Limitations of this study

The main limitation of this study was its small sample size of 11 women. Recruitment was challenging in all three local authority areas. The face-to-face approach was by far the most productive (10 out of 11 women) but this was also time intensive. The recruitment rate was around 5% of women approached, despite focusing on children’s centres in the most deprived areas. Most women declined to participate because they were not eligible for Healthy Start. However, it is possible that some women may not have wanted to disclose their eligibility. In one area, two separate groups of new mothers were completely unaware of the programme, which may reflect problems with communication

163

at local and national levels. In two areas, local authority and children’s centre staff were enthusiastic about the project and helped to distribute flyers, but no women were recruited by referral. In the other area, staff were less receptive and various barriers to recruitment were encountered.

Historically, national data on Healthy Start beneficiaries have not been publicly available. However, in March 2017, data were obtained by HO from the Department of Health (DH) Healthy Start Issuing Unit on the number of beneficiaries in each local authority. This showed that, in all three recruitment areas, less than 5% of beneficiaries were pregnant women and the majority were children aged over one year (Table 16). The accompanying email explained that DH does not receive data on pregnant women from the benefits system (other government departments) and, therefore, they cannot be invited to apply for Healthy Start. Hence the reliance on health professionals to signpost low-income pregnant women to the programme. This data confirmed why it had been so difficult to recruit women who were using (or had recently used) Healthy Start vouchers during pregnancy.

Table 16. Number of Healthy Start beneficiaries by group, January – February 2017. Local authority Total Pregnant Child <1 Child >1

Barrow-in-Furness 408 16 103 289

Blackburn-with-Darwen 1261 53 298 910

Preston 970 26 203 741

Data reproduced with permission from DH Healthy Start Issuing Unit

These challenges were discussed with the study advisory group, who explained that low- income women (and families) are less likely to be eligible for Healthy Start since the introduction of Universal Credit. As explained in chapter 2, this new benefit was introduced in 2013 to replace six other means-tested benefits, with the aim of simplifying the social security system (Welfare Reform Act, 2017). Universal Credit became a qualifying benefit for Healthy Start from 1st November 2016 (National Health Service, 2017). The income threshold for families receiving Universal Credit is £408 or less per month (equivalent to £4896 or less per year), compared to the previous income threshold of £16,190 or less per year. This suggests that many fewer families will now be eligible for Healthy Start, and raises wider questions about the purpose and impact of the programme.

164

With all of this in mind, 11 women may be considered a small but realistic sample for a qualitative study about how low-income pregnant women use Healthy Start vouchers. Data saturation was not reached, and additional programme theories may have emerged from a larger and more diverse sample. The representativeness of the sample is unclear because data on socio-demographic characteristics of beneficiaries were not available from DH. Therefore, the evidence-based programme theories presented above are unlikely to represent all low-income pregnant women who are beneficiaries of the Healthy Start programme. A larger study would be needed to explore the prevalence of outcome patterns and compare subgroups of women. Recommendations for further research are discussed in chapter 7.

6.5

Chapter summary

This chapter has provided a comprehensive account of the methods and findings of empirical research undertaken in this PhD. It described how an innovative combination of realist and qualitative methods was used to further develop, refine and consolidate programme theories about how low-income pregnant women use Healthy Start vouchers. The study focused on women’s perspectives as programme beneficiaries, which revealed more nuanced programme theories compared to the realist review. Despite challenges with recruitment and a smaller sample than anticipated, the data provided in-depth, plausible explanations for five possible outcomes (intended and unintended). The evidence-based programme theories showed how low-income pregnant women made decisions and prioritised resources, and how Healthy Start vouchers influenced that process. This study confirmed that women may experience more than one outcome, as context is never static and different mechanisms may be activated by the programme in different circumstances. While the findings from this small qualitative study are not transferable to other contexts, some of the mechanisms identified may be transferable and this will be explored in the final chapter.

165

7.0

DISCUSSION AND FURTHER THEORY DEVELOPMENT

7.1

Introduction

This chapter draws together findings from the realist review and qualitative study. It starts by emphasising the original contribution to knowledge of this study so far – the development of evidence-based programme theories about Healthy Start using realist synthesis and realist evaluation methods. It extends the original contribution to knowledge by integrating the programme theories with three existing behaviour change theories, also known as ‘middle-range’ theories. The purpose of this integration is twofold: to strengthen the programme theories by using established concepts to explain the relationships between context, mechanisms and outcomes; to consider whether the generative mechanisms identified in the programme theories about Healthy Start may be transferable to other programmes. A theoretical model for Healthy Start presents the key findings of this study in terms of what works, for who, in what circumstances and why. This chapter considers implications of this study for policy makers and practitioners working to develop and support the Healthy Start programme. It makes tentative suggestions about who the programme works well for, and which women might need more support to achieve the intended outcome of dietary improvements. It concludes with some recommendations for further research.