What is known about the topic
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Take-up of free Healthy Start vitamin vouchers targeted to low-income pregnant women and preschool children in England is very low, despite good food voucher take-up.
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Suggested barriers include low maternal awareness and motivation, poor access, and health professionals’ mixed messaging or disengagement, but universal provision might improve access.
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Qualitative evidence is limited about receiving or facilitating these vitamin vouchers, particularly targeted vs universal access, via children’s centres.
What this paper adds
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Improving presentation, messaging, and practicality of vitamin vouchers may well improve take-up.
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Poor vitamin take-up may well reflect overcomplicated procedures while relying on underfunded centres, organizational goodwill, and families’ resilience.
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Higher ‘universal’ vitamin take-up may well reflect that being vitamin-aware becomes everyone’s business.
Background
The Healthy Start scheme
“absence of leadership and support from senior management, and no coherent strategy for Healthy Start... Health professionals at all levels continue to work in silos, with little cross working.”
Healthy Start vitamins in this last decade
Methods
Design and governance
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—the University of Liverpool’s Faculty of Health and Life Sciences being Sponsor UoL000752 for administration and management, as per Health Research Authority [29];
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—National Research Ethics Service (NRES) (Proportionate Review Sub-Committee, East Midlands–Derby, ref. no. 11/EM/0362);
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—three local research and development (R&D) committees.
Quantifying Healthy Start take-up
Qualitative
Preparation and approach
Interviews
Qualitative data analysis
Observations of practice
Results
Quantitative
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Food voucher take-up decreased marginally from 80.9 to 79.3% but remained moderately high.
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Women’s and children’s vitamin take-up increased slightly, respectively, from 0.2 to 4.3% and 0.5 to 2.5%, but remained very low (Additional file 2).
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Children’s vitamins: 6.3% (376/5961) versus 1.8% (1736/94563) (p < 0.0001, χ2 = 545.2) (Additional file 2).
Qualitative
Why was food voucher take-up more than for vitamin vouchers?
Despite misunderstanding about participating shops (“It’s only like the Asda or… that’s the only place I really know that takes them” EM27-T), food vouchers’ monetary value was crucial:“[The letter] has it all there on the bottom. It told you, you can go to any supermarket and stuff, [ …] if you go to your corner shop you can use them. If you go to Tesco’s, Asda, Sainsbury’s…” EM26-T
The monetary value seemed inadequate though, because “with a £3.10 voucher you are having to pay up three of them together to cover the cost of one powdered milk… normally [needing] one a week…” EM10-U.“…any money that they can get off the shop is great…, but I think if people don’t take vitamins anyway then they’re not likely to go and pick them up at a children’s centre; it’s another thing to remember…” EM40-U
Commissioners explained higher food voucher take-up with reasons for low vitamin take-up.“…she’s £3.10 better off a week… she can go to the shop and actually use it for… fruit and veg and milk so there… whereas for the [vitamin] vouchers she has to go to a health centre, doesn’t she, and pick them up, or a community place [e.g. children’s centre or clinic]…” HP04-U
Why was vitamin voucher take-up so low?
