The first task was to find information about the Healthy Start programme, from which to identify review questions and develop candidate theories. I already had some familiarity with the Healthy Start literature, but it was important to check for new and additional sources of information (including academic and grey literature). A scoping search was conducted in January 2015 using the search terms ‘Healthy Start’ and ‘UK’ (there is an infant mortality reduction programme called Healthy Start in the United States) in PubMed, Scopus and Google. Reference lists of all documents identified were checked for additional sources. This scoping search identified 25 sources of information about Healthy Start including eight journal publications, six research reports, nine policy documents (or government reports) and two websites (Table 4).
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Table 4. Sources of information about Healthy Start identified from the scoping search (in order of publication/website last accessed)
Type of document Full reference
Policy document Department of Health. (2002) Healthy Start: Proposals for reform of the Welfare Food Scheme. London: Department of Health. Policy document Department of Health. (2003) Healthy Start: The results of the consultation exercise. London: Department of Health.
Policy document Department of Health. (2004) Healthy Start: Government response to consultation exercise. London: Department of Health. Policy document Department of Health. (2006) Healthy Start: Qualitative research to evaluate communication materials among potential
beneficiaries. London: Department of Health.
Research report Hills, D. (2006) Healthy Start: Rapid evaluation of early impact on beneficiaries, health professionals, retailers and contractors. London: Tavistock Institute/Symbia.
Research report Dyson, L., Renfrew, M. J., Jenkins, R., Thomas, J., McCormick, F., Pearce, A., & Law, C. (2007) Approaches to evaluating Healthy Start – a scoping review. Mother and Infant Research Unit, University of York.
Policy document Department of Health. (2008) The Healthy Start Scheme and Welfare Food (amendment) Regulations 2008. London: Department of Health.
Journal publication Ford, F. A., Mouratidou, T., Wademan, S. E., & Fraser, R. B. (2009) 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, 101(12), 1828-1836.
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Type of document Full reference
Journal publication 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.
Policy document Department of Health. (2012) Healthy Start: Retailer research summary. London: Department of Health.
Policy document Department of Health. (2012) Healthy Start: New statutory arrangements for Healthy Start vitamins. London: Department of Health.
Research report McAndrew, F., Thompson, J., Fellows, L., Large, A., Speed, M., & Renfrew, M. J. (2012) Infant Feeding Survey 2010. Health and Social Care Information Centre.
Journal publication Moonan, M., Hanratty, B., & Whitehead, M. (2012) Which is more effective, a universal or targeted approach, to implementing the national Healthy Start programme? A mixed methods study. Journal of Epidemiology and Community Health, 66(Suppl 1), A44-A45.
Journal publication Lucas-Herald, A., Grosset, K., Robertson, M., & Ahmed, S. F. (2012) The GP's role in improving the uptake of Healthy Start vitamins. British Journal of General Practice, 62(601), 407.
Policy document Department of Health. (2012/13) Delivering a Healthy Start for pregnant women, new mums, babies and young children. London: Department of Health.
Journal publication Jessiman, T., Cameron, A., Wiggins, M., & Lucas, P. J. (2013) A qualitative study of uptake of free vitamins in England. Archives of Disease in Childhood, 98(8), 587-591.
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Type of document Full reference
Research report Lucas, P. J., Jessiman, T., Cameron, A., Wiggins, M., Hollingworth, K., & Austerberry, C. (2013) Healthy Start vouchers study: The views and experiences of parents, professionals and small retailers in England. School for Policy Studies, University of Bristol.
Research report McFadden, A., Fox-Rushby, J., Green, J. M., Williams, V., Pokhrel, S., McLeish, J.,…Renfrew, M. J. (2013) Healthy Start: Understanding the use of vouchers and vitamins. College of Medicine, Dentistry and Nursing, University of Dundee.
Journal publication McFadden, A., Green, J. M., Williams, V., McLeish, J., McCormick, F., Fox-Rushby, J., & Renfrew, M. J. (2014) 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, 14(1), 1-24.
