Video Abstract

Video Abstract

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OBJECTIVES

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is a federal program that improves the health of low-income women (pregnant and postpartum) and children up to 5 years of age in the United States. However, participation is suboptimal. We explored reasons for incomplete redemption of benefits and early dropout from WIC.

METHODS

In 2020–2021, we conducted semistructured interviews to explore factors that influenced WIC program utilization among current WIC caregivers (n = 20) and caregivers choosing to leave while still eligible (n = 17) in Massachusetts. By using a deductive analytic approach, we developed a codebook grounded in the Consolidated Framework for Implementation Research.

RESULTS

Themes across both current and early-leaving participants included positive feelings about social support from the WIC clinic staff and savings offered through the food package. Participants described reduced satisfaction related to insufficient funds for fruits and vegetables, food benefits inflexibility, concerns about in-clinic health tests, and in-store item mislabeling. Participants described how electronic benefit transfer cards and smartphone apps eased the use of benefits and reduced stigma during shopping. Some participants attributed leaving early to a belief that they were taking benefits from others.

CONCLUSIONS

Current and early-leaving participants shared positive WIC experiences, but barriers to full participation exist. Food package modification may lead to improved redemption and retention, including increasing the cash value benefit for fruits and vegetables and diversifying food options. Research is needed regarding the misperception that participation means “taking” benefits away from someone else in need.

Via 37 semi-structured interviews, this study explored the factors current and past WIC caregivers identify in relation to decisions around enrollment and benefits redemption.

What Is Known on This Subject

Previous research suggests several factors contribute to early drop-out, including dissatisfaction with the food package, reduction in food benefit value at the child’s first birthday, lack of time and transportation to access appointments, common misconceptions around eligibility, and cultural barriers.

What This Study Adds

No researchers have examined or compared the facilitators and barriers identified by both current and early-leaving, though eligible, WIC caregivers after the implementation of novel innovations to facilitate shopping and clinical experiences.

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is a federal nutrition program that provides millions of low-income women, infants, and children with nutrition education, breastfeeding support, and health care services.1  WIC also provides benefits in the form of either paper vouchers or electronic benefits transfer (EBT) cards, which act like debit cards for purchase of eligible foods from WIC-approved retailers.2  The quantity and type of foods in each food package depend on participant age and stage but generally include staple foods, such as milk, whole grains, and fruits and vegetables (F&V).

Although 14 million people are eligible for WIC, less than half are enrolled.3  Of those enrolled, many do not use the full extent of services offered.4,5  Suboptimal retention and redemption patterns reveal that many participants face barriers to full participation.4,5  Underutilization of WIC3  is a pediatric health concern, given the well-documented benefits of WIC for nutrition,6,7  health,8  cognition,9  and access to care1013  during an important developmental period.14,15  An urgent need exists to identify opportunities to better facilitate participation.

Previous researchers have attributed suboptimal engagement to dissatisfaction with the WIC food package16,17 ; lack of time,18,19  transportation,20  and/or childcare for appointments18,21 ; increased income19,22 ; linguistic barriers23 ; and misinformation.24,25  However, most studies on early termination and low redemption were conducted before the 2009 food package update,26  which, among many changes, added F&V and whole grains to better align with the Dietary Guidelines for Americans.27  Most studies also preceded recent changes to program delivery, including the introduction, in many states, of electronic tools like EBT cards and smartphone shopping apps,1719 ,21,22  which can be used in stores to scan and identify WIC-eligible products. Furthermore, few researchers have investigated the perspectives of families who dropped out of the program early despite still being eligible. By using the Consolidated Framework for Implementation Research (CFIR),28  we documented the perspectives of current WIC enrollees and those who dropped out of the program early to identify key aspects of program structure and delivery that may be related to program underutilization.3,20 

This qualitative study was conducted in Massachusetts in partnership with the state WIC office, which served ∼110 000 to 113 000 individuals in a given month during the study period (August 2020 to January 2021).29  We spoke to caregivers of WIC-eligible children under the age of 5 years who were currently enrolled in WIC (current participants) or recently (ie, 6–24 months before the date of the interview) chose to leave WIC for reasons other than ineligibility (early-leaving participants). To participate in this study, caregivers also had to be age >18 years; live in Massachusetts; speak English, Spanish, or Portuguese; have a WIC-eligible child under the age of 5 years; and have participated in WIC for at least 6 months.

