2

The WIC Participant Experience

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participant experience, illustrated in Figure 2-1, is influenced by a number of factors, including racial and ethnic differences in food preferences and infant and child feeding practices; behavioral barriers and motivators; environmental and economic factors affecting the availability of and access to food; and administrative and vendor challenges associated with the WIC food packages. A better understanding of these factors can help to ensure that WIC food packages are culturally suitable, efficient for nationwide distribution, and nonburdensome to administration. This chapter reviews available evidence relevant to these factors in relation to the WIC participant experience.

ASSESSING PARTICIPANT ACCEPTANCE OF WIC FOODS

Given the racial and ethnic diversity of the WIC population, which was described in Chapter 1, the committee conducted a review of the literature to evaluate racial and ethnic differences in satisfaction with the 2009 food package revisions and in infant and child feeding styles and practices. A summary of findings is included here.

Racial and Ethnic Differences and Acceptance of the WIC Food Packages

Although multiple studies have documented moderate to high satisfaction with the 2009 changes in the WIC food packages (Gleason and Pooler, 2011; Whaley et al., 2012; Ishdorj and Capps, 2013; Bertmann et al., 2014;

Ritchie et al., 2014), evidence also indicates cultural variation in participants’ satisfaction with certain types or amounts of food items (Black et al., 2009, Ritchie et al., 2014). Black et al. (2009) conducted interviews and focus groups with WIC participants and caregivers throughout Maryland to assess perceptions of the proposed food package changes and examine differences in food preferences by race and ethnicity. Although food preferences appeared to be similar between non-Hispanic black and non-Hispanic white participants, more Hispanic respondents preferred beans compared to peanut butter and expressed dislike for frozen and canned vegetables. In a statewide survey of WIC participants and caregivers in California, Ritchie et al. (2014) reported that of the nearly 3,000 participants and caregivers surveyed, most (91 percent) were satisfied with the new food items introduced (fruits and vegetables, whole grains, and lower-fat milk). However, participant satisfaction was significantly higher among individuals who spoke primarily Spanish compared with individuals who spoke primarily English. Additionally, a higher proportion of primarily Spanish speakers were satisfied with vouchers for whole grains, vouchers for lower-fat milk, and the amount of juice, and a higher proportion of primarily English speakers were satisfied only with the amount of milk and not with other amounts of other foods.

Racial and Ethnic Differences in Infant and Child Feeding Styles and Practices

Parental styles and practices for infant and child feeding may shape early food preferences and eating patterns and, as discussed in Chapters 6 and 7, have been associated with the risk of being overweight or obese and related health conditions. Studies of WIC participants and low-income populations have reported cultural differences in breastfeeding initiation and duration, foods available and accessible to young children in the home, parent modeling, parent encouragement, and family rules (Bonuck et al., 2005; Kasemsup et al., 2006; Hurley et al., 2008; Mistry et al., 2008; Arthur, 2010; Evans et al., 2011; Skala et al., 2012; Marshall et al., 2013; Odoms-Young et al., 2014; St. Fleur et al., 2014). The American Academy of Pediatrics (AAP) (2014) reviewed racial and ethnic similarities and differences related to parental feeding styles, and although differences in feeding styles were evident among subjects, the results were too heterogeneous to draw general conclusions for racial or ethnic groups. In terms of specific feeding practices, the AAP acknowledges the strong influence of culture on parental behaviors related to food choice, preparation, and consumption (AAP, 2014).

Racial and Ethnic Differences in the Prevalence of Breastfeeding

The national prevalence of breastfeeding is increasing, with proportions of breastfeeding women at or near their historic highs in 2011, with the exception of the non-Hispanic American Indian/Alaska Native category (HHS/CDC, 2015). However, even at their historic highs, rates have varied among other racial and ethnic groups as well (see Table 2-1). From 2008 to 2011, the prevalence of breastfeeding at 6 months was consistently lowest for non-Hispanic black (30 to 36 percent of infants) and highest for non-Hispanic Asian (60 to 70 percent of infants) (HHS/CDC, 2015). Studies of breastfeeding prevalence in the WIC population have similarly shown variation by cultural group, with fewer African American women initiating and sustaining breastfeeding compared to other racial and ethnic groups (Hurley et al., 2008; Marshall et al., 2013). The underlying reasons for racial and ethnic differences in breastfeeding prevalence are not well understood at this time, but it is clear that the greatest differences occur at the point of initiation (AAP, 2014). Chapter 7 summarizes the committee’s evaluation of breastfeeding trends and barriers, motivation, and support of breastfeeding.

Racial and Ethnic Differences in Provision of Foods to Young Children

Evidence suggests that cultural variations in infant and child feeding practices may affect the use of specific WIC foods. Kim et al. (2013) reported that satisfaction with jarred baby foods varied across ethnic groups; whereas, about half of whites and African Americans preferred cash

TABLE 2-1 6-Month Breastfeeding Prevalence by Race

NOTE: Data are not adjusted for income.

SOURCE: National Immunization Survey Data, as analyzed by the Office of Disease Prevention and Health Promotion, Healthy People 2020 (HHS/CDC, 2015).

value vouchers (CVVs) for fruits and vegetables compared to jarred baby foods, more than two-thirds of Latinos and those identifying as “Other” preferred CVVs for fruits and vegetables. However, redemption of jarred infant foods declined at similar rates with increasing infant age across all ethnic groups.

BARRIERS AND INCENTIVES TO WIC PARTICIPATION AND REDEMPTION

The extent to which the WIC food packages can affect food and nutrient intake is dependent on whether eligible individuals elect to participate and how participants make use of the food benefit. This section summarizes the committee’s review of evidence of barriers to participation in WIC or other national food assistance programs, barriers to redemption of WIC foods, and incentives to WIC participation and redemption. An overall summary of the literature review related to barriers to participation and redemption is presented in Box 2-1. Also included in this section is a discussion of concepts from the field of behavioral economics that might be helpful during phase II of the study when considering ways to incentivize WIC participation and redemption and strengthen breastfeeding promotion efforts.