Entitled and non-entitled mothers from both areas were also unaware of vitamin benefits, feeling poorly informed by health professionals (EM06-U, Table 1). A frustrated mother wondered “What was the point!” and stopped seeking further vitamins, feeling “put-off”, after feeling dismissed with, “Alright, here, take these” NEM16-T (also Table 1).“I have seen all these pictures and I thought ‘I wonder what that is?’ and then, when they [health professionals] did actually make me aware, I didn’t realise it is from when you are 12 weeks pregnant… So, I had missed out on all that time, my whole pregnancy, [through] a lack of communication.” EM13-T
Mothers (Universal): Own lack of awareness of the vitamin scheme or receiving vouchers “I got the food ones, but I never got the vitamin vouchers, and this has been going on for two years! All I ever get is the food vouchers and a letter.” EM10-U “…couldn’t remember if I had received any, ‘cause it doesn’t look like a voucher at the top. …by the time a friend told me about it, I was like ‘oh gosh, I will have to use it’, and then they stopped coming [because she returned to work] so I missed out.” EM18-U “No, I only just started getting the vitamin tablets with my second child; …because no one told me.” EM06-U Mothers (Targeted): Own lack of awareness of where to use vouchers and feeling poorly advised “…I’ve always seen the vouchers and thought… ‘oh I will have to find out where you go…’, but I’ve never actually followed it through.” EM30-T “Yeah [I noticed the vitamin voucher]… but it didn’t say where you get them from or how…” EM25-T “No, no one has spoken to me about vitamins. ...and I did actually go and ask my GP because… I was slightly overweight, so… […] she basically just told me to join Weight Watchers, and I wasn’t given any other advice at all.” NEM16-T Health professional (Universal): Mothers’ lack of awareness of vitamin vouchers “I wonder how much notice people take of it because it is just an add-on on the form [letter] really” HP04-U Health professional (Targeted): Mothers’ lack of awareness of vitamin/voucher importance When HP14-T highlighted the voucher: “…they say ‘oh yeah I get that all the time’ and when you explain to them that the take-up of the vitamins is really low and that you can get them from here [for free] they are shocked and they go ‘OK’ but they sometimes still don’t come [to the centre] and get them. I don’t think they understand the relevance or the importance...” HP14-T Commissioner (Universal): Mothers’ lack of awareness of vitamin importance “a lot… don’t particularly believe in the need” C03-U Commissioner (Targeted): Health professionals’ lack of awareness of who decided eligibility “I met with health professionals at the hospital… [but] instead of… [discussing] Healthy Start and the vitamins, and getting them signed up, they just said, well, we’re not doing this, because we’ll be making a judgement about the women. They missed the point completely! […] The [HSIU] has the information and will make the decision about eligibility’.” C01-T |
For some entitled mothers in the targeted area, poor vitamin supply discouraged continued use: “[children’s centres] just never have them.” EM26-T. Futile searching for children’s vitamin drops was typical: “everywhere I ask they go ‘we haven’t got them in’, like in the children’s centre…” EM27-T.“I have a friend who has just turned 18 [in January] and she’s pregnant. She can’t get her vouchers until she claims child tax credits. She can’t claim child tax credits because they’ve just changed the rules and her mum has to claim child benefit for her until September… So, the government is expecting her to live, and her baby, to live off £20… [sighs]…” EM38-U
Some health professionals (mainly from targeted area) did not know where mothers could redeem vitamin vouchers: “…there should be a list of addresses…” HP24-T. Some were unclear about the administrative processes:“They probably said ‘oh here you are, you can give these healthy vitamins’.” HP36-T
Health professionals sometimes forgot or attended poorly to discussing the vitamins, particularly blaming inadequate training and perinatal staffing and a crammed consultation:“I had absolutely no idea until last Thursday, that, when you’ve had your baby, in order to get the vitamin drops, you have to let [HSIU] know…” HP02-T
Nevertheless, no-one suggested improving communication between, for example, midwives, health visitors, and social workers to improve their individual and collective agency in the system. Staying connected with close colleagues was hard enough:“We definitely need to cover reducing the risk of cot death… We then talk about immunisations, ask them to sign an intent form for the Child Health department for when the immunisations are due. We talk to them about development checks, their own health, any family history of anything, and we also talk about smoking, alcohol, diet, and smoke alarms, child benefits, and somewhere in there we have to fit in the vitamins! And that’s for a straightforward mum; some of the cases I come across in the community have safeguarding issues and the like.” HP05-U
Complicated administration introduced delay, blocked access, and frustrated staff with the form-filling (chasing applications “for a 97p bottle of vitamins” HP15-T), ‘hidden’ vitamin vouchers, and poor supply:“Even within your own team, […] even when you’re all working towards the same goal, you are working in silos to a degree…” HP08-T
To avoid ‘red tape’, health professionals thought that they should personally hand mothers the vitamins, particularly if vulnerable (“instead of the mothers having to go somewhere else” HP04-U, i.e. to another centre):“…quite frequently I get people ringing me asking me for the Healthy Start number, because they haven’t heard [about their application]…” HP04-U
“…then they have to ‘re-register’† once the baby is born so it’s… a lot of red tape and forms…” HP15-T [†This can be by telephone though.]