Study flyers were as the primary method of recruitment; directors of local WIC clinic and community organizations (eg, Head Start, libraries, pantries, schools) posted electronic flyers to their social media sites and newsletters. We also posted paper flyers at the end of checkout lanes and diaper aisles in grocery stores that accept WIC. The Massachusetts WIC office used administrative records to identify early-leaving caregivers and mailed them a study flyer. We screened 62 caregivers, spanning urban and rural Massachusetts, of whom 41 were eligible and 21 ineligible (Fig 1). Of the 41 eligible caregivers, 4 withdrew and 37 were interviewed (20 current participants, 17 early-leaving participants) between August 2020 and January 2021.

FIGURE 1

Flow diagram documenting recruitment and enrollment.

FIGURE 1

Flow diagram documenting recruitment and enrollment.

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Underutilization is an undesirable outcome of program implementation. We used an implementation science perspective to consider multiple levels of WIC’s implementation—its structure and delivery—that may affect program utilization. Informed by CFIR28  and previous investigations into determinants of poor redemption and retention,16,19,3034  we developed a demographic survey (Supplemental Data 1 and 2) and interview guide (Supplemental Data 3 and 4). Areas of inquiry, including general WIC experience, food benefits, WIC at home, shopping experiences, and appropriateness of WIC in context, were mapped onto CFIR constructs28  and thus organized into intervention characteristics, process, and outer setting (Fig 2). Trained qualitative researchers conducted and audio recorded 45-minute phone interviews with current (n = 20) and early-leaving (n = 17) participants in English, Spanish, and Portuguese. Before each interview, caregivers were asked to complete the anonymous online demographic survey (18 current participants; 17 early-leaving participants). After completing the survey and the interview, participants were sent a $50 gift card.

FIGURE 2

Conceptual framework informed by the CFIR: why does WIC exhibit suboptimal implementation?

FIGURE 2

Conceptual framework informed by the CFIR: why does WIC exhibit suboptimal implementation?

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The short demographic survey data were downloaded as a comma-separated values file from Qualtrics. We used Excel to calculate the frequency of responses for each question, stratified by WIC enrollment status. We ran χ2 tests to examine differences by WIC enrollment status.

The interviews were audio recorded and transcribed verbatim. English and Spanish transcripts were analyzed in their original languages; Portuguese transcripts were professionally translated to English for analysis. All quotes included in the article have been translated into English; illustrative quotes (Table 2) were selected through a final review of all codes after theme generation. Before analysis, C.M.G. created a preliminary codebook, deductively informed by CFIR, with codes related to the 5 main CFIR constructs listed above.

Trained qualitative researchers (C.M.G., J.O.W., M.J.M., and A.C.-A.) were involved in developing the guides and conducting the interviews. In their collection, analysis, and interpretation of the data, these researchers brought salient identities, including, but not limited to, their gender, race and ethnicity, language preference, and family composition. C.M.G. is white Hispanic American, bilingual (English and Spanish), and childless. M.J.M. is white American and a native English speaker; she has biological and stepchildren aged 2 to 24 years. A.C.-A. is white Mexican, bilingual (Spanish and English), and childless. J.O.W. is Black American, native English and proficient Spanish speaker, childless, and a former child recipient of WIC.

Current and early-leaving participant transcripts were coded independently before theme generation, allowing for potential differences in codes to inductively arise for current versus early-leaving participants, should different codes prove relevant to each sample. Given that similar codes were identified for the 2 groups, a single codebook was used with all codes applicable to both groups, although themes were generated separately among current versus early-leaving participants. Next, researchers independently coded the same 3 transcripts, met over video to compare codes, arrived at an agreement on differing codes through discussion, and updated the codebook to address inconsistencies (Supplemental Table 4). This revision involved no conceptual changes but rather clarification of specifics and collapse of redundant or unnecessary codes. Seven of the remaining transcripts were double coded by 2 independent reviewers for comparison to ensure consistency in coding using the updated codebook; subsequently, the team met to reconcile differences and reach agreement through discussion.35,36  All coding differences were due to the representation of multiple codes in 1 segment; no conceptual differences in code meaning were noted. With confidence that coding was conceptually consistent across the research team, the remaining 28 transcripts were coded by single reviewers; all uncertainties were brought to the coding team for agreement through video discussion. NVivo version 12 (QSR International) was used to organize and analyze coded data.

Most of our sample was female (97%), age >30 years (70%), with up to 3 children (n = 30, 86%; Table 1). Participants were most likely to identify as Hispanic (63%) and white (47%). Approximately half joined WIC before 2014 (43%) and were referred by their doctor (51%). Compared with early-leaving participants, significantly more current participants identified as Hispanic (67% vs 59%), married (78% vs 35%), enrolled before 2014 (59% vs 23%), and never enrolled in the Supplemental Nutrition Assistance Program (SNAP; 61% vs 29%). Fewer current participants reported being recipients of formula through WIC either presently or in the past (22% vs 82%).

