Evaluation of the Healthy Start Scheme: An Evidence Review

5. Recommendations

5.1. In light of evidence presented in the previous chapter, increasing awareness of, availability of and access to the Healthy Start Scheme remains an important public health objective. This chapter offers possible actions that can be undertaken in order to improve the scheme's effectiveness. In particular a number of barriers and shortcomings, discussed in the evaluation chapter, should be addressed. Due to the specificity of each component of the HS scheme, proposed recommendations will be discussed separately under two sub-headings: the Healthy Start Foods and the Healthy Start Vitamins. It is also worth noting that propositions of separating the HS Foods from the HS Vitamins have been also raised by a range of health and social care professionals in Scotland (Scottish Government, 2015b).

Healthy Start Foods

5.2. Awareness about the HS Foods scheme and importance of healthy diets and nutrition before and during pregnancy and early years should be increased. As the main sources of information about the HS scheme, according to findings of the Infant Feeding Survey (McAndrew et al, 2012), include: midwife, health visitor, a partner, friend or relative and the local benefit office or Jobcentre Plus, it would be reasonable to use these networks better to promote the scheme and its message, especially in the local/community contexts. Increasing collaborative multiagency work between health and welfare services, providing every pregnant woman with health advice from health professionals and ensuring that women understand and are aware of the scheme (McFadden et al., 2013; Scottish Government, 2015b) are some of the strategies which should be implemented in order to increase the awareness of the scheme.

5.3. Eligibility criteria to the HS scheme could be extended to low-income women in the first weeks of pregnancy and children up to the age of five. Furthermore, families with uncertain immigration status (e.g. asylum seekers) should be entitled to the HS Food Vouchers

5.4. Income threshold eligibility criteria should be increased in order to include families with fluctuating incomes, in and out of employment while the criteria regarding tax credits should be simplified. Other propositions include basing eligibility criteria on household income and family size rather than on income threshold (Khanom et al., 2015; Scottish Government, 2015b).

5.5. Voucher value should keep pace with rising food prices. In particular, Scottish health professionals provided an example from "public health group in Glasgow who worked out what an average diet would be for a family of four. They discovered it would be possible to live, not badly, on £6 - £8 a week on food vouchers, but only if someone had the ability to drive to the shops, budget and cook" (Scottish Government, 2015b:16).

5.6. The application process should be simplified: application forms should be made as easy to fill in as possible and women should be offered help with filling in the form. The requirement for a counter-signature by a health professional should be removed, along with the need to reapply once a child is born. An alternative solution, proposed by Scottish health, social care and welfare professionals in the field of maternal and child health and nutrition, would be to eliminate the application process completely and subsume it under existing benefit system. They argued that such solution would bring together HMRC, DWP and the NHS "with the aim of making the application process less difficult and time-consuming" (Scottish Government, 2015b:17).

5.7. The existing helpline should be made free of charge for mobile phone calls, as many low-income families do not have landlines (Lucas et al., 2013).

5.8. More small and local shops, especially in rural areas, should be encouraged to join the scheme in order to increase its availability as well as access to culturally appropriate foods (Lucas et al., 2013).

Healthy Start Vitamins

5.9. This subchapter will discuss recommendations for two scenarios - if vitamin-supplementation was to become a universal provision (section 5.10) and under the current framework for the Healthy Start Vitamins - the targeted provision (section 5.11).

5.10. A strong support amongst health professionals for the universal provision of vitamin supplementation for all women planning pregnancy, pregnant women and young children under age 5 has been widely reported across the literature (Jessiman et al., 2013; McFadden et al., 2015, Scottish Government, 2015b). In particular, they argue that the universal provision of vitamins would be more cost-effective than a targeted provision as it would reduce the high costs of complex administration or of the treatment of vitamins deficiency. Furthermore, it is also pointed out that universal provision would contribute to improving health outcomes on a national level as well as increase the likeliness of reaching the most vulnerable and/or disadvantaged populations, including the current beneficiaries of the Healthy Start (McFadden et al., 2015).

