Programme theories not supported by this study

Three programme theories that were identified during the realist review (either as candidate theories or evidence-informed theories) were not further developed and refined in this qualitative study. However, they are considered worthy of further investigation.

1. Support from health professionals 2. Lack of empowerment

3. Stigmatisation

Firstly, in the theory development stage of the realist review (chapter 4), support from health professionals was considered as part of the programme resources. This candidate theory was derived from Healthy Start policy documents, which stated that health professionals would provide tailored information, advice and support to low-income families (Department of Health, 2004). More recent guidance on maternal and child nutrition stated that parents receiving Healthy Start vouchers should be offered “advice on how to use them to increase the amount of fruit and vegetables in their family's diet” (National Institute for Health and Care Excellence, 2015b). It was hypothesised that this kind of advice, provided alongside the vouchers, would motivate pregnant women to eat well and they would be more likely to use the vouchers to improve their diets (Table 6B). However, this candidate theory was not substantiated in the realist review. A previous evaluation of Healthy Start concluded, “We can find no examples of parents who recall information about the food vouchers provided by health professionals explicitly linked to health and nutrition advice” (Lucas et al., 2013, p. 62). Likewise, in this qualitative study, some women said they had received general advice (e.g. foods to avoid in pregnancy) or specific advice relating to medical issues (e.g. lactose intolerance), but they did not recall any discussions about the importance of nutrition in pregnancy or advice on how the vouchers could be used to support healthy eating.

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“Yes, kind of they didn’t really. Obviously, I understood that the baby gets the nutrients from me but they didn’t make it, how can I explain it, they really didn’t say how important. I knew it was important but they didn’t say how important it was if that makes sense.” (Emma).

“No, all they really did was sign the form for me and stamped it they didn’t really explain it…Staying healthy it just said vouchers to help you get some things while you are pregnant, like fruit and veg. They didn’t really explain.” (Sophie)

This theory was discussed in the stakeholder consultation meeting with the study advisory group. They shared good practice from their areas, where midwives and health visitors consider supporting Healthy Start to be an important part of their role. However, they acknowledged that support varies depending on the needs of the woman and the judgement of the midwife. For example, if the woman has issues such as smoking, alcohol or drug abuse, then nutrition and healthy eating may not be discussed in antenatal appointments. This was described as a ‘self-fulfilling prophecy’ whereby women who showed an interest in nutrition and healthy eating might receive more support than women who did not. The study advisory group felt that support from health professionals could be considered as context (routine support for all women) and resources (targeted support for low-income families). It has been tentatively included in Figure 10 based on their feedback only.

Secondly, one of the evidence-informed programme theories presented in the realist review was about pregnant women who may not be empowered to make decisions about how to use their Healthy Start vouchers, and may instead hand them over to other family members (5.4.6). The evidence supporting this CMOc was limited to one study of African American women, who lived in multi-generational households and handed over WIC benefits (from the Special Supplemental Nutrition Program for Women, Infants and Children) to their mothers, older sisters or grandmothers (Reyes et al., 2013). A previous evaluation of Healthy Start found that young women (especially teenagers) may be “under the influence of their parents” (Lucas et al., 2013, p. 34), but this context was not linked to the mechanism of handing over vouchers. This theory was represented by one of the vignettes used in this qualitative study: “Mum does the shopping, so I give her the vouchers. I don’t know what she spends them on.” The sample included two pregnant teenagers but neither of them agreed with or responded to this vignette. Only one woman (aged 25) responded, but her experience was cooperative and she had chosen to use her

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vouchers to contribute to the family shopping. This quote does not indicate lack of empowerment:

“I did this when I was pregnant with my eldest son, I lived with my dad at the time so I was getting the Healthy Start vouchers and would just give them to my dad to go and get the shopping…he would say I am going to go shopping today and I would pass him a voucher and say you can put this towards the milk or the potatoes or anything he needs in that sense any fruit or veg or milk. I would just give it to him and he would go and get the shopping with it.” (Emma)

Thirdly, in the theory development stage of the realist review (chapter 4), stigmatisation was considered as a possible reason why women may not use their Healthy Start vouchers. This candidate theory was informed by discussions with midwives from Barrow-in- Furness, who felt that stigmatisation might affect women who rely on smaller shops, which offer less anonymity compared to supermarkets. However, this candidate theory was not substantiated in the realist review. An evaluation of Healthy Start found that some women had experienced judgemental attitudes from staff and customers (McFadden et al., 2013), but this was not clearly linked to outcomes. In this qualitative study, two women expressed feelings of awkwardness or embarrassment in relation to using Healthy Start vouchers in supermarkets, but they both said this had not prevented them from using the vouchers. For example:

“Yes, they accept them but they tend to, when you present them they are not very happy with you and then because they then have to type in the home number and they have got people moaning in the queue. You have to scan one side then the other side and every time they’ve tried they can’t scan them. So it is a bit embarrassing bringing them out because you can see everyone in the queue, looking at you and then the checkout person is like ‘oh not these again’…when they have got big queues that’s when they make you feel awful…I keep using them but I dread getting them out, if that makes sense.” (Lucy)

The midwives raised this again during the stakeholder consultation meeting with the study advisory group (June 2017). They said they knew of women in more affluent, rural areas of the South Lakes who did not use their vouchers due to fears about stigmatisation. They also knew of women who were eligible for the vouchers but had chosen not to apply for similar reasons. The study advisory group agreed that stigmatisation is likely to be very

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context dependent, and further insights might have emerged from a larger, more diverse sample.