TABLE 1

Sample Characteristics of Participants Currently or Previously Enrolled (ie, Early-Leaving) in WIC, 2020–2021 (n = 37)

Participants
Total (n = 35)Current (n = 18)aEarly-leaving (n = 17)bPc
Demographics and socioeconomic status     
 Interview language    .6 
  English 46 40 53  
  Spanish 38 45 29  
  Portuguese 16 15 18  
 Age, yearsd    .2 
  18–29 29 17 44  
  30–34 32 39 25  
  35–44 38 44 31  
 Raced    .9 
  Black 18 18 18  
  White 47 47 47  
  Other 35 35 35  
 Hispanic (vs not) 63 67 59 .04 
 Completed high school (vs not)e 73 67 80 .4 
 Employed (vs other)f 43 27 60 .07 
 SNAP    .02 
  Currently enrolled 34 33 35  
  Enrolled in the past 14 24  
  Never enrolled 46 61 29  
 Food insecure (vs not)g 49 39 59 .2 
Household     
 Married (vs not)h 57 78 35 .01 
 Number of children at home     
  1 31 17 47 .1 
  2 31 33 29  
  ≥3 37 50 24  
History with WIC     
 First enrolled before 2014 43 59 23 .05 
 Referred by a doctor (vs other) 51 44 59 .3 
 Knew someone in WIC before joining 59 50 69 .3 
 Told others about WIC since joining 86 83 88 .7 
 Receive(d) formula (vs no) 51 22 82 <.001 
Participants
Total (n = 35)Current (n = 18)aEarly-leaving (n = 17)bPc
Demographics and socioeconomic status     
 Interview language    .6 
  English 46 40 53  
  Spanish 38 45 29  
  Portuguese 16 15 18  
 Age, yearsd    .2 
  18–29 29 17 44  
  30–34 32 39 25  
  35–44 38 44 31  
 Raced    .9 
  Black 18 18 18  
  White 47 47 47  
  Other 35 35 35  
 Hispanic (vs not) 63 67 59 .04 
 Completed high school (vs not)e 73 67 80 .4 
 Employed (vs other)f 43 27 60 .07 
 SNAP    .02 
  Currently enrolled 34 33 35  
  Enrolled in the past 14 24  
  Never enrolled 46 61 29  
 Food insecure (vs not)g 49 39 59 .2 
Household     
 Married (vs not)h 57 78 35 .01 
 Number of children at home     
  1 31 17 47 .1 
  2 31 33 29  
  ≥3 37 50 24  
History with WIC     
 First enrolled before 2014 43 59 23 .05 
 Referred by a doctor (vs other) 51 44 59 .3 
 Knew someone in WIC before joining 59 50 69 .3 
 Told others about WIC since joining 86 83 88 .7 
 Receive(d) formula (vs no) 51 22 82 <.001 

Shown are the frequencies as percentages. Because of missing data, some categories may not sum to 100% of the study sample.

a

Two participants (current WIC caregivers) chose not to complete the anonymous demographic survey; additionally, 1–2 participants chose not to respond to specific survey questions, including those on race, employment status, and date of first enrollment.

b

One to 4 early-leaving participants chose not to respond to specific survey questions, including those on age, educational attainment, employment status, food security, date of first enrollment in WIC, and whether they knew someone in WIC before joining.

c

Significant differences by WIC enrollment status (current or early-leaving) were determined from χ2 tests.

d

Options included Black or African American, white, American Indian, Asian American, multiracial/multiethnic, and other (open response).

e

Options included less than a high school degree, high school degree or equivalent, some college but no degree, associate degree, bachelor’s degree, and graduate degree.

f

Options included employed and working part time, employed and working full time, unemployed, and prefer not to say. Prefer not to say was counted as missing.

g

Those who responded agreed to 1 or both of the following questions included in the food insecure frequency: (1) Since the start of the COVID-19 pandemic (February 2020), we worried about whether our food would run out before we got money to buy more (may not add up to 20 because of missing data or incomplete surveys) and/or (2) since the start of the COVID-19 pandemic (February 2020), the food we bought just did not last, and we did not have money to get more.

h

Those who reported living with a partner were included in the married frequency.

A key theme that arose in both current and early-leaving participants was related to the package’s perceived value, which is characterized as an “intervention characteristic” critical to implementation success (Fig 2). Regardless of enrollment status, caregivers reported general satisfaction with the food benefits package (Table 2). Caregivers unanimously reported that WIC performed well at “covering the basics,” such as milk, eggs, and bread. F&V were among the most important offerings; many reported buying and consuming more F&V over time. Some even mentioned that the F&V allowance was the main motivation for continued enrollment. However, most caregivers found the cash value benefit to be insufficient, set at $11 per month in Massachusetts per woman and child (age 1–5 years) at the time of the interviews. Although struggling to acquire enough F&V each month, caregivers reported an overabundance of other benefits (eg, dairy, cereal). Early-leaving participants were also more likely to report receiving formula and commented on its high financial value.

