Caregiver Perspectives on Underutilization of WIC: A Qualitative Study

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.

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,^{16,19,30–34}  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.

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%).

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.

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 benefits^16,30  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.^43–48 

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.^{33,38,51–54}  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 eligibility^61–63  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 data^3,64  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).

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.

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