Date of Defense:
April 26, 2019
Introduction: The Special Supplemental Nutrition Program for Women, Infant and Children (WIC) Program is a federal program that provides grants for supplemental foods, health care referrals and nutrition education for low-income pregnant, breastfeeding, and non-breastfeeding postpartum women, and infants and children up to age five.1 The mission is to safeguard the health of low-income women, infants and children up to age 5 who are at nutrition risk. WIC foods provide clients with essential nutrients and promote an increased consumption of fruits, vegetables, protein and dietary fiber.2 Clients also participate in education visits about nutrition, breastfeeding, and well-being. WIC is administered at the state-, county- and local-level.
Purchasing WIC foods was traditionally done using paper vouchers. With these vouchers, WIC clients often had a difficult time identifying which food items were included in their benefit package, felt stigma during checkout, were more likely to feel frustrated or uncomfortable, and did not redeem the full benefit package.3 The program is in the process of transitioning from paper vouchers to Electronic Benefits Transfer (EBT) cards that are referred to as eWIC. The goal is to provide clients with a purchase method that is fast, flexible and simple. A pilot program was administered in Dakota and Scott/Carver County in October 2018 and the statewide rollout began in January 2019 with Hennepin County and Bloomington Public Health. All WIC state agencies must transition to the eWIC by October 1, 2020. The transition also includes an eWIC app and alternative options for quarterly WIC visits (e.g. by phone or virtual meeting).
Organization: Bloomington Public Health (BPH) is an accredited local health division that serves Bloomington, Richfield and Edina. The mission of BPH is to “engage the community in promoting, protecting and improving the health of all.” The division is part of the City of Bloomington, which has more than 500 full-time employees, with 52 total employees in the Public Health Division (36.6 total full time effort (FTE) in 2018). The WIC program has 16 dedicated staff that include Public Health Nurses, Registered Dietitians, Spanish Interpreters, a Program Manager, and 8 Peer Breastfeeding Counselors who work to provide culturally competent care for pregnant and breastfeeding mothers. The WIC program is administered with an ongoing, long-term grant and over 3,000 clients were served in 2017. The clients served by BPH are disproportionately low income and people of color.4
According to a customer satisfaction survey conducted in 2017, 88% of BPH WIC clients strongly agreed that the services and information provided by the WIC program met their needs. Since the program is undergoing a significant transition, it is important to gain an understanding of how the client experience is impacted by the implementation of eWIC. Therefore, the field experience summarized in this document supported the mission and strategic priorities of BPH by gathering information on the impact of the transition to eWIC from clients, vendors and staff.
Experience: In order to gain insight on the retention and satisfaction of WIC clients and vendors for the eWIC implementation, the project began with a formative evaluation with the objective of gathering feedback on strengths, weaknesses and areas for improvement. Data collected in the formative evaluation will be used to make necessary adjustments to the rollout of eWIC and to guide the framework for ongoing data collection and long-term evaluation.
By collaborating with WIC staff, an open-ended question set was developed using the focused conversation method and qualitative data was collected by connecting with WIC clients, staff and vendors.5 WIC appointments were observed when clients received their eWIC card for the first time and clients were asked: What is most exciting about being able to purchase foods with your new eWIC card?; What are your initial concerns or where are you confused?; How can WIC staff help you to feel better prepared to use your eWIC card at the store? In addition, WIC vendors were contacted and 30-minute interviews were conducted with those who agreed to participate. Finally, facilitated conversations were conducted with WIC staff and Peer Breastfeeding Counselors after two months of eWIC rollout. Feedback was qualitatively analyzed in order to identify key themes, patterns, connections and relationships.6
Initial Results: The following key themes emerged from different populations through analyses carried out for the field experience:
- Clients: Clients were excited to have less paperwork to carry, more flexibility to redeem benefits, and an improved experience at the checkout line. Few concerns were expressed.
- BPH WIC Staff: Staff believed eWIC is more client-centered and user friendly, and that clients use more of their benefits because they no longer try to buy all of the items in one shopping trip.
- Vendors: Vendors believed changes are having positive outcomes in stores because eWIC, which is computerized, eliminates common sources for errors and vendor violations that were associated with the use of paper vouchers.
- All Stakeholders: Each population expressed that a key benefit is the reduction of the stigma experienced by WIC clients at the store when other patrons recognized their paper vouchers in the check-out line.
Lessons Learned: While working with BPH staff and observing the WIC clinic first-hand, I learned about the challenges that are faced in efforts to serve low-income and nutritionally at-risk women, infants and children. It is challenging to deliver key health information to WIC clients because the appointments often involve distractions; language barriers are common, mothers bring their young children, and they are often navigating a complex social service system, making it challenging to deliver key health information. Therefore, I was impressed by the ability that WIC staff demonstrated in developing trusted relationships with clients; these relationships are likely key to success for positive health outcomes.
Recommendations: As BPH moves forward with ongoing data collection and long-term evaluation, the following recommendations are offered:
- Use findings from the formative evaluation to develop strategies for a quality improvement (QI) project with WIC staff that involves investigating the retention of clients.
- Develop strategies to quantify the changes clients make in redeeming their benefits with eWIC (e.g., whether clients are able to purchase more nutritious food in a given month).
- Continue to build relationships with local WIC vendors to improve the client experience.
Conclusions: Having the opportunity to observe the operations of a key Maternal and Child Health program first-hand was valuable in gaining an understanding of the complex health needs of vulnerable populations, as well as essential professional skills. This experience reinforced the importance of developing skills in relationship building, collaboration and partnership to promote, protect and improve the health of all.
- Women, Infants, and Children (WIC) – United States Department of Agriculture. (2017, October 10). Retrieved March 24, 2019, from https://www.fns.usda.gov/wic/women-infants-and-children-wic
- Women, Infants and Children (WIC) Program – Minnesota Department of Health. (2019, February 7). Retrieved March 24, 2019, from https://www.health.state.mn.us/people/wic/
- Chauvenet, De Marco, Barnes, & Ammerman. (2019). WIC Recipients in the Retail Environment: A Qualitative Study Assessing Customer Experience and Satisfaction. Journal of the Academy of Nutrition and Dietetics, 119(3), 416-424.e2.
- Bloomington Public Health. (2019, March 04). Retrieved March 24, 2019, from https://www.bloomingtonmn.gov/ph/public-health
- Stanfield, R. B. (2013). The Art of Focused Conversation. Gabriola Island: New Society.
- Adams, J., Khan, H., Raeside, R., & White, D. (2007). Qualitative Data Analysis. In Research Methods for Graduate Business and Social Sciences Students. SAGE Publications India Pvt. http://dx.doi.org/10.4135/9788132108498