An exploration of the statutory Healthy Start vitamin supplementation scheme in North West England

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While universal implementation probably requires a more extensive scheme to be cost-effective, the everyday experience of different ways of receiving or facilitating Healthy Start, especially via children’s centres, also requires further evidence. This study therefore aimed to explore (in the context of low take-up levels) perceptions of mothers, health professionals, and commissioners about Healthy Start vitamin and food voucher take-up and compare experiences in a targeted and a universal implementation-area for those vitamins. Methods Informed by quantitative analysis of take-up data, qualitative analysis focused on 42 semi-structured interviews with potentially eligible mothers and healthcare staff (and commissioners), purposively sampled via children’s centres in a similarly deprived universal and a targeted implementation-area of North West England. Results While good food voucher take-up appeared to relate to clear presentation, messaging, practicality, and monetary (albeit low) value, poor vitamin take-up appeared to relate to overcomplicated procedures and overreliance on underfunded centres, organizational goodwill, and families’ resilience. Conclusion Higher ‘universal’ vitamin take-up may well have reflected fewer barriers when it became everyone’s business to be vitamin-aware. Substantive Healthy Start reform in England (not just cosmetic tinkering) is long overdue. Our study highlights that ‘policy, politics, and problem’ should be aligned to reach considerable unmet need. 237 words Health Economics & Outcomes Research Environmental Policy Health Policy child preschool England Healthy Start food subsidy food voucher health inequalities mothers nutrition poverty universal and targeted services vitamins What Is Known About The Topic Take-up of free Healthy Start vitamin vouchers targeted to low-income pregnant women and pre-school children in England is very low, despite good food voucher take-up. Suggested barriers include low maternal awareness and motivation, poor access, and health professionals’ mixed messaging or disengagement, but universal provision might improve access. Qualitative evidence is limited about receiving or facilitating these vitamin vouchers, particularly targeted vs universal access, via children’s centres. What This Paper Adds Improving presentation, messaging, and practicality of vitamin vouchers may well improve take-up. Poor vitamin take-up may well reflect overcomplicated procedures while relying on underfunded centres, organizational goodwill, and families’ resilience. Higher ‘universal’ vitamin take-up may well reflect that being vitamin-aware becomes everyone’s business. Background As health inequalities continue to widen in the United Kingdom (UK), government nutritional welfare support from the ‘Healthy Start’ scheme for pregnant women and preschool children remains crucial to health improvement. Poverty-related food insecurity has increased over the last decade , with low-income households facing complex cost, access, and availability barriers to healthy eating 1 , . Sure Start ‘children’s centres’ for preschool child and family support have facilitated Healthy Start implementation in England, including maternal information and advice. Children’s centres have been particularly effective in disadvantaged areas but have progressively dwindled 1,3 since ringfenced funding ended (2011) exposing them to government austerity. In England, Marmot et al.’s 2020 ten-year review of health equity 1 has recommended re-investing in early years’ services, including children’s centres. In the COVID-19 pandemic, children’s centres have helped in referring low-income families for foodbank support and in distributing food or vouchers, when schools are closed, to children eligible for free school meals , . The Healthy Start scheme In 2006, Healthy Start replaced the Welfare Foods Scheme (established during wartime rationing in 1941, complementing the 1940 National Milk Scheme) to improve maternal and child health. Welfare Foods started as universal provision but was later subsidized and then ‘targeted means-tested’ like Healthy Start. The first major scientific review of Welfare Foods recommended urgent improvement in vitamin distribution and uptake . From the outset, entitled low-income families with children under 4 (under-4s), low-income pregnant women, and pregnant females under 18 (under-18s) received monetary Healthy Start ‘food vouchers’ by post. These paid for cow’s milk, infant formula milk, fruit, or vegetables at registered retailers. The food vouchers may have improved maternal nutrition more than Welfare Foods , , . They may well promote fruit and vegetable consumption , although evidence is conflicting . Additional ‘vitamin vouchers’ were exchanged for Government-commissioned children’s drops (6−48 months: vitamins A, C, D) and pregnant and lactating women’s tablets (folic acid; vitamins C, D). Locally arranged vitamin distribution-points included children’s centres and community health clinics. There was initial concern about the Healthy Start design and implementation for nutritional support , . Furthermore, piloting had revealed (p2) : 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 In February 2012, the four UK chief medical officers (CMOs) were concerned about vitamin D deficiency in at-risk groupsࣧpregnant and breastfeeding women, under-5s, 65-years-and over, and people with insufficient sun exposure. They reminded primary care health professionals that Healthy Start vitamins included vitamin D and were crucial for the public’s health , but low take-up needed tackling 7,16 , . By 2016, the Scientific Advisory Committee on Nutrition (SACN) was recommending whole-population vitamin D supplementation for musculoskeletal health (regarding rickets, osteomalacia, falls, and muscle strength and function). By January 2021, in recognition of more time indoors during the pandemic, clinically extremely vulnerable people and care home residents were receiving free vitamin D supplementation . England’s CMO did contemplate making Healthy Start vitamin provision universal . In 2012, Moy et al. reported observational evidence from Birmingham (high proportion of high-risk ethnic minorities) suggesting that changing from targeted to universal Healthy Start vitamins could reduce symptomatic vitamin D deficiency and increase public awareness about vitamin D . This was despite vitamin take-up only increasing to 17% of pregnant women and preschool children. The only previous similar evidence involved Glasgow’s vitamin D supplementation for British Asian children, which significantly reduced rickets . Evidence is limited but suggests that low Healthy Start vitamin take-up is associated with: mixed messages about early years’ vitamin D requirements ; health professionals not promoting Healthy Start , ; low parental awareness about vitamin importance 21,24 and the Healthy Start programme and vitamins 25 , ; low maternal motivation to use vitamins 24 ; poor vitamin access 24,25 ; and obstructive application procedures and logistically complicated distribution 23,24,25 . Calls for universal implementation 23 require further evidence from everyday experience of receiving or facilitating Heathy Start, especially via children’s centres. This study therefore aimed to explore (in the context of low take-up levels) perceptions of mothers, health professionals, and commissioners about Healthy Start vitamin and food voucher take-up and compare experiences in a targeted and a universal implementation-area for those vitamins. Methods Design and governance Within the pragmatism paradigm, this sequential explanatory mixed-methods study (labelled as per Ivankova et al. ) comprised qualitative analysis of 42 semi-structured interviews with mothers and professionals, about Healthy Start voucher take-up, informed by quantitative analysis ( Additional file 1 ). The latter used the percentage voucher ‘take-up’ extracted from quarterly data around the time of the interviews, requested from the Healthy Start Issuing Unit (HSIU) (Department of Health) . Interviews were in North West EnglandࣧArea-1: universal vitamin implementation-area (one of two), Area-2: targeted implementation-areaࣧclosely located, both in the most deprived fifth of local authorities, with similar life expectancies and childhood obesity, but Area-2 had a larger and younger population. Governance involved: -the University of Liverpool’s Faculty of Health and Life Sciences being Sponsor UoL000752 for administration and management, as per Health Research Authority ; -National Research Ethics Service (NRES) (Proportionate Review Sub-Committee Committee East Midlands–Derby, ref no. 11/EM/0362); Quantifying Healthy Start take-up Basic descriptive epidemiology compared take-up between English regions and between the North West primary care trust (PCT) areas, which included between universal (n=2) and targeted (n=22) implementation-areas ( Additional file 2 ). Analysis used Chi-squared test (IBM-SPSS v20). Qualitative Preparation and approach Quantitative findings and pilot interviews (two commissioners, two midwives, one mother) influenced topic-guide and participant information-sheet development. The topic-guide allowed flexible semi-structured interviews, including in-depth exploration of unanticipated topics. One author (MM) interviewed the all-female participants on NHS or local authority premises or via telephone (February−September 2012), with written or electronic consent, highlighting the information-sheet, confidentiality, and ability to withdraw without detriment. Data saturation was progressively sought at the level of individual interviews and the overall dataset. Voice-recordings were deleted after transcripts were checked. Tong et al.’s checklist guided reporting, implicitly or explicitly. Regarding two of the 32 items though, there was no participant-checking of transcripts or findings. Interviews Mothers’ (n=25: 11 universal area; 14 targeted area) interviews involved a diverse purposive sample of potentially eligible Healthy Start beneficiaries, whether entitled (application accepted) or not, i.e. English-speaking mother of an under-4-year-old, attending one of six children’s centres (universal area: two; targeted area: four). The six children’s centre managers facilitated recruitment. MM briefed mothers (identified by midwife interviewees or visiting mothers) by telephone or in infant-toddler groups. Three mothers refused interviews. Participants confirmed if they were Healthy Start-entitled or not. Health professionals (n=11: 5 universal area; 6 targeted area) : All local authority-employed health professionals working with Healthy Start vitamins participated. Midwives and health visitors (n=8) mostly chose telephone-interview and health promotion officers (n=3) chose face-to-face interview at the centre. Commissioners and national HSIU staff (n=6) Interviews were with the Healthy Start commissioners (n=3) from Area-1 and Area-2 and, giving a second perspective, from the only other North West universal implementation-area (Area-3) plus the three national HSIU staff for context. No-one declined. Qualitative data analysis Qualitative analysis of anonymised transcripts used QRS-NVivo v9.2 and followed the tenets of Ritchie and Spencer’s framework approach , particularly its ‘diagnostic’ (why things are so) and ‘evaluative’ (what affects effectiveness) aspects. Familiarization with the raw data (immersion) and field-notes identified emergent and recurrent themes . Abstracting, conceptualizing, discussing between co-authors, and coding five transcripts generated and refined iteratively a thematic framework of deductive (from topic-guide) and inductive components. Full analysis included indexing and charting (case-charts, theme-charts). Mapping sought associations, wide-ranging experience, and exceptions. Observations of practice At each children’s centre, MM gained permission to review the content of the locked vitamin cupboard ( Additional file 2 ). MM checked availability and cost of similar vitamins at the nearest pharmacy. Results Quantitative Take-up of food vouchers exceeded vitamin vouchers considerably, vitamin take-up remained very low, but food and vitamin voucher take-up appeared higher in the universal versus targeted areas of the North West ( Additional file 2 ). Qualitative The qualitative component explored why these observed differences in take-up arose. (N)EM=(non-)entitled mother; HP=health professional; C=commissioner; DH=Department of Health; universal=U, targeted=T Why was food voucher take-up more than for vitamin vouchers? Mothers explained higher food voucher take-up mostly in terms of awareness, accessibility, and acceptability. Those vouchers were conspicuous in the letter and straightforward (“ brilliant ” EM18−U ) to use: “[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 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: “…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 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 Health professionals also mostly explained higher food voucher take-up in terms of awareness, accessibility, and acceptability. Echoing mothers, they mentioned better visibility (“ much more noticeable” HP04−U ) in the letter plus practical and monetary value: “…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 Commissioners explained higher food voucher take-up with reasons for low vitamin take-up. Why was vitamin voucher take-up so low? Mothers explained low vitamin take-up in terms of suboptimal awareness (and attitude) ( Table 1 ), accessibility, acceptability, and adequacy of supply. Mothers in both areas were unclear on eligibility, overlooked receiving the national vitamin vouchers, and mentioned ‘missing out’: “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 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 ). Table 1: Why was vitamin voucher take-up so low? Lack of ‘awareness’ theme: Illustrative quotations Mothers (Universal) re: 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) re : 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) re : 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) re : Mothers’ lack of awareness of importance of vitamins or vouchers 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) re : Mothers’ lack of awareness of importance of vitamins “a lot… don’t particularly believe in the need” C03−U Commissioner (Targeted) re : Health professionals’ lack of awareness of who decided mothers’ 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 From interviews in 2012 with potentially eligible mothers, health professionals, and commissioners about Healthy Start (in a universal and a targeted area in North West England) (N)EM=(entitled mother; HP=health professional; C=commissioner; universal=U, targeted=T HSIU=Healthy Start Issuing Unit The letter did not say where to obtain the vitamins and mothers did not recall being told, particularly in the targeted area: “I now know it was my midwife who should have told me from day one!” EM13−T. Some entitled mothers were aware of receiving the vitamin vouchers but did not use them ( EM30−T, EM25−T , Table 1 ). Dissatisfaction with taste ( “too chalky” EM38−U ) or palatability (“I just throw up” EM06-U ) also stopped vitamin use. Complicated administrative processes and perceived unfairness also caused dissatisfaction: “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 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 Health professionals from both areas also explained low vitamin take-up in terms of suboptimal awareness (of mothers and health professionals), accessibility, attention, agency, and adequacy of supply (but not acceptability). The vitamin voucher ‘hidden in plain sight’ was a substantial barrier ( HP04−U , Table 1 ). One health professional attributed poor maternal awareness of vitamin benefits to lower socio-economic status and education ( HP14−T , Table 1 ). From universal and particularly targeted areas, health professionals lacked knowledge (e.g. which vitamins; from where; or whether suitable for special diets). Some health professionals knew of colleagues withholding the vitamins through misunderstanding the constituents (mistakenly “thought vitamin A was in the pregnant woman’s [vitamin tablets] ” HP02−T ), blaming this on suboptimal training. Vitamin vouchers were not a priority in consultations (“we midwives can be quite precious about our time” HP05−U) or training: “They probably said ‘oh here you are, you can give these healthy vitamins’.” HP36−T 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: “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 Health professionals sometimes forgot or attended poorly to discussing the vitamins, particularly blaming inadequate training and perinatal staffing and a crammed consultation: “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 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: “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 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: “…quite frequently I get people ringing me asking me for the Healthy Start number, because they haven’t heard [about their application]…” HP04−U 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): “…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.] “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 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: “…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 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 ). Commissioners also cited poorly visible vitamin vouchers. One commissioner who had worked in the universal area since Healthy Start began highlighted improvements though: “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 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): “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 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: “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 “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 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: “…[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 Children’s vitamin drops were a medicine (not a supplement), requiring local pharmaceutical approval. One commissioner worked around this with local Medicines Management: “…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 