Client satisfaction with the nutrition education component of the California WIC program

Feasibility, Acceptability, and Initial Efficacy of a Digital Intervention to Improve Consumption of Foods Received within a National Nutrition Assistance Program

Many mothers are vulnerable to poor diet quality, particularly those living in low-income households. The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides nutrient-rich foods through its benefits packages, but many WIC participants are not redeeming them. We assessed the feasibility and acceptability of a digital intervention to support redemption and consumption of WIC-approved foods to ultimately improve diet quality. We enrolled 54 maternal-child dyads receiving WIC benefits to receive three to four weekly text messages for 12 weeks focused on behavioral goals to improve consumption of WIC-approved foods. We assessed engagement with weekly tracking messages and satisfaction and collected 24 h dietary recalls to assess preliminary efficacy on dietary intake. Participants were mostly non-Hispanic white (63%) and working (63%), and responded to 7.4 (standard deviation: 4.6) of the 12 weekly messages. Half (n = 27) were high engagers (responded to 80% or more of weekly messages), with 28% (n = 15) responding to all messages. Most felt the feedback (94%) and tips (87%) were helpful and would recommend the program (91%). More were consuming leafy green vegetables compared to baseline (p = 0.01). Mothers of children enrolled in WIC found a text messaging intervention focused on consumption of WIC-approved foods enjoyable and helpful.

WIC Participants' Perceptions of COVID-19-Related Changes to WIC Recertification and Service Delivery

Many Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinics implemented alternatives to in-person service delivery in response to the COVID-19 pandemic, including virtual visits and electronic document sharing. The objective of this cross-sectional study was to describe WIC participants’ experiences with remote service delivery and recertification during the pandemic. Participants included mothers and infants who participated in a WIC-based intervention between June 2019-August 2020. All participants (N = 246) were invited to complete a follow-up survey between November 2020-February 2021; 185 mothers completed the survey. The survey assessed sociodemographics, employment, food security, experiences with remote WIC recertification and service delivery, and experiences with obtaining WIC foods during the pandemic. Average age for mothers was 29.2 ± 6.3 years and for infants was 17.7  ± .2 months; 80% (n = 147) identified as Hispanic. Approximately 34% (n = 62) of participants reported very low or low food security and 40% (n = 64) had difficulties buying WIC foods during the pandemic. Among participants who recalled providing documentation of income and address virtually, the majority felt comfortable providing information via email (60%) and text messaging (72%). Participants reported high levels of satisfaction with remote methods of service delivery, as well as overall satisfaction with the WIC program during the pandemic. While ~ 25% of study participants preferred for all WIC services to remain remote, 75% still desired at least some in-person contact with WIC staff after the pandemic. In conclusion, remote methods of WIC service delivery addressed existing barriers to WIC participation and were well-received by study participants.

A Qualitative Study of Breastfeeding and Formula-Feeding Mothers' Perceptions of and Experiences in WIC

OBJECTIVE

To explore Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participants' perspectives about why formula-fed infants are less likely to be recertified at 1 year compared with breastfed infants.

DESIGN

Four focus groups of WIC mothers, stratified by language spoken (English or Spanish) and feeding mode (breastfeeding [BF] or formula-feeding [FF]).

SETTING

Two WIC sites within Los Angeles County, CA.

PARTICIPANTS

Mothers of 6- to 12-month-old infants (n = 31) in the WIC program.

PHENOMENON OF INTEREST

Mothers' perceptions of (1) how WIC supports BF and FF mothers; and (2) experiences of FF mothers in WIC, with a focus on how these experiences may affect desire to recertify their infant in WIC at age 1 year.

ANALYSIS

Thematic analysis of verbatim transcripts.

RESULTS

Mothers in all focus groups discussed the perceived positive value of BF support, food assistance, nutrition education, referrals, convenient WIC services, and social support from staff. Themes related to experiences of FF mothers included feeling judged for not BF, perceptions of WIC as a formula provider, and perceived difficulties obtaining formula. Mothers indicated that these experiences affected motivations to recertify.

CONCLUSIONS AND IMPLICATIONS

Although WIC provides important and effective support to low-income families, especially related to BF, some FF mothers may feel underserved with respect to support for their feeding decisions.

A Smartphone App for Families With Preschool-Aged Children in a Public Nutrition Program: Prototype Development and Beta-Testing

Background

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in the United States provides free supplemental food and nutrition education to low-income mothers and children under age 5 years. Childhood obesity prevalence is higher among preschool children in the WIC program compared to other children, and WIC improves dietary quality among low-income children. The Children Eating Well (CHEW) smartphone app was developed in English and Spanish for WIC-participating families with preschool-aged children as a home-based intervention to reinforce WIC nutrition education and help prevent childhood obesity.