TABLE 2

Illustrative Quotations Stratified by WIC Current and Early-Leaving Participants

Current ParticipantsEarly-Leaving Participants
Theme 1: F&V benefits are insufficient.  
 Insufficient F&V “It gives about 10%. For example, they pay $11 for fruits and vegetables…[but] I spend more than that every time.” (record 19) “They give you $11 worth of fruits and vegetables, but that was all that I was using…I didn’t think it was worth it.” (record 65) 
 “I just asked if we could get more money like allowance for actual fruit or veggies…they gave me 4 more dollars for fruits and...it’s not enough.” (record 7) “We did buy the veggies, but it’s not [a] big amount…we always bought more than that...we want more veggies.” (record 72) 
Theme 2: Food benefits’ inflexibility prevents full redemption.  
 Benefits’ inflexibility “They just don’t give you a lot of alternatives…even if it’s for another healthy [food].” (record 19) “[I want for WIC] to give a little bit more freedom for a different kind of bread…so you can use it.” (record 59) 
 Allergies “WIC didn’t want to change his milk because it was a special formula, even with the form from the doctor asking for a new formula.” (record 21) “I told them that it wasn’t working, that my son was allergic, and…I had to take what they gave me.” (record 71) 
 Preferences “But it’s a personal preference. I prefer to have almond milk over Lactaid.” (record 17) “I just noticed a lot of the benefits that they were offering, I wasn’t really using, so I slowly just stopped using them.” (record 65) 
 Cultures “One of the foods that we have missed the most…[was] our Brazilian rice, Tio João…these things, we pay them in cash.” (record 21) “We’re not from US originally…[and] the way we cook and the meals we are used to are a little different from American.” (record 71) 
Theme 3: EBT cards and smartphone apps improve the shopping experience; however, in-store item mislabeling is still linked with embarrassment at checkout.  
 EBT cards “I think it’s a lot easier because I was around with my older kids when they had the paper checks. So, I think it’s a lot easier.” (record 13) “I was more embarrassed that it would take so much time when it was the…checks and…this time around I was like, ‘Oh my God, it’s like a credit card.’” (record 27) 
 Smartphone shopping apps “The app keeps track of what is left for the month. It reminds…so [you can] try to use up whatever you have left.” (record 14) “The app was the best thing ever.” (record 69) 
 Checkout “I was having trouble at the register, and I tried like 4 different stores [which is] like a lot of work for the employees as well.” (record 14) “It was always a problem…and it’s embarrassing…are you going to leave all your stuff and go find the right one?” (record 31) 
Theme 4: Both current and early-leaving participants reported positive clinical experiences; however, barriers to care were more often reported by early-leaving participants.  
 Positive experience “I don’t have any bad experiences; I’ve had really good ones. I feel like it helps me.” (record 24) “The service is good, the communication is good, the support is good, the help is good. There are no complaints.” (record 62) 
 Wait times “The appointments were quick.” (record 21) “They ended up taking their walk-ins before their scheduled appointments.” (record 65) 
 Ability to reschedule “I am close to the WIC office, and they have availability and everything…it has been easy for me.” (record 10) “Let’s say if I missed 1 appointment, it will cost me the whole month because I will get the other appointment in 3 weeks.” (record 53) 
 Recertification “I don’t think it’s difficult to apply for WIC if you’re qualified.” (record 25) “I feel like they should’ve been more understanding…[and] given me more time [to gather the required documents].” (record 31) 
Theme 5: Caregivers will not accept benefits that they do not need.  
 Consideration of need “I use it because I need it. And it helps out a lot.” (record 24) “I am lucky enough to be blessed enough with having a mom that was able to help me with everything…I wouldn’t want to take away from somebody else if they needed it more than I do.” (record 69) 
 “But if I had a better job, if my financial situation was better, I wouldn’t use it because I’m not the kind of person that just wants things for free if you’re not in need.” (record 25) “I don’t really need it because I get food stamps. When I did run out of milk and stuff like that and the eggs, WIC was that backup.” (record 62) 
