National WIC Association

Winter 2019 WIC Research to Practice

Introduction

“Seek real partnerships based on mutual interests as opposed to trying to impose a research agenda onto WIC.”

Happy new year! The quote above is from Dr. Pia Chapparo, featured in this issue’s Researcher Spotlight. Chapparo stresses the importance of researchers putting WIC participants and WIC staff at the center of research projects and actively collaborating to conduct research that moves the needle on pressing issues facing WIC. Genuine engagement is key to any productive partnership. This is a theme across content of this issue. We learn about a meeting in Vermont that proactively brought together diverse stakeholders to discuss caseload in WIC, and we consider the value of a health equity lens in both WIC innovations and research.

We have a new section in Research to Practice – Caseload Trends. We will be reporting on national caseload trends and highlighting any agencies that appear to be bucking the downward trend that we’ve become used to seeing in recent years (there are a few!). As always, we provide some research hacks, links to the most recent research publications, and opportunities to share your WIC research. If there are studies or reports you would like us to highlight in the spring issue, please contact Georgia Machell, gmachell@nwica.org.

Caseload Trends

Welcome to “Caseload Corner,” a new feature of NWA’s Research to Practice newsletter. Each quarter, we will present the latest WIC participation data as well as recent developments in WIC caseload research and recruitment and retention innovations.

Current Participation Trends
As of January 2019, the latest participation data published by the US Department of Agriculture’s Food and Nutrition Service (FNS) is through September 2018. Keep in mind that the participation data for fiscal year 2018 is preliminary – it will likely not be finalized by FNS for quite some time. Please see the chart below for participation trends from October 2017 through September 2018.

As shown in this chart, participation continued to decline in FY 2018, from a high of 7.14 million in October 2017 to a low of 6.68 million in September 2018. This trend continues the ongoing decline in WIC participation that began in 2011. The overall participation in FY 2018 (the average of all the monthly participation numbers) was 6.87 million, compared to 7.29 million in FY 2017. There were some months in 2018 in which participation increased from the previous month. These included January, May, and August.

The majority of state agencies (76 out of 90) experienced participation declines between 2017 and 2018, which contributed to the national decline. Fourteen state agencies, however, including two geographic states, experienced increased participation during this time. These state agencies include: Colorado, Mississippi, Pleasant Point Passamaquoddy Reservation, Omaha Sioux, Santee Sioux Tribe, Inter-Tribal Council of Nevada, Pueblo of Isleta, Santo Domingo WIC Program, Acoma, Canoncito & Laguna, Seneca Nation, Three Affiliated Tribes, Citizen Potawatomi Nation, Osage Nation, and Cheyenne River Sioux Tribe. This is a promising trend for these state agencies, as many were experiencing participation declines in the previous four years.

Innovation Spotlight: Vermont WIC Agency Holds WIC Summit with Partner Organizations

The Vermont WIC Program recently held a WIC summit that brought together diverse stakeholders from the state and local levels to discuss innovative strategies to better recruit and retain WIC participants. The summit was part of a larger project that Vermont WIC is currently leading to address participation declines in the state, at the request of the Vermont state legislature. In addition to calling for the summit, the legislature has also directed the Vermont Department of Health to “solicit input on methods of increasing WIC enrollment from current and former WIC participants, as well as WIC-eligible nonparticipants, and the Department for Children and Families through interviews and surveys” and to “present recommended actions” to the legislature by April 1, 2019.

Summit participants included representatives from the Vermont Department of Health (both WIC and non-WIC), the Department of Children and Families, the Vermont Food Bank, community health organizations, local health departments, nonprofit organizations, and others. A representative of the National WIC Association was also in attendance.

The summit, a two-and-a-half hour event, consisted of WIC updates from Vermont WIC state office staff as well as group discussions focused on current strategies, ongoing challenges, and innovative ideas around recruitment and retention of WIC participants. Some challenges discussed by summit participants included:

  • barriers to accessing WIC for non-parent family members who are caring for children
  • an overwhelming number of different applications for programs targeting new parents and young children
  • transportation challenges
  • stigma associated with participation

WIC staff and partners in the room discussed a number of innovative strategies to overcome these and other challenges, some of which have been used in other states but not yet in Vermont, and some of which have been used on a small scale in Vermont but are not yet statewide. Proposed innovations included:

