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1.  Referrals of participants in an urban WIC program to health and welfare services. 
Public Health Reports  1992;107(2):173-178.
The Special Supplemental Food Program for Women, Infants, and Children (WIC) provides supplemental food, nutrition education, and referrals to available health and welfare services. Recipients are income-eligible pregnant and postpartum women, their infants, and their children who are younger than 5 years of age. Although studies have documented the nutritional benefits of the program, the extent to which WIC nutritionists help eligible women to obtain available health and welfare services, and the degree to which this referral activity promotes health, is largely unknown. The researchers examined the referral activity at one urban WIC clinic, but did not evaluate the outcomes. Of 1,850 persons seen, there were 762 referrals by WIC nutritionists for 597 persons at the Lawrence, MA, clinic during a 2-month period. Of the 597 persons, 494 (83 percent) were WIC participants and 103 (17 percent) were nonparticipants. The rate of referrals for WIC participants was 27 percent. Multiple referrals were common, with 127 people receiving more than one referral. WIC nutritionists at this site offered a variety of referrals to their clients. The majority of referrals (61.7 percent) were for supplemented food. Nonnutrition-related referrals were to medical and dental services (20.5 percent), developmental and educational services (12.5 percent), and social services (5.4 percent). Nonnutrition-related referrals for women included referrals for family planning, substance abuse, job training, teenaged parenting, and high school equivalency programs. Infants and children were referred for dental care, growth failure, the Head Start Program, kindergarten enrollment, early intervention, and protective services.(ABSTRACT TRUNCATED AT 250 WORDS)
PMCID: PMC1403627  PMID: 1561299
2.  Factors influencing early prenatal enrollment in the WIC program. 
Public Health Reports  1989;104(3):301-306.
Women's access to prenatal nutrition services was explored using a nationally representative sample of pregnant participants in the Special Supplemental Food Program for Women, Infants, and Children (WIC) in 1984. The probability was examined of the participant entering the program during her first trimester, rather than the second or third trimester. Other research has suggested that length of participation in the program during pregnancy is associated with increased birth weight. The data were adjusted for various personal and local operational factors, such as prior WIC participation, race, age, income, household size, WIC priority level, availability of prenatal or other health services, targeted outreach policies, years of local operation, and local agency size. Previous participation in the WIC Program was the only factor significantly associated with early enrollment (adjusted odds ratio 2.1). Race was marginally significant. Neither the presence of local policies of outreach targeted to pregnant women, nor co-location of WIC services with prenatal or other health services, showed significant effects on early enrollment.
PMCID: PMC1579914  PMID: 2498982
3.  WIC program participation--a marketing approach. 
Public Health Reports  1991;106(5):547-556.
Recent evaluation studies have described the benefits accruing to low-income women and children who participate in the Special Supplemental Food Program for Women, Infants, and Children (WIC). However, participation is not uniform among all groups of eligible persons. This study examines the geographic variation in WIC participation rates of eligible pregnant women in Rhode Island to determine whether the program is effective in reaching the neediest segments of the population. Eight groups of small geographic areas in Rhode Island (census tracts) were formed on the basis of need for maternal and child health services, as determined from a statistical method employing factor and cluster analysis of existing health and sociodemographic data. Among these eight groups, participation rates in WIC during 1983-84 ranged from 46 percent to more than 100 percent of estimated eligible pregnant women. The rates were positively correlated with measures of need, strongly (r = 0.92) with an index of maternal risk, and less strongly (r = 0.79) with an index of birth outcomes. The results of this study have enabled the Rhode Island WIC Program to direct its outreach efforts more specifically to geographic areas where the need for the program's assistance is greatest. The procedures described in this report comprise a technique that can be generally applied to measure program effectiveness in marketing and outreach where relevant data are available by small geographic areas. The data requirements are (a) population-based estimates of program need and (b) program utilization measures. If these data can be aggregated to a common set of small geographic areas, the use of marketing analysis techniques becomes possible, and program benefits in the area of outreach and recruitment can be realized.
PMCID: PMC1580300  PMID: 1910189
4.  Increasing Access to Farmers Markets for Beneficiaries of Nutrition Assistance: Evaluation of the Farmers Market Access Project 
Introduction
Increased acceptance of nutrition benefits at farmers markets could improve access to nutritious foods for low-income shoppers. The objective of this study was to evaluate a pilot project to increase participation by farmers markets and their vendors in the Supplemental Nutrition Assistance Program (SNAP) and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).