from both areas were frustrated at the ad hoc vitamin supply affecting take-up: “…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 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: “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 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. Why might vitamin voucher take-up be more in the universal area? Higher vitamin take-up (albeit still low) in the universal area related to awareness (staff), accessibility, attention (priority), and adequacy of supply ( Table 2 ). Mothers from the universal area reported that they could exchange vouchers for vitamin tablets or drops in several places ( “I can get them here [children’s centre]; there’s lot of places I could get them” EM09−U ), and the process appeared easy and immediate (“they just gave me this… yellow card [a local card], and each time you come you have to have it signed” NEM19−U; “went to a weaning group and they told us… [and] we got them [there]” NEM12−U ). This accessibility and adequacy of supply contrasted with mothers’ frustration in the targeted area at the ‘mystery’ of supply. Health professionals in the universal area seemed more knowledgeable about vitamin access, which they considered to be timely but might improve “if midwives actually had them...” HP04−U to provide at the ‘booking-in’ (first) consultation. Commissioners in the universal area considered that offering Healthy Start vitamins to all women raised staff awareness because previously, when their Healthy Start was targeted, access and adequacy of supply suffered. Table 2: Why might vitamin voucher take-up be more in the universal area? Illustrative quotations of themes 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 themࣧthey 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 From interviews in 2012 with potentially eligible mothers, health professionals, and commissioners about Healthy Start (in a universal and a targeted area in North West England) EM=entitled mother; HP=health professional; C=commissioner; universal=U, targeted=T HSIU=Healthy Start Issuing Unit Discussion This study has shown that the national vitamin vouchers were hidden in plain sight, evading busy mothers and staff caught in an overcomplicated system. Poor Healthy Start vitamin take-up from the statutory scheme was linked to precarious, overcomplicated procedures that confused, frustrated, or escaped its main stakeholders. Scheme success relied on underfunded children’s centres, organizational goodwill, and the resilience of participating families. Food and vitamin voucher take-up was significantly higher in the universal administration-areas of the North West compared with the remaining areas. It seems likely that barriers, including stigma about targeted use of children’s centres , decrease when the vitamins become everyone’s business. Studying mothers’, health professionals’, and commissioners’ perceptions about Healthy Start take-up suggested that take-up was consistently much higher for food than vitamin vouchers because the food vouchers had clearer presentation and messaging and had practical and monetary (albeit low) value. Barriers to vitamin take-up included suboptimal awareness (and attitude) of mothers and staff, attention to its priority, accessibility, acceptability, and adequacy of supply. All pregnant women in Scotland have qualified for free Healthy Start vitamins since April 2017 , . Attempts to improve England’s scheme have continued, e.g. more obvious vitamin vouchers and the food voucher covering pulses and frozen vegetables, but the scheme remains broadly similar to when our study was undertaken in 2012. Digitizing vouchers has been delayed until late 2021. While the food voucher works better than a cash-equivalent benefit 9 , , and its subversion is probably uncommon , its monetary value has progressively lagged food costs 12,25 . From April 2021, the weekly food voucher increased from £3.10p (since 2009) to £4.25p (matching Scotland) . Low food voucher value might explain falling take-up over this last decade. By the beginning of 2020 and 2021, take-up was only 54% and 53% in England and 54% and 54% in the North West, respectively 28 , i.e. down about one-quarter on 2012/13 (Quarter 1 (Q1): 70% and 73%, Additional file 2 ). Jessiman et al. found that midwife reminders about Healthy Start eligibility were patchy and beneficiaries easily fell off the scheme, especially by not reporting the birth 24 . Furthermore, health professionals may well progressively add well-intentioned edicts (to avoid fraud or non-viable pregnancies), which then delay the application process, and “the fragile nature of improvement work ” (p4) hinders sustained remediation. Meanwhile, continued very low vitamin take-up receives little attention, documented when individual public health teams publish quarterly HSIU 28 data. The HSIU website was displaying food voucher take-up data only but now none. The figures are stark. For example, Birmingham implements Healthy Start universally and has documented systematically a 5-year falling ‘vitamin take-up for eligible’ people from about 4% to <1% (and for non-eligible from about 25% to about 10%) . In 2020, one member of parliament highlighted Healthy Start dataset inadequacies , an underpublicized issue. This study complements and extends findings from a similar era about frustrated staff trying to overcome improvement barriers 21,23,24,25,26 . They encountered Heath Robinson-level system complications. In our study though, health professionals in the universal area seemed more knowledgeable about vitamin access and devised local solutions to supply-chain barriers. Futile searching by mothers arose from suboptimal vitamin access and supply, similar to Jessiman et al. 24 , particularly when targeted. Nevertheless, even a universal scheme commissioner felt like, “we were paying to throw vitamins in the bin” . Jessiman et al. 24 found that midwives engaged more directly in universal pilot-areas by issuing vitamins in-person with timely advice to embed the vitamins ‘habit’ 42(p77) . This study contextualizes calls for universal implementation 23,24 , . This would only be cost-effective if covering all the target group plus all women planning pregnancy or below 10 weeks’ pregnant (reflecting folic acid impact), infants 0–6 months, and 4−5 year-olds . Machell’s policy analysis of how Healthy Start developed highlighted little meaningful convergence of the problem tackled for potential beneficiaries, the implementation policy, and the politics. Politics drove development not evidence about eligible beneficiaries’ food culture and access to food. In our study, mothers, i.e. Machell’s “hidden participants” 50(p24) to policy-making, clearly articulated unmet need, despite the Government now describing Healthy Start as “demand-led… not target driven” and apparently ignoring food and vitamin vouchers in its ‘The Best Start for Life’ vision . Strengths/limitations/implications This study involved only two local administrative areas, however the dystopian experience of staff and 25 potentially eligible mothers converged from six children’s centres sampled specifically to compare a similarly deprived universal and targeted area. Jessiman et al. 24 likewise recruited successfully via children’s centres, but their 107 parents were from a single postcode in thirteen English administrative areas that were sampled on criteria other than universal versus targeted implementation. Nearly all McFadden et al.’s 25 109 (potential) beneficiaries’ views (including four males) came from participatory workshops and focus groups, but our study used semi-structured interviews for in-depth probing, like Jessiman et al. 24 . Our findings have illuminated this unfit-for-purpose vitamin-delivery system. Since the data were collected, child poverty has continued to grow and population nutrition to deteriorate, emphasizing the need for action. Crawley and Dodds 37(p7) considered this to be: 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. 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) . Since our own study, system improvements have been small and fragmented (e.g. food voucher value increasing modestly, belatedly, in 2021). Meanwhile, progressive underfunding of children’s centres has compromised health improvement and Healthy Start delivery. Healthy Start has become news again though in 2021. Marcus Rashford (English Premier League footballer) has promoted voucher take-up in his healthy nutrition campaign for low-income families , , for whom determinants of ‘nutrition choices’ are more structural than lifestyle . Additionally, the Health Secretary (England) conceded a legal challenge in June 2021 about a low-income mother who was awaiting settled UK status being deemed ineligible . This prompted government commitment to reviewing the scheme to ensure that it is non-discriminatory. Our study should be replicated elsewhere to contribute to such a review, updating on participants’ insights. Conclusion Substantive Healthy Start reform in England (not just cosmetic tinkering) is long overdue. Meanwhile, childhood nutritional rickets continues in high-risk groups lacking intended Healthy Start vitamins . Poverty-related food insecurity still requires much re-investment in early years’ services 1 . “Meaningful engagement and co-production with people with lived experience of poverty ” (p5) would mean asking families how best to simplify vitamin take-up. Our study highlights that ‘policy, politics, and problem’ should be aligned to reach considerable unmet need. Abbreviations CMOs UK chief medical officers HSIU Healthy Start Issuing Unit NICE National Institute for Health and Care Excellence NRES National Research Ethics Service PCT primary care trust Q1 Quarter 1 (of data collection-year) R&D research and development SACN Scientific Advisory Committee on Nutrition UK United Kingdom Declarations Ethics approval and consent to participate The University of Liverpool’s Faculty of Health and Life Sciences was Sponsor UoL000752 for administration and management, as per Health Research Authority. The National Research Ethics Service (NRES) (Proportionate Review Sub-Committee Committee East Midlands–Derby, ref no. 11/EM/0362) approved the proposal and three local research and development (R&D) committees were involved. All participants gave written informed consent to be interviewed. The research complied with the Helsinki Declaration. Consent for publication Not applicable Availability of data and materials The qualitative datasets generated and analysed in this study are not publicly available due to data privacy reasons, as per ethics approval. The Results section presents the relevant interview data from written transcripts of participants’ audio-recordings, which were deleted post-transcription as per approval agreements. The corresponding author would answer questions about these data. The quantitative data were obtained and used with permission from the Healthy Start Issuing Unit. Such data requests should be directed to that Unit28. Competing interests The authors declare that there are no competing interests. Funding There are no funding sources to declare Authors' contributions MM undertook the data collection as part of her doctoral research thesis, supervised by MW, GM, and BH. GM wrote the first draft of this paper built on core findings, in consultation with MW, and incorporated critical input from MM and BH, such that MM and GM should be considered joint first authors. All authors reviewed the full draft and suggested important revisions. All authors read and approved the final version. Acknowledgements We thank the participants for their valuable contributions. This work built on a doctoral thesis [i] undertaken while MM was a clinical lecturer/honorary specialty registrar in public health [i] Moonan M. An exploration of the UK Healthy Start vitamin supplementation programme in North West England. Doctor of Medicine (MD) thesis. Liverpool: The University of Liverpool, 2018:189pp. References Marmot M, Allen J, Boyce T, Goldblatt P, Morrison J. The Marmot Review 10 years on: Health equity in England. London: Institute of Health Equity (Department for Epidemiology & Public Health, University College London), 2020: 170 pp. Available at http://www.instituteofhealthequity.org/resources-reports/marmot-review-10-years-on [Last accessed: September 2021] Williamson S, McGregor-Shenton M, Brumble B, Wright B, Pettinger C. Deprivation and healthy food access, cost and availability: a cross-sectional study. Journal of Human Nutrition and Dietetics 2017; 30 (6):791-799. https://doi.org/10.1111/jhn.12489 Cattan S, Conti G, Farquharson C, Ginja R. The health effects of Sure Start. London: The Institute of Fiscal Studies, June 2019. https://doi.org/10.1920/re.ifs.2019.0155 Available at https://www.ifs.org.uk/publications/14139 [Last accessed: September 2021] Hodgson D (Mayor of Bedford Borough). Mayor Dave launches free school meals scheme over Christmas [web-page]. Bedford: Bedford Borough Council, 22.12.20. Available at https://mayordave.org.uk/en/article/2020/1387734/mayor-dave-launches-free-school-meals-scheme-over-christmas [Last accessed: September 2021] The Trussell Trust. Emergency food [web-page]. Salisbury: The Trussell Trust. Available at https://www.trusselltrust.org/get-help/emergency-food/ [Last accessed: September 2021] Committee on Medical Aspects of Food and Nutrition Policy: Panel on Child and Maternal Nutrition of the Committee on Medical Aspects of Food and Nutrition Policy (chaired by Sir John Grimley Evans). Scientific review of the Welfare Food Scheme [Report 51 on Health & Social Subjects]. London: The Stationery Office, Department of Health, 2002: 147 pp. I SBN: 0 II 322589 X Ford FA, Mouratidou T, Wademan SE, Fraser RB. Effect of the introduction of ‘Healthy Start’ on dietary behaviour during and after pregnancy: Early results from the ‘before and after’ Sheffield study. British Journal of Nutrition 2009; 101 (12):1,828-1,836. https://doi.org/10.1017/S0007114508135899 Mouratidou, T., Ford, F.A., Wademan, S.E. & Fraser, R.B. (2010). Are the benefits of the ‘Healthy Start’ food support scheme sustained at three months postpartum? Results from the Sheffield ‘before and after’ study. Maternal and Child Nutrition , 6 (4), 347-357. https://doi.org/10.1111/j.1740-8709.2009.00215.x Griffith R, von Hinke S, Smith S. Getting a healthy start: The effectiveness of targeted benefits for improving dietary choices. Journal of Health Economics 2018; 58 :176-187. https://doi.org/10.1016/j.jhealeco.2018.02.009 Lovelace S, Rabiee‐Khan F. Food choices made by low-income households when feeding their pre-school children: a qualitative study. Maternal and Child Nutrition 2015; 11 (4):870-881. https://doi.org/10.1111/mcn.12028 Scantlebury RJ, Moody A, Oyebode O, Mindell JS. Has the UK Healthy Start voucher scheme been associated with an increased fruit and vegetable intake among target families? Analysis of Health Survey for England data, 2001-2014. Journal of Epidemiology and Community Health 2018; 72 (7):623-629. https://doi.org/10.1136/jech-2017-209954 Parnham J, Millett C, Chang K, Laverty AA, von Hinke S, Pearson-Stuttard J, Vamos EP. Is the Healthy Start scheme associated with increased food expenditure in low-income families with young children in the United Kingdom? medRxiv . 2020:21 pp. https://doi.org/10.1101/2020.11.04.20225094 Belton NR. Healthy Start – will it provide optimal infant and child nutrition? Nutrition and Food Science 2005; 35 (2):74-80. https://doi.org/10.1108/00346650510602444 Maynard K, on behalf of the Citizens Advice Bureau. Welfare foods and Healthy Start: CAB Evidence on the provision of milk tokens. CAB Evidence Briefing. November 2006. London: Citizens Advice Bureau 2006:10 pp. Available at https://www.citizensadvice.org.uk/Global/Migrated_Documents/corporate/welfare-foods---healthy-start-final.pdf [Last accessed: September 2021] Hills D. Healthy Start: Rapid evaluation on early impact on beneficiaries, health professionals, retailers and contractors [executive summary]. London, England: Tavistock Institute/Symbia; 2006:7 pp. Available at https://www.tavinstitute.org/projects/evaluation-of-a-healthy-start/ [Last accessed: September 2021] Chief Medical Officers, UK. Vitamin D - advice on supplements for at risk groups: Letter from UK chief medical officers. London: Department of Health, 2.2.12. Available at https://www.gov.uk/government/publications/vitamin-d-advice-on-supplements-for-at-risk-groups [Last accessed: September 2021] Lewis L. Tackling vitamin D deficiency in children and at-risk families. Primary Health Care 2014; 24 (4):20-24. https://doi.org/10.7748/phc2014.04.24.4.20.e857 Scientific Advisory Committee on Nutrition. SACN vitamin D and health report: The Scientific Advisory Committee on Nutrition (SACN) recommendations on vitamin D . London: Public Health England, July 2016:289 pp. [Online document]. Available at https://www.gov.uk/government/publications/sacn-vitamin-d-and-health-report [Last accessed: September 2021] Department of Health and Social Care. At-risk groups to receive free winter supply of vitamin D [press release]. London: Department of Health and Social Care, Nov 2020. Available at https://www.gov.uk/government/news/at-risk-groups-to-receive-free-winter-supply-of-vitamin-d [Last accessed: September 2021] Davies S. Annual report of the Chief Medical Officer 2012: Our children deserve better: prevention pays. London: Department of Health, Oct 2013. Available at https://www.gov.uk/government/publications/chief-medical-officers-annual-report-2012-our-children-deserve-better-prevention-pays/cmos-annual-report-2012-our-children-deserve-better-cmos-summary-as-a-web-page [Last accessed: September 2021] Moy RJ, McGee E, Debelle GD, Mather I, Shaw NJ. Successful public health action to reduce the incidence of symptomatic vitamin D deficiency. Archives of Disease in Childhood 2012; 97 (11):952-954. https://doi:10.1136/archdischild-2012-302287 Dunnigan MG, Glekin BM, Henderson JB, McIntosh WB, Sumner D, Sutherland GR. Prevention of rickets in Asian children: Assessment of the Glasgow Campaign. British Medical Journal (Clinical Research) 1985; 291 (6490):239-242. https://doi.org/10.1136/bmj.291.6490.239 McFadden A, Green JM, McLeish J, McCormick F, Williams V, Renfrew MJ. Healthy Start vitamins-a missed opportunity: Findings of a multimethod study. BMJ Open 2015; 5 (1):1-7. https://doi:10.1136/bmjopen-2014-006917 Jessiman T, Cameron A, Wiggins M, Lucas PJ. A qualitative study of uptake of free vitamins in England. Archives of Disease in Childhood 2013; 98 (8):587-591. https://doi.org/10.1136/archdischild-2013-303838 McFadden A, Green JM, Williams V, McLeish J, McCormick F, Fox-Rushby J, Renfrew MJ. 