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Review of WIC Food Packages: Improving Balance and Choice: Final Report (2017)

Chapter:Appendix G: Barriers to Participation and Redemption

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Suggested Citation:"Appendix G: Barriers to Participation and Redemption." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
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Appendix G

Barriers to Participation and Redemption

The extent to which the food packages for the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) can affect food and nutrient intake of the WIC-eligible population is dependent upon the extent to which eligible individuals participate. Factors that affect the decision to participate range from individual level to vendor level to variations in the food environment. Table G-1 summarizes the committee’s review of the evidence related to these factors. Table G-2 presents the results of a quasi-experimental study of changes in availability of fruits and vegetables at WIC vendors before and after the 2009 WIC food package changes. The results suggest that benefits yielded by expansion of WIC food options vary by participant ethnicity and vendor type. A detailed discussion of barriers and incentives to participation in WIC can be found in the phase I interim report (NASEM, 2016).

Suggested Citation:"Appendix G: Barriers to Participation and Redemption." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
×

TABLE G-1 Literature Findings on Barriers and Incentives to WIC Participation and Redemption

Article Barriers Incentives/Strategies
Bertmann et al., 2014 Negative interactions in stores: annoyance or anger expressed by cashier or other shoppers Confusion over WIC rules: fluctuation in enforcement of redemption rules store to store and week to week Cashiers lack training: participants have to explain the rules Feeling of embarrassment when using CVV Find strategic choice of times and locations at which to shop Choose particular cashiers Pool CVV (using multiple vouchers at once)
Christie et al., 2006 Long duration of appointment wait time
Dissatisfaction with customer service
Dissatisfaction with the physical environment
Decrease wait times by extending clinic hours and/or changing clinic flow
High level of satisfaction with WIC personnel
Gleason and Pooler, 2011 Underutilization of infant food benefits Issue a CVV for V/F for caregivers who prefer preparing own infant foods
Implement targeted nutrition education to subpopulations with high nonuse of food instruments
Gleason et al., 2011 Maintaining food freshness (small WIC vendors)
Availability of products in allowable form (e.g., bread in approved size)
Continue and expand vendor training
Continue to engage food suppliers
Continue nutrition education of participants
Use state WIC data for internal program management, policy making, ongoing monitoring
Examine effect of minimum stocking requirements
Suggested Citation:"Appendix G: Barriers to Participation and Redemption." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
×
Article Barriers Incentives/Strategies
Gleason et al., 2014 Participants:
Gaps in knowledge (determining the amount of V/F with CVV)
Incorrect information provided by cashier
Limited selection of some WIC foods at local vendors and poor quality produce
Lack of transportation (e.g., tribe located 30 minutes from a store)
Vendors:
Delivery of spoiled items
Difficulty anticipating demand and maintaining adequate supply of some WIC foods
Challenges in serving participants who lack knowledge
Challenges in communicating with local WIC agency
Participants:
Use more than one check at a time when transportation is an issue
Vendors:
Adopt practices that will make it easier for participants to shop
WIC Staff: Use open-ended question and probing to encourage discussion with participants
Expand nutrition education opportunities
Inform participants of local vendors
Local WIC Directors:
Establish open lines of communication with vendors Increase cross-program collaboration
State WIC Agencies:
Offer additional training opportunities to staff
Expand allowable WIC foods to include frozen and canned vegetables
Develop a formalized local vendor liaison (LVL) program (CA example: LVL makes visits)
Najjar, 2013 Food package policies (e.g., container size)
Negative grocery store experiences and personal misunderstanding and embarrassment
Helpful vendors
Vendor and participant understanding about the use of CVV and other WIC benefits
Phillips et al., 2014 Certain individual WIC foods have low rates of full redemption
Could not use certain foods (i.e., received too much)
Participants or their children disliked the food or did not know how to prepare them
Implement targeted educational efforts to promote full utilization of WIC benefits
Tailor nutrition education to include foods that are commonly underused and focus on culturally relevant approaches to incorporating these foods into meals and snacks
Suggested Citation:"Appendix G: Barriers to Participation and Redemption." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
×
Article Barriers Incentives/Strategies
USDA/ERS, 2010 Of those exiting WIC at 1 year, transaction costs of participation may be a barrier: program requires too much effort and the benefits are not worth the time (26.2%) or they have scheduling or transportation problems (10%) Program requires too much effort, or scheduling, or transportation problems
USDA/ERS, 2012 Improved national economic conditions generally reduce participation rates for WIC and other national assistance programs Poorer economic conditions and unemployment rates tend to improve participation rates when the program is fully funded

NOTES: CA = California; CVV = cash value voucher; V/F = vegetables and fruits; LVL = local vendor liaison.