Methods
The intervention targeted 9 markets in lower-income regions of King County, Washington. Markets and vendors were offered subsidized electronic benefits transfer (EBT) terminals for processing SNAP, and vendors could apply to accept WIC cash value vouchers. WIC staff received information on using SNAP and vouchers at farmers markets. We used mixed methods post-implementation to measure participation, describe factors in acceptance of benefits, and assess information needs for WIC staff to conduct effective outreach.
Results
Of approximately 88 WIC-eligible vendors, 38 agreed to accept vouchers. Ten of 125 vendors installed an EBT terminal, and 6 markets installed a central market terminal. The number of market stalls accepting SNAP increased from 80 to 143, an increase of 79%. Participating vendors wanted to provide access to SNAP and WIC shoppers, although redemption rates were low. Some WIC staff members were unfamiliar with markets, which hindered outreach.
Conclusion
Vendors and markets value low-income shoppers and, when offered support, will take on some inconvenience to serve them. To improve participation and sustainability, we recommend ongoing subsidies and streamlined procedures better suited to meet markets’ capabilities. Low EBT redemption rates at farmers markets suggest a need for more outreach to low-income shoppers and relationship building with WIC staff.
doi:10.5888/pcd10.130121
PMCID: PMC3804120  PMID: 24135392
5.  Factors associated with rates of participation in WIC by eligible pregnant women. 
Public Health Reports  1992;107(1):60-65.
The relationship between sociodemographic, biological, and prenatal care characteristics, and participation rates of pregnant women in the Special Supplemental Food Program For Women, Infants, and Children (WIC) was studied by interviewing 200 postpartum patients in a Buffalo, NY, hospital between October 1988 and January 1989. Among the 136 women eligible for the program, 94 (69 percent) participated during their index pregnancies. WIC participation was found to be highly associated with source of prenatal care and having made more frequent prenatal visits. WIC was related to having fewer children and earlier initiation of prenatal care. Multivariate analysis showed that program participation remained highly associated with the source of prenatal care and the number of prenatal visits, when combined with other factors considered, such as age, education, marital status, number of living children, and timing of initial prenatal visit. The results suggest the need for a WIC enrollment effort directed to providers of prenatal care, who would be urged to encourage women to seek early and adequate prenatal care through the program.
PMCID: PMC1403602  PMID: 1738810
6.  WIC in Your Neighborhood: New Evidence on the Impacts of Geographic Access to Clinics 
Journal of public economics  2013;102:51-69.
A large body of evidence indicates that conditions in-utero and health at birth matter for individuals’ long-run outcomes, suggesting potential value in programs aimed at pregnant women and young children. This paper uses a novel identification strategy and data from birth and administrative records over 2005–2009 to provide causal estimates of the effects of geographic access to the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). My empirical approach uses within-ZIP-code variation in WIC clinic presence together with maternal fixed effects, and accounts for the potential endogeneity of mobility, gestational-age bias, and measurement error in gestation. I find that access to WIC increases food benefit take-up, pregnancy weight gain, birth weight, and the probability of breastfeeding initiation at the time of hospital discharge. The estimated effects are strongest for mothers with a high school education or less, who are most likely eligible for WIC services.
doi:10.1016/j.jpubeco.2013.03.009
PMCID: PMC3772681  PMID: 24043906
WIC; health at birth; pregnancy; public programs; low-income women and children
7.  Using linked program and birth records to evaluate coverage and targeting in Tennessee's WIC program. 
Public Health Reports  1991;106(2):176-181.
Public health nutrition programs are intended to serve low-income families who are at greater nutritional risk than the general population. Not all persons who are program-eligible are at equal risk, however. It would be desirable to evaluate a program's ability to enroll persons from higher risk backgrounds in the population (coverage) and, conversely, the extent to which those enrolled in this program are at higher risk (targeting). A method for the evaluation of coverage and targeting was developed using data from the Tennessee Women, Infants, and Children Special Supplemental Food Program (WIC) linked with birth certificates. The linked computer file was created by matching the name and date of birth in both record files. The birth records were the common source of information used to characterize the risk background for both the WIC and non-WIC participants. Maternal sociodemographic information on the birth records was used to define the health risk background of each child. The coverage and targeting of "at-risk" children were computed and compared for 50 counties or county-aggregates in Tennessee. Considerable variation in the coverage and targeting rates of at-risk children was observed among Tennessee counties, although the counties within each WIC administrative region tended to have similar coverage and targeting patterns. Using the existing data in linked program and vital records provides a direct evaluation of a program. Coverage and targeting evaluation can be used to detect underserved populations within small geographic areas.
