National WIC Association

Fall 2018 WIC Research to Practice

Welcome

In this issue of WIC Research to Practice, the Hot Topic is “TeleWIC.” We explore how this emerging technology is being used in WIC. We share anew ERS report on price variability and vendor types in WIC. The Researcher Spotlight with Dr. Angela Odoms-Young from the University of Illinois, Chicago illustrates the value of a shared goal between academic researchers and a state WIC agency. In addition, we have some research hacks and as always, links to recent publications.

Thanks for reading WIC Research to Practice! If there are studies or reports you would like us to highlight in the winter issue, please contact Georgia Machell, gmachell@nwica.org.

"TeleWIC": An Emerging Technology With the Potential to Help With Participant Retention

Qualitative research from the past several years has indicated that a primary reason families drop out of WIC or choose not to enroll is that WIC participation can be difficult and burdensome.1 2 3 4 Difficulties associated with the WIC experience include transportation barriers, problems with the shopping experience, and long clinic wait times. With this in mind, WIC agencies across the country are trying to improve the WIC experience and make participating in the program easier and more accessible. Technologies that leverage the digital connectedness of millennial moms and the pervasiveness of smartphones and tablets have played a vital role in bringing WIC into the 21st century, making the program more flexible and convenient.5 One such technology that has been of interest to many WIC agencies in recent years is telehealth.

A small but mounting evidence base indicates that telehealth (also known as telemedicine, telecounseling, or, in the case of WIC, "teleWIC") is a promising technological tool for use by WIC professionals and paraprofessionals. 6 7 Telehealth in the context of WIC generally describes the use of videoconferencing platforms or telephones to conduct WIC appointments so that participants do not need to come into the clinic. Telehealth can also be used to conduct lactation counseling from a remote location, as in the case of Texas, where a WIC IBCLC is stationed at a centrally located breastfeeding support center, and participants visit their local WIC clinics for the video consult with the IBCLC.8

In addition to Texas, several other states, including Washington, DC, Nevada, Georgia, Mississippi, West Virginia, Virginia, Oregon, and Massachusetts, have begun to use telehealth to provide nutrition counseling or breastfeeding support in areas with a large geographic area to cover but limited staff available. Some of these states use telehealth services offered by an external company, meaning that WIC participants receive counseling from professionals not employed by WIC. Other states use videoconferencing "in house," meaning that WIC participants are interfacing with WIC staff members.

One state that has explored and piloted telehealth extensively is California. In fact, the California WIC Association published a brief titled TeleWIC: Keeping Up with the Times in February of this year.9 This brief provides an overview of telehealth and its potential usefulness in WIC, touching on benefits, challenges, and lessons learned from WIC pilots as well as the use of telehealth in the healthcare industry. The brief culminates in a short list of recommendations for how WIC agencies should move forward in the telehealth space.

*California WIC Association, 2018. CWA Photo Library

 

Although most WIC agencies do not use telehealth for WIC appointments, WIC does have a long history of providing "warm lines" for more immediate or after-hours breastfeeding support. It makes sense, then, that counseling via text or cell phone appears to happen most often in the context of WIC breastfeeding peer counselors.10 Furthermore, while "teleWIC" has yet to catch on nationwide, the majority of agencies do offer online nutrition education and texting for nutrition education, appointment reminders, and other purposes. Research from the past several years on the effectiveness and acceptability of online nutrition education indicates that it is both popular and effective among WIC participants.11 12 For example, a survey conducted last year in remote Alaska Native communities found that the vast majority of WIC participants studied (85.8%) thought it would be somewhat or very useful to obtain nutrition information on a phone or computer.13

Online nutrition education has allowed some states that have implemented EBT to issue benefits remotely, thereby decreasing the number of times per year a family needs to come into the WIC clinic. Telehealth could allow these and other agencies to take the next step, and provide personalized, "face-to-face" WIC appointments remotely.

There are many benefits to telehealth, beyond helping to address transportation barriers for WIC participants. In addition to allowing flexibility of location, telehealth can also allow flexibility of time--providing options for participants to interface with nutrition and lactation staff outside of regular clinic hours. As mentioned above in the case of Texas, telehealth can enable agencies to provide participants with professional lactation counseling in rural or remote areas with shortages of highly trained staff. In addition, telehealth can help to address the diverse language and cultural needs of WIC families. Rather than use a translation service, if there are WIC staff in one part of a state with desired language skills, these staff members can be connected to participants in another part of the state via teleconference. For these reasons, the USDA Food and Nutrition Service (FNS) has recognized the need for more state agencies to offer nutrition education via video conference.14

As with most new technologies and innovations, the use of telehealth also poses a number of challenges for WIC agencies. These include, but are not limited to: confidentiality and security concerns; cost; additional IT staffing needs; technology access issues faced by WIC participants including limited data plans; and USDA regulations that require participants to be physically present for certain WIC procedures. Even in the face of these challenges, a number of states have adopted this technology, so we know it is possible with enough willpower, resources, and creativity.