Barriers to Participation

A number of qualitative studies and reports include information about barriers to participation in WIC (Tiehen and Jacknowitz, 2008; USDA/ERS, 2010; Gleason and Pooler, 2011; Gleason et al., 2011, 2014; Bertmann et al., 2014; Phillips et al., 2014; see Appendix G, Table G-1) or in national food assistance programs generally (Martin et al., 2003; Algert et al., 2006; USDA/ERS, 2013). Based on an examination of nationally representative data from the Early Childhood Longitudinal Study-Birth Cohort, Jacknowitz and Tiehen (2007) examined WIC program exits and found that those participants who exited the program early reported that taking part required too much effort (25.7 percent) or they had scheduling or transportation problems (10 percent). Transportation has been cited in other studies as a barrier to participation (Gleason et al., 2014). Some studies have noted language spoken by WIC staff as a barrier to participation (e.g., Tiehen and Jacknowitz, 2008), but others note that some groups like Hispanics tend to enroll earlier in WIC than their non-Hispanic counterparts (e.g., Swann, 2007).

The most extensive quantitative study on barriers to WIC participation was conducted in New York State (Woelfel et al., 2004).¹ In this study, a total of 3,167 parents and caretakers at 51 local agency sites completed a survey on barriers that was developed through qualitative and focus group work. Of the 68 potential barriers included in the survey, 11 were identified by more than 20 percent of respondents. Waiting too long in the waiting room was the most frequently cited barrier (48 percent). Difficulties in bringing the infant or child to recertify and rescheduling appointments were key variables associated with failure to pick up WIC benefits. Features of the physical environment (e.g., crowded, with limited kid-friendly areas) were reported as reducing participant interest in coming to the WIC site. Duration of appointment wait time, customer service, and to a lesser extent facility environments, were identified by WIC participants as potential areas for improvement in a smaller study in Florida conducted by Christie et al. (2006).

Barriers to participation in other national food assistance programs may have implications for WIC, although eligibility and certification requirements differ substantially among programs. Algert et al. (2006), for example, showed that lack of a permanent address, language barriers, changes in eligibility restrictions, and stigma were associated with lower rates of participation in the Supplemental Nutrition Assistance Program (SNAP). Moreover, participants often perceived that the differing

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¹ Although this study fell outside the committee’s search parameters in terms of publication year, the committee considered its findings to be particularly applicable to the current task (see Chapter 3 for the literature search strategy details).

administrative requirements for food assistance programs were complicated (Gilbert et al., 2014). Also of note, participation patterns generally followed patterns of national economic health (USDA/ERS, 2013) with increasing participation during times of recession. In a study of food assistance programs not including WIC, Martin et al. (2006) described lack of comfort, difficulty with paperwork, and difficulty carrying food home as barriers to participation. Both Martin et al. (2006) and Jacknowitz and Tiehen (2007) found that believing one’s family was ineligible was a reason for either not participating or exiting a program early.

Redemption Patterns and Barriers to Redemption

Redemption of WIC Foods

Publicly available data on redemption of WIC foods have not yet been collected on a national level. Limited data are available at the state level on redemption after the implementation of the 2009 rule. The most comprehensive study of WIC food package redemption thus far was conducted by the Altarum Institute using electronic benefit transfer (EBT) data from three states: Kentucky, Michigan, and Nevada (Phillips et al., 2014). The findings are summarized in Box 2-2. From January through March 2012, full redemption² of issued food packages ranged from 9.5 to 16.4 percent, partial redemption ranged from 75.6 to 84.4 percent, and nonredemption ranged from 4.1 to 8.0 percent. Differences in redemption were related to race and ethnicity, geography, household size, and the number of WIC family members. The likelihood of nonredemption did not differ greatly based on race or ethnicity in any of the three states and was lower for rural compared to urban residents only in Nevada. Odds of full redemption were significantly higher in households with an infant less than 6 months of age. Based on focus group work, barriers to redemption included receiving too much of a food, dislike of a food, and lack of knowledge on how to prepare a food.

Foods with the highest redemption rates included infant formula, fruits and vegetables, milk, and eggs (Phillips et al., 2014). The final rule specified that, for individuals more than 2 years of age, only skim or 1% milk could be issued, barring any qualifying medical conditions (USDA/FNS, 2014a). In a recent study, Rimkus et al. (2015) found that the availability of lower-fat milks was limited in certain communities. They surveyed 8,959 food stores in 468 communities where a nationally representative sample

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² Full redemption means that all foods prescribed were purchased. Partial redemption means that some of the foods were redeemed. Nonredemption means that none of the prescribed foods were redeemed.

of students attending public schools resided and found that the odds of carrying lower-fat milks was up to 67 and 58 percent lower in majority black or Hispanic communities, respectively, than in white communities. Important to note is that data for this study were collected between 2010 and 2012, before the final rule eliminating milks of 2 percent fat or higher was implemented (in 2014).

Despite the potentially limited availability of lower-fat milks, milk had one of the highest redemption rates of the WIC foods in 2012 (Phillips et al., 2014). Foods with the lowest redemption rates included jarred baby meats, beans, peanut butter, infant cereal, jarred fruits and vegetables, and whole grains (Phillips et al., 2014). Gleason and Pooler (2011) found that redemption of infant food was low compared to other foods in a study of Wisconsin WIC participants. At 18 months after the implementation of the 2009 package changes, infant fruit and vegetable vouchers were redeemed at 50 percent and infant meat at 34 percent, compared to cheese, eggs, juice, and milk, which were redeemed at 91 to 97 percent post-implementation. Kim et al. (2013) found that redemption rates of jarred infant foods declined with age in a study of WIC participants in California. In this study, participants indicated high satisfaction with jarred infant foods although 66 percent reported that they would prefer to have CVVs for fruits and vegetables for their 6- to 11-month-old infants instead of the jarred foods if permitted. The 2014 final rule allows a $4 or $8 CVV for fruits and vegetables in place of a portion of jarred infant food (USDA/FNS, 2014a).