PMCID: PMC1580230  PMID: 1902310
8.  Effects of Reduced Juice Allowances in Food Packages for the Women, Infants, and Children Program 
Pediatrics  2013;131(5):919-927.
OBJECTIVES:
In 2009, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) implemented revisions to the composition and quantities of WIC food packages. Juice allowances were reduced by approximately half. This report describes changes in purchases of 100% juice and other beverages among WIC participants after the WIC revisions.
METHODS:
Scanner data from a New England supermarket chain were used to assess juice and other beverage purchases among 2137 WIC-participating households during a 2-year period (N = 36 051 household-months). Purchased beverage amounts were compared before (January–September 2009) and after (January–September 2010) implementation of the revised WIC packages. Generalized estimating equation models were used.
RESULTS:
Before the revisions, WIC juice accounted for two-thirds of purchased juice volume among WIC households. After implementation of the revisions, WIC juice purchases were reduced on par with allowance changes (43.5% of juice volume, 95% confidence interval [CI] 41.9%–45.1%). This reduction was only partly compensated for by an increase of 13.6% (8.4%–19.0%) in juice purchases using personal and other non-WIC funds. In total, juice purchases declined by 23.5% (21.4%–25.4%) from an adjusted monthly total of 238 oz to 182 oz per household. WIC households increased purchases of fruit drinks by 20.9% (14.9%–27.3%) and other noncarbonated beverages by 21.3% (12.1%–31.2%) but purchased 12.1% (8.1%–15.0%) less soft drinks.
CONCLUSIONS:
After the WIC revisions, total purchases of 100% juice among WIC households declined by about a quarter, with little compensation occurring from non-WIC funds for juice and other beverages. The public health impact of the shift in beverage purchase patterns could be significant.
doi:10.1542/peds.2012-3471
PMCID: PMC4074658  PMID: 23629613
food assistance; WIC; juice; food policy
9.  Early Exclusive Breastfeeding and Maternal Attitudes Towards Infant Feeding in a Population of New Mothers in San Francisco, California 
Breastfeeding Medicine  2010;5(1):9-15.
Abstract
Background
Positive parental attitudes towards infant feeding are an important component in child nutritional health. Previous studies have found that participants in the Special Supplemental Women, Infants, and Children (WIC) Program have lower breastfeeding rates and attitudes that do not contribute towards healthy infant feeding in spite of breastfeeding and nutrition education programs targeting WIC participants. The objective of this study was to assess the frequency of exclusive breastfeeding in the early postpartum period and maternal attitudes towards breastfeeding in a population of mothers at two San Francisco hospitals and in relation to WIC participation status.
Methods
We interviewed women who had recently delivered a healthy newborn using a structured interview.
Results
A high percentage (79.8%) of our sample was exclusively breastfeeding at 1–4 days postpartum. We did not find any significant differences in rates of formula or mixed feeding by WIC participant status. Independent risk factors for mixed or formula feeding at 1–3 days postpartum included Asian/Pacific Islander ethnicity (odds ratio [OR] 2.90, 95% confidence interval [CI] 1.17–7.19). Being a college graduate was associated with a decreased risk of formula/mixed feeding (OR 0.28, 95% CI 0.10–0.79). We also found that thinking breastfeeding was physically painful and uncomfortable was independently associated with not breastfeeding (OR 1.41, 95% CI 1.06–1.89).
Conclusions
Future studies should be conducted with Asian-Americans and Pacific Islanders to better understand the lower rates of exclusive breastfeeding in this population and should address negative attitudes towards breastfeeding such as the idea that breastfeeding is painful or uncomfortable.
doi:10.1089/bfm.2009.0003
PMCID: PMC2936253  PMID: 19772374
10.  Psychiatric Disorders and Treatment in Low-Income Pregnant Women 
Journal of Women's Health  2010;19(7):1251-1262.
Abstract
Aims
This study estimated the prevalence of twenty-two 12-month and lifetime psychiatric disorders in a sample of 744 low-income pregnant women and the frequency that women with psychiatric disorders received treatment.
Method
To identify psychiatric disorders, the Diagnostic Interview Schedule (DIS) was administered to Medicaid or Medicaid-eligible pregnant women enrolled in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC). The sample was stratified by the rural or urban location of the WIC sites in southeastern Missouri and the city of St. Louis. Eligible women were enrolled at each site until their numbers were proportional to the racial distribution of African American and Caucasian pregnant women served there.
