This study was conducted in response to the Scottish Government's commitment to improve the Welfare Foods policy 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 Healthy Start Scheme and the Nursery Milk Scheme, which are the key Welfare Foods policy in Scotland and the UK, work effectively and meet their strategic aims. Central to the schemes is the thoroughly documented belief that certain vulnerable groups require more state support than others - as they are more exposed to risk factors contributing to poor health outcomes (Scottish Government, 2010b). This report focuses on the following vulnerable groups: teenage mothers, pregnant and breastfeeding women from disadvantaged backgrounds, as well as their infants and young children (Lucas et al., 2015).
Healthy Start is a nationally implemented policy that provides low-income families at risk of nutritional insufficiency with coupons for free vitamins and vouchers for certain healthy foods (milk, fruit and vegetables, and infant formula milk) in order to improve their diet. It is designed as a form of an economic incentive combined with a 'nudge' effect - a policy intervention intending to influence day-to-day nutritional choices by providing a financial facilitator to opt for healthier choices (Griffith et al., 2015). The scheme also aims to provide health information through accessing health services early in pregnancy to promote breastfeeding and healthy diets (Griffith et al., 2015; Lucas et al., 2013; McFadden et al., 2015).
A significant number of medical and social literature databases were searched and relevant evidence was identified and evaluated. However, there is limited literature on the Healthy Start scheme, most of which has been produced in England, and therefore conclusions may not apply directly to the Scottish context.
The positive impact of Healthy Start on diet and nutrition is clearly recognised by both low-income families and health professionals, which provides sufficient evidence to argue that food vouchers are to some extent responsible for the increased intake of fruit and vegetables for at least some of the scheme's beneficiaries. Moreover, for some low income families Healthy Start definitely works as nutritional safety net (Lucas et al., 2015; McFadden et al., 2015) and has even shown the potential to improve the nutrition and diets of mothers and young children in the longer term (Griffith et al., 2015; Khanom et al., 2015; Lucas et al., 2015; McFadden et al., 2015). However, it remains difficult to asses the impact of the scheme on other dietary choices since concerns 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).
Food vouchers were also recognised providing an important financial safety net by helping with the costs of food products and to may to some extent improve low-income households' food security (Lucas et al., 2013). However, 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). More generally, current responses to health inequalities are argued to remain too narrow as they mostly adopt an "individualistic model as a basis for public health policies relating to diet and nutrition" (Attree, 2006:75). However, implementation of the 'Setting the table' guidance (NHS Scotland, 2015) could become an important step in recognising strutural inequalities affecting dietary choices of low-income populations (Scottish Government, 2015b).
The impact of the Healthy Start 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 increased since 2009 (Lucas et al., 2015). Moreover, narrow restrictions on eligibility criteria such as a low income threshold and the exclusion of severaly vulnerable populations including asylum seekers serve to limit the scheme's potential to reduce health inequalities. Additionally, proposals to include the food vouchers under Universal Credit may threaten low-income families to secure the money for healthy (or sometimes any) food against other household expenses (Lucas et al., 2015).
A very low uptake of Healthy Start Vitamins serves to limit the impact of the scheme on improving the nutrition of low-income women and young children and reducing birth defects and future negative health outcomes. Logistical problems with the distribution of vitamins were mentioned as one of the major reasons behind the low uptake. Furthermore, providing free vitamins only from the tenth week of gestation does not provide adequate folic acid supplementation, since folic acid should be used preconceptually and up to the twelfth week of pregnancy to protect against neural tube defects. Consequently, the current policy may be contributing to the increase in health inequalities. In response to the low rates of vitamin-supplementation amongst pregnant/breastfeeding women and young children, health professionals strongly advocate a change from a targeted provision of Healthy Start Vitamins to a universal approach, seeing it as more cost-effective than the existing 'overly bureaucratic and expensive administration' (McFadden et al., 2015; Scottish Government, 2015b).
Finally, some tensions between the scheme's objectives have also emerged. In particular, the inclusion of infant formula is perceived by some health professionals 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). Some suggested that including formula milk into the scheme incentivises women to formula feed or discourages them from breastfeeding; while others argued that low income families should have access to resources to feed their children and pointed out that the vouchers value should cover the whole costs of the formula (McFadden et al., 2014).
While there is an overall consensus that the Healthy Start scheme works as a nutritional and financial safety net for some low income families, it is also argued that Healthy Start and other other public health policies and initiatives in the UK, still "fail to take into account the full impact of structural influences on food choices, or recognize the social and emotional factors that influence diet and nutrition" (Attree, 2006:67). However, this evidence review supports the claim that initiatives such as the Healthy Start Scheme are useful and needed as they provide low-income families with some level of nutrition and food security (Lucas et al., 2015). In order to work more effectively and to meet their strategic aims and its users' needs, a number of barriers to awareness of, availability of, and access to the scheme should be addressed and overcome.
Email: Odette Burgess