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A realist review to explore how low-income pregnant women use food vouchers from the UK’s Healthy Start programme
  1. Heather Ohly,
  2. Nicola Crossland,
  3. Fiona Dykes,
  4. Nicola Lowe,
  5. Victoria Hall-Moran
  1. College of Health and Wellbeing, University of Central Lancashire, Preston, UK
  1. Correspondence to Heather Ohly; HOhly{at}


Objectives To explore how low-income pregnant women use Healthy Start food vouchers, the potential impacts of the programme, and which women might experience these impacts and why.

Design A realist review.

Eligibility criteria for selecting studies Primary or empirical studies (of any design) were included if they contributed relevant evidence or insights about how low-income women use food vouchers from the Healthy Start (UK) or the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) programmes. The assessment of ‘relevance’ was deliberately broad to ensure that reviewers remained open to new ideas from a variety of sources of evidence.

Analysis A combination of evidence synthesis and realist analysis techniques was used to modify, refine and substantiate programme theories, which were constructed as explanatory ‘context–mechanism–outcome’–configurations.

Results 38 primary studies were included in this review: four studies on Healthy Start and 34 studies on WIC. Two main outcome strands were identified: dietary improvements (intended) and financial assistance (unintended). Three evidence-informed programme theories were proposed to explain how aspects of context (and mechanisms) may generate these outcomes: the ‘relative value’ of healthy eating (prioritisation of resources); retailer discretion (pressure to ‘bend the rules’); the influence of other family members (disempowerment).

Conclusions This realist review suggests that some low-income pregnant women may use Healthy Start vouchers to increase their consumption of fruits and vegetables and plain cow’s milk, whereas others may use them to reduce food expenditure and save money for other things.

  • pregnant
  • women
  • food
  • vouchers
  • realist
  • review

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See:

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  • Acknowledgements The authors would like to thank the stakeholder group for their contributions to theory development, and Eleanor Kotas (Information Specialist) for her assistance with the electronic database searches.

  • Contributors HO was the lead reviewer, while other authors completed the second reviewer tasks (as indicated in the Methods). All authors contributed to the development of programme theories through regular discussions. HO drafted the initial manuscript and all authors contributed to the final manuscript.

  • Competing interests None declared.

  • Ethics approval University of Central Lancashire Science, Technology, Engineering, Medicine and Health (STEMH) Ethics Committee.

  • Provenance and peer review Not commissioned; externally peer reviewed

  • Data sharing statement No additional data are available.

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