"TeleWIC" is still in its early stages, and therefore has not been studied extensively. Quantitative and qualitative research is needed to explore the effectiveness and acceptability of teleconferencing in WIC. In addition, analysis is needed to investigate whether the adoption of telehealth has a positive impact on retention of WIC participants. Finally, various videoconferencing tools must be studied and compared, so that WIC agencies can make informed decisions when selecting a new tool. NWA is currently working with the Center on Budget and Policy Priorities (CBPP) and Social Interest Solutions (SIS) to develop a toolkit for WIC agencies with information on how to go about launching new participant-facing technologies, including telehealth. This toolkit should be available in fall 2018.

If you have tested teleconferencing in your agency and were not mentioned in this piece, please email Elisabet at eeppes@nwica.org and let us know about your experiences. NWA would like to continue sharing best practices and lessons learned as agencies try out new technologies in WIC.

To view the footnotes, please click here.

New ERS Report

A recently published report from the USDA Economic Research Service (ERS) uses 2014 WIC Electronic Benefit Transfer (EBT) transaction data to examine how prices of WIC foods purchased by participants with WIC benefits vary across four SAs— Midwest, Western, Southwest, and Mountain Plains—by product category and store format. Price variability of WIC foods was observed across store formats with varying magnitudes after controlling for size and rurality of the store. You can find a summary of key findings and access the full report here.

Researcher Spotlight: Angela Odoms-Young, PhD

Dr. Angela Odoms-Young is an Associate Professor in the Department of Kinesiology and Nutrition at the University of Illinois (UIC), Chicago. Dr. Odoms-Young started researching WIC in 2005 and has since built a strong relationship with the Illinois State Agency and through a data sharing agreement has been able to use WIC administrative records to contextualize research that has largely focused on interventions to recruit and retain WIC eligible children until age five. In addition, Dr. Odoms-Young has served as a Committee Member on the past two National Academy of Sciences, Engineering and Medicine review of the WIC food package. Dr. Odoms-Young brings a wealth of research expertise to the WIC community; we are delighted to feature her in this edition of WIC Researcher Spotlight.

What drew you to study WIC?
My research interests focus strongly on examining intervention strategies/approaches that support and improve the health and well-being of low-income mothers and families. In 2003, I was invited to serve on a National Academies of Sciences-Health and Medicine Division (formerly the Institute of Medicine) committee to review the WIC food packages. This experience gave me a more in-depth understanding of the benefits of WIC.

What are the goals of your most recent research on WIC?
We recently completed a study in collaboration with Illinois WIC called WIC to 5. Informed by the Theory of Planned Behavior, that project focused on identifying and addressing barriers to WIC participation and retention among eligible children in Illinois. The goals of WIC to 5 were to: 1) Raise Client Awareness of WIC Eligibility and Benefits; 2) Increase Staff Incentives and Promote Staff Wellness; 3) Increase Image/Understanding of WIC among Health Care and Child Care Providers; and 4) Provide Outreach and Potentially Training for Vendors.

Results from formative research was used to develop an intervention called WIC to 5, that highlighted five benefits (Save, Grow, Nourish, Connect, and Learn) of participating in WIC until five years of age. Based on promoting these five benefits, WIC to 5 included community engagement/outreach (specifically with child care and health care providers), a 6 month and 1 year targeted/tailored counseling intervention that was delivered by WIC staff, and a facilitated group discussion module focused on addressing barriers to identifying and purchasing WIC foods. To evaluate the intervention, we used a quasi-experimental design (4 Local WIC agencies/clinics received the intervention vs. 4 comparison agencies). Methods included analysis of state administrative data, a longitudinal survey of WIC participants (n=176), in-depth interviews and surveys, and site observations.

Lack of awareness, stigma, structural factors (e.g. transportation), and perceived value were cited by stakeholders as key barriers to WIC participation and retention among eligible children. Additionally, about 10% of WIC parents/caregivers of 6 month old infants reported that they did not intend to participate until the child’s 5th birthday. Implementation adherence of the WIC to 5 was moderate ranging from approximately 44% to 76% across the 4 sites. However, clients that received the intervention at 6 months were approximately 1.5 times more likely to stay enrolled in the program at 1 year compared to those that did not receive the intervention.

Based on the findings from this study, more research needs to be conducted to test easy to use tools that can be implemented by WIC staff to encourage clients, raise awareness, and address barriers to WIC participation and retention; and better identify strategies to engage diverse partners in promoting WIC to reduce stigma.