Current ParticipantsEarly-Leaving Participants
Theme 1: F&V benefits are insufficient.  
 Insufficient F&V “It gives about 10%. For example, they pay $11 for fruits and vegetables…[but] I spend more than that every time.” (record 19) “They give you $11 worth of fruits and vegetables, but that was all that I was using…I didn’t think it was worth it.” (record 65) 
 “I just asked if we could get more money like allowance for actual fruit or veggies…they gave me 4 more dollars for fruits and...it’s not enough.” (record 7) “We did buy the veggies, but it’s not [a] big amount…we always bought more than that...we want more veggies.” (record 72) 
Theme 2: Food benefits’ inflexibility prevents full redemption.  
 Benefits’ inflexibility “They just don’t give you a lot of alternatives…even if it’s for another healthy [food].” (record 19) “[I want for WIC] to give a little bit more freedom for a different kind of bread…so you can use it.” (record 59) 
 Allergies “WIC didn’t want to change his milk because it was a special formula, even with the form from the doctor asking for a new formula.” (record 21) “I told them that it wasn’t working, that my son was allergic, and…I had to take what they gave me.” (record 71) 
 Preferences “But it’s a personal preference. I prefer to have almond milk over Lactaid.” (record 17) “I just noticed a lot of the benefits that they were offering, I wasn’t really using, so I slowly just stopped using them.” (record 65) 
 Cultures “One of the foods that we have missed the most…[was] our Brazilian rice, Tio João…these things, we pay them in cash.” (record 21) “We’re not from US originally…[and] the way we cook and the meals we are used to are a little different from American.” (record 71) 
Theme 3: EBT cards and smartphone apps improve the shopping experience; however, in-store item mislabeling is still linked with embarrassment at checkout.  
 EBT cards “I think it’s a lot easier because I was around with my older kids when they had the paper checks. So, I think it’s a lot easier.” (record 13) “I was more embarrassed that it would take so much time when it was the…checks and…this time around I was like, ‘Oh my God, it’s like a credit card.’” (record 27) 
 Smartphone shopping apps “The app keeps track of what is left for the month. It reminds…so [you can] try to use up whatever you have left.” (record 14) “The app was the best thing ever.” (record 69) 
 Checkout “I was having trouble at the register, and I tried like 4 different stores [which is] like a lot of work for the employees as well.” (record 14) “It was always a problem…and it’s embarrassing…are you going to leave all your stuff and go find the right one?” (record 31) 
Theme 4: Both current and early-leaving participants reported positive clinical experiences; however, barriers to care were more often reported by early-leaving participants.  
 Positive experience “I don’t have any bad experiences; I’ve had really good ones. I feel like it helps me.” (record 24) “The service is good, the communication is good, the support is good, the help is good. There are no complaints.” (record 62) 
 Wait times “The appointments were quick.” (record 21) “They ended up taking their walk-ins before their scheduled appointments.” (record 65) 
 Ability to reschedule “I am close to the WIC office, and they have availability and everything…it has been easy for me.” (record 10) “Let’s say if I missed 1 appointment, it will cost me the whole month because I will get the other appointment in 3 weeks.” (record 53) 
 Recertification “I don’t think it’s difficult to apply for WIC if you’re qualified.” (record 25) “I feel like they should’ve been more understanding…[and] given me more time [to gather the required documents].” (record 31) 
Theme 5: Caregivers will not accept benefits that they do not need.  
 Consideration of need “I use it because I need it. And it helps out a lot.” (record 24) “I am lucky enough to be blessed enough with having a mom that was able to help me with everything…I wouldn’t want to take away from somebody else if they needed it more than I do.” (record 69) 
 “But if I had a better job, if my financial situation was better, I wouldn’t use it because I’m not the kind of person that just wants things for free if you’re not in need.” (record 25) “I don’t really need it because I get food stamps. When I did run out of milk and stuff like that and the eggs, WIC was that backup.” (record 62) 