Research report Griffiths, R., von Hinke Kessler Scholder, S., & Smith, S. (2015) Getting a healthy start: The effectiveness of targeted benefits for improving dietary choices. London: Institute of Fiscal Studies.
Journal publication Machell, G. (2015) 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, 14(1), 14-34.
Journal publication McFadden, A., Green, J. M., McLeish, J., McCormick, F., Williams, V., & Renfrew, M. J. (2015) Healthy start vitamins – a missed opportunity: Findings of a multimethod study. BMJ Open, 5(1) doi:10.1136/bmjopen-2014-006917
Website Healthy Start Alliance. (2017) Healthy Start Alliance. Retrieved from: http://www.healthystartalliance.org/
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After reading the information from the scoping search several times over, a visual mapping exercise was conducted by hand drawing a ‘mind map’ of the Healthy Start programme (see Figure 6). This involved identifying the ‘steps along the programme pathway’ from the beneficiary perspective, such as how potential beneficiaries become involved, what processes they go through, who else is involved, what resources they receive and what the intended outcomes are. Pawson (2006) described how ‘mapping the terrain’ can help the reviewer “to establish which programme theories seem important; to get a feel for the circumstances in which they tend to get tried; to gather hunches on implementation difficulties; to tease out ways in which the programme might misfire, and so on” (p. 80). The resulting diagram of Healthy Start included the following steps, which started to resemble assumptions (or theories) about how the programme was intended to work:
• Woman attends antenatal appointment
• Health professional provides information and advice on healthy eating • Health professional signposts woman to information about Healthy Start • Woman checks eligibility criteria and completes application form • Woman asks health professional to complete and sign form • Woman returns form by post
• Woman receives Healthy Start vouchers and vitamin coupons by post • Woman finds out where she can use the vouchers/coupons
• Woman decides how to use the vouchers/coupons
After mapping out the general pathway of the programme, I used the information from the scoping search and her own knowledge about Healthy Start to annotate the diagram with any factors that seemed to be important (both internal and external to the programme). This included some of the barriers and facilitators identified in previous studies of Healthy Start (as reviewed in chapter 2). Different coloured pens were used to highlight possible aspects of context (yellow) and mechanisms (pink) along the programme pathway (Figure 6).
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Figure 6. Mind map of the Healthy Start pathway
The next stage was to decide which area of the programme pathway to focus on during this realist review. Pawson (2006) emphasised the importance of prioritising review questions and suggested this can be done based on the reviewer’s prior interests, burning issues or areas of dispute within the programme, and the time available. As described in the following reflexive section, these decisions reflected my personal interests, the research gaps identified (in section 2.6) and possible changes to Healthy Start that were being considered in early 2015.
I enjoyed the process of ‘mapping the terrain’ (as described by Pawson) and it helped me to identify which areas of Healthy Start I was most interested in exploring. As a public health nutrition researcher, I was keen to find out more about the potential nutritional benefits of the programme for low-income women and children. I felt that it was particularly important to explore the outcomes for low-income pregnant women as the first beneficiaries of Healthy Start and the primary decision makers (for themselves and their children). If pregnant women experience nutritional benefits from the programme, it is logical to anticipate that their children may also experience nutritional benefits. Previous studies focused
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less on this ‘end of the pathway’ compared to issues around the application process and eligibility criteria. A previous evaluation reported very low take-up of Healthy Start vitamins and recommended universal provision of free vitamins to all pregnant women (Jessiman et al., 2013). A report from the National Institute for Health and Care Excellence was anticipated later in 2015 (National Institute for Health and Care Excellence, 2015a). Therefore, in the light of possible changes to the vitamin component of the programme, I decided to focus on the food voucher component. I started to experiment with ideas about context, mechanisms and outcomes at this stage, but it was early in my realist training and I was still getting to grips with these methodological concepts.