Introduction
This article discusses findings from a qualitative study of the use of Healthy Start (HS), a UK food welfare scheme managed and run by the Department of Health in England, with an explicit public health agenda of providing a ‘nutritional safety net’ (Department for Work and Pensions, 2012) within a context of social protection. A key premise of HS is that families living on very low incomes are at risk of nutritional insufficiency and therefore policies should focus on improving access to more nutritious food. HS also has potential to provide evidence to inform the debate about whether providing ‘incentives for healthier choices’ leads to behavioural change: where these are either examples of a benefit in kind (i.e. not cash) or ‘nudges’ toward particular health behaviours (Jensen et al., Reference Jensen, Hartmann, De Mul, Schuit, Brug and Consortium2011). This study (and another commissioned alongside it) was the first to evaluate the implementation of HS.
Background
The health policy context for Healthy Start
In 2006, HS replaced the Welfare Food Scheme which had changed little since its introduction in 1940. The previous scheme provided infant formula and cow's milk only, and no longer reflected public health priorities to increase breastfeeding and fruit and vegetable intake (Department of Health, 2002a, b). Improving diet and targeting benefits to pregnant women and young children had been identified as a key route to tackling inequalities in health (Acheson, Reference Acheson1998), and a tranche of public health initiatives followed including HS, School Fruit (Department of Health, 2000) and Breakfast Clubs (Shemilt et al., Reference Shemilt, Harvey, Shepstone, Swift, Reading, Mugford, Belderson, Norris, Thoburn and Robinson2004).
HS provides vouchers which can be exchanged for infant formula, liquid cow's milk, fresh or frozen fruit and vegetables, and free vitamins to families that include a pregnant woman or children under the age of four years (Jessiman et al., Reference Jessiman, Cameron, Wiggins and Lucas2013). Families in receipt of Income Support, income-based Jobseeker's Allowance, income-related Employment and Support Allowance, pregnant women aged under eighteen and families receiving Child Tax Credit and with an income of £16,190 or less are eligible for HS (Department of Health, 2013). Food vouchers have a fixed value (£3.10 at the time of writing, unchanged since 2009) and eligible families receive two vouchers per week for babies under twelve months, and one voucher for each pregnant woman or child between twelve and forty-eight months. Vouchers are posted monthly to families, for use in participating retailers.
The Department of Health is legally responsible for HS, and application forms must be countersigned by a health professional (nurse, midwife, health visitor or doctor) who should also ensure that applicants are offered healthy eating advice (Department of Health, 2010).
Food welfare schemes, food vouchers, health and non-cash transfers
HS forms part of a tradition of providing benefits in kind rather than in cash. Policy makers prefer benefits in kind, particularly for children, to ensure both content (for example, healthy food) and the intended beneficiary (Currie, Reference Currie1994; Devaney et al., Reference Devaney, Ellwood and Love1997). Greater health benefits have been claimed for targeted financial incentives than for unrestricted cash or food benefits (Government Accountability Office, 2008). These claims are contested, and recent evidence suggests unconditional cash benefits have a positive impact on health (Gregg et al., Reference Gregg, Waldfogel and Washbrook2006; Lief Benderley, Reference Lief Benderley2011).
Food subsidy programs have been found to improve the nutritional quality of mothers’ diets (Black et al., Reference Black, Brimblecombe, Eyles, Morris, Vally and O’ Dea2012). The particular structure of HS, providing vouchers which can be exchanged for specific foods types, is relatively rare internationally. The best-known example is the USA's Special Supplemental Program for Women, Infants, and Children (Food and Nutrition Service, 2005). It targets low-income pregnant and postpartum women and children under five judged to be at ‘nutritional risk’ by a health professional. Numerous studies report health benefits for babies in the scheme, including increased birth weight, breastfeeding and well-baby checks (Chatterji and Brooks-Gunn, Reference Chatterji and Brooks-Gunn2004; Hoynes et al., Reference Hoynes, Page and Stevens2011). It may have particularly positive effects among the most disadvantaged groups (Khanani et al., Reference Khanani, Elam, Hearn, Jones and Maseru2010), and the recent inclusion of fruit and vegetables has increased family consumption of both (Whaley et al., Reference Whaley, Richie, Spector and Gomez2012).