Illustrating lack of agency, some health professionals in the targeted area felt frustrated and powerless at being unable to give vitamins to non-entitled families requesting them:“I am working with [a family in a complex situation] and she has had difficulties of obtaining the vitamins, due to [moving] a few times, and she’ll have been backwards and forwards with… in care, and the child is nearly 3 and could have really done with them, and all of the red tape has completely put her off… I have even rang the Department of Health and they can’t speak to me about it, because it’s her…” HP14-T
Commissioners from both areas highlighted aspects of awareness, accessibility, agency, and adequacy of supply, but also accountability. Besides mothers’ lack of vitamin awareness (C03-U, Table 1), commissioners appeared surprised and disappointed at poorly-informed health professionals, particularly in the targeted area. Some health professionals offered no vitamins as they believed mistakenly that:- they had to judge maternal socio-economic status; the vitamins for pregnant women inappropriately contained vitamin A (present in children’s vitamin drops only); or the vitamins were unsuitable for special diets. One commissioner highlighted health professionals’ lack of awareness of decision-making about eligibility (C01-T, Table 1).“…we had a family recently… She was from an ethnic minority and there were definitely some signs [of vitamin D deficiency], and I did recommend that she go to a doctor… she didn’t do that but… …She goes, ‘please just let me buy them’… ‘I can’t because there is a lot of red tape, again, surrounding the purchase of them’. She understood the need [but] all I could do was recommend… her to… find something similar, which was a big, big deal for her.” HP15-T
It was costly for mothers to telephone the HSIU to ask questions or to declare the birth to obtain children’s vitamin drops (albeit simpler than originally having to re-apply):“Healthy Start put a lot of things in those letter packages to people. And originally […] it was one line [about vitamins] on the letter and the writing was very small, but Healthy Start improved the look of the voucher; […] but it still wasn’t as big as the food voucher.” C03-U
Underfunding of local Healthy Start vitamin programmes affected both accessibility and supply, with complicated administrative processes. The commissioners described how the HSIU would fulfil their vitamin orders via the NHS ‘supply chain’ (distribution service), which delivered only to NHS estates. Without extra funding, the commissioners were responsible for local distributors (e.g. children’s centres) receiving vitamins. Delays meant out-of-date vitamins. Commissioners relied on the goodwill of other local distributors to overcome national governance requirements:“women can [now] just make a phone call and say, ‘I’ve had my baby’ […], …but it’s complicated… […] often, women who are in low-income households do not have a landline within their house, and they were using mobiles, […] on premium-rate numbers…” C01-T
“Through seeking the help of Estates [in the commissioning organization], we identified a local mailing van, like the NHS mail-van that goes from clinic to clinic. We identified one that goes from children’s centre to children’s centre. This really made distribution of the vitamins simple.” C03-U
Within commissioning, their ‘collective agency’ was over-reliant on goodwill to ensure vitamin distribution via hospitals and rather resistant general practices: “how much are you going to give me for doing this?” C01-T. Logistics were tricky:“Estates were involved in distribution of the vitamins ‘cause there was a lot of governance issues because we had NHS providing to the local authority […]. …but the way that we worked, it worked absolutely fabulously […] …Department of Health kept on saying to us – no you can’t do this because [of] governance issues, whilst it worked for us.” C22-U
Children’s vitamin drops were a medicine (not a supplement), requiring local pharmaceutical approval. One commissioner worked around this with local Medicines Management:“…[NHS] people… say, ‘hang on a minute, you are asking me to do something that’s out of my job description!’ And […] the Department of Health had never thought this through properly… […] This was all supposed to be done out of goodwill!” C01-T
Commissioners from both areas were frustrated at the ad hoc vitamin supply affecting take-up:“…we had one of their managers… arranged… approval for us to order through her, so everything was purchased up front, everything was distributed from Medicines Management, and then the accountant […] put [that] in as a return.” C01-T