  • Integrating applications and re-applications across programs as much as possible, including early childhood education, childcare, childcare financial assistance, SNAP, Medicaid, home visiting, and K-12 schools.
  • Allowing for WIC nutrition education activities to be completed through other programs, such as early childhood education, Head Start, childcare, parent child centers, etc.
  • Embedding social workers in healthcare and social service offices (e.g., pediatricians, OB/GYNs, primary care practices, parent child centers, etc.) to make referrals and ensure that families follow through. WIC staff could also be present in healthcare offices periodically (e.g., once a month) to do on-site certifications and even appointments.
  • Sending WIC staff to grocery stores at the beginning and end of each month to help WIC shoppers use benefits—in other words, establishing WIC grocery store “office hours.”
  • Creating a state WIC Council made up of current and/or past WIC participants who offer feedback on how to improve the program.
  • Incorporating WIC into services delivered by partners. This includes ensuring that screenings in early childhood development, economic assistance, etc. include questions about nutrition and food insecurity.
  • Creating a WIC 101 presentation for community partners across the state that the partner organizations can show to new staff.
  • Sharing Medicaid client lists with WIC to allow for targeted outreach.
  • Developing a way for partner programs to be updated if a client stops participating in WIC or misses multiple appointments.
  • Placing WIC promotional materials in strategic places such as in CSFP boxes for senior citizens who may be grandparents.
  • Performing outreach to caretakers, local birthing centers, and low-wage worksite human resource departments.
  • Collaborating with state SNAP agency on outreach.
  • Changing WIC policy at the national and/or state level to: allow benefits to roll over from month to month; increase choice in the WIC food package; allow for online ordering and delivery of WIC foods; and increase the WIC income threshold for “kin as parents”.

The National WIC Association is excited to see the final report that the Vermont WIC Office presents to the legislature, which will be a culmination of the summit, surveys, and interviews that they are conducting.

Applying a Health Equity Lens to WIC Innovations and Research

Health equity acknowledges historical trauma, environmental conditions, systemic practices, and other factors that prohibit individuals from reaching a universal goal, such as food security. The Achieving Health Equity page on the Robert Wood Johnson Foundation website provides additional helpful information on this topic. Integrating a health equity framework into WIC research and practice will help to bolster existing efforts to identify promising practices for improving the health of WIC participants and the communities where they reside.

Using a collective-impact approach embedded with health equity, local WIC agencies funded through NWA’s Community Partnerships for Health Mothers and Children (CPHMC) project (2014-2017) leveraged technology to share tools and resources, advance and build support for community health initiatives, and to sustain project interventions. These local agencies’ targeted outreach efforts included:

  • breastfeeding jingles
  • videos such as Eat Move Thrive by Racine/Kenosha Community Action Agency, Inc.
  • coalition websites
  • mobile apps
  • online toolkits such as the Healthy Food Pantry Toolkit by Tri-County (Colorado) Health Department
  • social media campaigns to improve access to healthy foods and beverages and strengthen referral networks.

As highlighted in the CPHMC’s project evaluation report, these and other activities from the project endowed WIC staff with new skills, gave them greater experience with community engagement, and helped to raise the profile of WIC. For example, one agency shared that its toolkit would be widely shared with public health partners in their state: “The Healthy Food Bank Toolkit for the food pantries has really been received positively and is in demand. The toolkit is now up on the TCHD website, is soon to be up on the Hunger Free Colorado website, has been promoted across the state in the Hunger Free Food Pantry newsletter, and is going up on the NWA website.”

What impact did these community health projects have on WIC client caseload? NWA staff and the project evaluation team explored this topic, but we didn’t have adequate data to analyze and make a conclusive statement since the question wasn’t included in the original evaluation plan. Anecdotally, several agencies stated that their increased visibility in the community resulted in more referrals and increases in their caseload. Given the heightened focus on WIC recruitment and retention issues, this area is ripe for further research.

Have you or your WIC agency applied a health equity lens to innovations or research that you are conducting? We would love to hear from you. Please contact Quinney Harris, Director of Health Equity and Community Partnerships, at qharris@nwica.org.

Research Hacks

Do you know where to find WIC participation data, food-cost data, and budget data on the Food and Nutrition Service website? Check out this page from the USDA-Food and Nutrition Service. This data is used by researchers, advocates, and practitioners to better understand trends by state, region, and nationally.

Researcher Spotlight: M. Pia Chaparro, MS, PhD

"I believe WIC is a key “equalizer,” working at improving the diets of vulnerable populations at higher risk of obesity and other chronic diseases."

Pia Chaparro is an assistant professor at Tulane University in New Orleans, LA. Originally from Peru and with a graduate degree from the University of Hawaii and PhD from the University of California Los Angeles (UCLA), Chaparro has lived and worked in a number of places. For over eight years, she has been conducting research on WIC, primarily in collaboration with Dr. Shannon Whaley, Director of Research and Evaluation at PHFE WIC in Los Angeles, and Dr. May Wang from UCLA. Chaparro shared some of her insights and expertise on academic and WIC agency partnerships as well as telling us about her most recent research project on the impact of the 2009 WIC food package changes.