There are good reasons to be optimistic about the health potential of HS. In Sheffield, researchers found that white women eligible for HS consumed significantly more portions of fruit and vegetables per day than a similar group eligible for welfare foods. However, the authors note that women in the HS group were simply eating more food overall, including unhealthy foods (Ford et al., Reference Ford, Mouratidou, Wademan and Fraser2009).
Study aims
The study reported here aimed to understand the views and experiences of families using the scheme (including unsuccessful applicants). We asked three research questions: (1) How can Healthy Start protect the health of vulnerable families and those most at risk of hunger?; (2) Do families understand Healthy Start as a health or welfare benefit?; (3) How do parents feel about receiving vouchers instead of cash?
Methods
Sample and recruitment
This was a qualitative study using in-depth interviews undertaken in 2011 and 2012. Participants were recruited from thirteen research sites across England, purposively selected to achieve variation across geography, deprivation, fruit and vegetable consumption, ethnicity and estimated HS uptake.
We recruited a range of families: parents currently or previously eligible for HS, low-income non-applicants, unsuccessful applicants; younger parents (in particular mothers under eighteen years); families of different sizes and ages of children; and different ethnic groups. Our primary recruitment method was face to face with parents attending health and welfare services for young families. Additionally, we used Department of Health records to contact families under-represented in our face-to-face recruitment. All participants received a £5 shopping voucher in thanks for their time. The full methodology is available elsewhere (Lucas et al., Reference Lucas, Jessiman, Cameron, Wiggins, Hollingworth and Austerberry2013). The Social Care Institute for Excellence Social Care Research Ethics Committee approved the study.Footnote 1
All interviews were digitally recorded, and field notes taken. We used framework analysis (Ritchie, Reference Ritchie, Ritchie and Lewis2003) to identify key themes and sub-themes that emerged from the data, and explored the data by both theme and respondent-type.
Sample
We interviewed 107 parents, described in Table 1. Most interviews were with mothers, but our sample included six fathers and one grandmother. Respondents were aged between sixteen and forty-eight years.
Table 1 Characteristics of recruited parents (n = 107, categories not mutually exclusive)
Findings
Uptake
Estimated uptake (the number of HS benefitting families as a proportion of those whose government records indicated likely entitlement) across the areas sampled for this study was 77.4 per cent. This was similar to the national average (78.4 per cent in January 2011) but we found uptake was lower in the more affluent areas we sampled (72‒77 per cent) compared to the most deprived (78‒86 per cent).
Applying for HS
Most parents who applied for HS found the process easy and had no concerns about the information requested. More than three-quarters had been signposted to the scheme by a health professional, and forms were typically distributed and later countersigned at routine antenatal appointments. Other parents heard about the scheme through word of mouth, and occasionally through the Jobcentre. Application forms are only available in English, so those who were not fluent in written English needed assistance.
While mediation of the scheme through health professionals worked well for most, it did create a barrier for those who do not regularly access health care, or who faced difficulties getting appointments:
Midwives, oh, when I’ve been up there they’re like ‘No you have to have an appointment’ . . . [they] fob you off. (Mother of toddler, current recipient)
Parents told us that compared to other benefits, HS applications were processed swiftly (most received vouchers two to four weeks after application). When they did occur, delays in the process left parents feeling ‘frazzled’. Parents seldom understood why their applications were delayed or rejected, and those who experienced problems told us that phoning the helpline to resolve these was expensive, particularly using mobile phones.
Following birth, eligibility for HS transfers from the mother to the child, and therefore parents must report the birth of their babies to the HS Issuing Unit. In contrast to the good experience of applying, this process was problematic for many. Some parents did not recall being advised to report their baby's birth (although this advice is included in written materials). These parents reported that vouchers stopped soon after birth and were confused about why. Consequently, there was often a lengthy period without vouchers.
