Participants' comments on changes in the revised special supplemental nutrition program for women, infants, and children food packages: the Maryland food preference study

Caregiver Perspectives on Underutilization of WIC: A Qualitative Study

OBJECTIVES

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is a federal program that improves the health of low-income women (pregnant and postpartum) and children up to 5 years of age in the United States. However, participation is suboptimal. We explored reasons for incomplete redemption of benefits and early dropout from WIC.

METHODS

In 2020-2021, we conducted semistructured interviews to explore factors that influenced WIC program utilization among current WIC caregivers (n = 20) and caregivers choosing to leave while still eligible (n = 17) in Massachusetts. By using a deductive analytic approach, we developed a codebook grounded in the Consolidated Framework for Implementation Research.

RESULTS

Themes across both current and early-leaving participants included positive feelings about social support from the WIC clinic staff and savings offered through the food package. Participants described reduced satisfaction related to insufficient funds for fruits and vegetables, food benefits inflexibility, concerns about in-clinic health tests, and in-store item mislabeling. Participants described how electronic benefit transfer cards and smartphone apps eased the use of benefits and reduced stigma during shopping. Some participants attributed leaving early to a belief that they were taking benefits from others.

CONCLUSIONS

Current and early-leaving participants shared positive WIC experiences, but barriers to full participation exist. Food package modification may lead to improved redemption and retention, including increasing the cash value benefit for fruits and vegetables and diversifying food options. Research is needed regarding the misperception that participation means "taking" benefits away from someone else in need.

Associations between milk fat content and obesity, 1999 to 2016

BACKGROUND

The relationship between milk fat content and body mass index (BMI) remains unclear. The objective of this study was to determine if milk fat content is associated with obesity in children, adolescents and young adults.

METHODS

We used repeated cross sections of National Health and Nutrition Examination Survey (NHANES), 1999 to 2016. Using logistic regression, we measured associations between first milk consumed after formula/breast milk (whole, 2%, 1%, or fat-free) and weight status (≥85th to <95th BMI percentile, overweight; ≥95th BMI percentile, obesity) among children 2 to 6 years (n = 8367). We also assessed associations between current milk type and weight status among those 2 to 20 years of age (n = 26 750).

RESULTS

Children 2 to 6 years with obesity were less likely to have been weaned to whole milk versus healthy weight children (adjusted odds ratio [aOR], 0.77; 95% CI, 0.60-0.98; P = .031). Individuals 2 to 20 years with overweight or obesity were less likely to drink whole milk as their current milk and more likely to drink fat-free or 1% milk compared with healthy weight children.

CONCLUSIONS

Whole milk consumers are less likely to have obesity. It is unclear whether this relationship is causal or a reflection of United States Department of Agriculture recommendations. Further examination of the factors that influence milk choice among diverse cohorts would lend clarity to this important issue.

Preferences and Perceived Value of WIC Foods Among WIC Caregivers

OBJECTIVE

To evaluate preferences for and values of Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) foods and packages and understand what factors may influence these preferences and values.

DESIGN

Using a mixed-methods approach, surveys and individual in-depth interviews were conducted to measure and understand preferences for specific WIC foods and how much WIC food packages are worth to participants.

SETTING

Eight WIC clinics across Illinois.

PARTICIPANTS

Caregivers of infants enrolled in WIC for at least 3-6 months.

PHENOMENON OF INTEREST

Preferences for WIC foods, WIC food package values, and factors that influence these categories.

ANALYSIS

Frequencies were gathered to analyze survey data and interview transcripts were analyzed using constant comparative analysis to identify emergent themes.

RESULTS

Survey (n = 150) and interview (n = 31) participants valued the food packages in WIC but they valued the infant packages more. The cash value fruit and vegetable voucher increased the perceived value of the program for many participants. Restrictions on food choice preferences (eg, type of milk) detracted value from the program.

CONCLUSIONS AND IMPLICATIONS

This study shows that providing more choice in the program could improve satisfaction with WIC overall. More research is warranted with a more representative sample to assess whether expanded food choice would improve value of and preference for WIC foods.

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.