A major change in the 2009 WIC food package was inclusion of the CVV for purchase of fruits and vegetables. As discussed in the committee’s Letter Report, very little information is available in the published literature or from reports to describe the extent to which the CVV is redeemed or how WIC participants apportion the CVV across types and forms of fruits and vegetables (IOM, 2015). As noted in Chapter 3, for this report the committee investigated potential sources for data on foods redeemed by WIC participants. Although obtaining nationally representative data remains challenging, available state agency redemption data indicate that the 74 to 78 percent of the CVV was redeemed in Texas from January to March 2015 (Texas Department of Health Services, 2015). Additional information on CVV redemption may become available to the committee during phase II of this study.

Barriers to Redemption of WIC Foods

Although studies are limited, qualitative work among WIC programs nationwide suggests that the participant shopping experience can be a key barrier to redemption of WIC foods. Prior to the food package revisions, a survey administered to parents and caretakers of WIC participants in New York State found that issues with food procurement (e.g., store policies, food availability) and the WIC food packages (e.g., adequacy, satisfaction with the items) were barriers to participation (Woefel et al., 2004). Since the 2009 food package change, factors identified that negatively affect the WIC shopping experience include food package policies (e.g., container

size), grocery store experiences (e.g., cashier interactions), and personal misunderstanding and embarrassment. Positive factors include helpful vendors and both vendor and participant understanding about the use of the CVV (Najjar, 2013).

With respect to the CVV, several small studies were carried out after implementation of the 2009 food package changes to evaluate the perception and use of the CVV by WIC participants. Bertmann et al. (2014) reported that CVVs were inconsistently redeemed in Arizona. They identified several barriers to redemption: participants’ perception of annoyance or anger expressed by cashier or other shoppers; cashiers’ lack of training; fluctuation in enforcement of WIC redemption rules from store to store and week to week; and feelings of embarrassment or judgment when using the CVV. The authors cautioned, however, that their findings might not be generalizable to other WIC populations. In a Wisconsin study of WIC participant CVV redemption patterns, Gleason and Pooler (2011) reported positive responses overall to the package changes, but with differences in non-use and maximum use of the CVV among some WIC subpopulations. Some participants described a level of discomfort with having to do math in the store, which the researchers hypothesized may be enough to deter use of the benefits. Other vendor-level challenges noted included difficulty maintaining fresh foods (particularly in smaller stores), anticipating client demand, and having the correct package sizes available. The effect of allowing split tender for CVV purchases (using a different payment method for the amount over the CVV benefit) on redemption has yet to be comprehensively evaluated.

Maximizing Participation and Redemption

The committee searched for literature exploring strategies to increase both participation in WIC and redemption of WIC benefits. Potential strategies identified included streamlining the registration process (Gilbert et al., 2014), enhancing customer service and reducing wait times for participants (Christie et al., 2006), informing participants of local vendors (Gleason et al., 2014), ensuring culturally appropriate nutrition messaging (Phillips et al., 2014), enhancing the perceived value of packages (Gleason and Pooler, 2011), and examining the impact of minimum stocking requirements on food availability (Gleason et al., 2011).

In the Altarum study described previously, Phillips et al. (2014) examined the transition to the EBT system and found that in WIC, EBT is preferred by vendors and participants over paper vouchers. Most participants considered the use of EBT a positive shopping experience that improved use of the benefits and minimized waste because of its convenience and portability, allowance for benefit balance tracking, and ease of checkout.

The researchers concluded that, although some technical challenges persist, EBT appears to have a promising positive effect on participant satisfaction and redemption.

Behavioral Economics

This section highlights concepts from the field of behavioral economics that might be helpful during phase II when considering incentives to promote WIC participation and redemption. Consumers often behave in ways (e.g., make decisions about foods) that contradict standard assumptions of economic theory (Just and Payne, 2009). Individuals often exhibit biases, a prime example being loss aversion (Kahneman and Tversky, 1984), when making choices. Loss aversion refers to the tendency to treat losses differently than gains, that is, people will pay less for an object they do not already have compared to what they will accept to give that object up. People also exhibit a tendency to remain within the status quo, even if choosing an alternative action seems clearly better. The implication for WIC is that there may be ways to frame food package choices to influence participant decisions, for example to make the breastfeeding package the status quo or “default” choice, or alternatively, to make it clear that when one chooses the partial or nonbreastfeeding package, the mother receives less food. There is evidence to suggest that when selecting new goods, individuals tend to focus on utilitarian characteristics (functional features of a good; an example for food is “healthful”), but when deciding what to give up, they focus instead on hedonic characteristics (experiential features of a good; an example for food is “taste”) (Dhar and Wertenbroch, 2000; USDA/ERS, 2007). Thus, individuals might be willing to consider healthfulness when adding foods to their diet, but be less willing to give up a food that is perceived as tasting good. In the context of WIC, an example would be a greater willingness to add low-fat yogurt compared to giving up higher-fat milk. The U.S. Department of Agriculture-Economic Research Service (USDA-ERS) also reviewed research showing that specific cues (i.e., appearance, brand, name, price, and information) can influence product choices, which may be relevant for the labeling of food items (USDA/ERS, 2007).

Cognitive overload can also affect choice. When there are too many options competing for one’s attention, one is more likely to make decisions based on habits or rules of thumb than on logic. This might be relevant for WIC participants trying to find the least expensive brands, which can change frequently in states with least-expensive-brand rules. Labeling of products as “WIC” food items or prepackaging fruits and vegetables in even-dollar amounts reduces the time and difficulty in making decisions for program participants and may also reduce the vendor costs of handling WIC products at the checkout. In the context of WIC, making healthier

choices easier to identify and select might increase purchase and consumption of these foods.