Among those who had not applied for HS, but whom we believed were likely to be eligible, were some whose lives had recently been disrupted, including by periods of homelessness. These women simply could not cope with the additional work of applying when other parts of life were challenging:
There has been that much going on. I just haven't thought about it. (Mother of six, not in receipt)
Another reported that she thought about applying, but:
I couldn't take another refusal. (Mother of three, not in receipt)
We also met a few non-applicants who simply did not know about the scheme. These were women who had not been signposted to the scheme by health professionals. We noted that these included middle-class women in wealthier neighbourhoods, confirming health professionals’ own reports to us that they do not mention HS to families who they think are unlikely to be eligible for other benefits (Lucas et al., Reference Lucas, Jessiman, Cameron, Wiggins, Hollingworth and Austerberry2013).
We also spoke to six parents whose vouchers had stopped arriving without explanation. Of these three were teenage parents, whose eligibility is different during pregnancy and after. Another three (all of whom had experienced housing difficulties) had stopped receiving vouchers since their baby was born but were unsure why. There was confusion about whether or not changing their address for other benefits would automatically update HS records. One woman who had been living in a crisis shelter told us:
I was only getting £32 a week off a crisis loan because my money all got messed up, so when my vouchers came through they did really, really help. (Mother of five-day old baby, previous recipient)
Finally, there were a number whose applications had been rejected who were moving in and out of eligibility. Often these respondents had a pattern of reapplying as circumstances (employment or relationship status) changed. Prominent among these were those with less secure employment; where they or their partners were employed part-time, were self-employed or moved in and out of employment. This ‘cliff edge’, where a small increase in income meant the loss of eligibility, put a financial strain on families:
I explained that my husband was only working seventeen hours and asked if they could give me extra help . . . All my money goes on the rent, the bills, clothes, shoes . . . Our income is a lot less than when we had the vouchers and were able to be in good health. (Mother of three, previous recipient)
Relieving hunger and improving diet
There were three ways in which HS supported the diet of those receiving it. HS could subsidise foods they were already buying, allow purchase of greater amounts and variety of fruit and vegetables, and sometimes provide a crucial safety net.
Parents reported that the food vouchers made a difference to their food budget. Over half described the food vouchers as a ‘big relief’ or ‘making a big difference’. When asked how much they budgeted for food, the majority who planned in this way said that they typically spent in the range of £30 to £50 per week (dependent on family size). The vouchers represented a considerable additional weekly allowance for food. Several parents mentioned that this had been especially important to them since the cost of essential goods had increased. Fruit and formula milk were both identified by parents as particularly expensive items. Most described their food budget as ‘tight’ and appreciated the difference that HS vouchers could make.
£3.10 a week when you’re 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. (Mother of two, current recipient)
Conversely, the loss of the vouchers by the youngest mothers when their babies were born meant they no longer felt able to afford the additional milk, fruit and vegetables they had bought during pregnancy.
Around one-third of current beneficiaries reported that having HS encouraged them to buy greater amounts and variety of fruit and vegetables than they would otherwise have done. Parents on a tight budget viewed fruit and vegetables as non-essential and these would often ‘fall off the list’ without the vouchers.
If I couldn't have the vouchers, I couldn't get fruit ‒ do you understand? Because it's expensive, so they wouldn't get fruit. (Mother of three, current recipient)
Some parents were aware that encouraging their children to eat fruit and vegetables soon after weaning might have a lasting impact on their food choices and were keen to embed healthy habits in their children from an early age. Commenting on her younger, unfussy, child who had benefited from HS, one mother told us:
I did try my best to get fruit and veg for my [older] son but I just couldn't afford it. I think it would have been a big help if I’d have had that (HS) back then to start off, I think he would now be a bit more open to it [fruit and vegetables]. (Mother of two, current recipient)
Fresh produce was a popular choice with their children, and vouchers enabled parents to buy produce they otherwise would not be able to afford, for example, soft fruits such as raspberries, grapes and, blueberries. Families on a restricted budget found it difficult to risk buying new and untried products because they might go to waste if their children did not like them. HS vouchers gave some families the flexibility to experiment with new foods.