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. BMC Public Health 2014; 14 (148):1-13. https://doi.org/10.1186/1471-2458-14-148 Lucas-Herald A, Grosset K, Robertson M, Ahmed SF. The GP’s role in improving the uptake of healthy start vitamins. British Journal of General Practice 2012; 62 (601):407. https://doi.org/10.3399/bjgp12X653525 Ivankova NV, Creswell JW, Stick SL Using mixed-methods sequential explanatory design: From theory to practice. Field Methods 2006; 18 (1):3-20. https://doi.org/10.1177/1525822X05282260 Department of Health and Social Care Healthy Start Issuing Unit (HSIU - Warrington). Healthy Start uptake data [website]. Newcastle upon Tyne: National Health Service (NHS) Business Services Authority (NHSBSA), 2021 Available at https://www.healthystart.nhs.uk/ & https://media.nhsbsa.nhs.uk/resources [Last accessed: September 2021] Health Research Authority (HRA). Roles and responsibilities: Sponsor [Online webpage]. London: HRA (National Health Service), 2021. Available at https://www.hra.nhs.uk/planning-and-improving-research/research-planning/roles-and-responsibilities/#sponsor [Last accessed: September 2021] Britten N. Qualitative interviews [Chapter 2]. In: C. Pope & N. Mays [Editors]. Qualitative Research in Health Care (3rd ed.). Oxford: John Wiley & Sons, 2006:pp. 12-20. ISBN: 0-7279-1396-4 Saunders B, Sim J, Kingstone T, Baker S, Waterfield J, Bartlam B, Burroughs H, Jinks C. Saturation in qualitative research: exploring its conceptualization and operationalization. Quality & Quantity 2018; 52 (4):1893-1907. https://doi.org/10.1007/s11135-017-0574-8 Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care 2007; 19 (6):349-357. https://doi.org/10.1093/intqhc/mzm042 Ritchie J, Spencer L. Qualitative data analysis for applied policy research. In: A Bryman, RG Burgess (Eds). Analysing Qualitative Data. London: Routledge, 1994:pp. 173-194. Lacey A Luff D. Qualitative data analysis . Nottingham & Sheffield: The NIHR Research Design Service for the East Midlands and for Yorkshire & the Humber, 2007 (updated 2009):46 pp. [Online document]. Available at https://www.rds-yh.nihr.ac.uk/wp-content/uploads/2013/05/9_Qualitative_Data_Analysis_Revision_2009.pdf [Last accessed: September 2021] Pope C, Ziebland S, Mays N. Analysing qualitative data [Chapter 7]. In: C. Pope & N. Mays [Editors]. Qualitative Research in Health Care (3rd ed.). Oxford: John Wiley & Sons, 2006:pp. 63-81. ISBN: 0-7279-1396-4 Avis M, Bulman D, Leighton P. Factors affecting participation in Sure Start programmes: a qualitative investigation of parents’ views. Health and Social Care in the Community 2007; 15 (3):203-211. https://doi.org/10.1111/j.1365-2524.2006.00673.x Crawley H, Dodds R. The UK Healthy Start scheme. What happened? What next? London: First Steps Nutrition Trust, 2018. e-ISBN: 978-1-908924-60-5 Available at https://www.firststepsnutrition.org/s/Healthy_Start_Report_for_web.pdf [Last accessed: September 2021] Scottish Government: Children and Families Directorate and Population Health Directorate. Free vitamins for all pregnant women [web-page]. Available at https://www.gov.scot/policies/maternal-and-child-health/free-vitamins-for-all-pregnant-women/ [Last accessed: September 2021] Hansard HC written answers. Department of Health and Social Care. Healthy Start Scheme. Jo Churchill, The Parliamentary Under-Secretary for Health and Social Care. Deb, 8 February 2021, cW. UIN 147076. Available at https://questions-statements.parliament.uk/written-questions/detail/2021-02-01/147076 [Last accessed: September 2021] Lucas PJ, Jessiman T, Cameron A. Healthy Start: The use of welfare food vouchers by low-income parents in England. Social Policy and Society 2015; 14 (3):457-469. https://doi.org/10.1017/S1474746415000020 Ohly H, Crossland N, Dykes F, Lowe N, Hall-Moran V. A realist review to explore how low-income pregnant women use food vouchers from the UK’s Healthy Start programme. BMJ Open 2017, 7 (4), e013731. https://doi.org/10.1136/bmjopen-2016-013731 Lucas PJ, Jessiman T, Cameron A, Wiggins M, Hollingworth K, Austerberry C. Healthy Start Vouchers Study: The views and experiences of parents, professionals and small retailers in England. Bristol & London: University of Bristol (School for Policy Studies) & Institute of Education (Social Science Research Unit), 2013:85 pp. Hansard HC written answers. Department of Health and Social Care. Healthy Start Scheme: Advertising. Jo Churchill, The Parliamentary Under-Secretary for Health and Social Care. Deb, 1 March 2021, cW. UIN 154976. Available at https://questions-statements.parliament.uk/written-questions/detail/2021-02-19/154976 [Last accessed: September 2021] Mackenzie G, Dougall A. Increasing Healthy Start food and vitamin voucher uptake for low income pregnant women (Early Years Collaborative Leith Pioneer Site). BMJ Quality Improvement Reports 2016, April 8; 5 (1):1-5. u210506.w4243. https://doi.org/10.1136/bmjquality.u210506.w4243 Birmingham City Council, Public Health. Birmingham Healthy Start Scheme webinar (Healthy Brum). 29 January 2021 Zoom Webinar on YouTube. 17:02 of 57:51. Available at https://www.youtube.com/watch?v=ko3TPO7EurE [Last accessed: September 2021] Halfon R. Robert Halfon: Delivering social justice means feeding children properly. We’re not doing so – and we must. ConservativeHome [blog]. 7 October 2020. Available at https://www.conservativehome.com/thecolumnists/2020/10/robert-halfon-delivering-social-justice-means-feeding-children-properly-were-not-doing-so-and-we-must.html [Last accessed: September 2021] Williams E. Heath Robinson's commercial art. Creative Review, 5.12.17. Available at https://www.creativereview.co.uk/heath-robinsons-commercial-art/ [Last accessed: September 2021] McFadden A, Fox-Rushby J, Green JM, Pokhrel S, McLeish J, McCormick F, Anokye N, Dritsaki M, McCarthy R, Bennett S, Entwistle F, Renfrew MJ. Healthy Start: understanding the use of vouchers and vitamins: summary for practitioners. Dundee: University of Dundee, April 2013, 12 pp. Available at https://discovery.dundee.ac.uk/ws/portalfiles/portal/6497930/Healthy_Start_Evaluation_summary_for_health_professionals_0_2_.pdf [Last accessed: September 2021] National Institute for Health and Care Excellence (NICE). Healthy Start vitamins: Special report on cost effectiveness: Equality impact assessment . London: NICE, 2015 [Online document]. Available at https://www.nice.org.uk/about/what-we-do/our-programmes/nice-guidance/nice-guidelines/types-of-guideline/additional-publications/healthy-start-vitamins [Last accessed: September 2021] Machell G. Considering influences on the policy formation of Healthy Start: A government-funded nutrition support program for low-income women and children in the UK. Journal of Policy Practice 2015; 14 (1):14-34. https://doi.org/10.1080/15588742.2014.956968 Hansard HC written answers. Department of Health and Social Care. Healthy Start Scheme. Jo Churchill, The Parliamentary Under-Secretary for Health and Social Care. Deb, 8 February 2021, cW. UIN 147077. Available at https://questions-statements.parliament.uk/written-questions/detail/2021-02-01/147077 [Last accessed: September 2021] Department of Health and Social Care. The best start for life. A vision for the 1,001 critical days: The Early Years Healthy Development Review Report [policy paper]. London: DHSC, 25 March 2021, 146 pp ISBN: 978-1-5286-2497-8 Available at https://www.gov.uk/government/publications/the-best-start-for-life-a-vision-for-the-1001-critical-days [Last accessed: September 2021] Mason KE, Alexiou A, Bennett DL, Summerbell C, Barr B, & Taylor-Robinson D. Impact of cuts to local government spending on Sure Start children’s centres on childhood obesity in England: a longitudinal ecological study. Journal of Epidemiology and Community Health 2021; 75 (9):860-866. https://doi.org/10.1136/jech-2020-216064 Coughlan S. Marcus Rashford's budget cookery serves up fish finger sandwich. BBC News (Family & Education) [on-line] 2021 April 22. Available at https://www.bbc.co.uk/news/education-56825700 [Last accessed: September 2021] Rashford, M. Every child deserves the best chance in life, and here is how health professionals can help. [Blog.] BMJ Opinion 2021 (4.8.21). Available at https://blogs.bmj.com/bmj/2021/08/04/marcus-rashford-every-child-deserves-the-best-chance-in-life-here-is-how-health-professionals-can-help/ [Last accessed: September 2021] Dahlgren G, Whitehead M. The Dahlgren-Whitehead model of health determinants: 30 years on and still chasing rainbows. Public Health 2021;199:20-24. https://doi.org/10.1016/j.puhe.2021.08.009 Casciani D. Matt Hancock caves in over vitamins for poor children. BBC News (UK) [on-line] 2021 June 2. Available at https://www.bbc.co.uk/news/uk-57333810 [Last accessed: September 2021] Julies P, Lynn RM, Pall K, Leoni M, Calder A, Mughal Z, Shaw N, McDonnell C, McDevitt H, Blair M. Nutritional rickets under 16 years: UK surveillance results. Archives of Disease in Childhood 2020; 105 (6):587-592. https://doi.org/10.1136/archdischild-2019-317934 Fenney D, Buck D. The NHS’s role in tackling poverty: Awareness, action and advocacy. London: The King’s Fund, 2021:51pp. Available at https://www.kingsfund.org.uk/publications/nhs-role-tackling-poverty [Last accessed: September 2021] Moonan M. An exploration of the UK Healthy Start vitamin supplementation programme in North West England. Doctor of Medicine (MD) thesis. Liverpool: The University of Liverpool, 2018:189pp. Additional Declarations No competing interests reported. Supplementary Files SUPPLEMENTARYAdditionalfile1HealthyStartvitaminsSequentialexplanatorymixedmethodsstudydesign.pdf SUPPLEMENTARY--Additional file 1--Healthy Start vitamins--Sequential explanatory mixed-methods study design.pdf Title: Sequential explanatory mixed-methods study of Healthy Start vitamin take-up in North West England, 2012 Description: This is a diagrammatic overview of the study design. SUPPLEMENTARYAdditionalfile2HealthyStartvitaminsQuantitativecommentaryandtable.pdf SUPPLEMENTARY--Additional file 2--Healthy Start vitamins--Quantitative--commentary and table.pdf Title: Healthy Start findings: Quantitative (and Observations): e-Commentary and e-Table Description: This is expanded commentary (colour-coded to link to data in e-Table below it): Take-up (%) of Healthy Start food, women’s vitamin, and children’s vitamin vouchers, by English region and North West areas in the lead-up to 2012 interviews of mothers, health professionals, and commissioners about Healthy Start voucher take-up (North West England) Cite Share Download PDF Status: Published Journal Publication published 24 Feb, 2022 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Major revision 25 Nov, 2021 Reviews received at journal 02 Nov, 2021 Reviewers agreed at journal 31 Oct, 2021 Reviewers agreed at journal 21 Oct, 2021 Reviewers invited by journal 19 Oct, 2021 Editor assigned by journal 19 Oct, 2021 Editor invited by journal 19 Oct, 2021 Submission checks completed at journal 19 Oct, 2021 First submitted to journal 04 Oct, 2021 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Whitehead","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxklEQVRIiWNgGAWjYHACxgcPDKDMB2CSjaAWZoMEmJYEIrWwSSTAmERp0Z12xqwioeCwnPns5oMPEhjs5Bkk0hLwajG7nWN2I8HgsLHMnWPJBgkMyYYNEmkHCGjJ3QbUkpY4QyLHDOhC5gQGifQGgloKgFrqoVrqidPCkGBgkyAB0XIYqIWgw/I/SwC1GM6QAfnF4LhhG8+zBAJa0hI/fPgjIS8hDQyxDxXV8vzsaQZ4tSCABIgwICYiUbWMglEwCkbBKMACAHMgQB5X9zy+AAAAAElFTkSuQmCC","orcid":"","institution":"University of Liverpool","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Margaret","middleName":"","lastName":"Whitehead","suffix":""}],"badges":[],"createdAt":"2021-10-04 11:44:01","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-955345/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-955345/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12889-022-12704-0","type":"published","date":"2022-02-24T18:50:30+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":18582438,"identity":"24cdb203-db6a-4da9-84e9-8ee67da0e903","added_by":"auto","created_at":"2022-02-24 18:50:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":673247,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-955345/v1/5f11fda3-5bd6-4b31-a5b5-42949f7bb6f8.pdf"},{"id":14731035,"identity":"af614613-34f9-45c0-aa9f-8e69dd8ddf8c","added_by":"auto","created_at":"2021-10-20 20:07:51","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":62434,"visible":true,"origin":"","legend":"SUPPLEMENTARY--Additional file 1--Healthy Start vitamins--Sequential explanatory mixed-methods study design.pdf\nTitle: Sequential explanatory mixed-methods study of Healthy Start vitamin take-up in North West England, 2012\nDescription: This is a diagrammatic overview of the study design.\n","description":"","filename":"SUPPLEMENTARYAdditionalfile1HealthyStartvitaminsSequentialexplanatorymixedmethodsstudydesign.pdf","url":"https://assets-eu.researchsquare.com/files/rs-955345/v1/d8cb3f5e9f2173753cd24e93.pdf"},{"id":14731036,"identity":"022c4424-2d77-4e75-accd-5f147a17e617","added_by":"auto","created_at":"2021-10-20 20:07:51","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":189984,"visible":true,"origin":"","legend":"SUPPLEMENTARY--Additional file 2--Healthy Start vitamins--Quantitative--commentary and table.pdf\nTitle: Healthy Start findings: Quantitative (and Observations): e-Commentary and e-Table\nDescription: This is expanded commentary (colour-coded to link to data in e-Table below it): Take-up (%) of Healthy Start food, women’s vitamin, and children’s vitamin vouchers, by English region and North West areas in the lead-up to 2012 interviews of mothers, health professionals, and commissioners about Healthy Start voucher take-up (North West England)\n","description":"","filename":"SUPPLEMENTARYAdditionalfile2HealthyStartvitaminsQuantitativecommentaryandtable.pdf","url":"https://assets-eu.researchsquare.com/files/rs-955345/v1/fe47e87562548d82427f7368.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"An exploration of the statutory Healthy Start vitamin supplementation scheme in North West England","fulltext":[{"header":"What Is Known About The Topic","content":"\u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eTake-up of free Healthy Start vitamin vouchers targeted to low-income pregnant women and pre-school children in England is very low, despite good food voucher take-up.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eSuggested barriers include low maternal awareness and motivation, poor access, and health professionals\u0026rsquo; mixed messaging or disengagement, but universal provision might improve access.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eQualitative evidence is limited about receiving or facilitating these vitamin vouchers, particularly targeted vs universal access, via children\u0026rsquo;s centres.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e"},{"header":"What This Paper Adds","content":"\u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eImproving presentation, messaging, and practicality of vitamin vouchers may well improve take-up.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePoor vitamin take-up may well reflect overcomplicated procedures while relying on underfunded centres, organizational goodwill, and families\u0026rsquo; resilience.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eHigher \u0026lsquo;universal\u0026rsquo; vitamin take-up may well reflect that being vitamin-aware becomes everyone\u0026rsquo;s business.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e"},{"header":"Background","content":"\u003cp\u003eAs health inequalities continue to widen in the United Kingdom (UK), government nutritional welfare support from the \u0026lsquo;Healthy Start\u0026rsquo; scheme for pregnant women and preschool children remains crucial to health improvement. Poverty-related food insecurity has increased over the last decade\u003ca class=\"FNLink\" href=\"#Fn2\" id=\"#FNLinkFn2\"\u003e\u003c/a\u003e, with low-income households facing complex cost, access, and availability barriers to healthy eating\u003csup\u003e\u003cb\u003e1\u003c/b\u003e,\u003c/sup\u003e\u003ca class=\"FNLink\" href=\"#Fn3\" id=\"#FNLinkFn3\"\u003e\u003c/a\u003e.\u003c/p\u003e \u003cp\u003eSure Start \u0026lsquo;children\u0026rsquo;s centres\u0026rsquo; for preschool child and family support have facilitated Healthy Start implementation in England, including maternal information and advice. Children\u0026rsquo;s centres have been particularly effective in disadvantaged areas\u003ca class=\"FNLink\" href=\"#Fn4\" id=\"#FNLinkFn4\"\u003e\u003c/a\u003e but have progressively dwindled\u003csup\u003e\u003cb\u003e1,3\u003c/b\u003e\u003c/sup\u003e since ringfenced funding ended (2011) exposing them to government austerity.\u003c/p\u003e \u003cp\u003eIn England, Marmot et al.\u0026rsquo;s 2020 ten-year review of health equity\u003csup\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sup\u003e has recommended re-investing in early years\u0026rsquo; services, including children\u0026rsquo;s centres. In the COVID-19 pandemic, children\u0026rsquo;s centres have helped in referring low-income families for foodbank support and in distributing food or vouchers, when schools are closed, to children eligible for free school meals\u003ca class=\"FNLink\" href=\"#Fn5\" id=\"#FNLinkFn5\"\u003e\u003c/a\u003e\u003csup\u003e,\u003c/sup\u003e\u003ca class=\"FNLink\" href=\"#Fn6\" id=\"#FNLinkFn6\"\u003e\u003c/a\u003e.\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eThe Healthy Start scheme\u003c/h2\u003e \u003cp\u003eIn 2006, Healthy Start replaced the Welfare Foods Scheme (established during wartime rationing in 1941, complementing the 1940 National Milk Scheme) to improve maternal and child health. Welfare Foods started as universal provision but was later subsidized and then \u0026lsquo;targeted means-tested\u0026rsquo; like Healthy Start. The first major scientific review of Welfare Foods recommended urgent improvement in vitamin distribution and uptake\u003ca class=\"FNLink\" href=\"#Fn7\" id=\"#FNLinkFn7\"\u003e\u003c/a\u003e.