The low adaptability of the food package (in relation to allergies, cultural appropriateness, and individual preferences) also arose as a key barrier to successful implementation (Fig 2). Participants reported challenges in acquiring proof of allergies, and many paid for alternatives out of pocket. Additionally, some immigrants in our sample cited unprocessed whole grains (alongside F&V) as culturally appropriate and foundational and argued that WIC does not offer enough quantity and variety. Individual preferences were most often reported in relation to dislike of dairy, yogurt flavors, and whole-wheat bread. As a result of benefits’ limited acceptability, caregivers wasted food, shared extras with others, and left benefits unspent.

Electronic tools have proved invaluable to the process of WIC service delivery. Participants reported positive experiences with paying with EBT cards and using smartphone shopping apps to identify eligible items and available benefits (Table 2). Those with older children reflected on the fundamental change they experienced while transitioning from paper vouchers to EBT cards, reporting reductions in stigma, administrative burden, and stress. Embarrassment was still reported, with checkout challenges resulting from in-store label mistakes (ie, products were labeled as “WIC eligible” when they were not). Almost all caregivers used smartphone shopping apps; those who did not use them blamed poor in-store Internet access/cell service, which prevented access to pictures and label scanning.

Almost all participants reported positive clinical experiences (Table 2). Only current participants reported having a specific advocate at their local clinic (ie, someone they trusted and had gotten to know over time). These advocates or “champions” emerged as a critical catalyst for promoting better retention by building and maintaining trust with their assigned WIC caregivers. This important resource is part of WIC’s implementation process (Fig 2). WIC participants who were aware of the clinical, therapeutic, and nutritional services offered rated them highly; however, many were not aware that these services are universally provided. Most negative feedback, usually cited by early-leaving participants, was related to administrative barriers, including lack of clarity in requirements for certification, challenges rescheduling appointments, long wait times, and challenges with transportation to and from appointments. In response, some participants requested that appointments move online to save time and avoid transportation issues; others requested the opportunity to submit recertification paperwork online to avoid issues on appointment day. Several early-leaving participants also described clinical requirements as unnecessary, redundant, and/or burdensome; examples included WIC staff repeating clinic measurements when they may be available through records offered by pediatricians, testing iron levels, and requesting child vaccination records.

Consideration of participant needs and resources is essential for successful implementation (Fig 2). When enrolling, current and early-leaving WIC caregivers made a clear distinction between eligibility for WIC and need for WIC benefits. Those who believed that WIC was unnecessary stopped recertifying, regardless of whether they were still eligible (Table 2). In their definition of need (described as fluid and transient), current participants often cited employment, housing, social services (eg, SNAP), partnership stability, immigration status, and food security as less stable compared with early-leaving participants. Participants also defined need as a concept relative to those around them; some reported leaving, or considering leaving, out of fear that participation would take resources from someone more in need. Of those who identified a sense of need, some paired it with feelings of shame, which they described as being related to a lack of self-sufficiency and as being highly visible to others.

Our study was one of the first to examine the perspectives of both current WIC caregivers and those who were eligible but left the program early. Previous studies were largely limited to the current caregiver experience,16,37,38  with that of the early-leaving caregivers nearly absent from the peer-reviewed literature. Informed by CFIR, we studied WIC implementation to identify unique opportunities to promote service adoption. We identified key themes across different levels of the WIC experience, many of which were consistent with earlier literature. Study participants were disappointed by the insufficiency of F&V benefits16,30  and described low adaptability of the food package,16  high satisfaction with WIC technologies,39  and positive feelings toward clinic staff.31  Current and early-leaving participants differed in their level of satisfaction with clinical services, perceived level of need, and degree of social connection with WIC staff.

Study participants reported a link between their perceptions of the benefits’ value, acceptability, and appropriateness and their own redemption behaviors and retention in the program. Consistent with previous literature stating that formula is a key driver of participation during infancy,34  the early-leaving participants were much more likely to report formula receipt during their period of enrollment and commented on the financial incentive to continue enrollment through infancy for that reason. Low package adaptability meant that participants were unable to make desired modifications to fit their needs. The US Department of Agriculture (USDA) should consider increasing food package flexibility,16  beyond the current substitutions allowed through waivers40  or medical documentation,41  while maintaining healthful standards. WIC may be able to diversify food package options on the basis of patterns derived from redemption data and cultural preferences.16  Perceived value may increase through an expansion of the monthly F&V allowance. Study participants were clear: $11 per month for F&V is not enough. The temporary increase to $35 per month, as part of the American Rescue Plan of 2021, should be evaluated and, if successful, made permanent, as it could encourage greater availability of F&V at local retailers42  and consumption among participants.4348 

Improving shopping and checkout experiences is also important; EBT cards and smartphone shopping apps have proved invaluable in this regard. Common complaints about the shopping experience were related to transaction errors at checkout,49,50  followed by limited in-store selection.33,38,5154  The USDA should continue to invest in EBT cards50  and smartphone shopping apps,39  which have led to increased redemption and reduced in-store stigma.50  To address adoption challenges and to optimize app use, WIC staff may continue to offer enrollees ongoing technical assistance; however, careful consideration must be given to the potential to exacerbate inequities for participants without access to smartphones. Additional recommendations offered by study participants include training grocery store staff on WIC-approved items, creating in-store spaces to highlight approved items, and developing peer-to-peer learning spaces for caregivers to share shopping strategies with one another.

Most participants (even early-leavers) cited positive experiences with their WIC clinic; however, only current participants could name a specific in-clinic champion. WIC clinics may help to foster consistency and familiarity in care by scheduling families with the same nutrition staff member for each appointment. WIC agencies can use this good rapport to better engage caregivers with resources and services beyond the food benefits, such as lactation consultations, nutrition education, and cooking demonstrations. Although these services are delivered to all WIC participants, many did not recognize or highly value service receipt. Those who acknowledged these as “services,” as opposed to “requirements,” seemed to rank them highly.

