Demos/Grant Projects

Barriers to Retention Among New York 
State WIC Infants and Children*

New York State Department of Health 
Division of Nutrition 
Evaluation and Analysis Unit 
December 2001

* Final report of a WIC Special Project Grant (1997) awarded to New York State, Department of Health, Division of Nutrition, by the U.S. Department of Agriculture, Food and Nutrition Service, Office of Analysis, Nutrition and Evaluation, Grant 59-3198-7-525. Results are the sole responsibility of the authors and may not reflect the views of the funding agency.

Executive Summary 

The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) became an authorized grant program in 1974 by amendment to the 1966 Child Nutrition Act (PL94-105). It is administered by the Food and Nutrition Service (FNS) of the U.S. Department of Agriculture (USDA) through grants to state agencies. WIC state agencies work within FNS regulatory guidelines that allow broad latitude in the delivery of services. State agencies, in turn, operate through a network of local WIC agencies. While working within federal and state rules and regulations, local WIC agencies have substantial discretion in implementing WIC. The barriers to retention experienced by WIC clients may be consequences of federal, state or local provider policies, rules, regulations, or procedures. Other barriers to retention may arise because of the particular circumstances of individual clients, their family or household situation, or the communities within which they reside.

At no cost to participants, WIC provides supplemental nutritious foods, nutrition education and health care referrals to low-income women, infants and children up to the age of five. Participants are given WIC checks that can be redeemed at WIC approved stores for the purchase of specific nutritious foods. To be eligible for WIC benefits and services, an applicant must: (1) be a woman who is pregnant or postpartum, or an infant or a child less than five years old; (2) have an income below 185 percent of federal poverty guidelines (set annually by the Department of Human Services); and (3) be at medical or nutritional risk as verified by a health professional. After they are officially certified as eligible, infants can participate for one year; children (aged 1 through 4) can participate for six months. At the end of each certification period, the participant must be re-certified to continue participating.

Purpose of Study

The purpose of this study was to identify barriers to retention of infants and children on WIC; that is, to identify barriers that deter parents/caretakers from continuing to participate in WIC, despite the continued eligibility of their infant or child. The specific objectives included identifying barriers to retention of infants and children in WIC; assessing differences in barriers to retention by race/ethnicity and geographic area; and identifying barriers to check usage.

Study Methods

A survey, designed to take approximately 15-20 minutes, was based on a review of the literature, results of five focus groups with WIC participants and suggestions from an expert guidance team. Information was collected on 68 potential barriers to retention, selected demographic and economic variables, participation in public assistance program, perceived benefits of WIC, social support and attitude information. Outcome information included failure to pick-up or cash WIC checks. The survey was administered to 3,167 parent/ caretakers at 51 NYS local WIC agency sites.

Respondent Characteristics

The majority of parents/caretakers of infants and children on WIC who participated in the survey had at least a high school education (74 percent). Approximately one in four, however, did not graduate from high school. Most were single (56 percent), a significant percentage were married (35 percent) and 9 percent were divorced or separated. The majority rented their homes (78 percent); about two-thirds lived in households with incomes below 100 percent of the federal poverty guidelines; about one in four lived in households with incomes below 50 percent of poverty. The average household size was 3.7 persons. Many parents/caretakers worked full time (23 percent) or part time (21 percent). Eight percent in upstate and 17 percent in NYC reported Sometimes or Frequently not having enough to eat in the past few months. Most respondents reported participation in one (51 percent) or two (35 percent) food programs.

A higher percentage of Hispanic respondents than Black and White respondents were younger, did not have a high school education, were not employed and reported experiencing food insecurity. White respondents were more likely to be married and own their homes, less likely to live below 50 percent of poverty or to receive Food Stamps, TANF, Medicaid or to participate in more than one food program.

In upstate NY, the majority of respondents were White, whereas in NYC the majority of respondents were Black or Hispanic. Compared to upstate NY, a higher percentage of NYC respondents received benefits from only one food program, rented their homes, were not employed, were single, did not finish high school and lived in households with incomes below 50 percent of poverty. A higher percentage of NYC respondents than upstate NY respondents reported food insecurity and fewer reported receiving Medicaid or Food Stamps.

Results

Results indicated that local WIC agency staff were almost universally perceived by survey respondents as customer friendly, speaking their language, culturally sensitive, attentive to their concerns, giving neither conflicting information or negative treatment. Few respondents reported problems with WIC rules and regulations, the certification process, scheduling an appointment or getting to a WIC site and few respondents reported personal or social factors affecting program retention. Survey respondents identified a comparatively small set of barriers to retention: 11 of 68 potential barriers identified in this study were reported by more than 20 percent of respondents to be a barrier sometimes or frequently. The identified barriers clustered into five organizational areas of WIC services: waiting time, the facility, nutrition education, food procurement and the food package.

