An exploration of the UK Healthy Start vitamin supplementation programme in North West England

Abstract

Background: The UK Healthy Start (HS) programme is a means-tested nutritional supplementation programme providing food (FV) and vitamin vouchers (VV) for children under the age of four years and pregnant and breastfeeding women. FV can be used for fruit, vegetables, fresh cow’s milk, and infant formula. VV can be exchanged for women’s tablets (folic acid, vitamin C and D) and children’s drops (vitamin A, C and D). The gap in the prior evidence-base since the launch of the HS programme was that no comparison was made in the take-up of vitamins between areas that used the universal versus targeted approach. Aim and objectives: The overarching aim of this study was to investigate the effect of a targeted versus universal implementation approach on the take-up of vitamins amongst the population ‘targeted’ by the Department of Health, i.e. low-income families. Thesis objectives: 1) identify differences in HS VV uptake between a demographically similar targeted and universal area and 2) explore the explanatory factors as perceived by potentially eligible mothers, HS healthcare professionals, and commissioners for similarities and differences in vitamin take-up between these two areas. Design: Sequential explanatory mixed-methods within a pragmatism paradigm. Secondary analysis of DH routine data of HS VV uptake for areas using a universal and targeted implementation approach. Findings from the quantitative data analysis drove the design of the study’s second-phase, which used semi-structured interviews. Setting: Two local health administrative areas (LHA) in North West England (NWE). Participants: Analysis - quantitative data for 22 LHA in NWE. Purposive samples of 25 potentially eligible mothers, 11 HS healthcare providers, three HS commissioners, and three DH HS unit coordinators. Results: Overall, VV uptake was low, with FV take-up consistently higher. The highest FV take-up recorded was 80.3%; the highest VV take-up was 7.3% and 3.6% for women and children, respectively. The uptake of both women’s and children’s VV in the universal area was significantly higher compared with the targeted area: 6.3% versus 1.6%, p < 0.001 and 3.2% versus 1.2%, p < 0.001, respectively. Mothers reported that HS vitamins were more accessible and healthcare professionals were more aware of the provision of HS vitamins in the universal area. Healthcare professionals in the universal area found it easier to remember to discuss HS vitamins at every consultation with a mother. Commissioners experienced the HS vitamin implementation process as bureaucratically cumbersome; the commissioner from the universal area had more engagement from key stakeholders. Conclusion: The take-up of the UK HS vitamin programme was very low, albeit significantly higher in the universal area. A UK-wide universal implementation approach will not on its own increase vitamin uptake to meaningful levels. Implementation process-steps and environmental factors need to be addressed to achieve meaningful progress in reducing health inequalities in vitamin D-related health.