What drew you to study WIC?
My overarching interest is in reducing social inequities in nutritional outcomes, and I believe WIC is a key “equalizer,” working at improving the diets of vulnerable populations at higher risk of obesity and other chronic diseases. Also, it is incredibly rewarding to work in partnership with WIC programs and see how the results of your research feed back into the program and, in conjunction with other research, has the potential to influence policy for the benefit of program participants and their families.

What are the goals of your most recent research on WIC?
The goal of my most recent study – funded by the American Heart Association and in partnership with PHFE WIC and UCLA – is to evaluate the impact of the 2009 WIC food package change on growth trajectories and obesity risk among WIC-participating children in Los Angeles County.

We are using longitudinal administrative data from WIC participants in Los Angeles County between 2003 and 2016 from the Data Mining Project, evaluating weight-for-height z-scores (WHZ) growth trajectories between 0 and 4 years of age and obesity risk at 4 years (obesity defined as BMI-for-age≥95th percentile) for children exposed to the old food package (before October 1, 2009) vs. those exposed to the new food package (after October 1, 2009).

Exposure to the new food package (compared to the old) from 0 to 4 years is associated with healthier growth trajectories (i.e., WHZ closer to the mean of 0 and further from the overweight category) and a 10-12% lower obesity risk at age 4 (10% for girls and 12% for boys).

We are currently working on investigating if the type of infant food package received from 0-12 months could explain the observed improved obesity outcomes among children exposed to the new food package. But there are many components contained in this “food package change” – impacting both mothers’ and children’s diet and nutritional status as well as the food environment – and we don’t know which of these components (or if all) are responsible for the decreased obesity risk observed. In addition, we use food package issuance as a proxy for diet consumption, but it would be useful to pair the issuance data with redemption data.

What do you think are the current gaps in WIC research?
A big issue is the geographic disparity related to where the research comes from. There are big gaps due to data availability (or lack of), with areas like California (Los Angeles in particular) and New York putting out a lot of research, some coming from Michigan, and little to no research coming from the South. There are national studies using either data collected for the purpose of the study or other data sources like NHANES. However, I am talking about the use of local administrative data or surveys collected among WIC participants.

Why are university and state WIC program collaborations important?
I think they are important and necessary as long as they are partnerships. Universities can provide research expertise, dollars, and time to dedicate to research. These are often lacking at the WIC program level. On the other hand, WIC can provide not only the data, but also the “insider” programmatic expertise needed to interpret the research findings. But again, it is important to work on building mutually beneficial partnerships in which the type of research conducted is based on what the local WIC program needs as well as what the university partner has expertise on.

What advice do you have for other researchers hoping to work with WIC state agencies and vice-versa?
Seek real partnerships based on mutual interests as opposed to trying to impose a research agenda onto WIC. I think it is important that both parties are willing and active participants in the design and development of the research project so there is co-ownership of the research product. I think this is the key for a sustainable successful relationship.

Opportunity to share your WIC research at the APHA Annual Meeting in Philadelphia, PA, Nov 2- 6

The American Public Health Association (APHA) Food and Nutrition Section (FN) invites you to view the 2019 Call for Abstracts and enter a submission. Abstract submissions are a critical part of developing an innovative and exciting program.

The FN Section invites abstracts and full session proposals for the 2019 APHA Annual Meeting, which will feature the theme of "Creating the Healthiest Nation: For Science. For Action. For Health." November 2- 6, 2019, in Philadelphia, PA.

APHA will be accepting submissions representing a wide range of food and nutrition topics. In recognition of the 2019 APHA Annual Meeting theme, APHA is looking for submissions that address the implementation of food and nutrition-related research, policies, advocacy, and programming. It is particularly interested in proposals that apply an equity lens to work focused on food and nutrition.

Please circulate the Call for Abstracts link and announcement to your relevant networks. The Call for Abstracts will remain open until February 23, 2019. APHA looks forward to receiving your submissions!

Below are two testimonials from NWA members who attended the 2018 APHA conference:

"This year APHA was particularly fantastic. The Food & Nutrition and Maternal & Child Health sections were exceptionally well organized with some excellent sessions marrying research and practice. It was a great venue to connect with public health professionals from around the country doing work that really complements WIC practice. It was also a place to expand my own knowledge and understanding of many important public health issues of the day that touch our lives and lives of WIC participants but aren’t part of my every day work but are things I think are important to know more about - from gun violence to implicit bias to changes in immigration policy." -- Shannon Whaley, PHFE WIC

"APHA is an outstanding forum where so many of WIC’s public health nutrition and maternal child health concerns come together and are viewed through an essential health equity lens. I would encourage all WIC practitioners to consider attending and/or presenting at APHA." -- Kathleen Merchant, SDSU Research Foundation WIC Program

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 Overweight and Obesity

Breastfeeding

Lead

Innovations

Recruitment and Retention of WIC Participants

Infant Formula

Spillover Mechanisms in the WIC Infant Formula Rebate Program

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.