Programme theory 1 – dietary improvements

Some women reported that Healthy Start vouchers enabled them to improve their diets during pregnancy (Table 15). Throughout this study, this has been assumed to be the intended outcome of the programme for low-income pregnant women. This theory depends on context whereby women value healthy eating enough for the vouchers to encourage behaviour change. It builds on the ‘prioritisation of resources’ mechanism identified in the realist review (5.4.4). This has been refined into a more nuanced realist explanation about the inner reasoning that underpins prioritisation. In summary:

For women who valued healthy eating and aspired to eat well during pregnancy [context], the vouchers made healthy foods more affordable [resources], which reinforced their existing values, beliefs and motivations [mechanism] and alleviated concerns about the cost of healthy foods [mechanism]. This led them to buy and consume more fruit and vegetables and cow’s milk, or a greater variety or fruit and vegetables during pregnancy [outcome].

Figure 10 shows the CMOc that contributed to this theory. The following examples illustrate how interview data were used to develop and refine the CMOc.

Mia admitted she ate ‘rubbish’ before she was pregnant [context] but she wanted to improve her diet so that her unborn daughter would benefit [context]. Healthy Start vouchers helped her to afford more healthy foods [resources] and reinforced her motivation to eat well during pregnancy [mechanism]. She used them to increase the amount of fruit and vegetables she bought and consumed [outcome].

“...when I used to go shopping I didn’t look at fresh foods or anything like that it didn’t really appeal to me but then with the vouchers that actually pushed me forward to start eating healthy and buy more stuff…I think that is what it was because I was pregnant as well and obviously I wanted to have the benefits, my daughter to have a good start instead of eating rubbish.” (Mia)

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Figure 10. CMOc leading to dietary improvements (programme theory 1)

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Katie (aged 19) was aware of the need to eat vegetables to be healthy [context]. She always tried to include vegetables with her evening meal, but it was difficult to find the money [context]. Healthy Start vouchers helped her to afford vegetables [resources] without having to worry about the money [mechanism]. She admitted to being a fussy eater [context] and she was concerned about food waste [mechanism], so she tended to use the vouchers to buy frozen vegetables [outcome].

“I have always liked to have a bit of veg with my tea so it is not completely unhealthy. I just never had the money to buy the veg before, so now it helps a lot because I can buy it and I don’t have to worry about it.” (Katie)

“We usually go for peas, carrots, sweetcorn just the usual because I am a fussy eater when it comes to veg…I don’t really use a lot of veg, so if it is frozen I don’t have to worry about it wasting.” (Katie)

Jane described the challenges of eating well on a low income [context – not included in Figure 10 because it applies to all Healthy Start beneficiaries]. She did not enjoy healthy eating or cooking before she was pregnant and admitted that her diet was poor [context]. However, she suffered with persistent sickness during pregnancy and the baby was growing slowly [context]. Healthy eating became more important to her for the sake of the baby’s development [context and mechanism]. The vouchers made healthy foods more affordable [resources] and she used them to buy extra fruit and vegetables [outcome].

“If I didn’t have the vouchers then no, I wouldn’t have got extra fruit and veg it is the cost when you have only got, when you are on a low income and you go shopping and you have only got £20-30 to go shopping with and you have got most of your food, freeze food, fridge food, cupboard food and you have got to get fruit and that you don’t have a lot of money left.” (Jane)

“I think when I became pregnant I became more healthy because before I fell pregnant I just ate whatever like crisps, sweets, junk so I just didn’t like cooking. When I was pregnant, I was like I need to eat healthy now she has got to gain weight so I started eating healthy.” (Jane)

Claire was aware of the importance of eating well during pregnancy [context], but also the higher cost of fruit and vegetables compared to less healthy foods [context]. The

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vouchers made the higher cost items more affordable [resources] and took away some of the financial stress of being pregnant [mechanism]. She also felt a sense of fairness compared to other women [mechanism] because she could buy the fruit and vegetables she needed [outcome].

“It gives people like it says, ease to be able to get the extras that they say you need rather than sit there and thing oh! my god I am pregnant I am not going to be able to afford. Let’s be honest veg and fruit are higher than chocolate and sugary foods anyway. So for us to be able to go and buy the higher food, it wouldn’t be fair if people like myself couldn’t afford it without the Healthy Start vouchers.” (Claire) Zoe was suffering with severe heartburn during pregnancy [context] and she found milk and vegetables (especially soup) were the most palatable foods. Her motivation to eat well was driven by this rather than long term health benefits [context]. Convenience was also important because she was registered blind [context]. She perceived Healthy Start vouchers as ‘extra money’ for healthy foods [resources], which made her more willing to buy more expensive items [mechanism]. Therefore, the vouchers were used to buy extra milk and a greater variety of fruit and vegetables, including pre-prepared vegetables for soup [outcome].

“For myself heartburn is really bad so I go through a lot of milk at the minute…I get through 8 pints of the skimmed milk that I like…I like to get the soup mixes as well. It is just basically ready prepared, it is all diced and chopped and mixed in for you already and then you just stick it in a pan with a veg stock cube and you can make soup with it, so that is quite good.” (Zoe)

“A lot of your pregnancy you have to eat what you can eat without either being sick or getting heartburn or just not fancying it. I think a lot of pregnancy you just have to listen to your body and eat what you can. You can try and eat healthy but it is better to eat at all than to eat nothing just because you don’t fancy a tuna salad bagel.” (Zoe)

“I would probably stick to the cheaper fruit and vegetables. I probably wouldn’t get the prepared soups if it wasn’t for the sake of the extra money being there it might as well be spent.” (Zoe)

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These findings provide further support for ‘relative value of healthy eating’ as an important aspect of context, and more nuanced explanations about why some women value healthy eating. These women valued healthy eating and aspired to eat well during pregnancy for different reasons; in some cases, these values originated from before pregnancy and, in other cases, were amplified by medical complications or illness during pregnancy. The vouchers made healthy foods more affordable, which enabled women to make decisions based on their values, beliefs and motivations, without worrying about the financial implications. Therefore, it was inferred that Healthy Start reinforced the motivation to eat well during pregnancy.