Evaluation of the Healthy Start voucher scheme on maternal vitamin use and child breastfeeding: a natural experiment using data linkage
Authors: Dundas Ruth , Boroujerdi Massoud , Browne Susan , Deidda Manuela , Bradshaw Paul , Craig Peter , McIntosh Emma , Parkes Alison , Wight Daniel , Wright Charlotte , Leyland Alastair H 
Published: April 2023

BackgroundHaving a good start in life during pregnancy and infancy has been shown to be important for living both a healthy life and a longer life. Despite the introduction of many policies for the early-years age group, including voucher schemes, with the aim of improving nutrition, there is limited evidence of their impact on health.ObjectivesTo assess the effectiveness of the Healthy Start voucher scheme on infant, child and maternal outcomes, and to capture the lived experiences of the Healthy Start voucher scheme for low-income women.DesignThis was a natural experiment study using existing data sets, linked to routinely collected health data sets, with a nested qualitative study of low-income women and an assessment of the health economics.SettingRepresentative sample of Scottish children and UK children.ParticipantsGrowing Up in Scotland cohort 2 (n= 2240), respondents to the 2015 Infant Feeding Study (n= 8067) and a sample of 40 participants in the qualitative study.InterventionsThe Health Start voucher, a means-tested scheme that provides vouchers worth £3.10 per week to spend on liquid milk, formula milk, fruit and vegetables.Main outcome measuresInfant and child outcomes – breastfeeding initiation and duration; maternal outcomes – vitamin use pre and during pregnancy.ResultsThe exposed group were women receiving the Healthy Start voucher (R), with two control groups: eligible and not claiming the Healthy Start voucher (E) and nearly eligible. There was no difference in vitamin use during pregnancy for either comparison (receiving the Healthy Start voucher, 82%; eligible and not claiming the Healthy Start voucher, 86%;p= 0.10 vs. receiving the Healthy Start voucher, 87%; nearly eligible, 88%;p= 0.43) in the Growing Up in Scotland cohort. Proportions were similar for the Infant Feeding Study cohort (receiving the Healthy Start voucher, 89%; eligible and not claiming the Healthy Start voucher, 86%;p= 0.01 vs. receiving the Healthy Start voucher, 89%; nearly eligible, 87%;p= 0.01); although results were statistically significantly different, these were small effect sizes. There was no difference for either comparison in breastfeeding initiation or breastfeeding duration in months in Growing Up in Scotland, but there was a negative effect of the Healthy Start voucher in the Infant Feeding Survey. This contrast between data sets indicates that results are inconclusive for breastfeeding. The qualitative study found that despite the low monetary value the women valued the Healthy Start voucher scheme. However, the broader lives of low-income women are crucial to understand the constraints to offer a healthy diet.LimitationsOwing to the policy being in place, it was difficult to identify appropriate control groups using existing data sources, especially in the Infant Feeding Study.ConclusionsAs the Healthy Start voucher scheme attempts to influence health behaviour, this evaluation can inform other policies aiming to change behaviour and use voucher incentives. The null effect of Healthy Start vouchers on the primary outcomes may be due to the value of the vouchers being insufficient to change the broader lives of low-income women to offer a healthy diet.Future workThe methods developed to undertake an economic evaluation alongside a natural experiment using existing data can be used to explore the cost-effectiveness of the Healthy Start voucher scheme.FundingThis project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme and will be published in full inPublic Health Research; Vol. 11, No. 11. See the NIHR Journals Library website for further project information.