Waiting too long in general was the most frequently cited barrier, reported by 48 percent of respondents. Waiting more than an hour to re-certify (27 percent) was also a frequently reported barrier. Facility barriers included reports of overcrowded, noisy facilities (36 percent) with nothing for children to do (42 percent). Nutrition education was viewed by many as boring (27 percent) and repetitive (33 percent). Many respondents reported difficulty matching the WIC food package size requirement with the food container size in stores (23 percent) and not getting the right cereal box size (41 percent). Many respondents reported that the WIC benefit provided too little formula (38 percent) or too little juice (27 percent). The most frequently cited barriers were the same across race/ethnic groups, for upstate NY and NYC respondents, although the rank order differed. However, there were some statistically significant differences across race/ethnic groups; mostly among barriers cited less frequently. A higher percentage of Black respondents than White and Hispanic respondents had difficulty getting off work when scheduling appointments (19, 12, 14 percent, respectively). A higher percentage of Hispanic respondents than Black or White respondents reported a language barrier (7, 0, 1 percent, respectively), the WIC diet as inconsistent with their cultural diet (9, 3, 6 percent, respectively), neighborhood safety (8, 3, 5 percent respectively) and too little milk (19, 10, 13 percent, respectively). Hispanic and Black respondents, more than White respondents, reported overcrowded sites (41, 40, 32 percent, respectively) and too little dry beans (9, 9, 4 percent, respectively). In NYC, four additional barriers were reported by at least 20 percent of respondents. These included too little cheese (23 percent), too little milk (21 percent) and nutrition education as too long and not very useful (27, 29 percent, respectively).

Forty-six percent of respondents reported failure to pick-up or cash their WIC checks during the prior few months period. Analyses to identify barriers predictive of failure to use all WIC benefits showed that total number of barriers, site of services, difficulties associated with bringing the infant/child to re-certify and rescheduling appointments were key variables associated with failure to use WIC checks. Results indicated that with each additional reported barrier, there was a two-percent increase in failure to use WIC checks. In addition, a large percentage of those who failed to use WIC checks (40%) also reported that they had difficulty rescheduling appointments or bringing the infant to re-certify. As noted, waiting too long was associated with an increased number of reported barriers and check usage.

Conclusion

Many barriers to retention may be addressed directly by local WIC agencies; other barriers are under the purview of state and federal policy makers. Strong and concerted efforts have been made to eliminate barriers identified in this study that affect retaining eligible infants and children in the NYS WIC Program. To this end, the NYS WIC Program followed a multi-faceted approach. First, the recently completed automation of the WIC Program should reduce barriers to retention. In particular, one goal of WIC automation was to reduce waiting times, which is an often cited barrier to retention. Second, NYS is working with the National Association of WIC Directors Evaluation Team to identify virtues and limitations of extending the children's certification period from 6 to 12 months; if feasible, this should reduce waiting times, reduce problems associated with bringing the infant/child to re-certify and difficulties rescheduling. Third, a new nutrition education curriculum was designed to revitalize nutrition education by making it more relevant to today's nutrition concerns. The new curriculum includes up-to-date practices, lesson plans and training aides; it aligns nutrition education with Eat Well Play Hard (EWPH), a NYS nutrition and physical activity intervention designed to prevent childhood overweight and reduce long-term risks for chronic disease. Relatedly, the WIC Program is concerned that the importance of the local WIC nutrition educator to the success of WIC is not always recognized. The NYS WIC Program therefore is attempting to determine the best approach to recognize and elevate the role of WIC nutrition educators in improving the health status of WIC participants. Fourth, an annual NYS WIC participant survey, already in place, will be used to monitor WIC participants' dietary practices, behaviors and physical activity. Fifth, the food card has been reevaluated and recommendations are being proposed to expand the choice of cereals and juice. Sixth, the NYS WIC Program Outreach and Retention Committee, which consists of state and local WIC agency staff, incorporated study findings into their local WIC agency training sessions. Study results were presented at three NYS Regional Summit Meetings on Outreach and Retention. Barriers identified were used as the basis of facilitated group discussion on creative and innovative solutions to reach and retain persons eligible for WIC. Future plans include assisting local WIC agencies to focus specifically on participant flow practices to determine if efficiencies in clinic operations can be improved to minimize waiting times.

It may be useful to conduct research to determine if reported barriers, such as waiting too long for services and overcrowded, noisy sites, are related to the allocation of resources from federal to states or from states to their local WIC agencies. The manner in which resources are allocated may differentially affect the ability of local WIC agency to adequately retain participants. Further, assessing differences between agencies with high rates of check usage to agencies with low rates of check usage and agencies with long waiting times to agencies with shorter waiting times may help identify best practices for smooth, efficient and effective service delivery.

Finally, study results indicated a higher percentage of food insecurity among Hispanic respondents than Black and White respondents and among NYC respondents than upstate NY respondents. While we need to ensure that appropriate referrals to other food programs are made to respondents who indicate food insecurity, it may also be useful to examine the WIC food package for this higher-risk group to ensure they receive appropriate levels of nutrition.

Last modified: 12/04/2008