A realist investigation of the impact of Healthy Start on the diets of low-income pregnant women in the UK

Healthy Start is the United Kingdom government’s food voucher programme for low-income, pregnant women and young children. Eligible women receive vouchers worth £3.10 per week, which can be exchanged for fruit and vegetables, plain cow’s milk or infant formula. There has been no robust evaluation of the impact of Healthy Start on nutritional outcomes since its introduction in 2006. Therefore, this study aimed to explore potential outcomes of the programme (including intended and unintended outcomes) and develop explanations for how and why these outcomes might occur. A realist review was conducted in two iterative and overlapping stages: 1) developing theories or hypotheses about how the Healthy Start programme works, for who, in what circumstances and why; 2) testing those theories using relevant evidence from existing studies of Healthy Start and a similar food voucher programme in the United States. The review findings comprised three ‘evidence-informed programme theories’ about how low-income pregnant women use Healthy Start vouchers and why. A qualitative study was undertaken to further refine and consolidate the programme theories derived from the realist review, and to develop new and emerging programme theories. Semi-structured interviews were conducted with 11 low-income women from North West England, who received Healthy Start vouchers during pregnancy. An innovative combination of realist interview techniques and vignettes was used to communicate and exchange theories with low-income women. A realist logic of analysis was applied to generate clear and transparent linkages between outcomes and explanations. Five ‘evidence-based programme theories’ were developed to explain why low-income pregnant women may experience one or more of the following outcomes from the Healthy Start programme: dietary improvements, shared benefits, financial assistance, stockpiling formula, misuse of vouchers. These programme theories were integrated with existing behaviour change theories and an overarching theoretical model for Healthy Start was developed. This model illustrates the combination of context and resources needed to generate the intended outcome of dietary improvements for low-income pregnant women, and the mechanisms by which this outcome may be generated

A systematic review of the health and well-being impacts of school gardening: synthesis of quantitative and qualitative evidence

Background: School gardening programmes are increasingly popular, with suggested benefits including healthier eating and increased physical activity. Our objectives were to understand the health and well-being impacts of school gardens and the factors that help or hinder their success. Methods: We conducted a systematic review of quantitative and qualitative evidence (PROSPERO CRD42014007181). We searched multiple databases and used a range of supplementary approaches. Studies about school gardens were included if they reported on physical or mental health or well-being. Quantitative studies had to include a comparison group. Studies were quality appraised using appropriate tools. Findings were narratively synthesised and the qualitative evidence used to produce a conceptual framework to illustrate how benefits might be accrued. Results: Evidence from 40 articles (21 quantitative studies; 16 qualitative studies; 3 mixed methods studies) was included. Generally the quantitative research was poor. Evidence for changes in fruit and vegetable intake was limited and based on self-report. The qualitative research was better quality and ascribed a range of health and well-being impacts to school gardens, with some idealistic expectations for their impact in the long term. Groups of pupils who do not excel in classroom activities were thought to particularly benefit. Lack of funding and over reliance on volunteers were thought to threaten success, while involvement with local communities and integration of gardening activities into the school curriculum were thought to support success. Conclusion: More robust quantitative research is needed to convincingly support the qualitative evidence suggesting wide ranging benefits from school gardens

Developing health service delivery in a poor and marginalised community in North West Pakistan

Objective: To improve maternal health and reduce child mortality through developing health service delivery in a poor and marginalised community in North West Pakistan. Methodology: A multifaceted intervention to extend and strengthen the range and quality of services provided at an existing health centre, in a rural community in Peshawar District, Khyber Pakhtunkhwa Province. The intervention was developed with community involvement and had four main components: service development, staff capacity development, community engagement and the introduction of a micro-credit scheme. The evaluation assessed the efficiency and effectiveness of project implementation, including a survey of maternal and child health indicators. Results: Between 2014 and 2017, a range of new health services were developed at the health centre. Local volunteers were trained to promote health awareness in the community and refer pregnant women to the health centre. The survey indicated health improvements, such as increased vaccination rates for women and children, and a dramatic reduction in unskilled deliveries. Conclusions: Community engagement was essential to achieve much needed maternal and child health improvements in this poor and marginalised community. Sustainability was achieved by training local volunteers as community health workers