Suggested Citation:"Appendix G: Barriers to Participation and Redemption." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
×

TABLE G-2 Changes in Fruit and Vegetable Availability and Selection Overall and by Vendor Type, Before Compared to After the 2009 WIC Food Package Changes

Availability or Selection Fresh Canned Frozen
Commonly Consumed FV African-American FV Latino FV Vegetables Low-Sodium Vegetables Fruits Vegetables Fruits
Availability
Overall change 2.14 2.53 1.72 2.69 1.84 1.97 2.15
(1.31, 3.50)b (1.31, 5.35)b (0.84, 3.98) NE (1.17, 6.22)a (0.91, 3.72) (1.05, 3.70)a (1.06, 4.37)a
Change by vendor type
Large 3.56 2.27 1.69 1.62 0.93 1.01 1.43 2.10
(1.22, 10.34)a (1.31, 5.48)a (0.94, 5.54) (0.81, 3.25) (0.25, 3.48) (0.41, 2.48) (0.91, 2.25) (0.86, 5.12)
Small 1.07 2.64 1.83 1.18 5.95 2.11 2.80 1.93
(0.51, 2.24) (1.09, 6.38)a (0.65, 5.17) (0.47, 2.94) (1.74, 20.29)b (0.95, 4.69) (1.13, 6.93)a (0.68, 5.53)
Pharmacy 1.38 1.25 0.71 1.06 1.34 2.24
NE (1.02, 1.88)a (0.92, 1.69) NE (0.12, 4.18) (0.04, 25.53) (0.34, 5.24) (0.19, 25.74)
Selection
Overall change 1.67 1.14 1.17 1.22 1.13 0.96 1.09 0.92
(1.14, 2.47)b (1.01, 1.42) (1.02, 1.33) (1.07, 1.40)b (0.98, 1.30) (0.77, 1.20) (0.82, 1.46) (0.69, 1.21)
Change by vendor type
Large 1.67 1.13 1.22 0.84 1.05 0.88 1.02 0.93
(1.03, 2.69)a (1.01, 1.43) (1.06, 1.36)a (0.68, 1.04) (0.91, 1.20) (0.71, 1.09) (0.74, 1.40) (0.69, 1.25)
Small 1.71 1.17 1.05 1.32 2.01 1.05 1.34 0.80
(1.06, 2.76)a (0.78, 2.19) (0.73, 1.58) (0.95, 1.85) (1.03, 3.84)a (0.53, 2.07) (0.79, 2.29) (0.33, 1.93)
Pharmacy 1.04 1.09 1.58 1.17 1.35 0.81 NE
NE (0.93, 1.20) (0.95, 1.21) (1.31, 1.91)b (0.18, 7.45) (0.06, 30.18) (0.32, 2.08)

NOTES: FV = fruits and vegetables; NE = odds ratio not estimated due to lack of variability in outcome by year. Data presented as odds ratio (95% confidence interval). An odds ratio of 1.0 for this contrast indicates that the post-policy change from 2009 to 2010 was greater than the pre-policy change from 2008 to 2009.

a P < .05.

b P < .01.

SOURCE: Zenk et al., 2012 (used with permission).

Suggested Citation:"Appendix G: Barriers to Participation and Redemption." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
×

REFERENCES

Bertmann, F. M., C. Barroso, P. Ohri-Vachaspati, J. S. Hampl, K. Sell, and C. M. Wharton. 2014. Women, Infants, and Children cash value voucher (CVV) use in Arizona: A qualitative exploration of barriers and strategies related to fruit and vegetable purchases. Journal of Nutrition Education and Behavior 46(3 Suppl):S53-S58.