Objective

This paper describes the development and beta-testing of the CHEW smartphone app. The objective of beta-testing was to test the CHEW app prototype with target users, focusing on usage, usability, and perceived barriers and benefits of the app.

Methods

The goals of the CHEW app were to make the WIC shopping experience easier, maximize WIC benefit redemption, and improve parent snack feeding practices. The CHEW app prototype consisted of WIC Shopping Tools, including a barcode scanner and calculator tools for the cash value voucher for purchasing fruits and vegetables, and nutrition education focused on healthy snacks and beverages, including a Yummy Snack Gallery and Healthy Snacking Tips. Mothers of 63 black and Hispanic WIC-participating children ages 2 to 4 years tested the CHEW app prototype for 3 months and completed follow-up interviews.

Results

Study participants testing the app for 3 months used the app on average once a week for approximately 4 and a half minutes per session, although substantial variation was observed. Usage of specific features averaged at 1 to 2 times per month for shopping-related activities and 2 to 4 times per month for the snack gallery. Mothers classified as users rated the app’s WIC Shopping Tools relatively high on usability and benefits, although variation in scores and qualitative feedback highlighted several barriers that need to be addressed. The Yummy Snack Gallery and Healthy Snacking Tips scored higher on usability than benefits, suggesting that the nutrition education components may have been appealing but too limited in scope and exposure. Qualitative feedback from mothers classified as non-users pointed to several important barriers that could preclude some WIC participants from using the app at all.

Conclusions

The prototype study successfully demonstrated the feasibility of using the CHEW app prototype with mothers of WIC-enrolled black and Hispanic preschool-aged children, with moderate levels of app usage and moderate to high usability and benefits. Future versions with enhanced shopping tools and expanded nutrition content should be implemented in WIC clinics to evaluate adoption and behavioral outcomes. This study adds to the growing body of research focused on the application of technology-based interventions in the WIC program to promote program retention and childhood obesity prevention.

A realist review to explore how low-income pregnant women use food vouchers from the UK's Healthy Start programme

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.

If You Build It They Will Come: Satisfaction of WIC Participants With Online and Traditional In-Person Nutrition Education

OBJECTIVE

To examine satisfaction with in-person group and online nutrition education and compare findings based on language preference by Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participants.

METHODS

A total of 1,170 WIC participants were randomly assigned to 2 nutrition education modalities between March, 2014 and October, 2015 in Los Angeles, CA. Logistic regressions compared differences between groups in satisfaction outcomes.

RESULTS

Participants in both education groups were highly satisfied regardless of modality of nutrition education (89% and 95%; P = .01). The online group reported a stronger preference for online education than did the in-person group (P < .001). In the in-person group, Spanish-speaking participants were less likely than were English-speaking participants to prefer online education (P < .001). A training video improved access to online education.

CONCLUSIONS AND IMPLICATIONS

Online delivery of education can be an acceptable addition for WIC participants with online access. High-quality online education platforms represent an important avenue to promote continued satisfaction with nutrition education.

Optimizing Nutrition Education in WIC: Findings From Focus Groups With Arizona Clients and Staff

OBJECTIVE

To understand staff and clients' experiences with delivering and receiving nutrition education in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

METHODS

Focus groups involving WIC staff, clients, and former clients in Arizona. Client and staff perceptions of WIC nutrition education, preferences, and suggestions for improvement were examined. Transcripts were analyzed using a deductive thematic approach to identify emerging themes.

RESULTS

Findings from 10 focus groups with 25 WIC staff and 29 clients suggested that existing materials were time-consuming and unresponsive to client needs, and additional resources were needed to engage children while parents were in session; new delivery formats for nutrition education, including videos and interactive demonstrations focused on child-friendly preparations of WIC foods, were preferred.

CONCLUSIONS AND IMPLICATIONS

Collaboration among existing nutrition education programs, including Supplemental Nutrition Assistance Program-Education, Expanded Food and Nutrition Education Program, community gardens, and Head Start, can complement and enhance WIC nutrition educations in this region.

Satisfaction of California WIC participants with food package changes

OBJECTIVE

Assess California Women, Infants, and Children (WIC) participant satisfaction with the 2009 food package revisions and compare satisfaction based on language preference and timing of WIC enrollment relative to the revisions.

METHODS

Computer-assisted telephone interviews of 2,996 WIC participants in 2010.