A realist qualitative study to explore how low-income pregnant women use Healthy Start food vouchers

Healthy Start is the UK government's food voucher programme for low‐income pregnant women and young children. It was introduced in 2006, but the impact of the programme on nutritional outcomes remains understudied. This study sought to explore potential outcomes of the Healthy Start programme (including intended and unintended outcomes) and develop explanations for how and why these outcomes might occur. A realist review preceded this study, in which programme theories were developed and tested using existing evidence. This qualitative study aimed to further refine and consolidate the programme theories from the realist review while remaining open to new and emerging theories (or hypotheses) about how low‐income pregnant women use Healthy Start vouchers. Semistructured interviews were conducted with 11 low‐income women from North West England, who received Healthy Start vouchers during pregnancy. A realist logic of analysis was applied to generate clear and transparent linkages between outcomes and explanations. The findings suggested that some women used the vouchers to improve their diets during pregnancy (intended outcome), whereas some women were diverted towards alternative or unintended outcomes. Women's circumstances, values, beliefs, and motivations influenced how they perceived and responded to the vouchers. This paper presents four evidence‐based programme theories to explain four contrasting (and potentially overlapping) outcomes: dietary improvements (theory refined from review), shared benefits (new theory), financial assistance (theory refined from review), and stockpiling formula (new theory). It considers how the Healthy Start programme could be improved, to increase the possibilities for low‐income women to experience the intended outcome of dietary improvements

The BiZiFED project: Biofortified Zinc Flour to Eliminate Deficiency in Pakistan

Zinc deficiency is a global public health problem, affecting ~17% of the world’s population, with the greatest burden in low and middle-income countries. An increasing body of evidence suggests that biofortification may be a cost-effective and sustainable approach to reducing zinc and other micronutrient deficiencies. Biofortification enhances the nutritional quality of food crops through conventional plant breeding techniques and agronomic practices. This paper presents our ongoing research on biofortification in Pakistan, where over 40% of women are zinc deficient. The Biofortified Zinc Flour to Eliminate Deficiency (BiZiFED) project aims to investigate the impact of biofortification as a strategy to alleviate zinc deficiency in Pakistan. The project is supported by the Biotechnology and Biological Sciences Research Council (BBSRC) Global Challenges Research Fund from May 2017 to April 2019. This paper outlines the four objectives and work packages within the BiZiFED project: 1) a doubleblind, randomised controlled trial to examine the effect of consuming flour made from a high zinc variety of biofortified wheat (Zincol- 2016/NR-421) on dietary zinc intake and status; 2) a cost-effectiveness study to assess the health and economic impact of agronomic biofortification of wheat; 3) a mixed methods study to explore the cultural acceptability and sustainability of biofortification in Pakistan; 4) capacity building and development of long-term research partnerships in Pakistan. The findings will contribute to the evidence base for the potential impact of biofortification to alleviate zinc deficiency among the poorest communities

Can an ethics code help to achieve equity in international research collaborations? Implementing the Global Code of Conduct for Research in Resource-Poor Settings in India and Pakistan.

The Global Code of Conduct for Research in Resource-Poor Settings (GCC) aims to stop the export of unethical research practices from higher to lower income settings. Launched in 2018, the GCC was immediately adopted by European Commission funding streams for application in research that is situated in lower and lower-middle income countries. Other institutions soon followed suit. This article reports on the application of the GCC in two of the first UK-funded projects to implement this new code, one situated in India and one in Pakistan. Through systematic ethics evaluation of both projects, the practical application of the GCC in real-world environments was tested. The findings of this ethics evaluation suggest that while there are challenges for implementation, application of the GCC can promote equity in international research collaborations

Examining the effectiveness of consuming flour made from agronomically biofortified wheat (Zincol-2016/NR-421) for improving Zn status in women in a low resource setting Pakistan: Study protocol for a randomised, double blind, controlled cross over trial (BiZiFED)