In terms of how choices affect consumption, additional evidence cited in USDA-ERS (2007) indicates that when the salience of food is increased, people consume more of it, suggesting that increasing the salience (how much particular items stand out or are noticed) of better food choices might increase consumption. In the context of WIC, making better food choices in the food packages more salient through advertising might increase purchase and consumption of those foods. USDA-ERS (2007) also cited evidence showing that more variety can lead to more consumption.

Based on evidence from SNAP literature, mental accounting, another type of bias whereby people make choices based on having allocated specific funds for specific purposes, might also have implications for WIC food packages (USDA/ERS, 2007). If participants think of their WIC vouchers as special, they might purchase and consume more WIC foods than they would otherwise (i.e., if they were making their food choices based on total income and treating the vouchers as cash).

Finally, there is considerable evidence from the field of behavioral economics that the present time is valued more than future time and that individuals respond differently when asked what they would trade “now” for $10 provided in 2 weeks compared to what they would trade 1 month from now for $10 provided in 6 weeks (Loewenstein, 1988).³ In the context of this decision being faced by a new WIC woman participant, the trade-off would be what the participant might receive now compared to the value of what would be received later. The choice now is the value of 806 fluid ounces of formula right away and less food in her package compared to the value of the breastfeeding package now (extra food in the package for the mother and nothing for the infant). The option (choice) later in the period of 6 to 12 months from now is the relatively lower value of the formula package but no benefits for the mother compared to the value of the breastfeeding package (maternal food and some additional food [meats] for the infant). The participant might be inclined to select the breastfeeding package at higher rates than if she had made the decision at some point before the baby was born, over both choices which occur in the future. Recommitment has been suggested as a strategy to address this tendency, or present bias. In the WIC program, periodic WIC office visits and breastfeeding peer counseling offer participants continuing opportunity for (re)commitment.

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³ There is a body of literature that suggests food assistance recipients consume more of their allotment right around the time the benefits are disbursed (e.g., Wilde and Ranney, 2000). One explanation for this is that recipients have a high personal discount rate and value the present much more than the future.

FACTORS AFFECTING ACCESS TO FOOD

The committee was tasked (during its phase II portion of the study) with ensuring that foods recommended in the food packages are available to WIC participants. This section summarizes findings from the literature on factors that affect availability and access to food in low-income populations. Studies have examined where WIC participants shop for WIC foods; means of transportation; employment; food prices; and the effect of the 2009 food package changes.

Where WIC Participants Shop for WIC Foods

Several studies have examined the distance to WIC food stores and the number of stores within a defined radius. Ford and Dzewaltowski (2010) found that WIC mothers had access to many food stores within a 3-mile radius of their home, whether residing in a micropolitan or a metropolitan area. A recent study of SNAP and WIC households using nationally representative data from National Household Food Acquisition and Purchase Survey (FoodAPS) indicated that the nearest store was an average of 2.0 miles from the household, but the store primarily used for grocery shopping was, on average, 3.4 miles from the household (USDA/ERS, 2015a).

In the National Survey of WIC Participants II (NSWP-II) study conducted in 2009 (USDA/FNS, 2012), WIC participants redeemed their benefits primarily at large grocery stores and supermarkets (63 percent) or combination food store and retail outlets (22 percent). Only 7 percent redeemed vouchers primarily at small grocery stores. Most WIC participants used their vouchers and did most other food shopping at the same store (84 percent). Reasons provided for shopping at a different store for WIC foods included convenience (44 percent) and cost (32 percent). More recently, the USDA-ERS reported that 52 percent of WIC households in the survey shopped primarily at a supercenter-type store, and 39 percent at a supermarket (USDA/ERS, 2015a) (see Table 2-2).

Transportation

The ability of WIC participants to use the food packages may be limited by transportation. The USDA’s FoodAPS survey includes information on transportation resources for shopping for WIC foods (USDA/ERS, 2015c). Eighty-seven percent of WIC households responding to the survey accessed grocery stores using their own vehicle, and 8 percent of WIC households reported walking, biking, using public transport, shuttle, delivery, or some other form of transportation (USDA/ERS, 2015c). Using one’s own vehicle allows more flexibility in store choice; lack of a vehicle limits the ability to

TABLE 2-2 Preference for Type of Store for WIC or Non-WIC Households

^a Non-WIC, income below 185% of federal poverty threshold.

^b Supercenters include mass merchandisers.

^c Supermarkets include supermarkets, commissaries, and other large grocery stores.

^d Other includes smaller grocery stores, specialty retailers, convenience stores, pharmacies, and dollar stores.

SOURCE: USDA/ERS, 2015a.

transport large or heavy items or a large number of items. Distance to the grocery store also affects food safety, since spoilage may occur with longer travel times.

Employment

When the 2006 Institute of Medicine (IOM) committee issued its recommendations, data from the National Survey of WIC Participants (NSWP) had been used to determine that approximately 25 percent of women were employed when applying to WIC and about 28 percent of WIC mothers were employed, with the highest employment rate among pregnant WIC women (32 percent) (USDA/FNS, 2001). At the time of delivery of this report, current data were not available on the employment status of WIC participants, and the most recent NSWP (NSWP II, published in 2012) did not include employment information.

National Census Bureau data for 2013 indicate that 20.3 percent of working women (15.1 million women) were below 185 percent of poverty. Thirty-seven percent of these were working full-time (5.6 million), and 62 percent were working part-time (9.5 million) (USCB, 2014). The number of low-income working families in the United States rose from 10.2 million in 2010 to 10.4 million in 2011 (Roberts et al., 2013). In 2012, 39 percent of these families were headed by working mothers. Of all families, the share of low-income female-headed working families increased from 54 percent in 2007 to 58 percent in 2012 (Povich et al., 2014). Families with working adults may have expenses for transportation to work that reduce money available for other transportation purposes, such as shopping for WIC foods.