Results
The 12-month prevalence of one or more psychiatric disorders was 30.9%. Most common were affective disorders (13.6%), particularly major depressive disorder (8.2%) and bipolar I disorder (5.2%). Only 24.3% of those with a psychiatric disorder reported that they received treatment in the past year. Lifetime prevalence of at least one disorder was 45.6%, with affective disorders being the most frequent (23.5%). Caucasian women were more likely than African Americans to have at least one 12-month disorder, with the difference largely accounted for by nicotine dependence. Higher prevalence of lifetime disorders was also found in Caucasian women, particularly affective disorders and substance use disorders. There were no differences in the prevalence of 12-month or lifetime psychiatric disorders by the urban or rural residence of subjects.
Conclusions
With nearly one third of pregnant women meeting criteria for a 12-month psychiatric disorder and only one fourth receiving any type of mental health treatment, comprehensive psychiatric screening during pregnancy is needed along with appropriate treatment.
doi:10.1089/jwh.2009.1854
PMCID: PMC2940455  PMID: 20524895
11.  A Randomized Controlled Community-Based Trial to Improve Breastfeeding Rates Among Urban Low-Income Mothers 
Academic pediatrics  2009;10(1):14.
Objective
The purpose of this study was to assess whether providing a breastfeeding support team (BST) results in higher breastfeeding rates at 6, 12, and 24 weeks postpartum among urban low-income mothers.
Methods
Design: A randomized controlled trial with mother-infant dyads recruited from two urban hospitals. Participants: Breastfeeding mothers of full term infants who were eligible for Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) (n=328) were randomized to intervention (n=168) or usual care group (n=160). Intervention: The 24 week intervention included hospital visits by a breastfeeding support team (BST), home visits, telephone support, and 24 hour pager access. The usual care group received standard care. Outcome Measure: Breastfeeding status was assessed by self report at 6, 12, and 24 weeks postpartum.
Results
There were no differences in the sociodemographic characteristics between the groups: 87% were African American, 80% single, and 51% primiparous. Compared to the usual care group, more women reported breastfeeding in the intervention at 6 weeks postpartum, 66.7% vs. 56.9% OR 1.71 (95% CI 1.07, 2.76). The difference in rates at 12 weeks postpartum, 49.4% versus 40.6%, and 24 weeks postpartum, 29.2% versus 28.1%, were not statistically significant.
Conclusions
The intervention group was more likely to be breastfeeding at six weeks postpartum compared with usual care group, a time that coincided with the most intensive part of the intervention.
doi:10.1016/j.acap.2009.07.005
PMCID: PMC2818063  PMID: 19854119
breastfeeding; low-income mothers; randomized controlled trial; community intervention
12.  A proposal for detecting and managing gestational diabetes by coordinating existing services. 
Public Health Reports  1986;101(1):94-97.
A significant improvement in the quality of births by low-income women can be achieved by implementing a low-cost screening procedure and by coordinating private and public sector services that these women may already be receiving. This proposal outlines a screening program for gestational diabetes, coupled with multidisciplinary team management of this disorder through cooperative efforts of private sector medical practitioners and the public sector nutrition program for Women, Infants, and Children (WIC). The investment in this proposal is catalytic: the long-term intent is to persuade those in the medical community in the targeted geographic area to adopt the screening procedure and coordination with the WIC Program as a standard part of their prenatal care. If this proposed program is successful, it could be replicated in other parts of the country.
PMCID: PMC1477655  PMID: 3080799
13.  The impact of the April 1992 civil unrest on the Los Angeles REI WIC program and its participants. 
Public Health Reports  1994;109(5):606-614.
This paper discusses the findings of a study conducted in south central Los Angeles in August 1992 among women in the Special Supplemental Food Program for Women, Infants, and Children. The goals of the study were to determine the current demographics of WIC participants; examine the financial hardship, need for relief services, and extent of hunger resulting from the civil unrest of April 1992; look at the effects of the unrest on different ethnic groups; determine the unmet need for WIC services; and evaluate the State and local WIC responses to the unrest. The 1,189 respondents were approximately 77 percent Latina, 20 percent African American, and 3 percent white. Half or more were recent immigrants, 19 percent were pregnant and parenting adolescents, 74 percent were school dropouts, and 56 percent were single mothers. Only 1 percent had any problems using WIC vouchers after the unrest, although more than half of their grocery stores had closed. Thirty-five percent experienced food deficits in their households, and 33 percent of those who applied for emergency food stamps had trouble getting them. Four percent said their children had gone to bed hungry in the last week, and 9 percent said they, the respondents, had as well. Only 2 percent needed shelter, and 1 percent became homeless, but 6 percent had family members who lost jobs due to the unrest. This study suggests that the chronically substandard conditions under which many families in south central Los Angeles live affect them more profoundly than did the dramatic consequences of the civil unrest.