\u003c/p\u003e \u003cp\u003eFrom the outset, entitled low-income families with children under 4 (under-4s), low-income pregnant women, and pregnant females under 18 (under-18s) received monetary Healthy Start \u0026lsquo;food vouchers\u0026rsquo; by post. These paid for cow\u0026rsquo;s milk, infant formula milk, fruit, or vegetables at registered retailers. The food vouchers may have improved maternal nutrition more than Welfare Foods\u003ca class=\"FNLink\" href=\"#Fn8\" id=\"#FNLinkFn8\"\u003e\u003c/a\u003e\u003csup\u003e,\u003c/sup\u003e\u003ca class=\"FNLink\" href=\"#Fn9\" id=\"#FNLinkFn9\"\u003e\u003c/a\u003e\u003csup\u003e,\u003c/sup\u003e\u003ca class=\"FNLink\" href=\"#Fn10\" id=\"#FNLinkFn10\"\u003e\u003c/a\u003e. They may well promote fruit and vegetable consumption\u003ca class=\"FNLink\" href=\"#Fn11\" id=\"#FNLinkFn11\"\u003e\u003c/a\u003e\u003csup\u003e,\u003c/sup\u003e\u003ca class=\"FNLink\" href=\"#Fn12\" id=\"#FNLinkFn12\"\u003e\u003c/a\u003e although evidence is conflicting\u003ca class=\"FNLink\" href=\"#Fn13\" id=\"#FNLinkFn13\"\u003e\u003c/a\u003e. Additional \u0026lsquo;vitamin vouchers\u0026rsquo; were exchanged for Government-commissioned children\u0026rsquo;s drops (6\u0026minus;48 months: vitamins A, C, D) and pregnant and lactating women\u0026rsquo;s tablets (folic acid; vitamins C, D). Locally arranged vitamin distribution-points included children\u0026rsquo;s centres and community health clinics.\u003c/p\u003e \u003cp\u003eThere was initial concern about the Healthy Start design and implementation for nutritional support\u003ca class=\"FNLink\" href=\"#Fn14\" id=\"#FNLinkFn14\"\u003e\u003c/a\u003e\u003csup\u003e,\u003c/sup\u003e\u003ca class=\"FNLink\" href=\"#Fn15\" id=\"#FNLinkFn15\"\u003e\u003c/a\u003e. Furthermore, piloting had revealed\u003ca class=\"FNLink\" href=\"#Fn16\" id=\"#FNLinkFn16\"\u003e\u003c/a\u003e\u003csup\u003e\u003cb\u003e(p2)\u003c/b\u003e\u003c/sup\u003e:\u003cdiv class=\"BlockQuote\"\u003e\u003cdiv id=\"Par50\" class=\"Para\"\u003eabsence 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.\u003c/div\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eHealthy Start vitamins in this last decade\u003c/h2\u003e \u003cp\u003eIn February 2012, the four UK chief medical officers (CMOs) were concerned about vitamin D deficiency in at-risk groupsࣧpregnant and breastfeeding women, under-5s, 65-years-and over, and people with insufficient sun exposure. They reminded primary care health professionals that Healthy Start vitamins included vitamin D and were crucial for the public\u0026rsquo;s health\u003ca class=\"FNLink\" href=\"#Fn17\" id=\"#FNLinkFn17\"\u003e\u003c/a\u003e, but low take-up needed tackling\u003csup\u003e\u003cb\u003e7,16\u003c/b\u003e,\u003c/sup\u003e\u003ca class=\"FNLink\" href=\"#Fn18\" id=\"#FNLinkFn18\"\u003e\u003c/a\u003e. By 2016, the Scientific Advisory Committee on Nutrition (SACN)\u003ca class=\"FNLink\" href=\"#Fn19\" id=\"#FNLinkFn19\"\u003e\u003c/a\u003e was recommending whole-population vitamin D supplementation for musculoskeletal health (regarding rickets, osteomalacia, falls, and muscle strength and function). By January 2021, in recognition of more time indoors during the pandemic, clinically extremely vulnerable people and care home residents were receiving free vitamin D supplementation\u003ca class=\"FNLink\" href=\"#Fn20\" id=\"#FNLinkFn20\"\u003e\u003c/a\u003e.\u003c/p\u003e \u003cp\u003eEngland\u0026rsquo;s CMO did contemplate making Healthy Start vitamin provision universal\u003ca class=\"FNLink\" href=\"#Fn21\" id=\"#FNLinkFn21\"\u003e\u003c/a\u003e. In 2012, Moy et al. reported observational evidence from Birmingham (high proportion of high-risk ethnic minorities) suggesting that changing from targeted to universal Healthy Start vitamins could reduce symptomatic vitamin D deficiency and increase public awareness about vitamin D\u003ca class=\"FNLink\" href=\"#Fn22\" id=\"#FNLinkFn22\"\u003e\u003c/a\u003e. This was despite vitamin take-up only increasing to 17% of pregnant women and preschool children. The only previous similar evidence involved Glasgow\u0026rsquo;s vitamin D supplementation for British Asian children, which significantly reduced rickets\u003ca class=\"FNLink\" href=\"#Fn23\" id=\"#FNLinkFn23\"\u003e\u003c/a\u003e.\u003c/p\u003e \u003cp\u003eEvidence is limited but suggests that low Healthy Start vitamin take-up is associated with: mixed messages about early years\u0026rsquo; vitamin D requirements\u003ca class=\"FNLink\" href=\"#Fn24\" id=\"#FNLinkFn24\"\u003e\u003c/a\u003e; health professionals not promoting Healthy Start\u003ca class=\"FNLink\" href=\"#Fn25\" id=\"#FNLinkFn25\"\u003e\u003c/a\u003e\u003csup\u003e,\u003c/sup\u003e\u003ca class=\"FNLink\" href=\"#Fn26\" id=\"#FNLinkFn26\"\u003e\u003c/a\u003e; low parental awareness about vitamin importance\u003csup\u003e\u003cb\u003e21,24\u003c/b\u003e\u003c/sup\u003e and the Healthy Start programme and vitamins\u003csup\u003e\u003cb\u003e25\u003c/b\u003e,\u003c/sup\u003e\u003ca class=\"FNLink\" href=\"#Fn27\" id=\"#FNLinkFn27\"\u003e\u003c/a\u003e; low maternal motivation to use vitamins\u003csup\u003e\u003cb\u003e24\u003c/b\u003e\u003c/sup\u003e; poor vitamin access\u003csup\u003e\u003cb\u003e24,25\u003c/b\u003e\u003c/sup\u003e; and obstructive application procedures and logistically complicated distribution\u003csup\u003e\u003cb\u003e23,24,25\u003c/b\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eCalls for universal implementation\u003csup\u003e\u003cb\u003e23\u003c/b\u003e\u003c/sup\u003e require further evidence from everyday experience of receiving or facilitating Heathy Start, especially via children\u0026rsquo;s centres. This study therefore aimed to explore (in the context of low take-up levels) perceptions of mothers, health professionals, and commissioners about Healthy Start vitamin and food voucher take-up and compare experiences in a targeted and a universal implementation-area for those vitamins.\u003c/p\u003e \u003c/div\u003e"},{"header":"Methods","content":"\u003cdiv class=\"Section2\" id=\"Sec7\"\u003e\n \u003ch2\u003eDesign and governance\u003c/h2\u003e\n \u003cp\u003eWithin the pragmatism paradigm, this sequential explanatory mixed-methods study (labelled as per Ivankova et al.\u003ca class=\"FNLink\" href=\"#Fn28\" id=\"#FNLinkFn28\"\u003e\u003c/a\u003e) comprised qualitative analysis of 42 semi-structured interviews with mothers and professionals, about Healthy Start voucher take-up, informed by quantitative analysis (\u003cstrong\u003eAdditional file 1\u003c/strong\u003e). The latter used the percentage voucher \u0026lsquo;take-up\u0026rsquo; extracted from quarterly data around the time of the interviews, requested from the Healthy Start Issuing Unit (HSIU) (Department of Health)\u003ca class=\"FNLink\" href=\"#Fn29\" id=\"#FNLinkFn29\"\u003e\u003c/a\u003e. Interviews were in North West EnglandࣧArea-1: universal vitamin implementation-area (one of two), Area-2: targeted implementation-areaࣧclosely located, both in the most deprived fifth of local authorities, with similar life expectancies and childhood obesity, but Area-2 had a larger and younger population.\u003c/p\u003e\n \u003cp\u003eGovernance involved:\u003c/p\u003e\n \u003cp\u003e-the University of Liverpool\u0026rsquo;s Faculty of Health and Life Sciences being Sponsor \u003cem\u003eUoL000752\u003c/em\u003e for administration and management, as per Health Research Authority\u003ca class=\"FNLink\" href=\"#Fn30\" id=\"#FNLinkFn30\"\u003e\u003c/a\u003e;\u003c/p\u003e\n \u003cp\u003e-National Research Ethics Service (NRES) (Proportionate Review Sub-Committee Committee East Midlands\u0026ndash;Derby, ref no. 11/EM/0362);\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec8\"\u003e\n \u003ch2\u003eQuantifying Healthy Start take-up\u003c/h2\u003e\n \u003cp\u003eBasic descriptive epidemiology compared take-up between English regions and between the North West primary care trust (PCT) areas, which included between universal (n=2) and targeted (n=22) implementation-areas (\u003cstrong\u003eAdditional file 2\u003c/strong\u003e). Analysis used Chi-squared test (IBM-SPSS v20).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec9\"\u003e\n \u003ch2\u003eQualitative\u003c/h2\u003e\n \u003cdiv class=\"Section3\" id=\"Sec10\"\u003e\n \u003ch2\u003ePreparation and approach\u003c/h2\u003e\n \u003cp\u003eQuantitative findings and pilot interviews (two commissioners, two midwives, one mother) influenced topic-guide and participant information-sheet development. The topic-guide\u003ca class=\"FNLink\" href=\"#Fn31\" id=\"#FNLinkFn31\"\u003e\u003c/a\u003e allowed flexible semi-structured interviews, including in-depth exploration of unanticipated topics.\u003c/p\u003e\n \u003cp\u003eOne author (MM) interviewed the all-female participants on NHS or local authority premises or via telephone (February\u0026minus;September 2012), with written or electronic consent, highlighting the information-sheet, confidentiality, and ability to withdraw without detriment. Data saturation\u003ca class=\"FNLink\" href=\"#Fn32\" id=\"#FNLinkFn32\"\u003e\u003c/a\u003e was progressively sought at the level of individual interviews and the overall dataset. Voice-recordings were deleted after transcripts were checked.\u003c/p\u003e\n \u003cp\u003eTong et al.\u0026rsquo;s checklist\u003ca class=\"FNLink\" href=\"#Fn33\" id=\"#FNLinkFn33\"\u003e\u003c/a\u003e guided reporting, implicitly or explicitly. Regarding two of the 32 items though, there was no participant-checking of transcripts or findings.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv class=\"Section3\" id=\"Sec11\"\u003e\n \u003ch2\u003eInterviews\u003c/h2\u003e\n \u003cp\u003e\u003cspan class=\"ItalicUnderline\" name=\"Emphasis\" type=\"ItalicUnderline\"\u003eMothers\u0026rsquo; (n=25: 11 universal area; 14 targeted area)\u003c/span\u003e interviews involved a diverse purposive sample of \u003cem\u003epotentially eligible Healthy Start\u003c/em\u003e beneficiaries, whether entitled (application accepted) or not, i.e. English-speaking mother of an under-4-year-old, attending one of six children\u0026rsquo;s centres (universal area: two; targeted area: four).\u003c/p\u003e\n \u003cp\u003eThe six children\u0026rsquo;s centre managers facilitated recruitment. MM briefed mothers (identified by midwife interviewees or visiting mothers) by telephone or in infant-toddler groups. Three mothers refused interviews. Participants confirmed if they were Healthy Start-entitled or not.\u003c/p\u003e\n \u003cp\u003e\u003cspan class=\"ItalicUnderline\" name=\"Emphasis\" type=\"ItalicUnderline\"\u003eHealth professionals (n=11: 5 universal area; 6 targeted area)\u003c/span\u003e: All local authority-employed health professionals working with Healthy Start vitamins participated. Midwives and health visitors (n=8) mostly chose telephone-interview and health promotion officers (n=3) chose face-to-face interview at the centre.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eCommissioners and national HSIU staff (n=6)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eInterviews were with the Healthy Start commissioners (n=3) from Area-1 and Area-2 and, giving a second perspective, from the only other North West universal implementation-area (Area-3) plus the three national HSIU staff for context. No-one declined.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec12\"\u003e\n \u003ch2\u003eQualitative data analysis\u003c/h2\u003e\n \u003cp\u003eQualitative analysis of anonymised transcripts used QRS-NVivo v9.2 and followed the tenets of Ritchie and Spencer\u0026rsquo;s\u003ca class=\"FNLink\" href=\"#Fn34\" id=\"#FNLinkFn34\"\u003e\u003c/a\u003e framework approach\u003ca class=\"FNLink\" href=\"#Fn35\" id=\"#FNLinkFn35\"\u003e\u003c/a\u003e, particularly its \u0026lsquo;diagnostic\u0026rsquo; (why things are so) and \u0026lsquo;evaluative\u0026rsquo; (what affects effectiveness) aspects. \u003cem\u003eFamiliarization\u003c/em\u003e with the raw data (immersion) and field-notes identified emergent and recurrent themes\u003ca class=\"FNLink\" href=\"#Fn36\" id=\"#FNLinkFn36\"\u003e\u003c/a\u003e. Abstracting, conceptualizing, discussing between co-authors, and coding five transcripts generated and refined iteratively a \u003cem\u003ethematic framework\u003c/em\u003e of deductive (from topic-guide) and inductive components. Full analysis included \u003cem\u003eindexing\u003c/em\u003e and \u003cem\u003echarting\u003c/em\u003e (case-charts, theme-charts). \u003cem\u003eMapping\u003c/em\u003e sought associations, wide-ranging experience, and exceptions.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec13\"\u003e\n \u003ch2\u003eObservations of practice\u003c/h2\u003e\n \u003cp\u003eAt each children\u0026rsquo;s centre, MM gained permission to review the content of the locked vitamin cupboard (\u003cstrong\u003eAdditional file 2\u003c/strong\u003e). MM checked availability and cost of similar vitamins at the nearest pharmacy.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eQuantitative\u003c/h2\u003e \u003cp\u003eTake-up of food vouchers exceeded vitamin vouchers considerably, vitamin take-up remained very low, but food and vitamin voucher take-up appeared higher in the universal versus targeted areas of the North West (\u003cb\u003eAdditional file 2\u003c/b\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eQualitative\u003c/h2\u003e \u003cp\u003eThe qualitative component explored why these observed differences in take-up arose.\u003c/p\u003e \u003cp\u003e \u003cem\u003e(N)EM=(non-)entitled mother; HP=health professional; C=commissioner; DH=Department of Health; universal=U, targeted=T\u003c/em\u003e \u003c/p\u003e \u003cdiv id=\"Sec17\" class=\"Section3\"\u003e \u003ch2\u003eWhy was food voucher take-up more than for vitamin vouchers?\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eMothers\u003c/span\u003e explained higher food voucher take-up mostly in terms of awareness, accessibility, and acceptability. Those vouchers were conspicuous in the letter and straightforward (\u0026ldquo;\u003cem\u003ebrilliant\u003c/em\u003e\u0026rdquo; \u003cem\u003eEM18\u0026minus;U\u003c/em\u003e) to use:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;[The letter] has it all there on the bottom. It told you, you can go to any supermarket and stuff, [\u0026hellip;] if you go to your corner shop you can use them. If you go to Tesco\u0026rsquo;s, Asda, Sainsbury\u0026rsquo;s\u0026hellip; EM26\u0026minus;T\u003c/em\u003e \u003c/p\u003e \u003cp\u003eDespite misunderstanding about participating shops \u003cem\u003e(\u0026ldquo;It\u0026rsquo;s only like the Asda or\u0026hellip; that\u0026rsquo;s the only place I really know that takes them\u0026rdquo; EM27\u0026minus;T\u003c/em\u003e), food vouchers\u0026rsquo; monetary value was crucial:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;any money that they can get off the shop is great\u0026hellip;, but I think if people don\u0026rsquo;t take vitamins anyway then they\u0026rsquo;re not likely to go and pick them up at a children\u0026rsquo;s centre; it\u0026rsquo;s another thing to remember\u0026hellip;\u0026rdquo; EM40\u0026minus;U\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe monetary value seemed inadequate though, because \u003cem\u003e\u0026ldquo;with a \u0026pound;3.10 voucher you are having to pay up three of them together to cover the cost of one powdered milk\u0026hellip; normally [needing] one a week\u0026hellip;\u0026rdquo; EM10\u0026minus;U\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eHealth professionals\u003c/span\u003e also mostly explained higher food voucher take-up in terms of awareness, accessibility, and acceptability. Echoing mothers, they mentioned better visibility (\u0026ldquo;\u003cem\u003emuch more noticeable\u0026rdquo; HP04\u0026minus;U\u003c/em\u003e) in the letter plus practical and monetary value:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;she\u0026rsquo;s \u0026pound;3.10 better off a week\u0026hellip; she can go to the shop and actually use it for\u0026hellip; fruit and veg and milk so there\u0026hellip; whereas for the [vitamin] vouchers she has to go to a health centre, doesn\u0026rsquo;t she, and pick them up, or a community place [e.g. children\u0026rsquo;s centre or clinic]...\u0026rdquo; HP04\u0026minus;U\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eCommissioners\u003c/span\u003e explained higher food voucher take-up with reasons for low vitamin take-up.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e \u003ch2\u003eWhy was vitamin voucher take-up so low?\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eMothers\u003c/span\u003e explained low vitamin take-up in terms of suboptimal awareness (and attitude) (\u003cb\u003eTable 1\u003c/b\u003e), accessibility, acceptability, and adequacy of supply. Mothers in both areas were unclear on eligibility, overlooked receiving the national vitamin vouchers, and mentioned \u0026lsquo;missing out\u0026rsquo;:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I have seen all these pictures and I thought \u0026lsquo;I wonder what that is?\u0026rsquo; and then, when they [health professionals] did actually make me aware, I didn\u0026rsquo;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.\u0026rdquo; EM13\u0026minus;T\u003c/em\u003e \u003c/p\u003e \u003cp\u003eEntitled and non-entitled mothers from both areas were also unaware of vitamin benefits, feeling poorly informed by health professionals (\u003cem\u003eEM06\u0026minus;U\u003c/em\u003e, \u003cb\u003eTable 1\u003c/b\u003e). A frustrated mother wondered \u003cem\u003e\u0026ldquo;What was the point!\u0026rdquo;\u003c/em\u003e and stopped seeking further vitamins, feeling \u003cem\u003e\u0026ldquo;put-off\u0026rdquo;\u003c/em\u003e, after feeling dismissed with, \u003cem\u003e\u0026ldquo;Alright, here, take these\u0026rdquo; NEM16\u0026minus;T\u003c/em\u003e (also \u003cb\u003eTable 1\u003c/b\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable 1: Why was vitamin voucher take-up so low?\u003c/b\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section3\"\u003e \u003ch2\u003eLack of \u0026lsquo;awareness\u0026rsquo; theme: Illustrative quotations\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"1\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMothers (Universal) re: Own lack of awareness of the vitamin scheme or receiving vouchers\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;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.