Christie, C., J. A. Watkins, A. Martin, H. Jackson, J. E. Perkin, and J. Fraser. 2006. Assessment of client satisfaction in six urban WIC clinics. Florida Public Health Review 3:35–42.

Gleason, S., and J. Pooler. 2011. The effects of changes in WIC food packages on redemptions: Final report. Portland, ME: Altarum Institute. http://naldc.nal.usda.gov/download/50613/PDF (accessed December 21, 2016).

Gleason, S., R. Morgan, L. Bell, and J. Pooler. 2011. Impact of the revised WIC food package on small WIC vendors: Insight from a four-state evaluation. Portland, ME: Altarum Institute. http://www.calwic.org/storage/FourStateWICFoodPackageEvaluation-Full_Report-20May11.pdf (accessed December 21, 2016).

Gleason, S., D. McGuire, and R. Morgan. 2014. Opportunities to enhance American Indian access to the WIC food package: Evidence from three case studies. Portland, ME: Altarum Institute. http://altarum.org/sites/default/files/uploaded-publication-files/Opportunities%20to%20Enhance%20Am%20Indian%20Access%20to%20the%20WIC%20FP_fmt_04.pdf (accessed December 21, 2016).

Najjar, S. 2013. Barriers to WIC benefits redemption among participants in Washington State. Master’s thesis, School of Public Health, University of Washington, Seattle, WA.

NASEM (National Academies of Sciences, Engineering, and Medicine). 2016. Review of WIC food packages: Proposed framework for revisions: Interim report. Washington, DC: The National Academies Press. doi: 10.17226/21832.

Phillips, D., L. Bell, R. Morgan, and J. Pooler. 2014. Transition to EBT in WIC: Review of impact and examination of participant redemption patterns: Final report. Portland, ME: Altarum Institute. http://altarum.org/sites/default/files/uploaded-publication-files/Altarum_Transition%20to%20WIC%20EBT_Final%20Report_071614.pdf (accessed December 21, 2016).

USDA/ERS (U.S. Department of Agriculture/Economic Research Service). 2010. WIC participation patterns: An investigation of delayed entry and early exit. Washington, DC: USDA/ERS. https://www.ers.usda.gov/webdocs/publications/err109/8018_err109.pdf?v=41056 (accessed December 21, 2016).

USDA/ERS. 2012. How economic conditions affect participation in USDA nutrition assistance programs. Washington, DC: USDA/ERS. https://www.ers.usda.gov/webdocs/publications/eib100/32191_eib100.pdf (accessed December 21, 2016).

Zenk, S. N., A. Odoms-Young, L. M. Powell, R. T. Campbell, D. Block, N. Chavez, R. C. Krauss, S. Strode, and J. Armbruster. 2012. Fruit and vegetable availability and selection: Federal food package revisions, 2009. American Journal of Preventive Medicine 43(4):423-428.

Suggested Citation:"Appendix G: Barriers to Participation and Redemption." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
×
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Suggested Citation:"Appendix G: Barriers to Participation and Redemption." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
×
Page542
Suggested Citation:"Appendix G: Barriers to Participation and Redemption." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
×
Page543
Suggested Citation:"Appendix G: Barriers to Participation and Redemption." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
×
Page544
Suggested Citation:"Appendix G: Barriers to Participation and Redemption." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
×
Page545
Suggested Citation:"Appendix G: Barriers to Participation and Redemption." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
×
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The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) began 40 years ago as a pilot program and has since grown to serve over 8 million pregnant women, and mothers of and their infants and young children. Today the program serves more than a quarter of the pregnant women and half of the infants in the United States, at an annual cost of about $6.2 billion. Through its contribution to the nutritional needs of pregnant, breastfeeding, and post-partum women; infants; and children under 5 years of age; this federally supported nutrition assistance program is integral to meeting national nutrition policy goals for a significant portion of the U.S. population.

To assure the continued success of the WIC, Congress mandated that the Food and Nutrition Service of the U.S. Department of Agriculture (USDA) reevaluate the program's food packages every 10 years. In 2014, the USDA asked the Institute of Medicine to undertake this reevaluation to ensure continued alignment with the goals of the Dietary Guidelines for Americans. In this third report, the committee provides its final analyses, recommendations, and the supporting rationale.

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