What do you think are the current gaps in WIC research?
We need to gain a more in-depth understanding of the factors that impact the lives of WIC-eligible individuals and families. Additionally, I think more ethnographic research needs to be conducted to understand patterns of WIC program usage overtime and that follow clients from their initial enrollment to the end of eligibility and/or early termination. Lastly, more research needs to be conducted to understand clients’ motivation for enrolling and the messages they received from their families, friends, and community about WIC and its benefits/challenges.

Describe your experiences as a researcher working with a state WIC agency.
I had a great experience working with Illinois WIC. I learned a lot about service delivery and what it is like to implement programs at a local WIC agency. Partnering with Stephanie Bess (and Penny Roth at the time our work started) was very rewarding because we were able to bring together the practice-based expertise of the Illinois Department of Human Services team with the research experience of the UIC team. It also helped us understand more about benefits and challenges faced by WIC.

How did you build rapport with the State WIC agency you were working with?
I think it took time to build rapport. Our team attending state conferences, had bi-weekly conference calls with IDHS, and went on site visits while developing WIC to 5 which helped foster collaboration. Additionally, WIC to 5 was a project initiated and funded by Illinois WIC, so the project was led by a state WIC agency.

What was the process like for accessing state level WIC data, did you have an MOU?
We had a contract and a data sharing agreement. Working with state data can be challenging because the primary purpose for collecting the data is not for research. However, accessing state level data is critical because it provides key insights into program implementation.

Why are university and state WIC program collaborations important?
I think university and state WIC collaborations are important because it allows you to bring diverse experiences to the table to develop new models, tools, and strategies to enhance WIC service delivery, as well as evaluate the efficacy of problem-solving approaches that emerge within WIC practice.

What advice do you have for other researchers hoping to work with WIC state agencies and vice-versa?
To be open and flexible, work together to identify a common agenda, and try to understand each other’s needs and limitations. Researchers, specifically, also need to understand the complexity of working with state data, as well as some of the barriers to retaining WIC participants in research studies. However, I think both WIC state agencies and researchers can greatly benefit from these collaborations because they provide many opportunities for learning and growth.

In addition to talking with Angela, we also spoke with Stephanie Bess, State Director of Illinois WIC. Stephanie described how working with UIC increased the capacity of the IL WIC program to conduct research that would not have otherwise been possible. When asked what the benefits were of teaming up with academics, Stephanie gave the following response:

Staff committed to the project; creative graduate students; colleagues in other disciplines that could be consulted- data strategies, anthropology etc.; capacity to get out and do focus groups and one on one interviews that State staff could not do.

Stephanie also shared how she was happy to share data with Angela and her team because both parties, UIC and IL WIC had a common goal - They (UIC) were working for the WIC program to make it better and help us engage families.

Partnerships between academics and WIC agencies are enormous assets to WIC and help build necessary research capacity. To learn more, attend the following NWA Evaluation Committee webinar, The Value of Collaborations between WIC and Academic Researchers on Thursday, October 11 at 3:00pm ET. Please register in advance.

Research Hacks! Sharing Research Instruments to Support Each Other

In an ideal world, all WIC state and local agencies would have teams of researchers who could collect new data and use existing data to conduct ongoing research. Many WIC agencies are looking for ‘research hacks’ to help them conduct evaluation with limited resources. Looking to colleagues in other parts of the country is a great place to start.

Sometimes, one of the biggest hurdles to getting a research or evaluation project off the ground, is developing the tools necessary to collect data. Did you know that a number of larger WIC agencies, publish their research tools online? PHFE WIC have developed the Los Angeles County WIC Survey. This survey has been conducted every three years since 2005 and the survey instruments are available online. Shannon Whaley, Director of Research at PHFE WIC recently presented on an NWA webinar titled Got Data? Planning and Conducting Research to Support Your WIC Program. The webinar contains lots of advice on how to conduct research with limited resources. NWA members can access this webinar on the online community here.

Texas WIC also publishes a number of surveys online. The questions in these surveys have been validated and can be used by other agencies to support their research.

If your agency has tried and tested research instrument that you can share, please let NWA know and we’ll include them in our soon to launch Research, Policy and Practice Hub.

Using Technology to Improve the WIC Participant Experiences

NWA is hosting their first online virtual conference this December. The theme is Using Technology to Improve the WIC Participant Experience. December 4-6, 2018. This online virtual conference will comprise eight pre-recorded presentations and four live presentations in the form of webinars over the course of three days. Virtual conference attendees will be able to access the sessions from the comfort of their own computers. The conference will feature voices from WIC agencies as well as researchers and other partners who have insights to share with regard to the use of technology in WIC.