\u0026rdquo; EM10\u0026minus;U\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;couldn\u0026rsquo;t remember if I had received any, \u0026lsquo;cause it doesn\u0026rsquo;t look like a voucher at the top. \u0026hellip;by the time a friend told me about it, I was like \u0026lsquo;oh gosh, I will have to use it\u0026rsquo;, and then they stopped coming [because she returned to work] so I missed out.\u0026rdquo; EM18\u0026minus;U\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;No, I only just started getting the vitamin tablets with my second child; \u0026hellip;because no one told me.\u0026rdquo; EM06\u0026minus;U\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMothers (Targeted) re\u003c/b\u003e: Own lack of awareness of where to use vouchers and feeling poorly advised\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;I\u0026rsquo;ve always seen the vouchers and thought\u0026hellip; \u0026lsquo;oh I will have to find out where you go\u0026hellip;\u0026rsquo;, but I\u0026rsquo;ve never actually followed it through.\u0026rdquo; EM30\u0026minus;T\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;Yeah [I noticed the vitamin voucher]\u0026hellip; but it didn\u0026rsquo;t say where you get them from or how\u0026hellip;\u0026rdquo; EM25\u0026minus;T\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;No, no one has spoken to me about vitamins. ...and I did actually go and ask my GP because\u0026hellip; I was slightly overweight, so\u0026hellip; [\u0026hellip;] she basically just told me to join Weight Watchers, and I wasn\u0026rsquo;t given any other advice at all.\u0026rdquo; NEM16\u0026minus;T\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHealth professional (Universal) re\u003c/b\u003e: Mothers\u0026rsquo; lack of awareness of vitamin vouchers\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;I wonder how much notice people take of it because it is just an add-on on the form [letter] really\u0026rdquo; HP04\u0026minus;U\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHealth professional (Targeted) re\u003c/b\u003e: Mothers\u0026rsquo; lack of awareness of importance of vitamins or vouchers\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhen \u003cem\u003eHP14\u0026minus;T\u003c/em\u003e highlighted the voucher:\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;they say \u0026lsquo;oh yeah I get that all the time\u0026rsquo; 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 \u0026lsquo;OK\u0026rsquo; but they sometimes still don\u0026rsquo;t come [to the centre] and get them. I don\u0026rsquo;t think they understand the relevance or the importance...\u0026rdquo; HP14\u0026minus;T\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCommissioner (Universal) re\u003c/b\u003e: Mothers\u0026rsquo; lack of awareness of importance of vitamins\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;a lot\u0026hellip; don\u0026rsquo;t particularly believe in the need\u0026rdquo; C03\u0026minus;U\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCommissioner (Targeted) re\u003c/b\u003e: Health professionals\u0026rsquo; lack of awareness of who decided mothers\u0026rsquo; eligibility\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;I met with health professionals at the hospital\u0026hellip; [but] instead of\u0026hellip; [discussing] Healthy Start and the vitamins, and getting them signed up, they just said, well, we\u0026rsquo;re not doing this, because we\u0026rsquo;ll be making a judgement about the women. They missed the point completely! [\u0026hellip;] The [HSIU] has the information and will make the decision about eligibility\u0026rsquo;.\u0026rdquo; C01\u0026minus;T\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eFrom interviews in 2012 with potentially eligible mothers, health professionals, and commissioners about Healthy Start (in a universal and a targeted area in North West England)\u003c/em\u003e \u003c/p\u003e \u003cdiv id=\"Sec20\" class=\"Section4\"\u003e \u003ch2\u003e(N)EM=(entitled mother; HP=health professional; C=commissioner; universal=U, targeted=T\u003c/h2\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section4\"\u003e \u003ch2\u003eHSIU=Healthy Start Issuing Unit\u003c/h2\u003e \u003cp\u003eThe letter did not say where to obtain the vitamins and mothers did not recall being told, particularly in the targeted area: \u003cem\u003e\u0026ldquo;I now know it was my midwife who should have told me from day one!\u0026rdquo;\u003c/em\u003e EM13\u0026minus;T. Some entitled mothers were aware of receiving the vitamin vouchers but did not use them (\u003cem\u003eEM30\u0026minus;T, EM25\u0026minus;T\u003c/em\u003e, \u003cb\u003eTable 1\u003c/b\u003e).\u003c/p\u003e \u003cp\u003eDissatisfaction with taste (\u003cem\u003e\u0026ldquo;too chalky\u0026rdquo; EM38\u0026minus;U\u003c/em\u003e) or palatability \u003cem\u003e(\u0026ldquo;I just throw up\u0026rdquo; EM06-U\u003c/em\u003e) also stopped vitamin use. Complicated administrative processes and perceived unfairness also caused dissatisfaction:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I have a friend who has just turned 18 [in January] and she\u0026rsquo;s pregnant. She can\u0026rsquo;t get her vouchers until she claims child tax credits. She can\u0026rsquo;t claim child tax credits because they\u0026rsquo;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 \u0026pound;20\u0026hellip;\u003c/em\u003e [sighs]...\u003cem\u003e\u0026rdquo; EM38\u0026minus;U\u003c/em\u003e\u003c/p\u003e \u003cp\u003eFor some entitled mothers in the targeted area, poor vitamin supply discouraged continued use: \u003cem\u003e\u0026ldquo;[children\u0026rsquo;s centres] just never have them.\u0026rdquo; EM26\u0026minus;T\u003c/em\u003e. Futile searching for children\u0026rsquo;s vitamin drops was typical: \u003cem\u003e\u0026ldquo;everywhere I ask they go \u0026lsquo;we haven\u0026rsquo;t got them in\u0026rsquo;, like in the children\u0026rsquo;s centre\u0026hellip;\u0026rdquo; EM27\u0026minus;T\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eHealth professionals\u003c/span\u003e from both areas also explained low vitamin take-up in terms of suboptimal awareness (of mothers and health professionals), accessibility, attention, agency, and adequacy of supply (but not acceptability).\u003c/p\u003e \u003cp\u003eThe vitamin voucher \u0026lsquo;hidden in plain sight\u0026rsquo; was a substantial barrier (\u003cem\u003eHP04\u0026minus;U\u003c/em\u003e, \u003cb\u003eTable 1\u003c/b\u003e). One health professional attributed poor maternal awareness of vitamin benefits to lower socio-economic status and education (\u003cem\u003eHP14\u0026minus;T\u003c/em\u003e, \u003cb\u003eTable 1\u003c/b\u003e).\u003c/p\u003e \u003cp\u003eFrom universal and particularly targeted areas, health professionals lacked knowledge (e.g. which vitamins; from where; or whether suitable for special diets). Some health professionals knew of colleagues withholding the vitamins through misunderstanding the constituents (mistakenly \u003cem\u003e\u0026ldquo;thought vitamin A was in the pregnant woman\u0026rsquo;s [vitamin tablets]\u003c/em\u003e\u0026rdquo; \u003cem\u003eHP02\u0026minus;T\u003c/em\u003e), blaming this on suboptimal training. Vitamin vouchers were not a priority in consultations \u003cem\u003e(\u0026ldquo;we midwives can be quite precious about our time\u0026rdquo;\u003c/em\u003e HP05\u0026minus;U) or training:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;They probably said \u0026lsquo;oh here you are, you can give these healthy vitamins\u0026rsquo;.\u0026rdquo; HP36\u0026minus;T\u003c/em\u003e \u003c/p\u003e \u003cp\u003eSome health professionals (mainly from targeted area) did not know where mothers could redeem vitamin vouchers: \u003cem\u003e\u0026ldquo;\u0026hellip;there should be a list of addresses\u0026hellip;\u0026rdquo; HP24\u0026minus;T.\u003c/em\u003e Some were unclear about the administrative processes:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I had absolutely no idea until last Thursday, that, when you\u0026rsquo;ve had your baby, in order to get the vitamin drops, you have to let [HSIU] know...\u0026rdquo; HP02\u0026minus;T\u003c/em\u003e \u003c/p\u003e \u003cp\u003eHealth professionals sometimes forgot or attended poorly to discussing the vitamins, particularly blaming inadequate training and perinatal staffing and a crammed consultation:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We definitely need to cover reducing the risk of cot death\u0026hellip; 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\u0026rsquo;s for a straightforward mum; some of the cases I come across in the community have safeguarding issues and the like.\u0026rdquo; HP05\u0026minus;U\u003c/em\u003e \u003c/p\u003e \u003cp\u003eNevertheless, 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:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Even within your own team, [\u0026hellip;] even when you\u0026rsquo;re all working towards the same goal, you are working in silos to a degree...\u0026rdquo; HP08\u0026minus;T\u003c/em\u003e \u003c/p\u003e \u003cp\u003eComplicated administration introduced delay, blocked access, and frustrated staff with the form-filling (chasing applications \u003cem\u003e\u0026ldquo;for a 97p bottle of vitamins\u0026rdquo; HP15\u0026minus;T\u003c/em\u003e), \u0026lsquo;hidden\u0026rsquo; vitamin vouchers, and poor supply:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;quite frequently I get people ringing me asking me for the Healthy Start number, because they haven\u0026rsquo;t heard [about their application]\u0026hellip;\u0026rdquo; HP04\u0026minus;U\u003c/em\u003e \u003c/p\u003e \u003cp\u003eTo avoid \u0026lsquo;red tape\u0026rsquo;, health professionals thought that they should personally hand mothers the vitamins, particularly if vulnerable (\u003cem\u003e\u0026ldquo;instead of the mothers having to go somewhere else\u0026rdquo; HP04\u0026minus;U\u003c/em\u003e, i.e. to another centre):\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;then they have to \u0026lsquo;re-register\u0026rsquo;\u003c/em\u003e \u003csup\u003e\u0026dagger;\u003c/sup\u003e \u003cem\u003eonce the baby is born so it\u0026rsquo;s\u0026hellip; a lot of red tape and forms...\u0026rdquo; HP15\u0026minus;T [\u003c/em\u003e\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003cem\u003eThis can be by telephone though.]\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;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\u0026rsquo;ll have been backwards and forwards with\u0026hellip; 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\u0026hellip; I have even rang the Department of Health and they can\u0026rsquo;t speak to me about it, because it\u0026rsquo;s her...\u0026rdquo; HP14\u0026minus;T\u003c/em\u003e \u003c/p\u003e \u003cp\u003eIllustrating 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:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;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\u0026hellip; she didn\u0026rsquo;t do that but\u0026hellip; \u0026hellip;She goes, \u0026lsquo;please just let me buy them\u0026rsquo;\u0026hellip; \u0026lsquo;I can\u0026rsquo;t because there is a lot of red tape, again, surrounding the purchase of them\u0026rsquo;. She understood the need [but] all I could do was recommend\u0026hellip; her to\u0026hellip; find something similar, which was a big, big deal for her.\u0026rdquo; HP15\u0026minus;T\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eCommissioners\u003c/span\u003e from both areas highlighted aspects of awareness, accessibility, agency, and adequacy of supply, but also accountability. Besides mothers\u0026rsquo; lack of vitamin awareness (\u003cem\u003eC03\u0026minus;U\u003c/em\u003e, \u003cb\u003eTable 1\u003c/b\u003e), 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:\u0026minus; they had to judge maternal socio-economic status; the vitamins for pregnant women inappropriately contained vitamin A (present in children\u0026rsquo;s vitamin drops \u003cem\u003eonly\u003c/em\u003e); or the vitamins were unsuitable for special diets. One commissioner highlighted health professionals\u0026rsquo; lack of awareness of decision-making about eligibility (\u003cem\u003eC01\u0026minus;T\u003c/em\u003e, \u003cb\u003eTable 1\u003c/b\u003e).\u003c/p\u003e \u003cp\u003eCommissioners also cited poorly visible vitamin vouchers. One commissioner who had worked in the universal area since Healthy Start began highlighted improvements though:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Healthy Start put a lot of things in those letter packages to people. And originally [\u0026hellip;] it was one line [about vitamins] on the letter and the writing was\u003c/em\u003e \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003every\u003c/span\u003e \u003cem\u003esmall, but Healthy Start improved the look of the voucher; [\u0026hellip;] but it still wasn\u0026rsquo;t as big as the food voucher.\u0026rdquo; C03\u0026minus;U\u003c/em\u003e\u003c/p\u003e \u003cp\u003eIt was costly for mothers to telephone the HSIU to ask questions or to declare the birth to obtain children\u0026rsquo;s vitamin drops (albeit simpler than originally having to re-apply):\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;women can [now] just make a phone call and say, \u0026lsquo;I\u0026rsquo;ve had my baby\u0026rsquo; [\u0026hellip;], \u0026hellip;but it\u0026rsquo;s complicated\u0026hellip; [\u0026hellip;] often, women who are in low income households do not have a landline within their house, and they were using mobiles, [\u0026hellip;] on premium-rate numbers...\u0026rdquo; C01\u0026minus;T\u003c/em\u003e \u003c/p\u003e \u003cp\u003eUnderfunding 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 \u0026lsquo;supply chain\u0026rsquo; (distribution service), which delivered only to NHS estates. Without extra funding, the commissioners were responsible for local distributors (e.g. children\u0026rsquo;s centres) receiving vitamins. Delays meant out-of-date vitamins. Commissioners relied on the goodwill of other local distributors to overcome national governance requirements:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;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\u0026rsquo;s centre to children\u0026rsquo;s centre. This really made distribution of the vitamins simple.\u0026rdquo; C03\u0026minus;U\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Estates were involved in distribution of the vitamins \u0026lsquo;cause there was a lot of governance issues because we had NHS providing to the local authority [\u0026hellip;]. \u0026hellip;but the way that we worked, it worked absolutely fabulously [\u0026hellip;] \u0026hellip;Department of Health kept on saying to us \u0026ndash; no you can\u0026rsquo;t do this because [of] governance issues, whilst it worked for us.\u0026rdquo; C22\u0026minus;U\u003c/em\u003e \u003c/p\u003e \u003cp\u003eWithin commissioning, their \u0026lsquo;collective agency\u0026rsquo; was over-reliant on goodwill to ensure vitamin distribution via hospitals and rather resistant general practices: \u003cem\u003e\u0026ldquo;how much are you going to give me for doing this?\u0026rdquo; C01\u0026minus;T\u003c/em\u003e). Logistics were tricky:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;[NHS] people\u0026hellip; say, \u0026lsquo;hang on a minute, you are asking me to do something that\u0026rsquo;s out of my job description!\u0026rsquo; And [\u0026hellip;] the Department of Health had never thought this through properly\u0026hellip; [\u0026hellip;] This was all supposed to be done out of goodwill!\u0026rdquo; C01\u0026minus;T\u003c/em\u003e \u003c/p\u003e \u003cp\u003eChildren\u0026rsquo;s vitamin drops were a medicine (not a supplement), requiring local pharmaceutical approval. One commissioner worked around this with local Medicines Management:\u003c/p\u003e \u003cp\u003e\u003cem\u003e \u0026ldquo;\u0026hellip;we had one of their managers\u0026hellip; arranged\u0026hellip; approval for us to order through her, so everything was purchased up front, everything was distributed from Medicines Management, and then the accountant [\u0026hellip;] put [that] in as a return.\u0026rdquo; C01\u0026minus;T\u003c/em\u003e\u003c/p\u003e \u003cp\u003eCommissioners from both areas were frustrated at the ad hoc vitamin supply affecting take-up:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;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\u0026rsquo;d end up in the bin, because no one claimed them; we were paying to throw vitamins in the bin\u0026hellip;\u0026rdquo; C03\u0026minus;U\u003c/em\u003e \u003c/p\u003e \u003cp\u003eCommissioners believed that improved vitamin take-up required more accountability. One commissioner was astonished that the HSIU did not \u003cem\u003e\u0026ldquo;want to know if the vitamins actually got to mothers; all they want is purchase data\u003c/em\u003e\u0026rdquo; \u003cem\u003eC01\u0026minus;T\u003c/em\u003e. Regular steering-group meetings in both areas encouraged accountability for vitamin distribution and take-up. In the targeted area, local authority staff in children\u0026rsquo;s centres appeared more engaged than NHS staff, possibly because local authority targets and inspections included Healthy Start vitamin performance:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Children\u0026rsquo;s centres [\u0026hellip;] have \u0026lsquo;OFSTED\u0026rsquo; inspections... Distributing Healthy Start vitamins is another way that they can show that they\u0026rsquo;re being beneficial to the community...\u0026rdquo; C01\u0026minus;T\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe HSIU was unconvinced about challenging \u0026lsquo;nought returns\u0026rsquo;: \u0026ldquo;\u003cem\u003eI think it would be unheard of for a government department to legally challenge another bit of the same public sector\u003c/em\u003e\u0026rdquo; \u003cem\u003eDH44\u0026minus;HSIU.\u003c/em\u003e One commissioner from the universal area believed that \u0026lsquo;nought returns\u0026rsquo; reflected that \u003cem\u003e\u0026ldquo;it is too costly for them to [file the return]\u0026rdquo; C03\u0026minus;U.\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section3\"\u003e \u003ch2\u003eWhy might vitamin voucher take-up be more in the universal area?\u003c/h2\u003e \u003cp\u003eHigher vitamin take-up (albeit still low) in the universal area related to awareness (staff), accessibility, attention (priority), and adequacy of supply (\u003cb\u003eTable 2\u003c/b\u003e).