title: Can food vouchers improve nutrition and reduce health inequalities in low-income mothers and young children: a multi-method evaluation of the experiences of beneficiaries and practitioners of the Healthy Start programme in England.
abstract: BACKGROUND
  Good nutrition is important during pregnancy, breastfeeding and early life to optimise the health of women and children. It is difficult for low-income families to prioritise spending on healthy food. Healthy Start is a targeted United Kingdom (UK) food subsidy programme that gives vouchers for fruit, vegetables, milk, and vitamins to low-income families. This paper reports an evaluation of Healthy Start from the perspectives of women and health practitioners.
  
  
  METHODS
  The multi-method study conducted in England in 2011/2012 included focus group discussions with 49 health practitioners, an online consultation with 620 health and social care practitioners, service managers, commissioners, and user and advocacy groups, and qualitative participatory workshops with 85 low-income women. Additional focus group discussions and telephone interviews included the views of 25 women who did not speak English and three women from Traveller communities.
  
  
  RESULTS
  Women reported that Healthy Start vouchers increased the quantity and range of fruit and vegetables they used and improved the quality of family diets, and established good habits for the future. Barriers to registration included complex eligibility criteria, inappropriate targeting of information about the programme by health practitioners and a general low level of awareness among families. Access to the programme was particularly challenging for women who did not speak English, had low literacy levels, were in low paid work or had fluctuating incomes. The potential impact was undermined by the rising price of food relative to voucher value. Access to registered retailers was problematic in rural areas, and there was low registration among smaller shops and market stalls, especially those serving culturally diverse communities.
  
  
  CONCLUSIONS
  Our evaluation of the Healthy Start programme in England suggests that a food subsidy programme can provide an important nutritional safety net and potentially improve nutrition for pregnant women and young children living on low incomes. Factors that could compromise this impact include erosion of voucher value relative to the rising cost of food, lack of access to registered retailers and barriers to registering for the programme. Addressing these issues could inform the design and implementation of food subsidy programmes in high income countries.
authors: Research Fellow, College of Medicine, Dentistry and Nursing, University of Dundee, 11 Arlie Place, Dundee DD1 4HJ, UK. a.m.mcfadden@dundee.ac.uk.
authors: Alison
authors: A
authors: McFadden
authors: Josephine M
authors: JM
authors: Green
authors: Victoria
authors: V
authors: Williams
authors: Jenny
authors: J
authors: McLeish
authors: Felicia
authors: F
authors: McCormick
authors: Julia
authors: J
authors: Fox-Rushby
authors: Mary J
authors: MJ
authors: Renfrew
mesh_terms: D000328:Adult; D002675:Child, Preschool; D004032:Diet; D004739:England; D005260:Female; D017144:Focus Groups; D005502:Food; D005638:Fruit; D006293:Health Promotion / Q000379:methods*; D054624:Health Status Disparities; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D009035:Mothers; D009752:Nutritional Status; D011203:Poverty; D011247:Pregnancy; D011632:Public Assistance; D012959:Socioeconomic Factors; D006113:United Kingdom; D014675:Vegetables; D055815:Young Adult