Commissioners believed that improved vitamin take-up required more accountability. One commissioner was astonished that the HSIU did not “want to know if the vitamins actually got to mothers; all they want is purchase data” C01-T. Regular steering-group meetings in both areas encouraged accountability for vitamin distribution and take-up. In the targeted area, local authority staff in children’s centres appeared more engaged than NHS staff, possibly because local authority targets and inspections included Healthy Start vitamin performance:“…health visitors were reluctant to tell somebody to go and get something that they thought was highly likely not to be there for them. So, even when you had them stocked, they’d end up in the bin, because no one claimed them; we were paying to throw vitamins in the bin…” C03-U
The HSIU was unconvinced about challenging ‘nought returns’: “I think it would be unheard of for a government department to legally challenge another bit of the same public sector” DH44-HSIU. One commissioner from the universal area believed that ‘nought returns’ reflected that “it is too costly for them to [file the return]” C03-U.“Children’s centres […] have ‘OFSTED’ inspections… Distributing Healthy Start vitamins is another way that they can show that they’re being beneficial to the community…” C01-T
Why might vitamin voucher take-up be more in the universal area?
Mothers (Targeted): Accessibility and Adequacy of supply “I try [to use the vitamin vouchers], if you can get them for free, you’ve seen I’ve got the voucher right here… but… I don’t know whether it’s because of the cutbacks or whether they’ve just stopped sending them, but the [children’s] centres where I go [to] ask for them—they just never have them.” EM26-T “There was nowhere really to get them. Every time I’d ask in the doctors’ they said, ‘see your midwife’, and the midwife told me to look on the internet, but I haven’t got any internet at home… I have never ever got the vitamins because I don’t know where to get them from or anything…” EM27-T Health professionals (Universal): Awareness and Accessibility “…available in every children’s centre so that’s… six… within a radius of about ten miles? So they’re quite freely available […] from the receptionist…” HP05-U. “Now locally […] [mothers are] given a form to come and get vitamins… from the children’s centre… […] Often I will give one of those forms to everybody because it means they can go and get them straight away because Healthy Start when you apply [takes ages] to come through.” HP04-U Commissioner (Universal): Accessibility and Adequacy of supply When the universal area had been a targeted area: “The clinic staff [receptionists] outside here, because they were very rarely asked for [the vitamins], or would forget [to ask mothers for the voucher], and they would go out of date… And managers would just stop stocking them… they’d just fall off the agenda.” C03-U Overclaiming did not explain higher vitamin take-up. Reimbursement claims related only to entitled mothers: “We keep a spreadsheet …from each children’s centre… mark E for eligible or L for local…” C03-U [Mothers could only use either the locally produced or national voucher.] Commissioner (Targeted): Attention (prioritizing) Key stakeholders paid insufficient attention to improving vitamin take-up. A working group lacked midwife and GP engagement and “we failed miserably” C01-T to engage an accountant to help file HSIU returns. That commissioner also wanted more active listening from: “[the Department of Health] …get people from different parts of the country, sit down and talk to them and say, OK, what, what are our barriers?” C01-T |
Discussion
Strengths/limitations/implications
They concluded that the scheme “has not been consistently supported either nationally or locally”(p69) and benefits system changes have not undergone impact assessment for Healthy Start. They recommended commissioning “a regular review of the effectiveness of the Healthy Start scheme in achieving its public health goals”(p17) and commissioning SACN or National Institute for Health and Care Excellence (NICE) to advise “on reformulating the Healthy Start vitamins as primarily vitamin D supplements”(p15).“a new era of child poverty and family food insecurity […] The reduction in the number of families eligible for Healthy Start appears incongruous against this backdrop of increasing hardship among low-income families.”