\u003c/p\u003e \u003cp\u003e \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eMothers\u003c/span\u003e from the universal area reported that they could exchange vouchers for vitamin tablets or drops in several places (\u003cem\u003e\u0026ldquo;I can get them here [children\u0026rsquo;s centre]; there\u0026rsquo;s lot of places I could get them\u0026rdquo; EM09\u0026minus;U\u003c/em\u003e), and the process appeared easy and immediate \u003cem\u003e(\u0026ldquo;they just gave me this\u0026hellip; yellow card\u003c/em\u003e [a local card], \u003cem\u003eand each time you come you have to have it signed\u0026rdquo; NEM19\u0026minus;U; \u0026ldquo;went to a weaning group and they told us\u0026hellip; [and] we got them [there]\u0026rdquo; NEM12\u0026minus;U\u003c/em\u003e). This accessibility and adequacy of supply contrasted with mothers\u0026rsquo; frustration in the targeted area at the \u0026lsquo;mystery\u0026rsquo; of supply.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eHealth professionals\u003c/span\u003e in the universal area seemed more knowledgeable about vitamin access, which they considered to be timely but might improve \u003cem\u003e\u0026ldquo;if midwives actually had them...\u0026rdquo; HP04\u0026minus;U\u003c/em\u003e to provide at the \u0026lsquo;booking-in\u0026rsquo; (first) consultation.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eCommissioners\u003c/span\u003e in the universal area considered that offering Healthy Start vitamins to all women raised staff awareness because previously, when their Healthy Start was targeted, access and adequacy of supply suffered.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable 2: Why might vitamin voucher take-up be more in the universal area?\u003c/b\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eIllustrative quotations of themes\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e \u003ccolgroup cols=\"1\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMothers (Targeted): Accessibility and Adequacy of supply\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;I try [to use the vitamin vouchers], if you can get them for free, you\u0026rsquo;ve seen I\u0026rsquo;ve got the voucher right here\u0026hellip; but\u0026hellip; I don\u0026rsquo;t know whether it\u0026rsquo;s because of the cutbacks or whether they\u0026rsquo;ve just stopped sending them, but the [children\u0026rsquo;s] centres where I go [to] ask for themࣧthey just never have them.\u0026rdquo; EM26\u0026minus;T\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;There was nowhere really to get them. Every time I\u0026rsquo;d ask in the doctors\u0026rsquo; they said, \u0026lsquo;see your midwife\u0026rsquo;, and the midwife told me to look on the internet, but I haven\u0026rsquo;t got any internet at home\u0026hellip; I have never ever got the vitamins because I don\u0026rsquo;t know where to get them from or anything\u0026hellip;\u0026rdquo; EM27\u0026minus;T\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHealth professionals (Universal)\u003c/b\u003e: Awareness and Accessibility\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;available in every children\u0026rsquo;s centre so that's\u0026hellip; six\u0026hellip; within a radius of about ten miles? So they're quite freely available [\u0026hellip;] from the receptionist\u0026hellip;\u0026rdquo; HP05\u0026minus;U.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;Now locally [\u0026hellip;] [mothers are] given a form to come and get vitamins\u0026hellip; from the children\u0026rsquo;s centre\u0026hellip; [\u0026hellip;] 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.\u0026rdquo; HP04\u0026minus;U\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCommissioner (Universal)\u003c/b\u003e: Accessibility and Adequacy of supply\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhen the universal area had been a targeted area:\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;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\u0026hellip; And managers would just stop stocking them\u0026hellip; they\u0026rsquo;d just fall off the agenda.\u0026rdquo; C03\u0026minus;U\u003c/em\u003e\u003c/p\u003e \u003cp\u003eOverclaiming did \u003cem\u003enot\u003c/em\u003e explain higher vitamin take-up. Reimbursement claims related only to entitled mothers: \u003cem\u003e\u0026ldquo;We keep a spreadsheet \u0026hellip;from each children\u0026rsquo;s centre\u0026hellip; mark E for eligible or L for local\u0026hellip;\u0026rdquo; C03\u0026minus;U\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e[Mothers could only use either the locally produced or national voucher.]\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCommissioner (Targeted)\u003c/b\u003e: Attention (prioritizing)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKey stakeholders paid insufficient attention to improving vitamin take-up. A working group lacked midwife and GP engagement and \u003cem\u003e\u0026ldquo;we failed miserably\u0026rdquo; C01\u0026minus;T\u003c/em\u003e to engage an accountant to help file HSIU returns. That commissioner also wanted more active listening from: \u003cem\u003e\u0026ldquo;[the Department of Health] \u0026hellip;get people from different parts of the country, sit down and talk to them and say, OK, what, what are our barriers?\u0026rdquo; C01\u0026minus;T\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eFrom interviews in 2012 with potentially eligible mothers, health professionals, and commissioners about Healthy Start (in a universal and a targeted area in North West England)\u003c/em\u003e \u003c/p\u003e \u003cdiv id=\"Sec24\" class=\"Section4\"\u003e \u003ch2\u003eEM=entitled mother; HP=health professional; C=commissioner; universal=U, targeted=T\u003c/h2\u003e \u003c/div\u003e \u003cdiv id=\"Sec25\" class=\"Section4\"\u003e \u003ch2\u003eHSIU=Healthy Start Issuing Unit\u003c/h2\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study has shown that the national vitamin vouchers were hidden in plain sight, evading busy mothers and staff caught in an overcomplicated system. Poor Healthy Start vitamin take-up from the statutory scheme was linked to precarious, overcomplicated procedures that confused, frustrated, or escaped its main stakeholders. Scheme success relied on underfunded children\u0026rsquo;s centres, organizational goodwill, and the resilience of participating families. Food and vitamin voucher take-up was significantly higher in the universal administration-areas of the North West compared with the remaining areas. It seems likely that barriers, including stigma about targeted use of children\u0026rsquo;s centres\u003ca class=\"FNLink\" href=\"#Fn37\" id=\"#FNLinkFn37\"\u003e\u003c/a\u003e, decrease when the vitamins become everyone\u0026rsquo;s business.\u003c/p\u003e \u003cp\u003eStudying mothers\u0026rsquo;, health professionals\u0026rsquo;, and commissioners\u0026rsquo; perceptions about Healthy Start take-up suggested that take-up was consistently much higher for food than vitamin vouchers because the food vouchers had clearer presentation and messaging and had practical and monetary (albeit low) value. Barriers to vitamin take-up included suboptimal awareness (and attitude) of mothers and staff, attention to its priority, accessibility, acceptability, and adequacy of supply.\u003c/p\u003e \u003cp\u003eAll pregnant women in Scotland have qualified for free Healthy Start vitamins since April 2017\u003ca class=\"FNLink\" href=\"#Fn38\" id=\"#FNLinkFn38\"\u003e\u003c/a\u003e\u003csup\u003e,\u003c/sup\u003e\u003ca class=\"FNLink\" href=\"#Fn39\" id=\"#FNLinkFn39\"\u003e\u003c/a\u003e. Attempts to improve England\u0026rsquo;s scheme have continued, e.g. more obvious vitamin vouchers and the food voucher covering pulses and frozen vegetables, but the scheme remains broadly similar to when our study was undertaken in 2012. Digitizing vouchers\u003ca class=\"FNLink\" href=\"#Fn40\" id=\"#FNLinkFn40\"\u003e\u003c/a\u003e has been delayed until late 2021.\u003c/p\u003e \u003cp\u003eWhile the food voucher works better than a cash-equivalent benefit\u003csup\u003e\u003cb\u003e9\u003c/b\u003e,\u003c/sup\u003e\u003ca class=\"FNLink\" href=\"#Fn41\" id=\"#FNLinkFn41\"\u003e\u003c/a\u003e, and its subversion\u003ca class=\"FNLink\" href=\"#Fn42\" id=\"#FNLinkFn42\"\u003e\u003c/a\u003e is probably uncommon\u003ca class=\"FNLink\" href=\"#Fn43\" id=\"#FNLinkFn43\"\u003e\u003c/a\u003e, its monetary value has progressively lagged food costs\u003csup\u003e\u003cb\u003e12,25\u003c/b\u003e\u003c/sup\u003e. From April 2021, the weekly food voucher increased from \u0026pound;3.10p (since 2009) to \u0026pound;4.25p (matching Scotland)\u003ca class=\"FNLink\" href=\"#Fn44\" id=\"#FNLinkFn44\"\u003e\u003c/a\u003e.\u003c/p\u003e \u003cp\u003eLow food voucher value might explain falling take-up over this last decade. By the beginning of 2020 and 2021, take-up was only 54% and 53% in England and 54% and 54% in the North West, respectively\u003csup\u003e\u003cb\u003e28\u003c/b\u003e\u003c/sup\u003e, i.e. down about one-quarter on 2012/13 (Quarter 1 (Q1): 70% and 73%, \u003cb\u003eAdditional file 2\u003c/b\u003e). Jessiman et al. found that midwife reminders about Healthy Start eligibility were patchy and beneficiaries easily fell off the scheme, especially by not reporting the birth\u003csup\u003e\u003cb\u003e24\u003c/b\u003e\u003c/sup\u003e. Furthermore, health professionals may well progressively add well-intentioned edicts (to avoid fraud or non-viable pregnancies), which then delay the application process, and \u003cem\u003e\u0026ldquo;the fragile nature of improvement work\u003c/em\u003e\u003csup\u003e\u003cb\u003e\u0026rdquo;\u003c/b\u003e\u003c/sup\u003e\u003ca class=\"FNLink\" href=\"#Fn45\" id=\"#FNLinkFn45\"\u003e\u003c/a\u003e\u003csup\u003e\u003cb\u003e(p4)\u003c/b\u003e\u003c/sup\u003e hinders sustained remediation.\u003c/p\u003e \u003cp\u003eMeanwhile, continued very low vitamin take-up receives little attention, documented when individual public health teams publish quarterly HSIU\u003csup\u003e\u003cb\u003e28\u003c/b\u003e\u003c/sup\u003e data. The HSIU website was displaying \u003cem\u003efood\u003c/em\u003e voucher take-up data only but now none. The figures are stark. For example, Birmingham implements Healthy Start universally and has documented systematically a 5-year falling \u0026lsquo;vitamin take-up for eligible\u0026rsquo; people from about 4% to \u0026lt;1% (and for non-eligible from about 25% to about 10%)\u003ca class=\"FNLink\" href=\"#Fn46\" id=\"#FNLinkFn46\"\u003e\u003c/a\u003e. In 2020, one member of parliament highlighted Healthy Start dataset inadequacies\u003ca class=\"FNLink\" href=\"#Fn47\" id=\"#FNLinkFn47\"\u003e\u003c/a\u003e, an underpublicized issue.\u003c/p\u003e \u003cp\u003eThis study complements and extends findings from a similar era about frustrated staff trying to overcome improvement barriers\u003csup\u003e\u003cb\u003e21,23,24,25,26\u003c/b\u003e\u003c/sup\u003e. They encountered Heath Robinson-level\u003ca class=\"FNLink\" href=\"#Fn48\" id=\"#FNLinkFn48\"\u003e\u003c/a\u003e system complications. In our study though, health professionals in the universal area seemed more knowledgeable about vitamin access and devised local solutions to supply-chain barriers. Futile searching by mothers arose from suboptimal vitamin access and supply, similar to Jessiman et al.\u003csup\u003e\u003cb\u003e24\u003c/b\u003e\u003c/sup\u003e, particularly when targeted. Nevertheless, even a universal scheme commissioner felt like, \u003cem\u003e\u0026ldquo;we were paying to throw vitamins in the bin\u0026rdquo;\u003c/em\u003e. Jessiman et al.\u003csup\u003e\u003cb\u003e24\u003c/b\u003e\u003c/sup\u003e found that midwives engaged more directly in universal pilot-areas by issuing vitamins in-person with timely advice to embed the vitamins \u0026lsquo;habit\u0026rsquo;\u003csup\u003e\u003cb\u003e42(p77)\u003c/b\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThis study contextualizes calls for universal implementation\u003csup\u003e\u003cb\u003e23,24\u003c/b\u003e,\u003c/sup\u003e\u003ca class=\"FNLink\" href=\"#Fn49\" id=\"#FNLinkFn49\"\u003e\u003c/a\u003e. This would only be cost-effective if covering all the target group \u003cem\u003eplus\u003c/em\u003e all women planning pregnancy or below 10 weeks\u0026rsquo; pregnant (reflecting folic acid impact), infants 0\u0026ndash;6 months, and 4\u0026minus;5 year-olds\u003ca class=\"FNLink\" href=\"#Fn50\" id=\"#FNLinkFn50\"\u003e\u003c/a\u003e.\u003c/p\u003e \u003cp\u003eMachell\u0026rsquo;s\u003ca class=\"FNLink\" href=\"#Fn51\" id=\"#FNLinkFn51\"\u003e\u003c/a\u003e policy analysis of how Healthy Start developed highlighted little meaningful convergence of the problem tackled for potential beneficiaries, the implementation policy, and the politics. Politics drove development not evidence about eligible beneficiaries\u0026rsquo; food culture and access to food. In our study, mothers, i.e. Machell\u0026rsquo;s \u003cem\u003e\u0026ldquo;hidden participants\u0026rdquo;\u003c/em\u003e\u003csup\u003e\u003cb\u003e50(p24)\u003c/b\u003e\u003c/sup\u003e to policy-making, clearly articulated unmet need, despite the Government now describing Healthy Start as \u003cem\u003e\u0026ldquo;demand-led\u0026hellip; not target driven\u0026rdquo;\u003c/em\u003e\u003ca class=\"FNLink\" href=\"#Fn52\" id=\"#FNLinkFn52\"\u003e\u003c/a\u003eand apparently ignoring food and vitamin vouchers in its \u0026lsquo;The Best Start for Life\u0026rsquo; vision\u003ca class=\"FNLink\" href=\"#Fn53\" id=\"#FNLinkFn53\"\u003e\u003c/a\u003e.\u003c/p\u003e \u003cdiv id=\"Sec27\" class=\"Section2\"\u003e \u003ch2\u003eStrengths/limitations/implications\u003c/h2\u003e \u003cp\u003e This study involved only two local administrative areas, however the dystopian experience of staff and 25 potentially eligible mothers converged from six children\u0026rsquo;s centres sampled specifically to compare a similarly deprived universal and targeted area. Jessiman et al.\u003csup\u003e\u003cb\u003e24\u003c/b\u003e\u003c/sup\u003e likewise recruited successfully via children\u0026rsquo;s centres, but their 107 parents were from a single postcode in thirteen English administrative areas that were sampled on criteria other than universal versus targeted implementation. Nearly all McFadden et al.\u0026rsquo;s\u003csup\u003e\u003cb\u003e25\u003c/b\u003e\u003c/sup\u003e 109 (potential) beneficiaries\u0026rsquo; views (including four males) came from participatory workshops and focus groups, but our study used semi-structured interviews for in-depth probing, like Jessiman et al.\u003csup\u003e\u003cb\u003e24\u003c/b\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eOur findings have illuminated this unfit-for-purpose vitamin-delivery system. Since the data were collected, child poverty has continued to grow and population nutrition to deteriorate, emphasizing the need for action. Crawley and Dodds\u003csup\u003e\u003cb\u003e37(p7)\u003c/b\u003e\u003c/sup\u003e considered this to be:\u003cdiv class=\"BlockQuote\"\u003e\u003cdiv id=\"Par180\" class=\"Para\"\u003ea new era of child poverty and family food insecurity [\u0026hellip;] The reduction in the number of families eligible for Healthy Start appears incongruous against this backdrop of increasing hardship among low-income families.\u003c/div\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThey concluded that the scheme \u003cem\u003e\u0026ldquo;has not been consistently supported either nationally or locally\u0026rdquo;\u003c/em\u003e\u003csup\u003e\u003cb\u003e(p69)\u003c/b\u003e\u003c/sup\u003e and benefits system changes have not undergone impact assessment for Healthy Start. They recommended commissioning \u003cem\u003e\u0026ldquo;a regular review of the effectiveness of the Healthy Start scheme in achieving its public health goals\u0026rdquo;\u003c/em\u003e\u003csup\u003e\u003cb\u003e(p17)\u003c/b\u003e\u003c/sup\u003e and commissioning SACN or National Institute for Health and Care Excellence (NICE) to advise \u003cem\u003e\u0026ldquo;on reformulating the Healthy Start vitamins as primarily vitamin D supplements\u0026rdquo;\u003c/em\u003e\u003csup\u003e\u003cb\u003e(p15)\u003c/b\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eSince our own study, system improvements have been small and fragmented (e.g. food voucher value increasing modestly, belatedly, in 2021). Meanwhile, progressive underfunding of children\u0026rsquo;s centres has compromised health improvement\u003ca class=\"FNLink\" href=\"#Fn54\" id=\"#FNLinkFn54\"\u003e\u003c/a\u003e and Healthy Start delivery.\u003c/p\u003e \u003cp\u003eHealthy Start has become news again though in 2021. Marcus Rashford (English Premier League footballer) has promoted voucher take-up in his healthy nutrition campaign for low-income families\u003ca class=\"FNLink\" href=\"#Fn55\" id=\"#FNLinkFn55\"\u003e\u003c/a\u003e\u003csup\u003e,\u003c/sup\u003e\u003ca class=\"FNLink\" href=\"#Fn56\" id=\"#FNLinkFn56\"\u003e\u003c/a\u003e, for whom determinants of \u0026lsquo;nutrition choices\u0026rsquo; are more structural than lifestyle\u003ca class=\"FNLink\" href=\"#Fn57\" id=\"#FNLinkFn57\"\u003e\u003c/a\u003e. Additionally, the Health Secretary (England) conceded a legal challenge in June 2021 about a low-income mother who was awaiting settled UK status being deemed ineligible\u003ca class=\"FNLink\" href=\"#Fn58\" id=\"#FNLinkFn58\"\u003e\u003c/a\u003e. This prompted government commitment to reviewing the scheme to ensure that it is non-discriminatory.\u003c/p\u003e \u003cp\u003eOur study should be replicated elsewhere to contribute to such a review, updating on participants\u0026rsquo; insights.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003e \u003cem\u003eSubstantive\u003c/em\u003e Healthy Start reform in England (not just cosmetic tinkering) is long overdue. Meanwhile, childhood nutritional rickets continues in high-risk groups lacking intended Healthy Start vitamins\u003ca class=\"FNLink\" href=\"#Fn59\" id=\"#FNLinkFn59\"\u003e\u003c/a\u003e. Poverty-related food insecurity still requires much re-investment in early years\u0026rsquo; services\u003csup\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sup\u003e. \u003cem\u003e\u0026ldquo;Meaningful engagement and co-production with people with lived experience of poverty\u003c/em\u003e\u003csup\u003e\u003cb\u003e\u0026rdquo;\u003c/b\u003e\u003c/sup\u003e\u003ca class=\"FNLink\" href=\"#Fn60\" id=\"#FNLinkFn60\"\u003e\u003c/a\u003e\u003csup\u003e\u003cb\u003e(p5)\u003c/b\u003e\u003c/sup\u003e would mean asking families how best to simplify vitamin take-up. Our study highlights that \u0026lsquo;policy, politics, and problem\u0026rsquo; should be aligned to reach considerable unmet need.