PMCID: PMC1403547  PMID: 7938380
14.  Cognitive measure stability in siblings following early nutritional supplementation. 
Public Health Reports  1985;100(6):656-662.
Cognitive data were obtained on 19 of the 21 pairs of siblings who had been in the authors' earlier study of behavioral outcomes associated with participation in the Special Supplemental Food Program for Women, Infants, and Children (WIC). The timing of WIC participation differed for the members of the sibling pairs, beginning in the perinatal period for one sibling and after 1 year of age for the other. The perinatally supplemented siblings received WIC services for an average of 22 months longer than the siblings whose supplementation began at 1 year of age. The present study determined that enhancements in IQ scores proved stable on blind retesting 32 months after the original study, with those siblings who were supplemented perinatally (and for a longer duration) continuing to exhibit higher scores. The group differences in school grade point averages were in the expected direction at followup, but fell short of statistical significance.
PMCID: PMC1425315  PMID: 3934703
15.  Feasibility of Increasing Childhood Outdoor Play and Decreasing Television Viewing Through a Family-Based Intervention in WIC, New York State, 2007-2008 
Preventing Chronic Disease  2011;8(3):A54.
Introduction
Active Families is a program developed to increase outdoor play and decrease television viewing among preschool-aged children enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Our objective was to assess its feasibility and efficacy.
Methods
We implemented Active Families in a large WIC clinic in New York State for 1 year. To this end, we incorporated into WIC nutrition counseling sessions a community resource guide with maps showing recreational venues. Outcome measures were children's television viewing and time playing outdoors and parents' behaviors (television viewing, physical activity), self-efficacy to influence children's behaviors, and parenting practices specific to television viewing. We used a nonpaired pretest and posttest design to evaluate the intervention, drawing on comparison data from 3 matched WIC agencies.
Results
Compared with the children at baseline, the children at follow-up were more likely to watch television less than 2 hours per day and play outdoors for at least 60 minutes per day. Additionally, parents reported higher self-efficacy to limit children's television viewing and were more likely to meet physical activity recommendations and watch television less than 2 hours per day.
Conclusion
Results suggest that it is feasible to foster increased outdoor play and reduced television viewing among WIC-enrolled children by incorporating a community resource guide into WIC nutrition counseling sessions. Future research should test the intervention with a stronger evaluation design in multiple settings, with more diverse WIC populations, and by using more objective outcome measures of child behaviors.
PMCID: PMC3103559  PMID: 21477494
16.  How Pregnant African-American Women View Pregnancy Weight Gain 
Objective
To gain insight into how low-income, pregnant African-American women viewed their weight gain while pregnant and how they managed their weight during pregnancy.
Design
Descriptive study using three focus groups.
Setting
Women were recruited from urban prenatal care sites and the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) services in a medium-sized urban Northeastern city.
Participants
Twenty-six adult, low-income, pregnant African-American women, aged 18–39; the majority were within the first 20 weeks of pregnancy.
Methods
Three focus groups were conducted utilizing open-ended questions related to pregnancy weight gain. Content analysis was used to analyze the verbatim transcripts. Analysis focused on meaning, intention and context. Groups were compared and contrasted at the within and between group levels to identify themes.
Results
Four themes were identified that provided insight into how women viewed their pregnancy weight gain and managed weight gain during pregnancy: (a) pregnancy weight gain: no matter how much means a healthy baby; (b) weight retention: it happens; (c) there is a limit: weight gain impact on appearance; and (d) watching and waiting: plans for controlling weight.
Conclusion
Low-income African-American women, though cognizant of the likelihood of retention of weight following pregnancy, are not focused on limiting their gestational weight gain. The cultural acceptance of a larger body size along with the belief that gaining more weight is indicative of a healthy infant present challenges for interventions to limit excessive gestational weight gain.
doi:10.1111/j.1552-6909.2012.01391.x
PMCID: PMC3473094  PMID: 22789036
pregnancy; gestational weight gain; African-American women; focus groups
17.  Validity of child anthropometric measurements in the Special Supplemental Nutrition Program for Women, Infants and Children 
Pediatric Research  2012;71(3):286-292.
