Review of WIC Food Packages: Improving Balance and Choice: Final Report (2017)
Chapter: Appendix G: Barriers to Participation and Redemption
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).
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 |
| 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 |
| 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.
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).
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.