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCMOs\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;UK chief medical officers\u003c/p\u003e\n\u003cp\u003eHSIU\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Healthy Start Issuing Unit\u003c/p\u003e\n\u003cp\u003eNICE\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;National Institute for Health and Care Excellence\u003c/p\u003e\n\u003cp\u003eNRES\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;National Research Ethics Service\u003c/p\u003e\n\u003cp\u003ePCT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;primary care trust\u003c/p\u003e\n\u003cp\u003eQ1\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Quarter 1 (of data collection-year)\u003c/p\u003e\n\u003cp\u003eR\u0026amp;D\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;research and development\u003c/p\u003e\n\u003cp\u003eSACN\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Scientific Advisory Committee on Nutrition\u003c/p\u003e\n\u003cp\u003eUK \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;United Kingdom\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe University of Liverpool\u0026rsquo;s Faculty of Health and Life Sciences was Sponsor \u003cem\u003eUoL000752\u003c/em\u003e for\u0026nbsp;administration\u0026nbsp;and management, as per Health Research Authority.\u003c/p\u003e\n\u003cp\u003eThe National\u0026nbsp;Research\u0026nbsp;Ethics Service (NRES) (Proportionate Review Sub-Committee Committee East Midlands\u0026ndash;Derby, ref no. 11/EM/0362) approved the proposal and three local research and development (R\u0026amp;D) committees were involved.\u003c/p\u003e\n\u003cp\u003eAll participants gave written informed consent to be interviewed. \u0026nbsp;The research complied with the Helsinki Declaration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe qualitative datasets generated and analysed in this study are not publicly available due to data privacy reasons, as per ethics approval. \u0026nbsp;The Results section presents the relevant interview data from written transcripts of participants\u0026rsquo; audio-recordings, which were deleted post-transcription as per approval agreements. \u0026nbsp;The corresponding author would answer questions about these data. \u0026nbsp;The quantitative data were obtained and used with permission from the Healthy Start Issuing Unit. \u0026nbsp;Such data requests should be directed to that Unit28.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that there are no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere\u0026nbsp;are\u0026nbsp;no funding sources to declare\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMM\u0026nbsp;undertook\u0026nbsp;the data collection as part of her doctoral research thesis, supervised by MW, GM, and BH. \u0026nbsp;GM wrote the first draft of this paper built on core findings, in consultation with MW, and incorporated critical input from MM and BH, such that MM and GM should be considered joint first authors. \u0026nbsp;All authors reviewed the full draft and suggested important revisions. \u0026nbsp;All authors read and approved the final version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank\u0026nbsp;the\u0026nbsp;participants for their valuable contributions.\u003c/p\u003e\n\u003cp\u003eThis work built on a doctoral thesis\u003ca href=\"#_edn1\" name=\"_ednref1\" title=\"\"\u003e[i]\u003c/a\u003e undertaken while MM was a clinical lecturer/honorary specialty registrar in public health\u003c/p\u003e\n\u003cdiv id=\"edn1\"\u003e\n \u003cp\u003e\u003ca href=\"#_ednref1\" name=\"_edn1\" title=\"\"\u003e[i]\u003c/a\u003e Moonan M. \u0026nbsp;\u003cem\u003eAn exploration of the UK Healthy Start vitamin supplementation programme in North West England.\u003c/em\u003e\u0026nbsp; Doctor of Medicine (MD) thesis. \u0026nbsp;Liverpool: The University of Liverpool, 2018:189pp.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003e\u0026nbsp;Marmot M, Allen J, Boyce T, Goldblatt P, Morrison J. \u0026nbsp;\u003cem\u003eThe Marmot Review 10 years on: Health equity in England.\u003c/em\u003e\u0026nbsp; \u0026nbsp;London: Institute of Health Equity (Department for Epidemiology \u0026amp; Public Health, University College London), 2020: 170 pp. \u0026nbsp;Available at\u0026nbsp;\u003ca href=\"http://www.instituteofhealthequity.org/resources-reports/marmot-review-10-years-on\"\u003ehttp://www.instituteofhealthequity.org/resources-reports/marmot-review-10-years-on\u003c/a\u003e \u0026nbsp;[Last accessed: September 2021]\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Williamson S, McGregor-Shenton M, Brumble B, Wright B, Pettinger C. \u0026nbsp;Deprivation and healthy food access, cost and availability: a cross-sectional study. \u0026nbsp;\u003cem\u003eJournal of Human Nutrition and Dietetics\u0026nbsp;\u003c/em\u003e2017;\u003cem\u003e30\u003c/em\u003e(6):791-799. \u0026nbsp;https://doi.org/10.1111/jhn.12489\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Cattan S, Conti G, Farquharson C, Ginja R. \u0026nbsp;\u003cem\u003eThe health effects of Sure Start.\u003c/em\u003e\u0026nbsp; London: The Institute of Fiscal Studies, June 2019. \u0026nbsp;https://doi.org/10.1920/re.ifs.2019.0155 \u0026nbsp;Available at\u0026nbsp;\u003ca href=\"https://www.ifs.org.uk/publications/14139\"\u003ehttps://www.ifs.org.uk/publications/14139\u003c/a\u003e \u0026nbsp;[Last accessed: September 2021]\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Hodgson D (Mayor\u0026nbsp;of Bedford Borough). \u0026nbsp;Mayor Dave launches free school meals scheme over Christmas [web-page]. Bedford: Bedford Borough Council, 22.12.20. \u0026nbsp;Available at\u0026nbsp;\u003ca href=\"https://mayordave.org.uk/en/article/2020/1387734/mayor-dave-launches-free-school-meals-scheme-over-christmas\"\u003ehttps://mayordave.org.uk/en/article/2020/1387734/mayor-dave-launches-free-school-meals-scheme-over-christmas\u003c/a\u003e\u0026nbsp; [Last accessed: September 2021]\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;The Trussell Trust. \u0026nbsp;\u003cem\u003eEmergency food [web-page].\u003c/em\u003e\u0026nbsp; Salisbury: The Trussell Trust. \u0026nbsp;Available at\u0026nbsp;\u003ca href=\"https://www.trusselltrust.org/get-help/emergency-food/\"\u003ehttps://www.trusselltrust.org/get-help/emergency-food/\u003c/a\u003e\u0026nbsp; [Last accessed: September 2021]\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Committee on Medical Aspects of Food and Nutrition Policy: Panel on Child and Maternal Nutrition of the\u0026nbsp;Committee\u0026nbsp;on Medical Aspects of Food and Nutrition Policy (chaired by Sir John Grimley Evans). \u0026nbsp;\u003cem\u003eScientific review of the Welfare Food Scheme [Report 51 on Health \u0026amp; Social Subjects]. \u0026nbsp;\u003c/em\u003eLondon: The Stationery Office, Department of Health, 2002: 147 pp. I SBN: 0 II 322589 X\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Ford FA,\u0026nbsp;Mouratidou\u0026nbsp;T, Wademan SE, Fraser RB. \u0026nbsp;Effect of the introduction of \u0026lsquo;Healthy Start\u0026rsquo; on dietary behaviour during and after pregnancy: Early results from the \u0026lsquo;before and after\u0026rsquo; Sheffield study. \u0026nbsp;\u003cem\u003eBritish Journal of Nutrition\u0026nbsp;\u003c/em\u003e2009;\u003cem\u003e101\u003c/em\u003e(12):1,828-1,836. \u0026nbsp;https://doi.org/10.1017/S0007114508135899\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Mouratidou, T., Ford, F.A., Wademan, S.E. \u0026amp; Fraser, R.B. (2010). Are the benefits of the \u0026lsquo;Healthy Start\u0026rsquo; food support scheme sustained at three months postpartum? Results from the Sheffield \u0026lsquo;before and after\u0026rsquo; study. \u0026nbsp;\u003cem\u003eMaternal and Child Nutrition\u003c/em\u003e, \u003cem\u003e6\u003c/em\u003e(4), 347-357. \u0026nbsp;https://doi.org/10.1111/j.1740-8709.2009.00215.x\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Griffith R, von\u0026nbsp;Hinke\u0026nbsp;S, Smith S. \u0026nbsp;Getting a healthy start: The effectiveness of targeted benefits for improving dietary choices. \u0026nbsp;\u003cem\u003eJournal of Health Economics\u0026nbsp;\u003c/em\u003e2018;\u003cem\u003e58\u003c/em\u003e:176-187. \u0026nbsp;https://doi.org/10.1016/j.jhealeco.2018.02.009\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Lovelace S, Rabiee‐Khan F. \u0026nbsp;Food choices made by low-income households when feeding their pre-school children: a qualitative study. \u0026nbsp;\u003cem\u003eMaternal and Child Nutrition\u0026nbsp;\u003c/em\u003e2015;\u003cem\u003e11\u003c/em\u003e(4):870-881. \u0026nbsp;https://doi.org/10.1111/mcn.12028\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Scantlebury RJ, Moody A, Oyebode O, Mindell JS. \u0026nbsp;Has the UK Healthy Start voucher scheme been associated with an increased fruit and vegetable intake among target families? Analysis of Health Survey for England data, 2001-2014. \u0026nbsp;\u003cem\u003eJournal of Epidemiology and Community Health\u0026nbsp;\u003c/em\u003e2018;\u003cem\u003e72\u003c/em\u003e(7):623-629. \u0026nbsp;https://doi.org/10.1136/jech-2017-209954\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Parnham J, Millett C, Chang K, Laverty AA, von Hinke S, Pearson-Stuttard J, Vamos EP. \u0026nbsp;Is the Healthy Start scheme associated with increased food expenditure in low-income families with young children in the United Kingdom? \u0026nbsp;\u003cem\u003emedRxiv\u003c/em\u003e. \u0026nbsp;2020:21 pp. \u0026nbsp; https://doi.org/10.1101/2020.11.04.20225094\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Belton NR. \u0026nbsp;Healthy Start \u0026ndash; will it provide optimal infant and child nutrition? \u0026nbsp;\u003cem\u003eNutrition and Food Science\u0026nbsp;\u003c/em\u003e2005;\u003cem\u003e35\u003c/em\u003e(2):74-80. \u0026nbsp; https://doi.org/10.1108/00346650510602444\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Maynard K, on behalf of the Citizens Advice Bureau. \u0026nbsp;\u003cem\u003eWelfare foods and Healthy Start: CAB Evidence on the provision of milk tokens. CAB Evidence Briefing.\u003c/em\u003e \u003cem\u003eNovember 2006.\u003c/em\u003e\u0026nbsp; London: Citizens Advice Bureau 2006:10 pp. \u0026nbsp;Available at\u0026nbsp;\u003ca href=\"https://www.citizensadvice.org.uk/Global/Migrated_Documents/corporate/welfare-foods---healthy-start-final.pdf\"\u003ehttps://www.citizensadvice.org.uk/Global/Migrated_Documents/corporate/welfare-foods---healthy-start-final.pdf\u003c/a\u003e \u0026nbsp;[Last accessed: September 2021]\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Hills D. \u0026nbsp;Healthy Start: Rapid evaluation on early impact on beneficiaries, health professionals, retailers and contractors [executive summary]. \u0026nbsp;London, England: Tavistock Institute/Symbia; 2006:7 pp. \u0026nbsp; Available at\u0026nbsp;\u003ca href=\"https://www.tavinstitute.org/projects/evaluation-of-a-healthy-start/\"\u003ehttps://www.tavinstitute.org/projects/evaluation-of-a-healthy-start/\u003c/a\u003e\u0026nbsp; [Last accessed: September 2021]\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Chief\u0026nbsp;Medical\u0026nbsp;Officers, UK. \u0026nbsp;\u003cem\u003eVitamin D - advice on supplements for at risk groups: Letter from UK chief medical officers.\u003c/em\u003e London: Department of Health, 2.2.12. \u0026nbsp;Available at\u0026nbsp;\u003ca href=\"https://www.gov.uk/government/publications/vitamin-d-advice-on-supplements-for-at-risk-groups\"\u003ehttps://www.gov.uk/government/publications/vitamin-d-advice-on-supplements-for-at-risk-groups\u003c/a\u003e \u0026nbsp;[Last accessed: September 2021]\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Lewis L. \u0026nbsp;Tackling vitamin D deficiency in children and at-risk families. \u0026nbsp;\u003cem\u003ePrimary Health Care\u0026nbsp;\u003c/em\u003e2014;\u003cem\u003e24\u003c/em\u003e(4):20-24. \u0026nbsp; https://doi.org/10.7748/phc2014.04.24.4.20.e857\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Scientific Advisory Committee on Nutrition. \u003cem\u003eSACN vitamin D and health report: The Scientific Advisory Committee on Nutrition (SACN) recommendations on vitamin D\u003c/em\u003e. \u0026nbsp;London: Public Health England, July 2016:289 pp. [Online document]. \u0026nbsp;Available at\u0026nbsp;\u003ca href=\"https://www.gov.uk/government/publications/sacn-vitamin-d-and-health-report\"\u003ehttps://www.gov.uk/government/publications/sacn-vitamin-d-and-health-report\u003c/a\u003e\u0026nbsp; [Last accessed: September 2021]\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Department of Health and Social Care. \u0026nbsp;\u003cem\u003eAt-risk groups to receive free winter supply of vitamin D [press release].\u003c/em\u003e\u0026nbsp; London: Department of Health and Social Care, Nov 2020. \u0026nbsp;Available at\u0026nbsp;\u003ca href=\"https://www.gov.uk/government/news/at-risk-groups-to-receive-free-winter-supply-of-vitamin-d\"\u003ehttps://www.gov.uk/government/news/at-risk-groups-to-receive-free-winter-supply-of-vitamin-d\u003c/a\u003e\u0026nbsp; [Last accessed: September 2021]\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Davies S. \u0026nbsp;\u003cem\u003eAnnual report of the Chief Medical Officer 2012: Our children deserve better: prevention pays.\u003c/em\u003e\u0026nbsp; London: Department of Health, Oct 2013. \u0026nbsp;Available at\u0026nbsp;\u003ca href=\"https://www.gov.uk/government/publications/chief-medical-officers-annual-report-2012-our-children-deserve-better-prevention-pays/cmos-annual-report-2012-our-children-deserve-better-cmos-summary-as-a-web-page\"\u003ehttps://www.gov.uk/government/publications/chief-medical-officers-annual-report-2012-our-children-deserve-better-prevention-pays/cmos-annual-report-2012-our-children-deserve-better-cmos-summary-as-a-web-page\u003c/a\u003e\u0026nbsp; [Last accessed: September 2021]\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Moy RJ, McGee E, Debelle GD, Mather I, Shaw NJ. \u0026nbsp;Successful public health action to reduce the incidence of symptomatic vitamin D deficiency. \u0026nbsp;\u003cem\u003eArchives of Disease in Childhood\u0026nbsp;\u003c/em\u003e2012;\u003cem\u003e97\u003c/em\u003e(11):952-954. \u0026nbsp;https://doi:10.1136/archdischild-2012-302287\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Dunnigan\u0026nbsp;MG, Glekin BM, Henderson JB, McIntosh WB, Sumner D, Sutherland GR. \u0026nbsp;Prevention of rickets in Asian children: Assessment of the Glasgow Campaign. \u0026nbsp;\u003cem\u003eBritish Medical Journal (Clinical Research)\u003c/em\u003e 1985;\u003cem\u003e291\u003c/em\u003e(6490):239-242. \u0026nbsp;https://doi.org/10.1136/bmj.291.6490.239\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;McFadden A, Green JM, McLeish J, McCormick F, Williams V, Renfrew MJ. \u0026nbsp;Healthy Start\u0026nbsp;vitamins-a missed opportunity: Findings of a multimethod study. \u0026nbsp;\u003cem\u003eBMJ Open\u0026nbsp;\u003c/em\u003e2015;\u003cem\u003e5\u003c/em\u003e(1):1-7. \u0026nbsp;https://doi:10.1136/bmjopen-2014-006917\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Jessiman T,\u0026nbsp;Cameron\u0026nbsp;A, Wiggins M, Lucas PJ. \u0026nbsp;A qualitative study of uptake of free vitamins in England. \u0026nbsp;\u003cem\u003eArchives of Disease in Childhood\u0026nbsp;\u003c/em\u003e2013;\u003cem\u003e98\u003c/em\u003e(8):587-591. \u0026nbsp; https://doi.org/10.1136/archdischild-2013-303838\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;McFadden A, Green JM, Williams V, McLeish J, McCormick F, Fox-Rushby J, Renfrew MJ. \u0026nbsp;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. \u0026nbsp; \u003cem\u003eBMC Public Health\u0026nbsp;\u003c/em\u003e2014;\u003cem\u003e14\u003c/em\u003e(148):1-13. \u0026nbsp;https://doi.org/10.1186/1471-2458-14-148\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Lucas-Herald A, Grosset K, Robertson M, Ahmed SF. \u0026nbsp;The GP\u0026rsquo;s role in improving the uptake of healthy start vitamins. \u0026nbsp;\u003cem\u003eBritish Journal of General Practice\u0026nbsp;\u003c/em\u003e2012;\u003cem\u003e62\u003c/em\u003e(601):407. \u0026nbsp;https://doi.org/10.3399/bjgp12X653525\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Ivankova NV, Creswell JW, Stick SL \u0026nbsp;Using mixed-methods sequential explanatory design: From theory to practice. \u0026nbsp;\u003cem\u003eField Methods\u0026nbsp;\u003c/em\u003e2006;\u003cem\u003e18\u003c/em\u003e(1):3-20. \u0026nbsp;https://doi.org/10.1177/1525822X05282260\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Department of Health and Social Care Healthy Start Issuing Unit (HSIU - Warrington). \u0026nbsp;\u003cem\u003eHealthy Start uptake data [website]. \u0026nbsp;\u003c/em\u003eNewcastle upon Tyne: National Health Service (NHS) Business Services Authority (NHSBSA), 2021 \u0026nbsp;Available at\u0026nbsp;\u003ca href=\"https://www.healthystart.nhs.uk/\"\u003ehttps://www.healthystart.nhs.uk/\u003c/a\u003e \u0026amp;\u0026nbsp;\u003ca href=\"https://media.nhsbsa.nhs.uk/resources\"\u003ehttps://media.nhsbsa.nhs.uk/resources\u003c/a\u003e [Last accessed: September 2021]\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Health Research Authority (HRA). \u0026nbsp;Roles and responsibilities: Sponsor [Online webpage]. London: HRA (National Health Service), 2021. \u0026nbsp;Available at\u0026nbsp;\u003ca href=\"https://www.hra.nhs.uk/planning-and-improving-research/research-planning/roles-and-responsibilities/#sponsor\"\u003ehttps://www.hra.nhs.uk/planning-and-improving-research/research-planning/roles-and-responsibilities/#sponsor\u003c/a\u003e\u0026nbsp; [Last accessed: September 2021]\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Britten N. \u0026nbsp;Qualitative interviews [Chapter 2]. \u0026nbsp;In: C. Pope \u0026amp; N. Mays [Editors]. \u003cem\u003eQualitative Research in Health Care (3rd ed.).\u003c/em\u003e\u0026nbsp; \u0026nbsp;Oxford: John Wiley \u0026amp; Sons, 2006:pp. 12-20. \u0026nbsp;ISBN: 0-7279-1396-4\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Saunders B, Sim J, Kingstone T, Baker S, Waterfield J, Bartlam B, Burroughs H, Jinks C. \u0026nbsp;Saturation in qualitative research: exploring its conceptualization and operationalization. \u003cem\u003eQuality \u0026amp; Quantity\u0026nbsp;\u003c/em\u003e2018;\u003cem\u003e52\u003c/em\u003e(4):1893-1907. https://doi.org/10.1007/s11135-017-0574-8\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Tong A, Sainsbury P, Craig J. \u0026nbsp;Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. \u0026nbsp;\u003cem\u003eInt J Qual Health Care\u0026nbsp;\u003c/em\u003e2007;\u003cem\u003e19\u003c/em\u003e(6):349-357. \u0026nbsp;https://doi.org/10.1093/intqhc/mzm042\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Ritchie J, Spencer L. \u0026nbsp;Qualitative data analysis for applied policy research. \u0026nbsp;In: A Bryman, RG Burgess (Eds). \u0026nbsp;\u003cem\u003eAnalysing Qualitative Data.