Caregivers who cited a high degree of coordination between their doctor and the WIC clinic reported higher in-clinic satisfaction; those who rated their in-clinic services poorly did so out of frustration with clinical requirements, which they regarded as unnecessary or repetitive (eg, iron testing, assessment of child vaccination records). Key areas for improvement include offering a clear explanation for the need and utility behind these requirements and streamlining health record data transfer between pediatricians and WIC clinics.55  Health care providers are also in the position to offer careful communication around WIC eligibility, perceived need, and potential for financial security, with obstetrician and pediatrician’s offices serving as a caregiver’s first point of contact with WIC.

WIC leaders should also consider continuing to build on technologies that support remote56  nutrition service delivery (eg, online nutrition education, telehealth) while still promoting the development of personal relationships by assigning families the same nutrition staff member for each appointment. By building off lessons, WIC administrators have learned through the past year of implementing COVID-19 waivers that a need exists to support flexibility in child nutrition authorization tied to physical presence requirements.

Even with significant advancements in the shopping experience, caregivers still reported shame with the acceptance of assistance, as has been documented for decades.20  As with previous studies,16,57,58  many in our sample justified WIC as a temporary service—something to leave as soon as possible to allow room for others. Addressing misperceptions about availability and eligibility, limiting barriers to entry, reducing administrative burden,59,60  and expanding eligibility6163  are key strategies that warrant future research. Although caregivers reported leaving to open space for others more in need, the early-leaving participants reported high rates of food insecurity and continued enrollment in SNAP; therefore, additional examination of the relationship between perceived need and the decision to disenroll from WIC is needed.

The present study has several strengths. Our research team is one of the first to summarize the feedback of both current and eligible, although early-leaving, WIC caregivers. Our timing provided the opportunity to examine the effects of several recent innovations, including increased uptake of EBT cards and smartphone shopping apps. Although these changes likely had an impact on retention,50  the extent of that impact is not yet fully reflected in the literature. Remote data collection methods also allowed us to reach caregivers from across the state, spanning rural and urban clinics.

Because the timing of our study (August 2020 to January 2021) was during the COVID-19 pandemic, some limitations were introduced. Participants may have had difficulty separating their experiences with WIC during COVID-19 from their experiences before, although interviewers offered reminders to think about prepandemic experiences. Limitations to the representativeness and generalizability of our findings may be associated with our relatively small sample size, common in qualitative research, and sampling from Massachusetts, where WIC coverage is higher than the national average. However, examination of national- and state-level data3,64  revealed that our sample of current WIC caregivers is relatively representative, and many of our findings are consistent with those from studies conducted in other states.16,57,58  Finally, social desirability bias may have been introduced by our format; to counter this, interviewers started each interview by emphasizing that there were no wrong answers.

The possible demographic differences between the current and early-leaving caregivers warrant additional research to better understand their role in WIC retention. Investigators should explore communication strategies to mitigate the comparison of relative need, which may be a barrier to enrollment. An urgent need exists for implementation and evaluation of reform at the policy, retail, and clinic level to combat barriers to redemption and retention, including low acceptability and flexibility of the food benefits, mixed feelings about clinical requirements, and administrative barriers to maintaining appointments (Table 3).

TABLE 3

Actionable Recommendations Addressing Key Facilitators and Barriers to Full Program Participation, as Described by Current and Early-Leaving Participants

ThemeRecommendations
Theme 1: F&V benefits are too small.
Theme 2: Food benefit inflexibility prevents full redemption. 
At a national level, USDA should consider increasing the F&V allowance. More broadly, the USDA should consider expanding the food package flexibility, while keeping the program’s focus on nutritional adequacy. 
Theme 3: Electronic tools improve the shopping experience. EBT cards50  and WIC smartphone apps39  have increased redemption and reduced in-store stigma.50  WIC should continue investing in these technologies, which make benefits use easier. 
Theme 4: Clinical and administrative requirements can be burdensome. WIC leaders could consider promoting stronger relationships between WIC caregivers and staff, making more services and administrative processes available remotely,56  and streamlining health record data transfer between pediatricians and clinics. 
Theme 5: Caregivers will disenroll early if not in need. At time of referral and recertification, health care providers can offer careful communication around WIC eligibility, perceived need, and potential for financial security.65  In terms of policy, expansion or universalization of eligibility61  (eg, Community Eligibility Provision62,63 ) may reduce barriers to entry and help to shift public perception around government assistance. 
ThemeRecommendations
Theme 1: F&V benefits are too small.
Theme 2: Food benefit inflexibility prevents full redemption. 
At a national level, USDA should consider increasing the F&V allowance. More broadly, the USDA should consider expanding the food package flexibility, while keeping the program’s focus on nutritional adequacy. 
Theme 3: Electronic tools improve the shopping experience. EBT cards50  and WIC smartphone apps39  have increased redemption and reduced in-store stigma.50  WIC should continue investing in these technologies, which make benefits use easier. 
Theme 4: Clinical and administrative requirements can be burdensome. WIC leaders could consider promoting stronger relationships between WIC caregivers and staff, making more services and administrative processes available remotely,56  and streamlining health record data transfer between pediatricians and clinics. 
Theme 5: Caregivers will disenroll early if not in need. At time of referral and recertification, health care providers can offer careful communication around WIC eligibility, perceived need, and potential for financial security.65  In terms of policy, expansion or universalization of eligibility61  (eg, Community Eligibility Provision62,63 ) may reduce barriers to entry and help to shift public perception around government assistance. 

