Subscribe
Share
Share
Embed
Podcast series from the MRC/CSO Social and Public Health Sciences Unit, University of Glasgow.
Anna Pearce:
Welcome to the latest edition of 15 Minutes on Health Inequalities. Today we're talking to Ruth Dundas about an evaluation of Healthy Start vouchers that she led on. I'm Anna Pearce from the MRC/CSO Social and Public Health Sciences Unit. And with me from the same Unit is.
Lia Demou:
Lia Demou
Ruth Dundas:
And Ruth Dundas.
Anna Pearce:
Thanks both. So, Lia, are you going to kick off?
Lia Demou:
Thanks, Ruth, for joining us today. Can we kick off by asking you to tell us a little bit more about the Healthy Start vouchers and what was the rationale behind them?
Ruth Dundas:
Yeah, I can tell you about that. But can I just start a little bit before that, if that's OK? I just really want to mention that having a good start in life during pregnancy and infancy has been shown to be important for both living a healthy life and a longer life. And despite the introduction of many policies in the early years, including voucher schemes that aim to improve nutrition, there's limited evidence on their impact on health. So, that was a kind of like starting point for this evaluation. And the Healthy Start voucher scheme is a targeted scheme for low-income pregnant women and their children in the UK. It has changed a little bit from the time period when we undertook the analysis, but the scheme in place when we did our evaluation was for pregnant women and mothers of children under the age of four. And if they were in receipt of means tested benefits, they're eligible to receive vouchers and these vouchers can be spent on liquid milk, formula milk, fruit and vegetables, and they also receive free vitamins. And it was really designed to provide this, kind of, additional assistance for low-income families to improve the nutrition of pregnant women and to try and increase fruit and vegetable intake and then to initiate and maintain breastfeeding and then to introduce foods in addition to milk to the child as part of a, kind of, progressively varied diet when the infants are six months old. So, the vouchers at the time of the study were worth £3.10 per week. The current scheme is administered a little bit differently in Scotland and the current Healthy Start voucher scheme in the rest of the UK, the vouchers are now for £4.25 per week. And the aim of the research project was do the Healthy Start vouchers improve the nutrition of pregnant women and do the improve the health outcomes of their infants? And there were two parts to the evaluation. We had a quantitative analysis of two existing data sets and a qualitative interview study of low-income women.
Anna Pearce:
Thanks Ruth. Can you tell us a bit more about those two approaches that you used?
Ruth Dundas:
Yeah, it was a mixed method study and we used a natural experiment design and by that we combined the quantitative evaluation with this integrated qualitative study that really allowed us to understand the lived experiences of low-income women. And within that we did secondary analysis of two existing survey data sets. We used Growing Up in Scotland, which is representative of the Scottish population and the Infant Feeding Survey which is representative of the UK population.
Anna Pearce:
Just to say you can find out more information on both of those data sets in the podcast notes.
Ruth Dundas:
Thanks, Anna. We also interviewed mothers to get more of an understanding of the processes involved in the, sort of, take up of the vouchers, the non-take up of the vouchers, some people were eligible and didn't claim the vouchers, or any discontinuation of the Healthy Start voucher scheme. And we also wanted to know the experience of using the Healthy Start vouchers and how the vouchers are used.
Lia Demou:
That's great. Can you tell us a little bit about what outcomes did you believe that the Healthy Start vouchers would benefit?
Ruth Dundas:
We had decided to look at a range of outcomes and really this was to try and give us as full a picture as possible for the impact of the Healthy Start vouchers on mothers and children's health. And partly this was driven by the aims of the Healthy Start voucher scheme itself and what they are trying to improve. And the main outcomes we thought would be affected were breastfeeding both initiation and duration, and also mothers’ vitamin use in pregnancy. And both of these outcomes relate to important periods of rest. So, mothers during pregnancy and the child in early infancy, and they measure important aspects of public health. The other outcomes we, king of, grouped into four categories, so we had child weight, we looked at birth weight and low birth weight, prevalence of low birth weight. We looked at child morbidity, so things like preterm birth, hospitalisations in the first year. We were interested in infant and child feeding. We looked at the use of formula milk and cow's milk. We were able to look at the age of introduction of solid food in both the Growing Up in Scotland and the Infant Feeding study data sets. And we also had measures of maternal health, so we had measures of maternal mental health, some physical health, we looked at smoking and alcohol use, and also financial strain.