We found a small number of parents who reported that the vouchers were a crucial safety net that ensured they were able to feed themselves and their children. For these families, HS meant that:
You can get a meal even when you’ve got no money. (Mother of two, current recipient)
Families in these circumstances mentioned the use of potatoes as the most basic and affordable of foodstuffs that would prevent them and their children going hungry.
You’re sort of relying on the vouchers just to get you a little meal . . . when we was on a short patch when the money was crossing over we didn't have a lot . . . So we’d go in the shop and get a jacket potato and think then, well we can't even get any cheese to go with [it]. (Mother of baby, current recipient)
One parent with a newborn baby told the researcher that she only had one pound in the house which would be used for a potato for her evening meal. Another reported a strategy of deliberately saving the vouchers for milk and potatoes to ‘see the family through’ until the end of the week.
The health meaning and health benefits of the Healthy Start Scheme
Considering the debate about the role of targeted incentives for health, we were interested in whether parents viewed HS as primarily a health or a welfare scheme. Respondents fell equally into those who saw it as an alternative form of financial support, those who saw it as primarily a health scheme intending to encourage ‘people to give their children healthy food’ (Pregnant mother of two, current recipient) and those who linked the two, seeing it as a subsidy for healthy items recognising they were unaffordable for low-income parents:
The idea is to encourage people to get at least some fresh fruit and veg into their diet because it can be very expensive and when you’re on a limited income. (Mother of four, previous recipient)
We report above those parents who felt HS had supported changes to their diet, but not all parents felt this was the case. Some just did not like fruit and vegetables and were unaffected by any support to buy more. For some, an extra £3.10 a week was simply not enough to influence purchasing. This was particularly the case for those buying expensive formula milk:
[Healthy Start] did help in pregnancy but now the baby is born and she needs formula, the vouchers do nothing, really. (Mother of baby, current recipient)
Finally, there was also a group of parents who already placed a high priority on a healthy diet. They reported a lot of time spent planning, shopping and preparing meals and, despite a limited budget, would not compromise on diet and often preferred to save money in other ways:
We can get clothes from the charity shop, and we do that, but food is important to me. (Mother of toddler, current recipient)
Spending vouchers: supermarkets, corner shops, value and stigma
We found no evidence of widespread misuse of vouchers (Lucas et al., Reference Lucas, Jessiman, Cameron, Wiggins, Hollingworth and Austerberry2013). Our study confirmed data supplied by the Department of Health which showed 73 per cent of vouchers are redeemed in supermarkets (Lucas et al., Reference Lucas, Jessiman, Cameron, Wiggins, Hollingworth and Austerberry2013). Supermarkets afforded parents convenience, a greater food range, lower prices, ease of use, and a greater ability to use the vouchers ‘anonymously’. There was a small group of parents who predominantly used local small retailers for their HS shopping, nearly all of whom were younger parents (younger than twenty-five years). They were chosen for similar reasons to supermarkets: easier accessibility, lower prices (particularly when only buying milk) and the perception that vouchers could be used more flexibly in these shops. Some of these younger parents had limited transport options, and using the local shop was a necessity, not a choice.
Parents did not often report feeling stigmatised for using the vouchers when shopping, but this is likely to be explained at least in part by their efforts to avoid embarrassment and exposure. Parents were making shopping choices that limited the risk of rejection, shame or public scrutiny by only visiting shops they knew accepted the vouchers, and where scrutiny of shopping was less intrusive.