\u003c/em\u003e\u0026nbsp; London: Routledge, 1994:pp. 173-194.\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Lacey A Luff D. \u0026nbsp;\u003cem\u003eQualitative data analysis\u003c/em\u003e. \u0026nbsp;Nottingham \u0026amp; Sheffield: The NIHR Research Design Service for the East Midlands and for Yorkshire \u0026amp; the Humber, 2007 (updated 2009):46 pp. \u0026nbsp;[Online document]. \u0026nbsp;Available at\u0026nbsp;\u003ca href=\"https://www.rds-yh.nihr.ac.uk/wp-content/uploads/2013/05/9_Qualitative_Data_Analysis_Revision_2009.pdf\"\u003ehttps://www.rds-yh.nihr.ac.uk/wp-content/uploads/2013/05/9_Qualitative_Data_Analysis_Revision_2009.pdf\u003c/a\u003e\u0026nbsp; [Last accessed: September 2021]\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Pope C, Ziebland S, Mays N. \u0026nbsp;Analysing qualitative data [Chapter 7]. \u0026nbsp;In: C. Pope \u0026amp; N. Mays [Editors]. \u0026nbsp;\u003cem\u003eQualitative Research in Health Care (3rd ed.).\u003c/em\u003e\u0026nbsp; Oxford: John Wiley \u0026amp; Sons, 2006:pp. 63-81. \u0026nbsp;ISBN: 0-7279-1396-4\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Avis M, Bulman D, Leighton P. \u0026nbsp;Factors affecting participation in Sure Start programmes: a qualitative investigation of parents\u0026rsquo; views. \u0026nbsp;\u003cem\u003eHealth and Social Care in the Community\u0026nbsp;\u003c/em\u003e2007;\u003cem\u003e15\u003c/em\u003e(3):203-211. \u0026nbsp; https://doi.org/10.1111/j.1365-2524.2006.00673.x\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Crawley H, Dodds R. \u0026nbsp;\u003cem\u003eThe UK Healthy Start scheme. \u0026nbsp;What happened? What next? \u0026nbsp;\u003c/em\u003eLondon: First Steps Nutrition Trust, 2018. \u0026nbsp;e-ISBN: 978-1-908924-60-5 \u0026nbsp;Available at\u0026nbsp;\u003ca href=\"https://www.firststepsnutrition.org/s/Healthy_Start_Report_for_web.pdf\"\u003ehttps://www.firststepsnutrition.org/s/Healthy_Start_Report_for_web.pdf\u003c/a\u003e\u0026nbsp; [Last accessed: September 2021]\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Scottish Government: Children and Families Directorate and Population Health Directorate. \u0026nbsp;\u003cem\u003eFree vitamins for all pregnant women [web-page].\u003c/em\u003e\u0026nbsp; Available at\u0026nbsp;\u003ca href=\"https://www.gov.scot/policies/maternal-and-child-health/free-vitamins-for-all-pregnant-women/\"\u003ehttps://www.gov.scot/policies/maternal-and-child-health/free-vitamins-for-all-pregnant-women/\u003c/a\u003e\u0026nbsp; [Last accessed: September 2021]\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Hansard HC written answers. \u0026nbsp;\u003cem\u003eDepartment of Health and Social Care. \u0026nbsp;Healthy Start Scheme. \u0026nbsp;\u003c/em\u003eJo Churchill, The Parliamentary Under-Secretary for Health and Social Care. \u0026nbsp; Deb, 8 February 2021, cW. \u0026nbsp;UIN 147076. \u0026nbsp;Available at\u0026nbsp;\u003ca href=\"https://questions-statements.parliament.uk/written-questions/detail/2021-02-01/147076\"\u003ehttps://questions-statements.parliament.uk/written-questions/detail/2021-02-01/147076\u003c/a\u003e\u0026nbsp; [Last accessed: September 2021]\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Lucas PJ, Jessiman T, Cameron A. \u0026nbsp;Healthy Start: The use of welfare food vouchers by low-income parents in England. \u0026nbsp;\u003cem\u003eSocial Policy and Society\u0026nbsp;\u003c/em\u003e2015;\u003cem\u003e14\u003c/em\u003e(3):457-469. \u0026nbsp;https://doi.org/10.1017/S1474746415000020\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Ohly H, Crossland N, Dykes F, Lowe N, Hall-Moran V. \u0026nbsp;A realist review to explore how low-income pregnant women use food vouchers from the UK\u0026rsquo;s Healthy Start programme. \u0026nbsp;\u003cem\u003eBMJ Open\u0026nbsp;\u003c/em\u003e2017, \u003cem\u003e7\u003c/em\u003e(4), e013731. \u0026nbsp;https://doi.org/10.1136/bmjopen-2016-013731\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Lucas PJ, Jessiman T, Cameron A, Wiggins M, Hollingworth K, Austerberry C. \u003cem\u003eHealthy Start Vouchers Study: The views and experiences of parents, professionals and small retailers in England.\u003c/em\u003e\u0026nbsp; Bristol \u0026amp; London: University of Bristol (School for Policy Studies) \u0026amp; Institute of Education (Social Science Research Unit), 2013:85 pp.\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Hansard HC written answers. \u0026nbsp;\u003cem\u003eDepartment of Health and Social Care. \u0026nbsp;Healthy Start Scheme: Advertising.\u003c/em\u003e\u0026nbsp; Jo Churchill, The Parliamentary Under-Secretary for Health and Social Care. \u0026nbsp;Deb, 1 March 2021, cW. \u0026nbsp;UIN 154976. \u0026nbsp; Available at\u0026nbsp;\u003ca href=\"https://questions-statements.parliament.uk/written-questions/detail/2021-02-19/154976\"\u003ehttps://questions-statements.parliament.uk/written-questions/detail/2021-02-19/154976\u003c/a\u003e \u0026nbsp;[Last accessed: September 2021]\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Mackenzie G,\u0026nbsp;Dougall\u0026nbsp;A. \u0026nbsp;Increasing Healthy Start food and vitamin voucher uptake for low income pregnant women (Early Years Collaborative Leith Pioneer Site). \u0026nbsp;\u003cem\u003eBMJ Quality Improvement Reports\u0026nbsp;\u003c/em\u003e2016, April 8;\u003cem\u003e5\u003c/em\u003e(1):1-5. \u0026nbsp;u210506.w4243. \u0026nbsp;https://doi.org/10.1136/bmjquality.u210506.w4243\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Birmingham City\u0026nbsp;Council, Public Health. \u0026nbsp;\u003cem\u003eBirmingham Healthy Start Scheme webinar (Healthy Brum).\u003c/em\u003e\u0026nbsp; 29 January 2021 Zoom Webinar on YouTube. \u0026nbsp;17:02 of 57:51. \u0026nbsp;Available at\u0026nbsp;\u003ca href=\"https://www.youtube.com/watch?v=ko3TPO7EurE\"\u003ehttps://www.youtube.com/watch?v=ko3TPO7EurE\u003c/a\u003e\u0026nbsp; [Last accessed: September 2021]\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Halfon R. \u003cem\u003eRobert Halfon: Delivering social justice means feeding children properly. We\u0026rsquo;re not doing so \u0026ndash; and we must.\u003c/em\u003e\u0026nbsp; ConservativeHome [blog]. \u0026nbsp;7 October 2020. \u0026nbsp;Available at\u0026nbsp;\u003ca href=\"https://www.conservativehome.com/thecolumnists/2020/10/robert-halfon-delivering-social-justice-means-feeding-children-properly-were-not-doing-so-and-we-must.html\"\u003ehttps://www.conservativehome.com/thecolumnists/2020/10/robert-halfon-delivering-social-justice-means-feeding-children-properly-were-not-doing-so-and-we-must.html\u003c/a\u003e\u0026nbsp; [Last accessed: September 2021]\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Williams E. \u0026nbsp;Heath Robinson\u0026apos;s commercial art. \u0026nbsp;Creative Review, 5.12.17. \u0026nbsp;Available at\u0026nbsp;\u003ca href=\"https://www.creativereview.co.uk/heath-robinsons-commercial-art/\"\u003ehttps://www.creativereview.co.uk/heath-robinsons-commercial-art/\u003c/a\u003e\u0026nbsp; [Last accessed: September 2021]\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;McFadden A, Fox-Rushby J, Green JM, Pokhrel S, McLeish J, McCormick F, Anokye N, Dritsaki M, McCarthy R, Bennett S, Entwistle F, Renfrew MJ. \u0026nbsp;\u003cem\u003eHealthy Start: understanding the use of vouchers and vitamins: summary for practitioners.\u003c/em\u003e\u0026nbsp; Dundee: University of Dundee, April 2013, 12 pp. \u0026nbsp;Available at\u0026nbsp;\u003ca href=\"https://discovery.dundee.ac.uk/ws/portalfiles/portal/6497930/Healthy_Start_Evaluation_summary_for_health_professionals_0_2_.pdf\"\u003ehttps://discovery.dundee.ac.uk/ws/portalfiles/portal/6497930/Healthy_Start_Evaluation_summary_for_health_professionals_0_2_.pdf\u003c/a\u003e \u0026nbsp;[Last accessed: September 2021]\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;National Institute for Health and Care Excellence (NICE). \u0026nbsp;\u003cem\u003eHealthy Start vitamins: Special report on cost effectiveness: Equality impact assessment\u003c/em\u003e. \u0026nbsp;London: NICE, 2015 [Online document]. \u0026nbsp;Available at\u0026nbsp;\u003ca href=\"https://www.nice.org.uk/about/what-we-do/our-programmes/nice-guidance/nice-guidelines/types-of-guideline/additional-publications/healthy-start-vitamins\"\u003ehttps://www.nice.org.uk/about/what-we-do/our-programmes/nice-guidance/nice-guidelines/types-of-guideline/additional-publications/healthy-start-vitamins\u003c/a\u003e\u0026nbsp; [Last accessed: September 2021]\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Machell G. \u0026nbsp; Considering influences on the policy formation of Healthy Start: A government-funded nutrition\u0026nbsp;support\u0026nbsp;program for low-income women and children in the UK. \u0026nbsp;\u003cem\u003eJournal of Policy Practice\u0026nbsp;\u003c/em\u003e2015;\u003cem\u003e14\u003c/em\u003e(1):14-34. \u0026nbsp;https://doi.org/10.1080/15588742.2014.956968\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Hansard\u0026nbsp;HC written answers. \u003cem\u003eDepartment of Health and Social Care. \u0026nbsp;Healthy Start Scheme. \u0026nbsp;\u003c/em\u003eJo Churchill, The Parliamentary Under-Secretary for Health and Social Care. \u0026nbsp;Deb, 8 February 2021, cW. \u0026nbsp;UIN 147077. \u0026nbsp; Available at\u0026nbsp;\u003ca href=\"https://questions-statements.parliament.uk/written-questions/detail/2021-02-01/147077\"\u003ehttps://questions-statements.parliament.uk/written-questions/detail/2021-02-01/147077\u003c/a\u003e \u0026nbsp;[Last accessed: September 2021]\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Department of Health and Social Care. \u0026nbsp;\u003cem\u003eThe best start for life. \u0026nbsp;A vision for the 1,001 critical days: The Early Years Healthy Development Review Report\u003c/em\u003e [policy paper]. \u0026nbsp;London: DHSC, 25 March 2021, 146 pp \u0026nbsp;ISBN: 978-1-5286-2497-8 \u0026nbsp;Available at\u0026nbsp;\u003ca href=\"https://www.gov.uk/government/publications/the-best-start-for-life-a-vision-for-the-1001-critical-days\"\u003ehttps://www.gov.uk/government/publications/the-best-start-for-life-a-vision-for-the-1001-critical-days\u003c/a\u003e\u0026nbsp; [Last accessed: September 2021]\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Mason KE, Alexiou A, Bennett DL, Summerbell C, Barr B, \u0026amp; Taylor-Robinson D. \u0026nbsp;Impact of cuts to local government spending on Sure Start children\u0026rsquo;s centres on childhood obesity in England: a longitudinal ecological study. \u0026nbsp;\u003cem\u003eJournal of Epidemiology and Community Health\u0026nbsp;\u003c/em\u003e2021;\u003cem\u003e75\u003c/em\u003e(9):860-866. \u0026nbsp;https://doi.org/10.1136/jech-2020-216064\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Coughlan S. \u0026nbsp;Marcus\u0026nbsp;Rashford\u0026apos;s\u0026nbsp;budget cookery serves up fish finger sandwich. \u0026nbsp;BBC News (Family \u0026amp; Education) [on-line] 2021 April 22. \u0026nbsp;Available at\u0026nbsp;\u003ca href=\"https://www.bbc.co.uk/news/education-56825700\"\u003ehttps://www.bbc.co.uk/news/education-56825700\u003c/a\u003e [Last accessed: September 2021]\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Rashford, M. \u0026nbsp;Every child deserves the best chance in life, and here is how health professionals can help. \u0026nbsp; [Blog.] \u0026nbsp;\u003cem\u003eBMJ Opinion\u0026nbsp;\u003c/em\u003e2021 (4.8.21). \u0026nbsp;Available at\u0026nbsp;\u003ca href=\"https://blogs.bmj.com/bmj/2021/08/04/marcus-rashford-every-child-deserves-the-best-chance-in-life-here-is-how-health-professionals-can-help/\"\u003ehttps://blogs.bmj.com/bmj/2021/08/04/marcus-rashford-every-child-deserves-the-best-chance-in-life-here-is-how-health-professionals-can-help/\u003c/a\u003e\u0026nbsp; [Last accessed: September 2021]\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Dahlgren G,\u0026nbsp;Whitehead\u0026nbsp;M. \u0026nbsp;The Dahlgren-Whitehead model of health determinants: 30 years on and still chasing rainbows. \u0026nbsp;\u003cem\u003ePublic Health\u003c/em\u003e 2021;199:20-24. \u0026nbsp;https://doi.org/10.1016/j.puhe.2021.08.009\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Casciani D. \u0026nbsp;Matt Hancock caves in over vitamins for poor children. \u0026nbsp;BBC News (UK) [on-line] 2021 June 2. \u0026nbsp;Available at\u0026nbsp;\u003ca href=\"https://www.bbc.co.uk/news/uk-57333810\"\u003ehttps://www.bbc.co.uk/news/uk-57333810\u003c/a\u003e [Last accessed: September 2021]\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Julies P, Lynn RM, Pall K, Leoni M, Calder A, Mughal Z, Shaw N, McDonnell C, McDevitt H, Blair M. \u0026nbsp;Nutritional rickets under 16 years: UK surveillance results. \u0026nbsp;\u003cem\u003eArchives of Disease in Childhood\u0026nbsp;\u003c/em\u003e2020;\u003cem\u003e105\u003c/em\u003e(6):587-592. \u0026nbsp; https://doi.org/10.1136/archdischild-2019-317934\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Fenney D, Buck D. \u0026nbsp;The NHS\u0026rsquo;s role in tackling poverty: Awareness, action and advocacy. \u0026nbsp;London: The King\u0026rsquo;s Fund, 2021:51pp. \u0026nbsp;Available at\u0026nbsp;\u003ca href=\"https://www.kingsfund.org.uk/publications/nhs-role-tackling-poverty\"\u003ehttps://www.kingsfund.org.uk/publications/nhs-role-tackling-poverty\u003c/a\u003e\u0026nbsp; [Last accessed: September 2021]\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Moonan M. \u0026nbsp;\u003cem\u003eAn exploration of the UK Healthy Start vitamin supplementation programme in North West England.\u003c/em\u003e\u0026nbsp; Doctor of Medicine (MD) thesis. \u0026nbsp;Liverpool: The University of Liverpool, 2018:189pp.\u003c/li\u003e\n\u003c/ol\u003e\n\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"child, preschool, England Healthy Start, food subsidy, food voucher, health inequalities, mothers, nutrition, poverty, universal and targeted services, vitamins","lastPublishedDoi":"10.21203/rs.3.rs-955345/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-955345/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eGovernment nutritional welfare support from the English \u0026lsquo;Healthy Start\u0026rsquo; scheme is targeted at low income pregnant women and preschool children, but take-up of its free food vouchers is much better than its free vitamin vouchers. While universal implementation probably requires a more extensive scheme to be cost-effective, the everyday experience of different ways of receiving or facilitating Healthy Start, especially via children\u0026rsquo;s centres, also requires further evidence. This study therefore aimed to explore (in the context of low take-up levels) perceptions of mothers, health professionals, and commissioners about Healthy Start vitamin and food voucher take-up and compare experiences in a targeted and a universal implementation-area for those vitamins.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eInformed by quantitative analysis of take-up data, qualitative analysis focused on 42 semi-structured interviews with potentially eligible mothers and healthcare staff (and commissioners), purposively sampled via children\u0026rsquo;s centres in a similarly deprived universal and a targeted implementation-area of North West England.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eWhile good food voucher take-up appeared to relate to clear presentation, messaging, practicality, and monetary (albeit low) value, poor vitamin take-up appeared to relate to overcomplicated procedures and overreliance on underfunded centres, organizational goodwill, and families\u0026rsquo; resilience.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eHigher \u0026lsquo;universal\u0026rsquo; vitamin take-up may well have reflected fewer barriers when it became everyone\u0026rsquo;s business to be vitamin-aware. \u003cem\u003eSubstantive\u003c/em\u003e Healthy Start reform in England (not just cosmetic tinkering) is long overdue. Our study highlights that \u0026lsquo;policy, politics, and problem\u0026rsquo; should be aligned to reach considerable unmet need. \u003cb\u003e237 words\u003c/b\u003e\u003c/p\u003e","manuscriptTitle":"An exploration of the statutory Healthy Start vitamin supplementation scheme in North West England","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-10-20 20:07:49","doi":"10.21203/rs.3.rs-955345/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2021-11-25T07:01:51+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2021-11-02T11:40:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"07dc5374-e49c-4e4a-9e8d-8cbd03ea1655","date":"2021-10-31T14:24:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"bf17be7b-c37f-4f74-8a9c-efcc0de1b0e8","date":"2021-10-21T14:58:31+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2021-10-20T00:42:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2021-10-20T00:34:15+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2021-10-19T11:40:43+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2021-10-19T11:30:12+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2021-10-04T11:31:46+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"255a4e8b-600e-4121-9102-d70db6e40ef2","owner":[],"postedDate":"October 20th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":7993748,"name":"Health Economics \u0026 Outcomes Research"},{"id":7993749,"name":"Environmental Policy"},{"id":7993750,"name":"Health Policy"}],"tags":[],"updatedAt":"2022-02-24T18:50:30+00:00","versionOfRecord":{"articleIdentity":"rs-955345","link":"https://doi.org/10.1186/s12889-022-12704-0","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2022-02-24 18:50:30","publishedOnDateReadable":"February 24th, 2022"},"versionCreatedAt":"2021-10-20 20:07:49","video":"","vorDoi":"10.1186/s12889-022-12704-0","vorDoiUrl":"https://doi.org/10.1186/s12889-022-12704-0","workflowStages":[]},"version":"v1","identity":"rs-955345","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-955345","identity":"rs-955345","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}