RESULTS

Most participants (91.3%) were satisfied with checks for new WIC foods (fruits/vegetables, whole grains, and lower-fat milk) and 82.7% of participants were satisfied with amounts of foods that were reduced in the revised food package (milk, cheese, eggs, and juice). Difficulty using new checks was reported by 13.7% of participants. Compared with English-speaking participants, a higher percentage of Spanish speakers reported satisfaction (P < .01) and a lower percentage reported difficulties using checks (P < .001). A higher percentage of newer enrollees reported satisfaction compared with those participating in WIC before the revisions (P < .01).

CONCLUSIONS AND IMPLICATIONS

This research suggests that recent policy change to the WIC food package improves WIC participant access to healthful food options without decreasing satisfaction.

Use of food labels, awareness of nutritional programmes and participation in the special supplemental program for Women, Infants and Children (WIC): results from the National Health and Nutrition Examination Survey (2005-2006)

Use of nutritional labels in choosing food is associated with healthier eating habits including lower fat intake. Current public health efforts are focusing on the revamping of nutritional labels to make them easier to read and use for the consumer. The study aims to assess the frequency of use of nutritional labels and awareness of the United States Department of Agriculture (USDA) nutritional programmes by low-income women including those participating in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) as surveyed in the National Health and Nutrition Examination Survey 2005-2006. Many low-income women do not regularly use the nutrition facts panel information on the food label and less than half had heard of the USDA Dietary Guidelines for Americans (38.9%). In multivariate logistic regression, we found that WIC participation was associated with reduced use of the nutrition facts panel in choosing food products [odds ratio (OR) 0.45, 95% confidence interval (CI) 0.22-0.91], the health claims information (OR 0.54, 95% CI 0.32-0.28) and the information on carbohydrates when deciding to buy a product (OR 0.44, 95% CI 0.20-0.97) in comparison with WIC eligible non-participants. Any intervention to improve use of nutritional labels and knowledge of the USDA's nutritional programmes needs to target low-income women, including WIC participants. Future studies should evaluate possible reasons for the low use of nutrition labels among WIC participants in comparison with eligible non-participants.

Impact of internet vs traditional Special Supplemental Nutrition Program for Women, Infants, and Children nutrition education on fruit and vegetable intake

The purpose of this project was to compare the impact of Internet nutrition education to traditional nutrition education on Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participant fruit and vegetable consumption. Interventions were delivered at 15 WIC clinics after normal WIC clinic operations or delivered online. A total of 692 and 872 participants from eight WIC agencies self-enrolled into two phases. A quasi-experimental design using an interrupted time series to determine the impact of two methods of nutrition education and follow-up nutrition counseling was used. Data were collected online and at Michigan WIC clinics during 2005-2007 at 3-month intervals during a 9-month period (per phase). Two Internet nutrition education modules were compared to WIC traditional nutrition education, which included either group classes or a self-guided nutrition education information mall. All interventions were based on the same program learning objectives. Optional motivational negotiation counseling followed 3 months post-intervention. Stage of change progression, belief in ability to change, and fruit and vegetable consumption were measured at baseline, immediately after the intervention, and 3 and 6 months post-intervention. Significance (P<0.05) was analyzed using independent samples t tests, χ(2) distribution, and sample tests for differences in binomial proportions. The Internet group experienced substantial positive differences in stage of change progression, perception that the intervention was helpful and easy to use, and fruit and vegetable consumption. Traditional nutrition education required follow-up counseling to achieve fruit and vegetable consumption levels similar to the Internet nutrition education group. Based on these findings, this study supports Internet nutrition education as a viable alternative to traditional nutrition education for increasing fruit and vegetable consumption in some WIC clients.

Using learner-centered education to improve fruit and vegetable intake in California WIC participants

OBJECTIVE

To examine the effectiveness of learner-centered education in conveying the message to change participants' fruit and vegetable consumption.

DESIGN

Focus groups were conducted with sites participating in the Finding the Teacher Within (FTW) program and comparison sites 4-6 months after participants attended the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) fruit and vegetable class.

SETTING

Six California WIC agencies.

PARTICIPANTS

Sixty predominantly Latina mothers with young children, 30 from 3 participating intervention agencies and 30 from 3 comparison agencies, participated in focus groups. Each agency independently recruited mothers for participation. Apart from selecting only mothers, no other exclusion criteria were applied.

INTERVENTION

An FTW learner-centered fruit and vegetable class.

ANALYSIS

An analytic team independently reviewed transcripts and coded themes. The long-table analytic approach was used to categorize results. Results from intervention and comparison groups were compared and ranked to create a textual summary.