In addition to its effect on access to WIC foods, employment may affect dietary patterns and the extent to which acquired or purchased WIC foods are actually consumed. Data from the American Time Use Survey (2003–2011) indicates that full-time employment appears to be associated with significantly reduced time spent preparing food (Sliwa et al., 2015). Data from the same survey (2006–2008) show that lower income and the presence of young children are both associated with significantly more time spent in food preparation (Senia et al., 2014). A smaller study of more than 2,000 mothers in Minnesota supports this finding, indicating that those with full-time employment spent less time on food preparation and consumed fewer fruits and vegetables compared to mothers with part-time or no employment (Bauer et al., 2012). Working mothers may also experience additional time stress that can affect preparation of healthy meals at home (Jabs and Devine, 2006; Beshara et al., 2010). Time constraints and a need for convenience are important when considering possible modifications to the WIC food packages.

Cost as a Factor in Access to Healthy Food Choices

Because WIC provides vouchers based on quantity, not value, WIC participants may pay less attention to food prices when redeeming their vouchers. The CVV, however, is a cash benefit, and purchasing power may vary regionally. In a study of 26 metropolitan market areas, Leibtag and Kumcu (USDA/ERS, 2011) found that the 20 most commonly purchased fruits and vegetables cost 30 to 70 percent more in the highest-priced market areas compared to the lowest.

Effect of the 2009 Food Package Changes on Food Availability

Several research groups have examined the effects of the 2009 changes to the WIC food packages on food availability, and therefore access. In a study of Illinois WIC vendors, Zenk et al. (2012) compared the availability of five fruit and vegetable types before versus after the 2009 food package changes. Overall, changes were positive for most vendor types and were statistically significant for several categories of fruits and vegetables (see Appendix G, Table G-2). Similarly, after comparing the availability of fruits, vegetables, and whole grains pre- and post-2009 in 252 stores and convenience stores in Connecticut, Andreyeva et al. (2011) concluded, “When facing new government regulations to stock certain healthy foods, Connecticut convenience and grocery stores found ways to deliver healthy foods that were previously lacking in their stores and communities.” Some carryover to stores that did not participate in WIC was also noted, possibly attributable to changes in the food supply chain. The greatest impact

was observed in low-income communities. Havens et al. (2012) likewise reported that the 2009 WIC food package revisions increased availability of healthy foods (defined as fresh fruits, fresh vegetables, whole grains, and lower-fat milk) among WIC-certifıed vendors compared to those without WIC authorization in Hartford, Connecticut. Improvement in the “healthy food supply score” varied from 16 percent in WIC convenience and grocery stores in higher-income neighborhoods to 39 percent in lower-income areas.⁴ Most of the increases were attributed to increased availability and variety of whole grain products (Andreyeva et al., 2012). O’Malley et al. (2015) also reported changes between 2009 and 2010 in both medium and small WIC stores and increased availability of cereals and grains, juices and fruit, and jarred infant fruits and vegetables. Rose et al. (2014) also reported the 2009 WIC food package changes improved the availability of these foods in small stores in New Orleans. A recent systematic review confirmed overall improved availability of WIC foods at WIC-authorized vendors in the four studies identified (Schultz et al., 2015).

Relationship of Food Availability to Food Choice

Changes in WIC package food availability may translate into healthier food choices. For example, Black et al. (2009) reported that participants viewed whole wheat bread as healthier and a majority indicated that they and their children would increase consumption if it were provided by WIC. In California, 94.6 percent of WIC participants reported they would use their WIC benefits to purchase whole grain bread (California WIC, 2007). Once made available, national EBT data reflecting redemption of WIC foods will provide an indication as to whether WIC participants actually do purchase whole grain options. Likewise, data on grain intake before and after the 2009 food package changes that will be presented in the phase II report may provide an indication of the degree to which the food packages may have affected intake of healthier options.

ADMINISTRATION OF THE WIC FOOD PACKAGES

At the request of the USDA’s Food and Nutrition Service (USDA-FNS), changes to the WIC food packages must not unduly add to the burden of the numerous state and local agencies responsible for WIC program administration. Nor should they unduly add to WIC vendor burden, given

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⁴ The “healthy food supply” score was a composite of data on availability, variety, quality, and prices of foods, including cow’s milk; soy milk; tofu; fresh, canned, and frozen fruit and vegetables; canned sardines and salmon; whole grain bread and tortillas; brown rice; and whole-grain cereals (Andreyeva et al., 2012).

that ease of WIC program administration is closely linked to the ability of WIC-authorized vendors to provide WIC foods (see Figure 2-1). This section summarizes the multileveled complexity of challenges to administering WIC food packages.

The complexity of the challenges with administering the WIC food package is perhaps best illustrated with an example. The 2006 IOM report recommended the inclusion of 1 to 2 pounds of whole wheat or whole grain bread in the food packages for women and children and specified that other whole grain foods, including brown rice, bulgur, oatmeal, barley, and soft corn or whole wheat tortillas, could substitute for whole wheat bread on an equal weight basis. The 1-pound size was recommended by the IOM committee as a way to provide a specific number of additional whole grain servings to better align the food package with the 2005 Dietary Guidelines for Americans (DGA). This size was available in the market, but not widely available at the time. The IOM committee did not fully recognize the consequences of this recommendation. USDA implemented the whole grain recommendation in interim and final rules (USDA/FNS, 2007, 2014a), requiring states to offer whole grain bread in a 1-pound loaf and permitting states the option to authorize an equivalent amount of any of the other whole grain options identified in the IOM report. As of 2015, all state agencies reported allowing at least one alternative to whole grain bread, and more than 90 percent offered at least two alternatives (USDA/FNS, 2015b). The diversity of whole grain options available from state to state reflects the different choices made at the state level.