Anna Pearce:
Wow, that's fantastic. So, can you tell us a bit about the different comparison groups that you looked at in the data analysis? It wasn't as simple as having one exposed and one unexposed group was it?
Ruth Dundas:
You're right, it wasn't that simple. So when evaluating policies that have eligibility criteria, it's quite difficult to find a suitable comparison group because those that are not eligible, even if they're comparable on all other characteristics, obviously differ by the eligibility criteria. And we did try to overcome some of these difficulties by having two different comparison groups. But maybe, before I start getting into the comparison or control groups, I should define what they exposed group was. So, in this case, the exposed group are those women who are in receipt of the Healthy Start vouchers. So, that's those who are eligible and actually claim the vouchers. In the Growing Up in Scotland data set we were able to establish eligibility due to the questions that they asked about income and benefit claims. So, we used those that were eligible for Healthy Start vouchers but not claiming them as one of the comparison groups. And then we were also able to have a second comparison group and these were women who were nearly eligible for Healthy Start vouchers. So, these were women who missed out on the eligibility for Healthy Start vouchers as their income was just above the level for claiming Healthy Start voucher. And then we were able to compare the exposed, so that was those receiving Healthy Start vouchers, to these two groups of eligible but not claiming and then this nearly eligible.
Lia Demou:
Thanks, Ruth. And what did you find?
Ruth Dundas:
For nearly all the outcomes across both the Growing Up in Scotland study and the Infant Feeding study, apart from ever breastfeeding and breastfeeding duration in the Infant Feeding study, the results indicated that there was no effects of the Healthy Start vouchers on these outcomes. For ever breastfed and duration of breastfeeding, there were differences between Growing Up in Scotland and that Infant Feeding study, indicating a negative effect of Healthy Start vouchers on breastfeeding. And so there was about 57% of mothers breastfeeding in the recipients group compared to 70% in the two comparison groups. And there might be different reasons for this. It was self-reported eligibility for the Healthy Start vouchers in the Infant Feeding study, but in GOS we were able to actually use the eligibility criteria from the questions in the survey and define that group ourselves. And we also had a slightly less accurate or less refined measure, I think, of nearly eligible. So again, in the Growing Up in Scotland study, we knew the income levels we were able to use that as nearly eligible. But in the Infant Feeding study, we had to use a kind of like area based measure of nearly eligible. For the other child outcomes there were differences in effect sizes across the different data sets and comparison groups, indicating that we can't really be sure about the effect of Healthy Start vouchers on these outcomes. However, for maternal mental health, there was no difference in vitamin use across all datasets and comparison groups. But here I think the real key finding was there was high – it was more than 80% vitamin use in all groups. So, that was quite a positive finding. But we did find large differences in smoking rates, so smoking rates in recipients of Healthy Start vouchers was about 40% and that was compared to 34% in the eligible but not claiming group and about 24% in the nearly eligible group. So, quite difference in smoking rates and that really indicated to us that there's more support needed for recipients of Healthy Start vouchers to stop smoking.
Anna Pearce:
How do these findings compare to the results from the qualitative study?