Reaching Low-Income Mothers to Improve Family Fruit and Vegetable Intake: Food Hero Social Marketing Campaign-Research Steps, Development and Testing

The objective of this study was to create/test a social marketing campaign to increase fruit/vegetable (FV) intake within Oregon Supplemental Nutrition Assistance Program (SNAP) eligible families. Focus groups (n = 2) and pre/post campaign phone surveys (n = 2082) were conducted in intervention counties (IC) and one control county. Participants were female (86%-100%) with 1-2 children at home. Mean FV intake/without juice was 3.1 servings/day; >50% preferred the Internet for delivery of healthy eating information. Participants reported time/financial burdens, low household FV variety and desirability of frozen/canned FV, and acceptance of positive messages. A Food Hero (FH) campaign was created/delivered daily August-October 2009 to mothers through multiple channels (e.g., grocery stores, online, educators). Results showed that the IC had better FH name recall (12%) and interpretation of intended messages (60%) vs. control (3%, 23%, respectively). Compared to controls, the IC were less likely to report healthy food preparation as time consuming or a FV rich diet expensive, and it was easier to get their family to eat fruit. Results did not vary based on county/household characteristics. The FH campaign increased FH awareness and positive FV beliefs. A longer campaign with FV assessments will increase understanding of the target audience, and allow for campaign refinement.

The Impact of the 2009 Special Supplemental Nutrition Program for Women, Infants, and Children Food Package Revisions on Participants: A Systematic Review

For the first time since 1980, the US Department of Agriculture Food and Nutrition Service Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food package policies were revised in 2009 to meet the Institute of Medicine's nutrition recommendations. These changes included increases in fruits, vegetables, whole grains, and low-fat dairy to improve nutrition and health of WIC participants. Our systematic review of the literature assessed the influence that the 2009 WIC food package revisions have had on dietary intake, healthy food and beverage availability, and breastfeeding participation. The systematic review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations. Four electronic databases were searched between April 1 and 30, 2014, for peer-reviewed research. Two reviewers screened the articles, extracted the data, and established inter-rater reliability by discussing and resolving discrepancies. Twenty articles were included that met our inclusion criteria. Nine of the studies analyzed changes in dietary intake, eight examined changes in healthy food and beverage availability, and three evaluated breastfeeding participation exclusively. The review demonstrated an improved dietary intake and an increase in the availability of healthier foods and beverages in authorized WIC stores. The revised food package was also associated with improved dietary intake of WIC participants. Mixed results were demonstrated in regard to improved breastfeeding outcomes. Further research is needed to assess the influence of WIC 2009 food package revisions on breastfeeding outcomes and to make conclusions about broad nutrition-related implications.

Can food vouchers improve nutrition and reduce health inequalities in low-income mothers and young children: a multi-method evaluation of the experiences of beneficiaries and practitioners of the Healthy Start programme in England

Background

Good nutrition is important during pregnancy, breastfeeding and early life to optimise the health of women and children. It is difficult for low-income families to prioritise spending on healthy food. Healthy Start is a targeted United Kingdom (UK) food subsidy programme that gives vouchers for fruit, vegetables, milk, and vitamins to low-income families. This paper reports an evaluation of Healthy Start from the perspectives of women and health practitioners.

Methods

The multi-method study conducted in England in 2011/2012 included focus group discussions with 49 health practitioners, an online consultation with 620 health and social care practitioners, service managers, commissioners, and user and advocacy groups, and qualitative participatory workshops with 85 low-income women. Additional focus group discussions and telephone interviews included the views of 25 women who did not speak English and three women from Traveller communities.

Results

Women reported that Healthy Start vouchers increased the quantity and range of fruit and vegetables they used and improved the quality of family diets, and established good habits for the future. Barriers to registration included complex eligibility criteria, inappropriate targeting of information about the programme by health practitioners and a general low level of awareness among families. Access to the programme was particularly challenging for women who did not speak English, had low literacy levels, were in low paid work or had fluctuating incomes. The potential impact was undermined by the rising price of food relative to voucher value. Access to registered retailers was problematic in rural areas, and there was low registration among smaller shops and market stalls, especially those serving culturally diverse communities.

Conclusions

Our evaluation of the Healthy Start programme in England suggests that a food subsidy programme can provide an important nutritional safety net and potentially improve nutrition for pregnant women and young children living on low incomes. Factors that could compromise this impact include erosion of voucher value relative to the rising cost of food, lack of access to registered retailers and barriers to registering for the programme. Addressing these issues could inform the design and implementation of food subsidy programmes in high income countries.