Although a 1-pound-sized loaf of whole grain bread was not widely available in the marketplace when the interim rule was released in 2007, prior to the 2009 implementation of the rule, food manufacturers were able to begin production and distribution of a 1-pound loaf of whole grain bread and meet the demand for the new size (USDA/FNS, 2015a). However, doing so required substantial changes to production. At the vendor level, the rule required changes to purchasing and distributing whole grain bread, as well as the dedication of shelf space and clear labeling of the 1-pound loaf for WIC participants. Similarly, 1-pound packages of soft corn and whole wheat tortillas were not commonly available in 2007, and manufacturers and vendors began producing and distributing tortillas in a 1-pound package size.

At the local agency and participant level, WIC education focused on the new whole grain option in the food package and specified clearly the package size and type of bread (100% whole wheat) that was authorized. Additional education was provided in those states allowing substitutions. Finally, the WIC participant had to find the 1-pound loaf of bread at the store, which was initially challenging as supply was not immediately abun-

dant in 2009. The fact remains that commercially packaged WIC bread is smaller than all other bread and is often difficult to locate in the store.

State-Level Challenges

Administrative Challenges: Package Sizing and the CVV

A key benefit of the 2009 food package changes was the ability for states to tailor the package where state options were allowed (USDA/FNS, 2007). Although this led to some inconsistencies in specific foods available from state to state, it enabled state administrators to make decisions that maximize the suitability of the foods to their regional population and also contain costs. For example, the final rule allowed children ages 12 to 24 months to receive fat-reduced milks if overweight or obesity was a concern (USDA/FNS, 2014a). Seventy-two percent of WIC state agencies adopted this option as of 2015, covering 60 percent of WIC participants (USDA/FNS, 2015b). Thirty percent of WIC state agencies, covering 41 percent of WIC participants, allowed organic forms of some WIC-eligible foods. WIC state agencies have the option to allow organic options for all foods except fruits and vegetables covered under the CVV, for which state agencies must allow organic purchases. Thirty-nine percent of WIC state agencies, covering 15 percent of WIC participants, allow infants to receive a $4 CVV and 64 ounces of jarred infant fruits and vegetables instead of 128 ounces of jarred fruits and vegetables. Eighty-five percent of state agencies provide package tailoring for homeless participants, making this option available to 87.8 percent of WIC participants nationwide (USDA/FNS, 2015b). Tables 2-3 and 2-4 provide data on forms of milk, cheese, peanut butter, beans and peas, whole grains, canned fish, and fruits and vegetables allowed by WIC state agencies, further illustrating the variability in WICapproved food lists among states.

Although the 2009 changes were well received, two notable administrative challenges were package sizing and the new CVV. The package size challenges around whole grain bread were illustrated above. As another example, to meet the maximum allowance of milk specified in the interim rule, states had to authorize the purchase of a quart size in addition to gallons and half gallons. The quart size of milk is not only less available across both large and small vendors, but often more expensive. The final rule now allows states to substitute yogurt for one quart of milk and cheese for three quarts of milk (USDA/FNS, 2014a), reducing but not eliminating the need to authorize the quart container. Furthermore, manufacturers changed some package sizes between the time of the interim and final rules, with many peanut butters available in the marketplace changing from 18 to 16 ounces

TABLE 2-3 Substitutions Allowed by WIC State Agencies, Fiscal Year 2015

NOTE: Data are from the WIC Food Package Policy Options II study (USDA/FNS, 2015b); responses for the study were received from 86 of 90 state agencies, covering 99.98 percent of WIC participants.

^a The final rule established 1% and nonfat milk as standard issuance for women and children age 2 and older (a change from the interim rule, which also included 2% milk as standard issuance). The final rule authorizes 2% milk, soy-based beverages, and tofu as substitutions for 1% and nonfat milk based on nutrition assessment and consultation with a health care provider if necessary. The final rule also permitted yogurt as a milk alternative for women and children. However, since this option was not implemented until after data collection for the study from which this table was derived was completed, data on number of state agencies authorizing yogurt are not documented here.

^b The final rule permits any type of mature dry beans, peas, or lentils in dry or canned forms. All WIC state agencies authorize some form of dry beans and peas; 81 percent of state agencies authorize all varieties of dry beans and peas.

^c WIC state agencies are required to offer whole wheat or whole grain bread. They also have the option to offer whole grain alternatives.

^d WIC state agencies are required to offer at least two types of canned fish.

SOURCES: USDA/FNS, 2014a, 2015b.

and some juices from 64 to 59 ounces, requiring states to modify their WIC-approved food lists in these categories (with permission from USDA).

Addition of the CVV marked the first time the WIC food package included a food item with a specified dollar value, meaning states had to decide if participants would be able to use their own funds or SNAP benefits to pay the difference. States were required to offer fresh fruits and vegetables with the CVV and were given the option to include dehydrated, frozen, and canned varieties (with no added sugars, fats, or oils). Implementation required extensive education for participants and vendors alike. Now that implementation is complete nationwide and all states have systems that allow split tender, further use of the CVV is not anticipated to present significant challenges. However, a hypothetical requirement that all states include canned fruit and vegetables has the potential to be challenging for

TABLE 2-4 Forms of Fruits and Vegetables Allowed by WIC State Agencies, Fiscal Year 2015

NOTE: Data are from the WIC Food Package Policy Options II study (USDA/FNS, 2015b); responses for the study were received from 86 of 90 state agencies, covering 99.98 percent of WIC participants.

SOURCE: USDA/FNS, 2015b.

some states, primarily due to the very large number of canned options that would have to be authorized. The October 2015 change to the mother’s CVV from $10 to $11 is unlikely to pose an administrative burden, with the exception of food package VII for women who are exclusively breastfeeding twins.⁵ These women are prescribed 1.5 times the maximum allowance, which will result in a CVV benefit of $16.50; some state systems do not allow programming of cents and will therefore be required to average the benefit over a 2-month period until their systems can be modified to accommodate cents.