The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) serves 50% of infants and 25% of preschool-aged children in the U.S. and collects height and weight measurements from eligible children every six months, making WIC data a valuable resource for studying childhood growth and obesity. We assessed the accuracy of measurements collected by WIC staff by comparing them to “gold standard” measurements collected by trained research staff. At seven WIC clinics in southern California, 287 children ages 2–5 years measured by WIC staff using WIC standard protocol were re-measured by research staff using a research protocol (duplicate measurements with shoes and outerwear removed taken by trained personnel). Intraclass correlation coefficients measuring agreement between WIC and research protocol measurements for height, weight and body mass index (BMI) were 0.96, 0.99 and 0.93, respectively. Although WIC measurements overestimated height by 0.6 cm and weight by 0.05 kg on average, BMI was underestimated by only 0.15 kg/m2 on average. WIC BMI percentiles classified children as overweight/obese versus underweight/normal with 86% sensitivity and 92% specificity. We conclude that height, weight and BMI measurements of children aged 2–5 years collected by trained WIC staff are sufficiently accurate for monitoring and research purposes.
doi:10.1038/pr.2011.37
PMCID: PMC3282987  PMID: 22337260
18.  WIC's promotion of infant formula in the United States 
Background
The United States' Special Supplemental Nutrition Program for Women, Infants and Children (WIC) distributes about half the infant formula used in the United States at no cost to the families. This is a matter of concern because it is known that feeding with infant formula results in worse health outcomes for infants than breastfeeding.
Discussion
The evidence that is available indicates that the WIC program has the effect of promoting the use of infant formula, thus placing infants at higher risk. Moreover, the program violates the widely accepted principles that have been set out in the International Code of Marketing of Breast-milk Substitutes and in the human right to adequate food.
Summary
There is no good reason for an agency of government to distribute large quantities of free infant formula. It is recommended that the large-scale distribution of free infant formula by the WIC program should be phased out.
doi:10.1186/1746-4358-1-8
PMCID: PMC1481608  PMID: 16722534
19.  Impact of education and training on type of care provided by community-based breastfeeding counselors: a cross-sectional study 
Background
Studies using community-based breastfeeding counselors (CBBCs) have repeatedly shown positive impact on breastfeeding initiation, exclusivity and duration, particularly among low-income mothers. To date, there has not been a comprehensive study to determine the impact of CBBC attributes such as educational background and training, on the type of care that CBBCs provide.
Methods
This was a cross-sectional study of a convenience sample of CBBCs to ascertain the influence of counselor education and type of training on type of support and proficiency of CBBCs in communities across the United States. Invitations to participate in this online survey of CBBCs were e-mailed to program coordinators of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), La Leche League, and other community-based health organizations, who in turn invited and encouraged their CBBCs to participate. Descriptive analysis was used to describe participants (N = 847), while bivariate analysis using χ2 test was used to examine the differences between CBBC education, training received and breastfeeding support skills used. Multivariate logistic regression was used to assess the independent determinants of specific breastfeeding support skills.
Results
The major findings from the research indicate that overall, educational attainment of CBBCs is not a significant predictor for the curriculum used in their training and type of support skills used during counseling sessions, but initial training duration was positively associated with the use of many breastfeeding support skills. Another major influence of counselor support to clients is the type of continuing education they receive after their initial training, with higher likelihood of use of desirable support skills associated with counselors continuing their breastfeeding education at conferences or trainings away from their job sites.
Conclusions
Our results show that different programs use different training curricula to train their CBBCs varying in duration and content. Counselor education is not a significant predictor of the type of training they receive. Continuing breastfeeding education is a significant determinant of type of counseling techniques used with clients. Further research is therefore needed to critically examine the content of the various training curricula of CBBC programs. This may show a need for a standardized training curriculum for all CBBC programs worldwide to make CBBCs more proficient and efficient, ensuring successful and optimum breastfeeding experiences for mothers and their newborns.
doi:10.1186/1746-4358-6-12
PMCID: PMC3177880  PMID: 21871062
20.  Progress on key issues in maternal nutrition 
Public Health Reports  1987;102(4 Suppl):50-52.