RESULTS

The most significant difference between the intervention and comparison groups' reports was that intervention participants identified more value, importance, and relevance of the fruit and vegetable information and adopting new fruit and vegetable practices after attending the class.

CONCLUSIONS AND IMPLICATIONS

California WIC demonstrated that messages delivered through this process can be retained and integrated into family life practices.

Improving service delivery in a county health department WIC clinic: an application of statistical process control techniques

Local public health agencies are challenged to continually improve service delivery, yet they frequently operate with constrained resources. Quality improvement methods and techniques such as statistical process control are commonly used in other industries, and they have recently been proposed as a means of improving service delivery and performance in public health settings. We analyzed a quality improvement project undertaken at a local Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinic to reduce waiting times and improve client satisfaction with a walk-in nutrition education service. We used statistical process control techniques to evaluate initial process performance, implement an intervention, and assess process improvements. We found that implementation of these techniques significantly reduced waiting time and improved clients' satisfaction with the WIC service.

Community empowerment: a partnership approach to public health program implementation

Public policy implementation models reflect who makes decisions, how success is defined, and whether learning is built into decision making. The extant implementation models capture many important features of public policy implementation, including the desire of large public bureaucracies to impose order and rationality on implementation structures that include many public and private organizations. Analysis of the three-decades-long process of implementation of the Special Supplemental Nutrition Program for Women, Infants, and Children suggests that a new public policy implementation model is needed. The new model builds on the iterative learning cycles and shared decision making of community participatory research and better addresses the transactional relationship between program targets and providers than do current implementation models.

Survey of Herbal Use by Kansas and Wisconsin WIC Participants Reveals Moderate, Appropriate Use and Identifies Herbal Education Needs

OBJECTIVE

To examine herbal use by a sample of low-income, nutritionally vulnerable children.

DESIGN

Caregivers completed a survey of child and caregiver herbal usage practices.

SUBJECTS/SETTING

A convenience sample of 2,562 caregivers to children participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in Kansas and Wisconsin who were attending a WIC clinic was selected. WIC project selection was random, with stratification for geographic and ethnic representation.

STATISTICAL ANALYSES PERFORMED

Herbal usage profiles were described with measures of central tendency. Groups were compared with a two-tailed independent t test and chi2 for continuous and categorical variables, respectively.

RESULTS

Child herbal use was reported on 917 surveys, representing 1,363 children ranging in age from 1 week to 17.5 years; 820 were younger than age 5 years. Herb use was greater among Latino children (48.4% vs 31.4%) and caregivers (43.4% vs 37.2%). Caregivers had a mean age of 27.8+/-8.32 years and 38.8% (n=994) denoted using herbs. Herbs most commonly used by children were aloe vera, chamomile, garlic, peppermint, lavender, cranberry, ginger, echinacea, and lemon. Reasons for herbal use paralleled recommendations. Family (78.9%) and friends (32.9%) were predominant information sources. Herbs with safety issues, such as St John's wort, dong quai, and kava were used. Herbal use characteristics did not differ between states, but were unique for Latino clients.

CONCLUSIONS

Herbal use by WIC children is mostly congruent with known indications; however, practices with potential to harm urge herbal education in WIC clinics, especially for Latinos.

Barriers to the use of WIC services

OBJECTIVES

To identify barriers that deter parents/caretakers of infants and children enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) from taking full advantage of the services provided by the program.

SUBJECTS/SETTING

A total of 3,167 parents/caretakers at 51 New York State WIC local agency sites completed a barriers survey.

DESIGN

Sixty-eight potential barriers to WIC were identified through a literature review, five focus groups with parents/caretakers of WIC participants, and an expert review panel. The barriers survey was administered person-to-person to parents/caretakers of infants and children on WIC. Statistical analysis Classification tree analysis was used to identify characteristics that best predict WIC check usage behavior.

RESULTS

A small set of barriers (n=11) were identified by more than 20% of respondents. Waiting too long was the most frequently cited barrier (48%). Difficulties in bringing the infant/child to recertify and rescheduling appointments were key variables associated with failure to use (ie, pick up or cash) WIC checks. Further analyses indicated that (a) for each additional reported barrier, there was a 2% increase in failure to use WIC checks (P<.0001); (b) waiting for services was related to an increase in the number of people who failed to use checks; and (c) the longer the reported wait, the greater the number of reported barriers (P<.0001).

CONCLUSIONS

Conducting this barriers research enabled the New York State WIC to improve services provided to participants and their families. A decrease in waiting times should generally reduce exposure to noisy, crowded facilities and lead to fewer reports of nothing for kids to do.