Take a moment to review the tentative agenda to see what is in store. This virtual conference is complimentary to NWA members and $100 for non-members. We invite you to register now.

Recent Publications

The last few months have seen a number of new publications in peer-reviewed journals on the topic of WIC. Below is a collection of some of our favorite articles. To view an abstract, click on the title of a paper.

WIC Food Package

Program Outcomes

Maternal Health

Childhood Obesity

Birth Outcomes

Behavior Change

The Impact of WIC on Infant Immunizations and Health Care Utilization.

WIC Participation

Refugee Children's Participation in the Women, Infants, and Children Supplemental Nutrition (WIC) Program in Massachusetts, 1998-2010.

Missed an Issue of WIC Research to Practice?

You can now view past issue of WIC Research to Practice on the NWA website.

As always, if there are topics you would like to see covered in WIC Research to Practice or know someone who would be great to feature in our WIC Researcher Spotlight, please email Georgia Machell, Senior Director of Research and Program Operations at gmachell@nwica.org.


"TeleWIC": An Emerging Technology With the Potential to Help With Participant Retention - Footnotes.

1 National WIC Association (2013) WIC Client Journey Map. Available online: https://s3.amazonaws.com/aws.upl/nwica.org/wic_journey_map.pdf
2 Tiehen L, Jacknowitz A (2010) WIC Participation Patterns: An Investigation of Delayed Entry & Early Exit. United States Department of Agriculture, Economic Research Service. Available online:https://www.ers.usda.gov/publications/pub-details/?pubid=44783.
3 Woelfel M, Abusabha R, Pruzek R, Stratton H, Chen S, Edmunds L (2004) Barriers to the Use of WIC Services. Journal Of The American Dietetic Association: Vol. 104, Issue 5, pp. 736-743. Available online: https://jandonline.org/article/S0002-8223(04)00234-2/fulltext.
4 Wilder Research (2013) Women, Infants, and Children (WIC): Awareness, experience, and access. Report to Minnesota Department of Health WIC Program. Access online: https://www.wilder.org/sites/default/files/imports/MDH_WIC_Study_Report_5-13.pdf.
5 Barner M (2012) The “Techie” Side of WIC. USDA Mountain Plains Regional Office WIC Program. Access online: https://fns-prod.azureedge.net/sites/default/files/8-22-12-OntheHorizon-1of3.pdf.
6 California WIC Association (2018) TeleWIC: Keeping up with the Times. Available online: http://www.calwic.org/storage/documents/reports/2018/WIC_VideoConferencing_Brief_fnl_pages.pdf.
7 Macnab I, Rojjanasrirat W, Sanders, A (2012) Breastfeeding and Telehealth. Journal of Human Lactation: 28(4), pp.446-449. Available online: https://www.researchgate.net/publication/232535267_Breastfeeding_and_Telehealth.
8 Macnab I, Rojjanasrirat W, Sanders, A (2012) Breastfeeding and Telehealth. Journal of Human Lactation: 28(4), pp.446-449. Available online: https://www.researchgate.net/publication/232535267_Breastfeeding_and_Telehealth.
9 California WIC Association (2018) TeleWIC: Keeping up with the Times. Available online: http://www.calwic.org/storage/documents/reports/2018/WIC_VideoConferencing_Brief_fnl_pages.pdf.
10 National WIC Association (2017) Outreach and Retention Survey.
11 Bensley R, Hovis A, Horton K, Loyo J, Bensley K, Phillips D, Desmangles C (2014) Accessibility and Preferred Use of Online Web Applications Among WIC Participants With Internet Access. Journal of Nutrition Education and Behavior: Vol. 46(3 Suppl), pp. 87-92. Available online: https://www.jneb.org/article/S1499-4046(14)00081-5/fulltext.
12 Au L, Whaley S, Gurzo K, Meza M, Ritchie L (2016) If You Build It They Will Come: Satisfaction of WIC Participants With Online and Traditional In-Person Nutrition Education. Journal of Nutrition Education & Behavior: Vol. 48, Issue 5, pp.336-342. Available online: https://www.jneb.org/article/S1499-4046(16)30032-X/fulltext.
13 Power Je, Braun K, Bersamin A (2017) Exploring the Potential for Technology-Based Nutrition Education Among WIC Recipients in Remote Alaska Native Communities. Journal of Nutrition Education and Behavior: Vol 49(7S2), pp. 186-191. Available online: https://www.jneb.org/article/S1499-4046(16)30885-5/fulltext.
14 Kealey M (2016) WIC Child Retention Strategies. National WIC Association 2016 Nutrition Education and Breastfeeding Promotion Conference. Available online: https://s3.amazonaws.com/aws.upl/nwica.org/marta-kealy.pdf.