• For example, Moy and colleagues (2012) evaluated the effectiveness of a small scale programme of universal provision of free HS vitamins for pregnant and lactating women and young children in Birmingham in terms of reducing symptomatic vitamin D deficiency. They found out that universal provision combined with a public awareness campaign about the importance of vitamin D has increased a supplement uptake rate to 17%. However, despite the still significantly low uptake, the number of cases of symptomatic vitamin D deficiency in children under 5 decreased dramatically by 59% (from 120/100 000 to 49/100 000) while public awareness of vitamin D deficiency has supposedly greatly increased. These findings suggest that the universal provision of vitamin supplements has the potential to improve children's health outcomes and may be cost-effective preventative action.
• Furthermore, NICE (2015) was commissioned to examine whether universal provision of vitamins to pregnant and breastfeeding women and young children would be more cost-effective than the current targeted provision under the Healthy Start Scheme. The reason behind this evaluation was a growing concern about the prevalence of vitamin D deficiency-related diseases amongst young children in the UK. As discussed in section 3, there are also growing concerns about low levels of folic acid supplementation before and during pregnancy in the UK associated with an increased risk of neural tube defects in infants (Bestwick et al., 2014).
• NICE (2015) reported that it would not be cost-effective to provide the universal provision of HS vitamins if only women from the 10th week of pregnancy and children between 6 months and 4 years would be in receipt of free vitamins. However, according to NICE (2015) findings, universal provision would be cost effective as long as the target group could also be extended to all women planning pregnancies and those in their first ten weeks of pregnancy, as well as children up to the age of 5 and infants between 0 to 6 months (according to the SACN recommendations on vitamin supplementation, SACN, 2015).
• Even though NICE (2015) evaluation of cost-effectiveness of universal vitamins provision was initiated by concerns about vitamin D deficiency, there was not enough data to assign a quality of life measure to the effects of vitamin D supplementation (as well as of vitamins A and C). The main analysis was therefore focused on the impact of universal folic acid supplementation, because it was the only nutrient with a measurable outcome, namely the prevention of neural tube defects. Furthermore, a paucity of data has been reported leading to a model based on a range of assumptions, some of which may have had a crucial impact on the assessment of the cost-effectiveness.
• Similarly, the costs of universal distribution of HS vitamins remain unclear as many different types of routes may be adopted (including pharmacies, health professionals, supermarkets etc.). What the mechanism for distributing vitamins would be and how effective it would be remains to be examined. Similarly, how women planning their pregnancies could be reached by this universal scheme remains unclear (NICE, 2015), not only because they may not be in contact with health professionals; but also because up to 50% of pregnancies in the UK are reportedly unplanned (Bestwick et al., 2014).

5.11. If the universal provision of vitamin supplements for all women planning pregnancy, pregnant women and children under 5 is not implemented, a range of other strategies and actions under current legislative framework could be considered:

• Increasing the awareness of the importance of vitamin supplementation (in particular vitamin D) especially amongst the groups at risk of vitamin-deficiency and front-line health professionals (GPs, health visitors and midwifery teams; Leaf, 2007; Lockyer & Porcellato, 2011; e. g. through specific training for health professionals about the importance of vitamin supplements during pregnancy and in early years, about various aspects of vitamin deficiency as well as about the HS scheme itself along with national and local-level activities promoting the importance of vitamin D supplements; Jessiman et al., 2013; Wood and Cheetham; 2015).
• For example, the new NICE (2014) public health guidance on how to increase vitamin D status amongst at-risk groups (such as pregnant and lactating women and young children) is directed at a range of public and voluntary sector organisations and practitioners, e.g. Public Health England and the Department of Health, Directors of public health, Local authorities, health and social care professionals, clinical commissioning groups, health and wellbeing boards etc. (for detailed recommended actions and activities see the NICE webpage^[12]).
• Recommendations on vitamin supplements should be coming from health professionals as research suggests that women are most likely "to comply with advice from healthcare professionals when it is specific and provides explanations as to why the recommendation is important." (Lucas et al., 2014:2475).
• Mandatory fortification of food products (such as flour) with folic acid as advised by SACN (2009) so long as a range of safety measures are introduced alongside (for details see the UK Government website^[13]).
• To simplify distribution routes (e.g. vitamins to be given out routinely by midwives and health visitors, or to be widely available at various places where women go regularly, such as: supermarkets, pharmacies, children's centres, health centres and GP practices, libraries and local authorities; Jessiman et al., 2013; Scottish Government, 2015b).
• Currently, the eligibility for the HS scheme starts at the tenth week of pregnancy which is counter-productive for folic acid supplementation therefore it should be extended to the first weeks of pregnancy (Scottish Government, 2015b). Similarly, eligible children up to their fifth birthday should be included into the scheme, accordingly with vitamin supplementation guidelines (McFadden et al., 2015; Scottish Government, 2015b).
• The most vulnerable populations should also be entitled to the vitamin supplements - such as asylum seekers or pregnant women in prison.

5.12. This chapter discussed possible actions that can be undertaken in order to improve the operation and effectiveness of the Healthy Start Foods and Vitamins. One should bear in mind however, that only some of the of the recommended solutions are under the Scottish Government's control as the Welfare Foods Policy remains one of the reserved powers. Yet, the Scottish Ministers may have more decision-making powers over the scheme's scope, administration and implementation if Welfare Foods are devolved.