Editor’s Note: Dr. Claire Castellano is a resident physician in pediatrics at the Children’s Hospital of Philadelphia. In addition to her M.D., Claire has a Master’s in Public Health, focusing on global epidemiology. Claire hopes to combine her interests in medical education and global health in her career as a pediatrician. -Rachel Y. Moon, MD, Associate Editor, Digital Media, Pediatrics
The Special Supplemental Nutrition Program for Women, Infants, and Children, more commonly known as WIC, exists to support child and maternal health. WIC provides access to nutritious foods and support through education and healthcare counseling for low-income individuals during pregnancy and post-partum as well as their children through the age of 5 years. WIC is associated with a plethora of good, from decreased child mortality and food insecurity to increased childhood immunization rates and primary care follow-up. However, national participation in WIC has been decreasing, from 9.2 million participants in 2009 to 6.3 million participants in 2020. Dr. Bryan Monroe and colleagues at Wake Forest University School of Medicine and Nationwide Children’s Hospital sought to understand what factors may be underlying this decline. They investigated factors contributing to WIC participation and proposed an intervention to improve WIC enrollment in the primary care setting, outlined in their article, “Assessing and Improving WIC Enrollment in the Primary Care Setting: A Quality Initiative,” being released early in Pediatrics this week (10.1542/peds.2022-057613).
This study was carried out at an academic primary care clinic in Winston-Salem, North Carolina, with a WIC office located at the same location as the pediatric clinic. Of note, 92% of the clinic patients were insured by Medicaid and 65% identified as Hispanic.
The intervention focused on WIC screening, education, and referrals, and was implemented in 3 iterations, using Plan-Do-Study-Act (PDSA) cycles, over a total of 18 months. All aspects of the intervention were available in both English and Spanish.
- Screening: Patients who came to the primary care clinic were screened with a 3-question survey, aimed at barriers to enrolling and interest in WIC. Providers were prompted to screen patients by adding in prompts to the under-five well-child note template in the electronic health record (EHR).
- Education: Patients were educated on WIC services by providers or by a specialist in food resources through a referral for that visit. Providers were also educated on WIC resources and eligibility during didactic sessions.
- Referrals: The EHR automatically sent WIC referrals for patients once WIC interest and consent was provided and documented in the chart.
They found that new WIC enrollments increased by 42.5% with the interventions. Providers also self-reported an increase in their confidence when counseling on WIC services.
In addition, WIC screening, education, and referral rates remained constant for at least 1 year after the intervention ended, suggesting that by embedding WIC reminders into the EHR, the intervention has power to have lasting change.
Finally, survey data revealed that the most common barriers to WIC enrollment were lack of access and knowledge. Interestingly, the authors hypothesize that unless access barriers are addressed, knowledge barriers to understanding WIC will persist, often unnoticed.
The authors also comment on findings specific to their study population, which was majority-Hispanic. Many of the Hispanic families who were not enrolled in WIC cited hesitancy to engage in government benefits, perhaps due to persistent effects of past federal legislation that intimidated and discouraged immigrants from using public resources. Understanding this potential barrier more could help target future interventions, such as “targeted education efforts to dispel fears that WIC impacts immigration status.”
This study outlines a low-cost, feasible primary-care-based intervention that has promising results to improve WIC enrollment, with known benefits for young children and their families. Although not all clinics have the ease of sharing space with a WIC office, this study challenges us to apply and scale this intervention to other practice settings and urges us to continue to think about the specific needs of our communities.