Introduction: Dietary zinc (Zn) deficiency is a global problem, particularly in low and middle-income countries where access to rich, animal-source foods of Zn is limited due to poverty. In Pakistan, Zn deficiency affects over 40% of the adult female population, resulting in sub-optimal immune status and increased likelihood of complications during pregnancy. Methods and analysis: We are conducting a double blind, randomised controlled feeding study with crossover design, in a low resource setting in Pakistan. Households were provided with flour milled from genetically and agronomically biofortified grain (Zincol-2016/NR-421) or control grain (Galaxy-2013. Fifty households were recruited. Each household included a female aged 16-49 years who is neither pregnant nor breastfeeding, and not currently consuming nutritional supplements. These women were the primary study participants. All households were provided with control flour for an initial 2-week baseline period, followed by an 8-week intervention period where 25 households receive biofortified flour (Group A) and 25 households receive control flour (Group B). After this eight-week period, Group A and B crossed over, receiving control and biofortified flour respectively for eight weeks. Tissue (blood, hair and nails) have been collected from the women at five time points: baseline, mid and end of period 1, mid and end of period 2. Ethics and dissemination: Ethical approval was granted from the lead University (reference number: STEMH 697 FR) and the collaborating institution in Pakistan. The final study methods (including any modifications) will be published in peer reviewed journals, alongside the study outcomes on completion of the data analysis. In addition, findings will be disseminated to the scientific community via conference presentations and abstracts and communicated to the study participants through the village elders at an appropriate community forum

Micronutrient Status and Dietary Diversity of Women of Reproductive Age in Rural Pakistan

Consuming a diverse diet is essential to ensure an adequate intake of micronutrients. The aim of this study was to assess the nutritional status and dietary diversity of women of reproductive age (WRA) living in a marginalized community in rural Pakistan. Forty-seven WRA (35 ± 7 years old) who were not pregnant or lactating at enrollment, were recruited to participate in the study. Twenty-four-hour dietary recall interviews were conducted by the study nutritionist, and the data collected were used to create a minimum dietary diversity for women score (MDD-W) on five occasions during the monsoon and winter seasons (October to February). Nutritional status was assessed using anthropometry and biochemical markers of micronutrient status. Height and weight were used to determine body mass index (BMI), and mid-upper-arm circumference was measured. Plasma zinc, iron, and selenium concentrations were measured using inductively coupled mass spectrometry, and iron status was assessed using serum ferritin and blood hemoglobin concentrations. The mean (±SD) food group diversity score was 4 ± 1 with between 26% and 41% of participants achieving an MDD-W of 5. BMI was 27.2 ± 5.5 kg/m2 with 28% obese, 34% overweight, and 6% underweight. The prevalence of zinc deficiency, based on plasma zinc concentration, was 29.8%; 17% of the participants had low plasma selenium levels; 8.5% were iron deficient; and 2% were suffering from iron deficiency anemia. The findings indicate that the women living in this community consume a diet that has a low diversity, consistent with a diet low in micronutrients, and that zinc deficiency is prevalent. Public health interventions aimed at increasing the dietary diversity of WRA are needed to improve the micronutrient intake, particularly of zinc, in this population

Community Perceptions of Zinc Biofortified Flour during an Intervention Study in Pakistan

Zinc-biofortified flour may be a cost-effective approach to improve zinc status of populations in low-resource settings. The success of biofortification programmes is subject to acceptability and uptake by consumers. This study explored community leaders’ and community members’ (n = 72) experiences and attitudes towards the flour provided during a cluster randomised controlled trial of zinc biofortified wheat in rural Pakistan (BiZiFED2). Focus group discussions (n = 12) were conducted and thematic analysis applied using an inductive, semantic, contextualist approach. Five themes were identified: (1) Contribution to food security; (2) Better sensory and baking properties than local flour; (3) Perceived health benefits; (4) Willingness to pay for the flour; and (5) Importance of trusted promoters/suppliers. Although the participants were blind to whether they had received control or biofortified flour, referred to collectively as “study flour”, the results indicated that the study flour performed well in terms of its taste and bread making qualities, with no adverse reports from participants in either arm of the BIZIFED2 RCT. Participants suggested that they would buy the biofortified wheat if this was available at a fair price due to perceived health benefits, reporting positive sensory characteristics and cooking attributes when compared to the flour available in the local markets. Overall, there was a positive reception of the programme and flour among the participants, and members of the community hoped for its continuation and expansion