Reglas de concordancia de cadenas

Some women reported that Healthy Start vouchers were used to deduct money from the shopping bill (Table 15). In other words, they used the vouchers to subsidise the cost of foods they would have bought even without the vouchers, rather than to improve their diets. The money saved was redirected to pay for other things. This theory is an alternative to theory 1, whereby context limits the ‘relative value of healthy eating’ and this influences how resources are prioritised. The mechanisms identified in this study relate to alleviation of stress and freeing up money without buying less than they did before. In summary:

For women who struggled to manage financially [context], Healthy Start vouchers were perceived as a contribution to the household budget [resources], which alleviated some

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of the stress associated with providing for the family [mechanism]. The vouchers were used to deduct money from the shopping bill [outcome] and the money saved was redirected towards other things [outcome] that were considered more important [context]. Figure 12 shows the CMOc that contributed to this theory. The following examples illustrate how interview data were used to develop and refine the CMOc.

Emily described how the vouchers she received for herself and 2-year-old child covered the cost of fruit and vegetables [resources] so it felt like they had been bought for her [mechanism]. The money she would otherwise have spent on fruit and vegetables was used for other things for the family, which she referred to as ‘essential’ [outcome]. This suggests that these other things were considered more important than the opportunity to buy and consume more healthy foods during pregnancy [context].

“They do because like I said at the beginning if I pay £10-£15 a fortnight on fruit and veg that is coming out of the vouchers it is not coming out of my money. It is like sounds cheap but it sounds like it has been bought for you. It saves you that money because if you think about it, that a month is £20-£30 a month being saved that can go towards kid’s cloths, days out, just stuff like that, essential other stuff that you need as well.” (Emily)

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Figure 12. CMOc leading to financial assistance (programme theory 3)

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Sophie, who had three children (7 weeks, 3 and 6 years) said she worried about money all the time [context] and constantly had to prioritise what was needed the most [context and mechanism]. Healthy Start vouchers helped to alleviate the stress [mechanism] and she used them to cover the cost of fruit and vegetables that she would have bought anyway [outcome]. She felt that Healthy Start should include a wider range of ‘essentials’ like bread (she also mentioned yoghurts and baby wipes in similar statements). Although she referred to ‘some people out there’, this comment suggests that she considered these other items to be more important than fruit and vegetables [context].

“All the time. All the time. Some weeks you’ve got to think about buying all your food but I always think she’s growing, how am I going to buy next size of clothes if I’m buying her nappies and milk. I don’t want to borrow money for clothes. You want to treat your kids all the time, but you’ve got to think about what you need first.” (Sophie)

“It just takes a little bit of worry off you.” (Sophie)

“That’s how I have always seen it yes, rather than buy extra with the £3.10 I would just take that £3.10 off the fruit and veg that I would already be buying in that week.” (Sophie)

“Yes, that is what I say, it should be essentials voucher rather than fruit and veg. I know it is healthy but there are some people out there that don’t get any food, never mind health food. It would be better if they had bread and milk in their cupboards than just fruit and veg.” (Sophie)

In some interviews, relevant data emerged when women discussed their experiences of using vouchers since they had their baby (i.e. women who were recently pregnant). For example, Anna, a single mother of two children (5 months and 3 years), received no financial support from their father and was totally reliant on benefits [context]. She said she would struggle without the vouchers, which suggests they alleviated some of the financial pressure [mechanism]. The money she saved on food was used to pay the bills [outcome].

“It is good because it helps people, like me…because with being on benefits and being on your own it does help. I don’t get no help from their dad I don’t get any money or anything like that so it is just literally my income support, child tax,

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child benefit and then the Healthy Start vouchers that’s all I get. So, it does help me out a lot.” (Anna)

“I wouldn’t be able to put as much on my gas and electric, I wouldn’t be able to afford all my bills, like the TV licence, water rates, I would struggle a lot.” (Anna) These findings suggest that financial stress may reduce the relative value or importance of healthy eating, such that Healthy Start vouchers provide an opportunity to save or conserve money, rather than to achieve dietary improvements (as in 6.3.3). This theory highlights that prioritisation of resources is an aspect of context (i.e. a process that happens all the time) as well as a mechanism (i.e. a response to the vouchers). The vouchers influenced or modified women’s prioritisation through alleviation of stress, and created a feeling that money had been released or freed up. This outcome has been assumed to be unintended throughout this study because women did not use the vouchers to improve their diets. However, the vouchers did provide a ‘nutritional safety net’ for these women because they freed up money without having to reduce the amount of healthy foods they bought.