Women Infant and Children program participants' beliefs and consumption of soy milk : Application of the Theory of Planned Behavior

The purpose of this study was to determine if Theory of Planned Behavior (TPB) variables predict soy milk intake in a sample of WIC participants in 2 Illinois counties (n = 380). A cross-sectional survey was used, which examined soy foods intake, behavioral beliefs, subjective norms, motivation, and intention. Soy product intake was low at both sites, and many participants (40%) did not know that soy milk was WIC approved. Most (> 70%) wanted to comply with their health care providers, but didn't know their opinions about soy milk (50-66%). Intention was significantly correlated with intake (0.507, P ≤ 0.01; 0.308, P ≤ 0.05). Environmental beliefs (0.282 and 0.410, P ≤ 0.01) and expectancy beliefs (0.490 and 0.636, P ≤ 0.01) were correlated with intention. At site 1, 30% of the variance in intention to consume soy milk was explained by expectancy beliefs and subjective norm beliefs (P < 0.0001); at site 2, 40% of the variance in intention was explained by expectancy beliefs. The TPB variables of expectancy beliefs predicted intention to consume soy milk in WIC participants. Therefore, knowing more about the health benefits of soy and how to cook with soy milk would increase WIC participants' intention to consume soy milk. Positive messages about soy milk from health care providers could influence intake.

Impact of personal preference and motivation on fruit and vegetable consumption of WIC-participating mothers and children in Atlanta, GA

OBJECTIVE

To determine the effect of psychosocial and sociodemographic factors on consumption of fruits and vegetables (F&V) for women and children participating in the Atlanta Special Supplemental Nutrition Program for Women, Infants, and Children.

METHODS

Participants (n = 249) were selected from 2 Atlanta Special Supplemental Nutrition Program for Women, Infants, and Children agencies. Data from this analysis were collected from in-person interviews. The dichotomous dependent variable was whether participants met recommended intakes for F&V. Independent variables were personal preference and motivation factors of F&V consumption, and sociodemographic factors. Bivariate analysis determined significant factors to include in logistic models.

RESULTS

Only 27.7% of mothers and 44.2% of their oldest child consumed > 5 servings of F&V daily. Not knowing how to prepare F&Vs and spoilage of F&V before eating them were significantly related to F&V consumption of mothers.

CONCLUSIONS AND IMPLICATIONS

Food storage and preparation resulted in significant differences in meeting criteria for F&V consumption. Future initiatives should include cooking classes and emphasize food preparation techniques.

Mothers prefer fresh fruits and vegetables over jarred baby fruits and vegetables in the new Special Supplemental Nutrition Program for Women, Infants, and Children food package

OBJECTIVE

This study examined Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participant use and satisfaction with jarred baby foods, assessed preference for cash value vouchers (CVVs) for fruits and vegetables vs jarred baby foods, and examined whether preferences varied among selected ethnic groups.

METHODS

A survey of California WIC participants and statewide redemption data were used.

RESULTS

Participants reported high satisfaction with the CVV for fruits and vegetables and jarred baby foods, with statistically significant variation across ethnic groups. About two thirds of all participants reported a preference for CVVs for fruits and vegetables over jarred baby foods. Redemption data indicated declining redemption rates for jarred fruits and vegetables with increasing age of the infant across all ethnic groups.

CONCLUSIONS AND IMPLICATIONS

Although the addition of jarred fruits and vegetables to the food package for infants ages 6-11 months was well received, many caregivers want the option to choose between jarred foods and fresh fruits and vegetables.

Participation in the Supplemental Nutrition Program for Women, Infants and Children (WIC) and breastfeeding: national, regional, and state level analyses

This research builds on literature that suggests a negative association between participation in the Supplemental Nutrition Program for Women, Infants, and Children (WIC) and breastfeeding. Variation in results at the national, regional, and state level has important policy implications for breastfeeding promotion through WIC. Using the 2007 National Immunization Survey dataset, Chi-square, ANOVA, and adjusted regression modeling techniques assess the relationship between WIC participation and breastfeeding initiation and duration. Adjusted regression models suggest a negative association between WIC participation and breastfeeding initiation rates (OR = 0.67, 95% CI: 0.61, 0.72). Of those who initiated breastfeeding, WIC participation was associated with a mean breastfeeding duration decrease of 0.63 months (95% CI: -0.86, -0.39). At the regional level, 3 of 7 regions showed a negative association between WIC participation and breastfeeding initiation. All of the regions indicated a negative association between WIC participation and breastfeeding duration. Out of 50 states, 13 had a statistically significant reduction in odds of initiation of breastfeeding and 10 had reduced duration of breastfeeding among participants of WIC when compared to non-participants. No state showed a positive association between WIC participation and breastfeeding. Regional and state differences in breastfeeding rates suggest that further research is needed to understand the role of national, regional, and state level policies which may undermine WIC's breastfeeding promotion efforts. Although WIC revised the food packages to create a stronger incentive for breastfeeding, a disincentive for breastfeeding may exist given the higher market value of the formula packages.