Finally, the final rule’s allowance for states to substitute a CVV for fruits and vegetables in lieu of a portion of infant food for the 9–11-month-old infant (USDA/FNS, 2014a) is slow to be implemented. Although some states are moving toward implementation of this option, other states cannot implement it because of the requirement that the substitution be only fresh fruits and vegetables. Limiting the infant CVV to only fresh fruit and vegetables creates a significant burden for participants and local agencies in states whose EBT systems do not readily accommodate the issuance of a fresh-only fruit and vegetable voucher (Personal communication, public comment submitted by Texas WIC, July 30, 2015).

State Management Information Systems and Electronic Benefit Transfer Systems

Some state-level administrative challenges arise from the specifications and limitations of management information systems (MISs) and EBT

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⁵ Reissued WIC Policy Memorandum 2015-4, Increase in the Cash Value Voucher (CVV) for Pregnant, Postpartum, and Breastfeeding Women.

systems being implemented. Although some states have linked their MIS changes with the adoption of EBT systems, others have elected to update their MIS and adopt EBT in separate steps. There is not a single MIS or EBT system that has been adopted nationwide. While some states are developing their own systems, other states and Indian Tribal Organizations (ITOs) have grouped together to share a common MIS platform (e.g., the Mountain Plains States Consortium) (USDA/FNS, 2013a). The diversity in MIS and EBT systems offers states unique abilities to tailor their systems to meet local needs. However, all systems are required by USDA-FNS to ensure consistent MIS standards and meet basic program administration and reporting requirements (USDA/FNS, 2013b).

All states are required to adopt EBT technology by 2020, and as of this writing, 12 states and four ITOs have completed the transition to EBT. Although there are many benefits to EBT, including improved tracking of issued and redeemed benefits, the challenges to state agencies in the planning and implementation of EBT are not trivial. The EBT system is developed to limit purchases to only those foods authorized by the program, and the linked databases that code “WIC-approved” foods must be updated continually in response to changes in the marketplace. USDA-FNS is in the process of developing a nationally representative Universal Product Code (UPC) database in collaboration with states, which should help to alleviate some of this burden. The effort is anticipated to improve efficiency across the WIC program. WIC benefits are grouped by EBT systems at the household rather than individual level, allowing more flexibility in food acquisition when more than one family member is a WIC participant. However, having more than one family member receiving benefits makes determining individual redemption rates more difficult. The early adopters of EBT systems have worked out a number of these challenges, paving the way for all states to move toward EBT by 2020.

Two methods of WIC EBT are currently in use: (1) offline EBT in which the food benefit data are placed on a “smart card” (a plastic card with an embedded computer chip), and (2) online EBT in which access to the food benefit data occurs through real-time communication between the WIC vendor and the entity maintaining the EBT prescription information. The decision about which method to employ is based on a variety of factors, including each state agency’s unique regulations and information systems capacity, technology costs and benefits, and the impact on WIC vendors and participants.

Cost Containment

All states must balance diversity and availability of WIC foods with cost, and cost-containment strategies are often viewed as limiting consumers’ choice. One of the WIC program’s primary cost-containment

practices is negotiating rebate contracts with manufacturers of infant formula. These rebates have contributed to significant savings and enabled WIC to serve a larger number of participants, but at the same time these rebates may limit the ability of the WIC program to protect, promote, and support breastfeeding (see Chapter 7). Additional cost-containment practices include limiting authorized vendors to stores with lower food prices and limiting approved brands, package sizes, forms, or prices (e.g., least expensive brand requirements).

Local Agency Challenges

At the local agency and participant level, education plays a role in the successful implementation of the WIC food package. Although local agency staff members typically do not have authority to make decisions about the foods that will be authorized, they are instrumental in providing participant-centered one-on-one and group education and nutrition counseling. This education and counseling is designed to both maximize participant understanding of what can be purchased with their WIC benefit and how to organize purchases at the vendor (e.g., separate their WIC foods from other foods they are purchasing), as well as how to provide and prepare WIC foods for the family in alignment with the DGA.

The introduction of new foods in the food package is facilitated at the local agency level by staff training and participant education prior to the changes. As an example, for the 2009 food package change, the California WIC program started a statewide campaign for staff training 9 months prior to the October 1 changes. Statewide participant education began 6 months prior to the changes. Together, these efforts eased the transition to the new food packages, which took effect all at one time (Ritchie et al., 2010, 2014). With release of the final rule in 2014, additional changes to the food packages have been implemented incrementally, which may have been more challenging. For example, all states were required to offer only skim and 1% milk to all women and children ages 2 and older by September 29, 2014 (most states allowed 2 percent milk prior to this date), and all states were allowed to offer yogurt, but few were able to implement both changes at the same time because of the approval processes required to add yogurt.

Vendor Challenges

Ensuring the Availability of WIC-Approved Foods

To become an authorized WIC vendor, individual stores must meet certain criteria established by the state agency, which may include minimum

stocking requirements, geographic need, and history of compliance. After receiving approval from the state agency and participating in required training, the vendor may enter into a vendor agreement with the state agency, consenting to comply with the agency’s rules and regulations (USDA/FNS, 2013c).

The 2007 WIC food package redesign challenged food vendors to supply some new food items and provide some existing items in unprecedented quantities, affecting the demand for food items and, in some cases, requiring vendors to change their supply systems. For example, authorized vendors are required by USDA to stock at least two different fruits and two different vegetables, but minimum stocking requirements vary from state to state. California requires vendors to stock at least five different fruits and five different vegetables, while other states require only the federal minimum (USDA/FNS, 2014b).

