Jennie Parnham shares insights into an evaluation of Healthy Start, a food assistance policy in England.
Low-income children have a much lower chance of eating a healthy diet than more affluent children, as highlighted by the recent campaigning of Marcus Rashford.
The causes of this disparity are very complex. It’s also important to say that although it’s more likely, it’s not deterministic. Many children of all backgrounds have a healthy diet. However, unfortunately factors tend to cluster together, making a healthy diet less likely for some. Let’s consider a single parent with a young child. One-third of children in single parent households live in poverty and it can cost up to 75% of their disposable income to buy the recommended food for a healthy diet. This is because healthy food is three times more expensive than less healthy foods. In their neighbourhood, there might be more places to buy ultra-processed fast food than healthy food. Finally, they may have less time to prepare healthy food, as there are fewer helping hands at home. In this environment, many families find their options for healthy eating limited.
What is the Government doing to help?
The Healthy Start scheme is an example of a food assistance policy in England. It provides vouchers to low-income pregnant women and children aged 0-3 years. The vouchers are worth £4.25/week and can be spent on plain fruit, vegetables and legumes, infant formula, and cow’s milk. Despite being in place since 2006, there has been little evaluation of the scheme, so not enough is known on whether the scheme is effective.
For example, one study demonstrated that when the programme was first implemented it was associated with positive impacts on families’ fruit and vegetable consumption. But this study only looked at the years 2006-08. Since then the voucher value has increased, from £2.80/week in 2006 to £4.25/week in 2021. These changes coupled with rising inflation mean that this study may no longer be applicable.
Policymakers need to know who is participating in Healthy Start, how families are using the vouchers and whether this is helping to increase the purchasing of fruit and vegetables in low-income households and reduce inequalities in healthy eating.
To answer these questions, my colleagues and I at the Public Health Policy Evaluation Unit along with colleagues from the University of Bristol, analysed household expenditure data (Living Costs and Food Survey years 2010-2017) and described the characteristics of households who participated in Healthy Start, such as whether they contain pregnant women or children. We tested if the vouchers were effective by comparing the food expenditure in households who received the vouchers and similar low-income families who did not. Our findings were recently published in BMC Public Health.
What did we find?
Uptake of Healthy Start vouchers was low.
We found that only 54% of eligible households used the scheme. Pregnant women were less likely to participate than households with children, in similarity with qualitative research with participants.
The vouchers were not associated with higher food purchases
We found no difference in the amount of fruit and vegetables purchased in households who use the vouchers compared to eligible households who did not. Also, there was no difference in the total food expenditure between participating and eligible non-participating households, suggesting the vouchers were used to help families buy their normal shopping, freeing up money in their budget to be spent elsewhere.
The vouchers may have had a positive impact on infant feeding practices
We found that households who received the vouchers spent less on infant formula than households who did not, indicating the vouchers may not discourage breastfeeding, as was feared by some public health practitioners. This is consistent with other research on the vouchers.
Looking forward: what would help?
So, we found that the vouchers were not associated with higher food purchases in households who received them compared to households who did not. Does that mean we should throw the baby out with the bathwater and scrap the scheme? In my view, no.
Our research covered a period when the vouchers were lower than they are now (£3.10/week) and had not been raised for some time. It is likely that inflation of the price of fruit and vegetables over the study period (2010-2017) effectively lowered the value of the voucher. As the vouchers were increased to £4.25/week in April 2021, they may now better enable households to buy more fruit and vegetables. This is a key area for future research.
Also, our research highlights important areas to increase programme uptake. Healthy Start uptake has been falling in England since 2011. Policy makers should focus on improving awareness in eligible pregnant women to ensure more people get the benefit of the vouchers, for a greater period, a point supported by Marcus Rashford and the National Food Strategy
Food assistance in the UK
There is no silver bullet for addressing inequalities. Healthy Start is just one steppingstone; it does not address all causes of dietary inequities. Other action in this area includes a recent expansion of a Holiday Activities and Food programme for low-income children and local authority restrictions on fast-food outlets. However, regular evaluation of the policies in place, such as Healthy Start, are needed to ensure that we are doing the best we can with the money that we spend.
Jennie Parnham is a NIHR SPHR funded PhD student in the Public Health Policy Evaluation Unit.
‘Is the healthy start scheme associated with increased food expenditure in low-income families with young children in the United Kingdom?‘ by Parnham et al and published in BMC Public Health.
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