Our study team is one of the first to describe the experiences of both current and early-leaving WIC caregivers. The findings reveal that caregivers highly value F&V benefits, desire more autonomy in food choices, benefit from social connectedness with clinic staff, and prefer more opportunities to fulfill administrative requirements remotely. Some participants who left early did so because they believed that they would free their spot for someone more in need. Providers who refer families to WIC, such as obstetricians and pediatricians, may help to shift understanding around WIC eligibility by communicating that there are enough benefits for everyone who is eligible; improved care coordination with WIC clinics may also facilitate continued enrollment.

We thank all the caregivers who shared their voices and feedback with us; they are essential contributors in the movement to continue improving services for future WIC families. We also thank all WIC clinic staff members and clinicians who work tirelessly to serve families nationally. This study was made possible by the invaluable efforts of our trained qualitative interviewers, Fernanda Antunes and Vivian Ortiz.

FUNDING: This work was supported by Harvard Catalyst | The Harvard Clinical and Translational Science Center (National Center for Advancing Translational Sciences, National Institutes of Health award UL 1TR002541) and financial contributions from Harvard University and its affiliated academic health care centers. The content is solely the responsibility of the authors and does not represent the official views of Harvard Catalyst, Harvard University and its affiliated academic health care centers, or the National Institutes of Health. Ms Gago was supported by the Harvard T32 Education Program in Cancer Prevention (training grant 5T32CA057711) from the National Institutes of Health. Dr Vercammen was supported by a Canadian Institute of Health Research doctoral foreign study award (0492002603). The Harvard Catalyst grant provided feedback on the initial proposal via consultation with a Community Advocacy Board. The National Institutes of Health and the Canadian Institute of Health Research had no role in the design and conduct of the study. Funded by the National Institutes of Health (NIH).

Ms Gago conceptualized and designed the study, designed the data collection instruments, coordinated and supervised data collection, collected data, contributed to the primary and secondary rounds of coding, designed and revised the codebook, drafted the initial manuscript, and reviewed and revised the manuscript; Ms Wynne contributed to the primary and secondary rounds of coding, reviewed and revised the codebook, contributed to data interpretation and theme development, and reviewed and revised the manuscript; Ms Moore coordinated and supervised data collection, collected data, contributed to the primary and secondary rounds of coding, reviewed and revised the codebook, contributed to data interpretation and theme development, and reviewed and revised the manuscript; Dr Cantu-Aldana collected data, contributed to the primary and secondary rounds of coding, reviewed and revised the codebook, interpreted data, contributed to theme development, and reviewed and revised the manuscript; Drs Vercammen and Zatz conceptualized and designed the study, critically reviewed and revised the data collection instruments, and reviewed and revised the manuscript; Ms May and Dr Stone conceptualized and designed the study, critically reviewed and revised the data collection instruments, coordinated contact and communication with partners at local clinics, and reviewed and revised the manuscript; Ms Andrade, Ms Mendoza, and Drs Mattei and Davison critically reviewed the manuscript for important intellectual content; Drs Rimm and Kenney and Ms Colchamiro conceptualized and designed the study, reviewed and revised the data collection instruments, supervised data collection and analysis, and critically reviewed the manuscript for important intellectual content; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

     
  • CFIR

    Consolidated Framework for Implementation Research

  •  
  • EBT

    electronic benefits transfer

  •  
  • F&V

    fruits and vegetables

  •  
  • SNAP

    Supplemental Nutrition Assistance Program

  •  
  • USDA

    US Department of Agriculture

  •  
  • WIC

    Special Supplemental Nutrition Program for Women, Infants, and Children

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Competing Interests

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.