Title: Evaluation of the Healthy Start Voucher Scheme in UK: a natural experiment using the Growing Up in Scotland record linkage study and the Infant Feeding Survey
Funder: Chief Scientist Office, Scotland

Abstract: The evaluation of a means tested voucher scheme can inform policy aiming to change behaviour, improve health outcomes and reduce inequalities. Interventions to improve outcomes of pregnancy in low socioeconomic status mothers are important for perinatal and child health and also adult health outcomes. The aim is to evaluate the Healthy Start Voucher (HSV) scheme; does it improve the health of pregnant women and mothers and health outcomes of their children and is it cost effective? We are also interested in reasons for uptake and non-uptake of the HSV scheme. The intervention being evaluated is the HSV scheme; a means tested voucher scheme for pregnant women and mothers with children under four. If these women are in receipt of certain means tested benefits then they are eligible for vouchers to be spent on milk, infant formula milk, fruit and vegetables. In addition women receive free vitamins. All mothers under 18 are eligible for the scheme. By targeting families on low incomes and young mothers, HSV is designed to reduce health inequalities. This evaluation of HSV will be able to assess the impact of HSV on reducing inequalities. The impact on health inequalities by area deprivation, maternal education and marital status will be examined. We propose to have two primary outcome measures one relating to the mother during pregnancy and one relating to the child in early infancy. These are important periods of risk and measure different but important aspects of public health. 1) Pregnancy: vitamin use in pregnancy 2) Early infancy: breast feeding initiation and duration Vitamin use during pregnancy is aiming to create a healthy uterine environment which is important for birth outcomes. In early infancy, breast feeding is beneficial for many aspects of child health and morbidity. An increase in both of these outcomes are the aims of the HSV. Several secondary outcomes from survey data and linked data sets are proposed. These relate to child growth, child morbidity, child feeding and maternal health. This analysis of existing data, incorporates a cost effectiveness analysis enhanced by an embedded qualitative study. There are three main parts to this evaluation: 1) secondary analysis of two existing data sets; 2) economic analysis to assess cost effectiveness; 3) qualitative interview study. The evaluation will take a natural experiment approach and use multiple unexposed groups, including those eligible but not claiming the vouchers and additionally those who just miss the eligibility criteria for HSV in terms of income and age, to assess the effectiveness and cost-effectiveness of the HSV. We will take a multiple analytical approach making use of propensity matching of exposed and unexposed and regression discontinuity to minimise bias inherent in both the study design (non-random allocation of the intervention) and types of analyses. The cost-effectiveness analysis will be based around relating the estimated cost of the intervention relative to the observed benefits of the programme (changes in the primary and secondary outcomes, resource use impacts). Research to understand the processes involved in the take-up or non take-up of HSV will require the collection of additional qualitative data. We propose to carry out interviews with 20 mothers who claim Healthy Start Vouchers and 20 who are eligible but do not claim, to elicit reasons for and experiences of participating and not participating in HSV.

Lay abstract: Evaluation of the benefits of a voucher scheme aimed at low income pregnant women and mothers of young children can help shape policies aimed at changing behaviours, improving health outcomes and reducing health inequalities. This proposal will evaluate the Healthy Start Voucher scheme which is intended to: improve the overall nutrition of pregnant women, increase their intake of fruits and vegetables, encourage breastfeeding and introduce a progressively varied diet when infants are six months old. Healthy Start Vouchers are available to women who are pregnant and to families with children under four years. Those eligible receive £3.10 per week (£6.10 per week for children less than a year old) to spend on milk, fruit and vegetables, as well as free vitamins if they also receive means tested benefits. The study, ‘Growing Up in Scotland’, together with the UK-wide Infant Feeding Survey, will provide public health decision makers with information on the pre- and postnatal benefits of these vouchers by comparing voucher scheme participants (mothers and children) to non-participants. There will be two primary outcomes assessed to measure the impact of the voucher scheme: the mother’s vitamin use during pregnancy, and breastfeeding initiation and duration. Both primary outcomes are aims of the Healthy Start Voucher scheme. Vitamin use during pregnancy helps provide nutrients for the mother and her developing baby. Good nutritional balance is important for birth outcomes. Breastfeeding is beneficial for child health in many ways, e.g. breastfed babies are less likely to be hospitalised in their first year of life. Other outcomes that will be used to assess the impact of the voucher scheme are the child’s weight, health and feeding (all up to age 3 years) and the mother’s health both during and after pregnancy. We will also evaluate whether the Healthy Start Voucher scheme is cost-effective; that is, whether money spent on the scheme by the government produces cost savings in the long term. We will do this by calculating savings created for society resulting from any improvements seen in the health of the mothers and children. We will conduct interviews with families who claim the Healthy Start Vouchers and with those who are eligible for the scheme but do not claim the vouchers. We will focus on understanding why people do or do not claim the vouchers and how the vouchers are used. The results from all three sections of the analyses will help policy-makers to understand if the Healthy Start Voucher scheme is effective in improving the health of low income mothers and their children. Knowledge of whether the scheme is providing value for money will help decision-makers determine where to allocate limited resources. Understanding reasons why people do not claim the vouchers will help to improve the uptake of Healthy Start Vouchers for eligible low income families.

Research activity codes: 3.1 PRIMARY PREVENTION INTERVENTIONS TO MODIFY BEHAVIOURS OR PROMOTE WELL-BEING
Health categories: REPRODUCTIVE HEALTH AND CHILDBIRTH