You feel a bit of an idiot because when you walk away when they don't accept the vouchers. You feel like a cheap skate . . . [but in supermarkets] you can do the self service. (Father of baby, current recipient)
Although it was not their usual experience, many parents had felt shamed at some point; checkout staff were sometimes ‘bloody-minded’ or ‘humiliating’. Many reported that their shopping was carefully checked by cashiers and while most were understanding and kind, this could be difficult:
They’ve got to go right through your receipt and there's a big long queue and it makes you feel really self-conscious, it's like ‘Oh you’re on the welfare! (Mother of four children, current recipient)
Where parents had under-spent (that is, bought fewer eligible goods than the value of the voucher) the risk of ‘losing’ the unspent part of vouchers was perceived by parents as the main problem with the fixed value of the food vouchers:
In some places . . . they would add it all up and then they would cross through the voucher. So they would waste one voucher, before you had time to say ‘oh no I’ll take that back and use it next time’. So like sometimes there might be £1.25 still left on it, and I could have used that . . . I would rather have like grabbed a bunch of apples or something. (Mother of two, current recipient)
Discussion and conclusions
Does Healthy Start protect the health of vulnerable families and those most at risk of hunger?
Healthy Start provided some level of protection for most families using it. For most, the scheme was easy to access, vouchers arrived quickly and its operation was viewed more positively than other benefits. Vouchers contributed significantly to the weekly food budget of many by subsidising food or by putting more expensive and/or risky food items within reach. For a small number, particularly when other payments were not being received, the vouchers ensured they could buy the bare essentials for their family in times of crisis. This protection may be even more important in the context of a tighter welfare regime and the loss of crisis loans.
Some very vulnerable families may not benefit from HS because they are not entitled to apply (for example, asylum seekers) or because of difficulties with application. HS materials are only available in English, disadvantaging parents who are not fluent in reading English, and those not in contact with health services may be missed. Recipients must reapply when their circumstances change, including when their baby is born; forgetting to renew eligibility after birth was quite common. Failing to update applications following changes in circumstances was particularly problematic for those with sudden changes in housing, where benefit status was changing and for those whose income or employment fluctuated. Some neighbourhoods, notably less deprived areas, had lower take-up. Both ex-recipients and unsuccessful applicants reported that they struggled to make ends meet without the support of the scheme.
The vouchers do appear to increase spending on food in general, and fruit and vegetables in particular (Ford et al., Reference Ford, Mouratidou, Wademan and Fraser2009, Griffith et al., Reference Griffith, von Hinke Kessler Scholder and Smith2014). These findings are in line with literature that suggests that income is an important restraint on preferred diet (Inglis et al., Reference Inglis, Ball and Crawford2009) and that concerns about money limit access to sufficient, varied and healthy foods (Skafida and Treanor, Reference Skafida and Treanor2014). When food budgets are very tight families are unwilling to buy foods their children are not certain to eat (Hayter et al., Reference Hayter, Draper, Ohly, Rees, Pettinger, McGlone and Watt2013). Families facing financial difficulties report ’trading down’ to cheaper and lower quality food, including more starchy foods, less fresh fruit and vegetables and more crisps and sweets (Skafida and Treanor, Reference Skafida and Treanor2014), relying more on local shops (avoiding travel costs and where unofficial credit might be given) and foods which have longer shelf lives. HS appears to be used by families as an alternate budgeting strategy, and one which protects spending on fruit and vegetables.
The extent to which HS will continue to meet this important need will depend on its monetary value in the future. The value of the vouchers has not increased since 2009, but food prices rose 12 per cent during the five years to 2012, and fresh fruit and vegetables by twice that amount (Department for Environment, Food and Rural Affairs, 2013). To keep pace with inflation, HS would have needed to increase to £3.62 by 2013 (Bank of England, 2014). If the real value of the vouchers continues to be eroded, they will no longer provide protection.
Do families understand Healthy Start as a health or welfare benefit?