Great progress on key issues in maternal nutrition has been made in the past few years, mainly because of the legislative requirements of the U.S. Department of Agriculture's Special Supplemental Food Program for Women, Infants, and Children (WIC Program). These advances are most timely because of the general recognition that, in this period of finite resources, we will need to make optimal use of resources such as the food package, nutrition education, and health services that together make up the WIC Program benefits. Major progress has been made in the following critical areas: (a) agreement on nutritional risk criteria; (b) identification of dietary risk factors; (c) increased availability of a variety of computer-assisted techniques for collecting, managing, and analyzing dietary intakes on large numbers of patients; and (d) recognition of the need for and availability of a variety of alternative dietary standards in the provision of overall services to pregnant women.
Of even greater importance is the recognition that we can no longer treat nutrition as a single variable, independent of the many other forces that together influence the course and outcome of a pregnancy. Rather, we recognize that there is a seamless web of influences, all of which need to be taken into account in attempts to provide for the needs of pregnant women at risk of poor pregnancy outcomes.
The timely application of all of these advances will greatly facilitate a more efficient and effective use of resources such as are provided by the WIC Program. They will also provide both the patients and their health care providers with more realistic expectations of what might be accomplished towards improving the outcomes of pregnancies at nutritional risk.
PMCID: PMC1478053  PMID: 16156081
21.  Factors Associated With Breastfeeding Duration Among Connecticut Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Participants 
This retrospective study aimed to identify factors associated with breastfeeding duration among women enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) of Hartford, Connecticut. The authors included mothers whose children were younger than 5 years and had stopped breastfeeding (N = 155). Women who had planned their pregnancies were twice as likely as those who did not plan them to breastfeed for more than 6 months (odds ratio, 2.15; 95% confidence interval, 1.00–4.64). One additional year of maternal age was associated with a 9% increase on the likelihood of breastfeeding for more than 6 months (odds ratio, 1.09; 95% confidence interval, 1.02–1.17). Time in the United States was inversely associated with the likelihood of breastfeeding for more than 6 months (odds ratio, 0.96; 95% confidence interval, 0.92–0.99). Return to work, sore nipples, lack of access to breast pumps, and free formula provided by WIC were identified as breastfeeding barriers. Findings can help WIC improve its breastfeeding promotion efforts.
doi:10.1177/0890334410365067
PMCID: PMC3131548  PMID: 20689103
acculturation; breastfeeding; pregnancy intention; support system; Special Supplemental Nutrition Program for Women; Infants; Children (WIC)
22.  Translation of the diabetes prevention program lifestyle intervention for promoting postpartum weight loss among low-income women 
ABSTRACT
The Women Infants and Children (WIC) program is a promising venue in which to implement weight loss interventions for low-income postpartum women. The goals of this study were to describe formative steps to translate the DPP lifestyle intervention to be delivered to diverse low-income postpartum women who are served by the WIC program, and to present the results of a pilot trial of the intervention. The steps of intervention translation involved were the following: (1) building partnerships, (2) understanding the target setting, (3) understanding the target population, (4) re-designing the intervention, and (5) refining the intervention. The pilot trial was a single group pre/post test comparison among 27 overweight/obese postpartum WIC clients. The intervention resulted in an average weight loss of 4.6 lb at a 4-month follow-up (p = 0.004). A dose–response association between intervention attendance and weight loss was observed. This translation of the DPP for diverse low-income postpartum women has potential for widespread implementation.
doi:10.1007/s13142-011-0069-4
PMCID: PMC3717665  PMID: 24073075
Weight loss; Health disparities; Intervention; Translational research
23.  Comparing Farmers’ Market Revenue Trends Before and After the Implementation of a Monetary Incentive for Recipients of Food Assistance 
Introduction
We examined the influence of an intervention to increase fruit and vegetable purchases at farmers’ markets for recipients of food assistance, Shop N Save (SNS), on revenue trends at a farmers’ market located at a federally qualified health center (FQHC) in rural South Carolina. We compared revenue trends for 20 weeks before the intervention (2011) and 20 weeks after (2012).
Methods
SNS provided one $5 monetary incentive per week to customers spending $5 or more in food assistance at the farmers’ market. SNS was available to any farmers’ market customer using Supplemental Nutrition Assistance Program (SNAP), Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and/or Senior or WIC Farmers’ Market Nutrition Program (FMNP) vouchers. Sales receipts were recorded for each transaction at the farmers’ market to document payment type and the cost of the purchase. All SNS participants completed a one-time enrollment survey.
