) and vitamin A (NHS Health Scotland, 2015). Furthermore, the Setting the table guidance (NHS Health Scotland, 2015) recognises the importance of cow's milk in diets of young children, recommending full fat milk for children between 1 and 5 as one of 3 required servings of dairy products a day.

4.25. On the other hand, excessive milk intake has been linked with an increased risk of iron deficiency or anaemia and therefore toddlers should not exceed 500 ml/day of unmodified cow's milk as (especially amongst low income families whose diets are more likely to be poorer in foods containing iron (such as fish or non-processed meat(Domellöf, et al., 2014). Nevertheless, findings of 'Diet and Nutrition Survey of Infants and Young Children in Scotland' (Scottish Government, 2013a) suggest that for the majority of toddlers, mean consumption of cow's milk stands at 329 ml per day, so it remains important to promote its inclusion in children's diets from a public health point of view.

4.26. As such, the evidence quoted above serves to argue a reduction in children's dairy-intake, and of milk in particular, may be risky for their overall nutrition and lead to negative consequences for their health and growth, especially for those who are already nutritionally vulnerable (e.g. growing up in disadvantage groups or communities; Shergill-Bonner, 2013; Westland and Crawley, 2012). This is why Food Based Dietary Guidelines (FBDG) "generally advise the use of cow's milk in moderate quantities (around 300 to 500 ml per day) as an important source of nutrients for young children" (Agostoni et al., 2013:73).

4.27. The Nursery Milk Scheme entitles all children under five (regardless of their background) who spend more than two hours in a day care to receive a free daily drink of milk (1/3 pint or 189 ml). However, it remains under child care providers' control whether to enter the scheme and claim the reimbursement of the full costs of the milk they provide. Unfortunately, the current uptake of the scheme stands at approximately 50%.

4.28. What could be done to increase the uptake amongst eligible childcare providers? Should the money spent on the NMS be included into the Foods and Vitamin parts of the HS budget instead and provided directly to low income families (Scottish Government, 2015b)? These questions remain to be answered and provide opportunities for future research.

4.29. This chapter focused on the evaluation of the Healthy Start Scheme in Scotland. In particular, it sought to establish how the scheme operates, what does and does not work from the stakeholders' perspective and how successful it is in meeting its aims and aspirations. Findings from literature suggest that the Healthy Start Scheme is perceived as an important initiative by its stakeholders. Yet, a number of barriers to the scheme need to be addressed if it is to work more effectively and better meet its beneficiaries' needs. The following chapter will discuss in detail which actions can be taken in order to improve the operation of the HS scheme.