The dual nature of the Healthy Start scheme was apparent to many parents in this study. This was in large part because of the role of health professionals in signposting and signing application forms. However, we did not speak to families who avoided contact altogether, so their views are not represented here. The need for a countersignature may be a barrier to HS where access to midwives and health visitors is limited. Health professionals were more likely than parents to see HS as just a welfare benefit (Lucas et al., Reference Lucas, Jessiman, Cameron, Wiggins, Hollingworth and Austerberry2013), and this meant not raising HS with families they thought unlikely to be ‘on welfare’.
The lack of access to suitable shops for some and the high rates of formula feeding among HS mothers (McAndrew et al., Reference McAndrew, Thompson, Fellows, Large, Speed and Renfrew2012) highlights the limitations of health initiatives which focus only on individuals’ behaviour, ignoring the wider structural and environmental determinants of diet and health (Fowles and Fowles, Reference Fowles and Fowles2008).
How do parents feel about receiving vouchers instead of cash?
While negative experiences of using vouchers were reported, these were not common. Parents took care to avoid shaming experiences by selecting shops carefully; the avoidance of situations that may expose poverty and hence induce shame is echoed in other UK studies (Chase and Walker, Reference Chase and Walker2013). Perhaps, also, the shame of living ‘on welfare’ eclipsed the additional shame of using vouchers. Sutton and colleagues have argued that recipients of welfare in Britain may be less likely to admit to feelings of shame, because poverty is seen (in policy and society) as a failure of the individual and thus it becomes important to claim resourcefulness and retain individual control while ‘on welfare’ (Sutton et al., Reference Sutton, Pemberton, Fahmy and Tamiya2014). This may be echoed in the voices of those who took pride in shopping carefully to protect a healthy diet.
The particular ‘protective’ nature of the food vouchers, which parents reported, may interact with this. The reality for families living on low incomes is that their choices are highly constrained by their circumstances, particularly in relation to food; but where families saw HS as outside of, and different from, their regular income, it became an additional coping strategy. Although vouchers afford less purchasing choice than their cash equivalent, their place outside of the family budget allowed for a different kind of choice which was perceived as a way to protect the food budget when times were tough.
We asked an open question about desired changes to the scheme, and parents did not ask for cash instead. It would be a mistake to over-interpret this silence, but earlier observations about how vouchers are used might play a part in seeing vouchers as a protection against crisis. This protection is not intrinsic to vouchers above cash, of course, and we know that parents with limited resources use these carefully to protect their children's food (Dowler, Reference Dowler1997; Hayter et al., Reference Hayter, Draper, Ohly, Rees, Pettinger, McGlone and Watt2013).
Although we believe HS supported healthy diets for some, the most clearly protective value of HS we observed was in its sitting outside other social security benefits. Access to money for food which was separate from other Social Security benefits when these are delayed, cancelled or lost, was seen by the families interviewed as a crucial safety net. The introduction of HS preceded the Benefits Cap and the move to Universal Credit (Department for Work and Pensions, 2010). Loss of this protection would be just one consequence of rolling HS into Universal Credit. At the time of writing (autumn 2014), HS remains outside of both (Department for Work and Pensions, 2012). A promised decision on the place of HS and other passported benefits within Universal Credit (Department for Work and Pensions, 2012) has not yet appeared.
The move from welfare foods to Healthy Start in the UK has improved the financial support to low-income breastfeeding mothers and those who want to buy fruit and vegetables. The evidence provided here that it has encouraged families to make dietary change is encouraging but tentative, and further research is needed. The value of HS to families is threatened both by erosion of the real value of the vouchers, and by the potential for it to be rolled up (and possibly lost) in Universal Credit.
Acknowledgements
This is an independent report commissioned and funded by the Policy Research Programme in the UK Department of Health (project reference DH PRP 0240031). All researchers are independent of the Department of Health, and the views expressed in the publication are those of the authors and not necessarily those of the Department of Health.
We would like to thank Meg Wiggins, Katie Hollingworth, Chloe Austerberry, Katherine Tyler and Shazia Basaria for research assistance, our advisory group, colleagues in Department of Health, and most particularly parents and professionals who took part in this research.