Results
A total of 336 customers self-enrolled in SNS from June through October 2012. Most SNS participants were female, African American, and patients at the FQHC. In total, the use of all forms of food assistance (SNAP, WIC, and FMNP) at the farmers’ market increased significantly after the intervention (from 10% before, to 25% after, P = .003). Senior FMNP vouchers and SNAP usage increased the most.
Conclusion
Interventions that provide incentives to recipients of food assistance programs at farmers’ markets are a viable strategy for increasing food assistance usage and revenue.
doi:10.5888/pcd11.130347
PMCID: PMC4032058  PMID: 24854238
24.  Use of Farmers Markets by Mothers of WIC Recipients, Miami-Dade County, Florida, 2011 
Introduction
Farmers market-based interventions, including the Farmers’ Market Nutrition Program of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), represent a promising strategy for improving dietary behaviors in low-income communities. Little is known, however, about the health-related characteristics of low-income parents who frequent farmers markets in urban settings. The objective of this study was to examine the relationship between family-health factors and the use of farmers markets by mothers of WIC recipients.
Methods
We recruited a convenience sample of mothers of children seeking care at a primary care clinic in a large urban public hospital in Miami, Florida, in 2011 (n = 181 total). The clinic was adjacent to a newly established farmers market at the hospital. Each mother completed an interviewer-administered survey that included self-reported measures of maternal and child health, acculturation, dietary behaviors, food insecurity, and use of farmers markets.
Results
Reported use of farmers markets was independently associated with maternal history of diabetes (odds ratio [OR], 6.9; 95% confidence interval [CI], 1.3–38.3) and increased maternal vegetable (but not fruit) consumption (OR, 3.5; 95% CI, 1.5–8.1). Intended future use of farmers markets was independently associated with being unemployed (OR, 2.4; 95% CI, 1.0–5.7), increased maternal vegetable consumption (OR, 2.5; 95% CI, 1.1–5.7), and food insecurity (OR, 3.6; 95% CI, 1.3–10.3).
Conclusions
This study provides a snapshot of factors associated with farmers market use in a diverse population of urban low-income families. Understanding these factors may inform public health approaches to increase fresh fruit and vegetable consumption in communities at high risk for preventable chronic conditions.
doi:10.5888/pcd10.120178
PMCID: PMC3684356  PMID: 23764344
25.  Paging “Dr. Google”: Does Technology Fill the Gap Created by the Prenatal Care Visit Structure? Qualitative Focus Group Study With Pregnant Women  
Background
The prenatal care visit structure has changed little over the past century despite the rapid evolution of technology including Internet and mobile phones. Little is known about how pregnant women engage with technologies and the interface between these tools and medical care, especially for women of lower socioeconomic status.
Objective
We sought to understand how women use technology during pregnancy through a qualitative study with women enrolled in the Women, Infants, and Children (WIC) program.
Methods
We recruited pregnant women ages 18 and older who owned a smartphone, at a WIC clinic in central Pennsylvania. The focus group guide included questions about women’s current pregnancy, their sources of information, and whether they used technology for pregnancy-related information. Sessions were audiotaped and transcribed. Three members of the research team independently analyzed each transcript, using a thematic analysis approach. Themes related to the topics discussed were identified, for which there was full agreement.
Results
Four focus groups were conducted with a total of 17 women. Three major themes emerged as follows. First, the prenatal visit structure is not patient-centered, with the first visit perceived as occurring too late and with too few visits early in pregnancy when women have the most questions for their prenatal care providers. Unfortunately, the educational materials women received during prenatal care were viewed as unhelpful. Second, women turn to technology (eg, Google, smartphone applications) to fill their knowledge gaps. Turning to technology was viewed to be a generational approach. Finally, women reported that technology, although frequently used, has limitations.
Conclusions
The results of this qualitative research suggest that the current prenatal care visit structure is not patient-centered in that it does not allow women to seek advice when they want it most. A generational shift seems to have occurred, resulting in pregnant women in our study turning to the Internet and smartphones to fill this gap, which requires significant skills to navigate for useful information. Future steps may include developing interventions to help health care providers assist patients early in pregnancy to seek the information they want and to become better consumers of Internet-based pregnancy resources.
doi:10.2196/jmir.3385
PMCID: PMC4060145  PMID: 24892583
qualitative research; prenatal care; pregnancy resources; Women, Infants, and Children Program; mhealth; mobile phones; smartphones; Internet; patient education; consumer health informatics

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