Vendors appeared to face some challenges when adapting to the 2009 revisions in WIC-eligible foods. Managers of small stores reported that they had difficulty in finding suppliers for some items (e.g., a 1-pound loaf of bread, fresh fruit, and low-fat milk), as demand was perceived to be low for healthier food items among the general population (Andreyeva et al., 2011; Gittelsohn et al., 2012). Gleason et al. (2014) reported that vendors serving American Indian communities found it difficult to anticipate demand and therefore maintain the supply of some WIC foods. Vendors have also reported issues with delivery of spoiled items (Gleason et al., 2014) and maintaining freshness (Gleason et al., 2011).

The 2009 WIC Food Package Changes and Vendor Sales

Despite challenges to ensuring WIC foods were available, most evidence suggests that the food package revisions were beneficial for vendors. They increased both sales and profitability for the items offered in the revised food package (Andreyeva et al., 2011) and sales of newly eligible food items to non-WIC customers (Gittelsohn et al., 2012). Increased demand, without a compensating change in supply, is frequently associated with an increase in price. Some vendors reported difficulty finding and maintaining suppliers for some foods. However, available evidence finds that prices did not increase for those items, suggesting that vendors adjusted their supply quantities without incurring increased costs (Zenk et al., 2014).

The revised food packages were designed to be cost neutral to WIC (not more than 10 percent above or below the current level of funding), and while sales apparently increased from WIC foods for some items (reduced-fat milk, whole grains, fruit and vegetables), sales likely decreased for others (whole milk, juice) (Andreyeva and Luedicke, 2013; Andreyeva et al., 2013, 2014).

The Electronic Benefit Transfer System

The Altarum study described earlier in this chapter (Phillips et al., 2014) reported that EBT implementation both improved the ability of vendors to track inventory and stabilized inventory because participants were able to make purchases throughout the month instead of during a single visit. Plus, vendor reimbursement occurred more quickly. Vendors also reported improved checkout experiences for participants. However, challenges remain. Maintenance of the UPC database is challenged by ever-changing package sizes and price changes. Vendors surveyed in Phillips et al. (2014) also mentioned the additional staff training needed during the transition to EBT.

Vendor Approaches to Offering WIC-Approved Foods

Shelf space is an important and limited asset for food retailers. Indeed, retailers often charge fees to suppliers for shelf space (“slotting allowances”) (FTC, 2003). Demand for foods in the WIC package affects how retail vendors allocate their shelf space. When WIC agencies require participants to purchase an item in a size or a style that is different from the size or the style that is predominantly purchased by non-WIC customers, retail vendors have been challenged to offer that item (see, e.g., Gittelsohn, 2012). Saitone et al. (USDA/ERS, 2014) found that smaller vendors, because of their typically higher operating and procurement costs, are more likely to charge higher prices for WIC products than larger vendors do. They also found, however, that small vendors comprise only a small percentage of total WIC redemptions. In a study in Texas, fruits and milk (two key WIC foods) were both significantly more expensive (approximately 27 cents more) per pound in rural than urban areas (Tisone et al., 2014).

The Case of “WIC-Only” Vendors

As mentioned earlier in this chapter, the majority (52 percent) of WIC households report using supercenter-type stores as their primary food shopping store (USDA/ERS, 2015a) (see Table 2-2). Research also suggests that low-income households in general are more likely to economize in their food shopping practices by purchasing more private-label products and buying in larger volumes (Leibtag and Kaufman, 2003). In the late 1990s and early 2000s, a new store type evolved that catered to WIC households. These “WIC-only” stores offered only WIC-approved foods and were usually located in the vicinity of WIC offices. Because these stores catered only to WIC participants, they were unconcerned about sales to non-WIC participants. Studies at the time showed that prices for some items at WIC-

only stores were 13 to 16 percent higher than similar items at other stores (Neuberger and Greenstein, 2004). Since then, USDA has implemented procedures to limit the ability of WIC-only stores to price WIC items higher than retailers that sell both WIC and non-WIC foods.⁶ There are few peer-reviewed papers that examine pricing at WIC-only stores, but McLaughlin et al. (2013) showed in a conference paper that WIC-only stores have an incentive to set prices at the maximum level allowed by USDA regulations. Saitone et al. (USDA/ERS, 2014) found that A-50 vendors (WIC-only stores fall in this category of vendor) in California redeemed food packages at the maximum allowable level 81 to 94 percent of the time. The “WIC-only” experience highlights the importance of competitive pricing to contain costs to the WIC program. The pressure on retail food stores to keep prices low to attract sales from non-WIC customers is a powerful incentive that keeps prices low for WIC items (Neuberger and Greenstein, 2004). If that pressure is missing, then prices are likely to rise.

Manufacturer Challenges

Like WIC vendors, manufacturers of WIC foods play a central role in the WIC participant experience (see Figure 2-1). A common perception is that food manufacturers will therefore respond to changes in the WIC foods or food package to meet the needs of this population. As mentioned previously, manufacturers were able to begin production and distribution of the 1-pound loaf of bread before 2009 implementation of interim rule (USDA/ERS, 2015b), but doing so required substantial changes to production. Even though a 1-pound loaf provides fewer servings than the more common 24-ounce loaf of bread, it is usually sold at the same or a higher price. As per the 2014 final rule, whole wheat pasta at a 1-pound size is permitted as a substitute for whole wheat bread. However, 87 percent of whole wheat pasta is sold in 12 and 13.5 ounce sizes. The Pasta Manufacturers Association conducted a cost analysis and determined that moving from the smaller to a 1-pound size would cost the two primary pasta manufacturers approximately $5 million per year, concluding that the change was economically infeasible (National Pasta Association, 2015).

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⁶ USDA groups vendors into peer groups and establishes maximum allowable redemption rates (MARRs) for WIC food packages for each peer group. In effect, MARRs serve as price ceilings. WIC-only stores are designated as A-50 vendors, vendors that have 50 percent or more of their food sales coming from WIC sales (USDA/ERS, 2014).

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