Ruth Dundas:
It was really a nice feature of the project to have the qualitative interview study, because it really enhanced the experience and we were able to get real rich accounts from the participants about their experiences of using the Healthy Start vouchers. The participants in this qualitative study were also from across the exposed and the two different comparison groups. And when analysing these findings from the qualitative study, it did give rise to four key themes. So, there was knowledge and awareness, take up and use of the health Start voucher scheme. We had opinions of the Healthy Start voucher schemes from the mothers and we were able to look at the effects of Healthy Start voucher scheme on diet and feeding choices for their babies and children. And they also talked a lot about the broader lives of these low-income women. And in terms of breastfeeding, the Healthy Start vouchers were not mentioned at all in their decision making around breastfeeding. Women's choice to breastfeed or formula feed was based on a range of other factors, including support to breastfeed and also assumptions and expectations of health professionals. And what we also found as well was that the mothers really valued the Healthy Start voucher scheme and they were able to incorporate them into budgeting strategies for the family and they were seen as a really good support in the context of the lives of these low-income women.
Lia Demou:
What would you say, Ruth, was the biggest challenge you faced during the work?
Ruth Dundas:
Haha. I would say that, as with all research projects, there were a few challenges, but the biggest one for me is the challenge of evaluating these national policies that are already in place. The Healthy Start vouchers is a national policy, but I suppose it's targeted to a particular population. And it was quite difficult to find a suitable control group. There are plenty of families who are not exposed to the policy, but they are not a good control group as they differ from those that are eligible for Healthy Start vouchers. And this lack of obvious control group was a challenge but we did try to overcome that in our design and analysis. We were able to find two existing data sets which identified the exposed group of the mothers claiming the Healthy Start vouchers. Am I allowed another challenge?
Lia Demou:
Sure.
Ruth Dundas:
A further challenge of using existing data sets is that the data not only had to identify the exposed and control or comparison groups, but they also had to collect measures relating to nutrition for mothers and children. And we really had to rely on the measures collected in these existing data sets. So, although our study did address in some way this kind of like nutrition outcomes, we weren't able to measure dietary intake itself for mothers and children. So, that I suppose that's a challenge as well. Making sure the data sets have the information in it that you need.
Anna Pearce:
So, would you say the conclusions are that Healthy Start vouchers are a good investment?
Ruth Dundas:
I mean that is a really good question and it gets the crux of the matter, doesn't it? I think from the evaluation that we've done using existing survey data and examining a whole range of health outcome, it is inconclusive. The null effect of the Healthy Start vouchers on the main outcomes of breastfeeding and vitamin use may be due to the value of the vouchers. It's really insufficient to change the broader lives of low-income women so that they can offer a healthy diet. But having said that, the vouchers were really highly valued by the women that receive them despite the value being quite low at £3.10 per week. I think I said previously that having a good start in life is important for living a healthy life and a longer life, and despite the introduction of many policies aimed at infancy and early childhood, very few of the policies have been evaluated in terms of health outcomes. So, that means there's limited evidence of their impact on health. So, this project, despite its limitations and challenges, as Lia offered me, it has added to the evidence and demonstrated that evaluations can be done. And broader learning from this project really is around using vouchers to influence health behaviour. You know, Healthy Start voucher does attempt to influence health behaviour and this evaluation can inform other policies aiming to change behaviour and use of voucher incentives.
Lia Demou:
Thanks, Ruth. As always, we like to finish by asking our speakers, what are the implications of these findings for inequalities?
Ruth Dundas:
There is certainly growing interest in provision of a minimum income guarantee or universal basic income as something that could reduce health inequalities. And although the Healthy Start voucher scheme is obviously a long way from that, there are some similar features. And in terms of the impact of Healthy Start vouchers and inequalities, the finding that receiving Healthy Start vouchers didn't discourage breastfeeding I think was a positive. And there was a high use of vitamins during pregnancy in all groups, so indicating that some interventions can reach all social groups, including low-income family.
Anna Pearce:
Thanks Ruth. It's been really interesting. And thanks also to everybody listening today. Please look to the podcast notes for more information on the study and the data sets that you've heard Ruth mention. And you can find other episodes in the series on most major podcast platforms by searching for 15 Minutes on Health Inequalities.