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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.  WIC (The Special Supplemental Nutrition Program for Women, Infants, and Children): Policy versus practice regarding breastfeeding 
Nursing outlook  2013;61(6):466-470.
The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides foods, education, and referrals to participants who are considered to be at nutritional risk. The outreach of the program is impressive, and nearly 9.17 million people participated in the program in 2010. WIC participation is associated with many positive outcomes, including improved birthweights and childhood dietary practices. Despite these benefits, WIC mothers experience lower breastfeeding rates when compared with demographically similar women who do not participate in the WIC program. According to WIC, “A breastfeeding mother and her infant shall be placed in the highest priority level.” Despite this statement and others that support breastfeeding, WIC allocates only 0.6% of its budget toward breastfeeding initiatives. Formula expenses accounted for 11.6% ($850 million) of WIC’s 2009 expenses. The inconsistency between WIC’s policies that encourage breastfeeding vs. practices that favor formula begs further examination. Research shows consistent success with peer counseling programs among WIC participants; however, little money is budgeted for these programs. Rebates included, WIC spends 25 times more on formula than on breastfeeding initiatives. The American Academy of Nursing Expert Panel on Breastfeeding is calling for a re-evaluation of how these taxpayer dollars are spent. Additionally, the American Academy of Nursing recommends a shift from formula bargaining to an investment in structured peer counseling programs. All WIC programs should offer peer counseling support services that encourage breastfeeding and meet the needs of the families they serve.
doi:10.1016/j.outlook.2013.05.010
PMCID: PMC4355911  PMID: 23993250
WIC; Breastfeeding; Peer counseling; Formula
3.  Insights in Public Health 
The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) is a proven, cost-effective investment in strengthening families. As part of the United States Department of Agriculture's (USDA) 15 federal nutrition assistance programs for the past 40 years, WIC has grown to be the nation's leading public health nutrition program. WIC serves as an important first access point to health care and social service systems for many limited resource families, serving approximately half the births in the nation as well as locally. By providing nutrition education, breastfeeding promotion and foods in addition to referrals, WIC plays a crucial role in promoting lifetime health for women, infants and children. WIC helps achieve national public health goals such as reducing premature births and infant mortality, increasing breastfeeding, and reducing maternal and childhood overweight. Though individuals and families can self-refer into WIC, physicians and allied health professionals have the opportunity and are encouraged to promote awareness of WIC and refer families in their care.
PMCID: PMC4174695  PMID: 25285258
4.  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
5.  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
6.  Prenatal participation in WIC related to Medicaid costs for Missouri newborns: 1982 update. 
Public Health Reports  1986;101(6):607-615.
This study replicates a 1980 evaluation of WIC prenatal participation in Missouri by using a file of 9,086 Missouri Medicaid records matched with the corresponding birth records. This file was divided into a WIC group containing 3,261 records and a non-WIC group of 5,825 records. The 1982 results generally confirm the 1980 results, with the 1982 findings showing slightly improved pregnancy outcomes for WIC participants and slightly reduced benefit-to-cost ratios compared with the 1980 findings. In 1982, WIC participation was found to be associated with an increase in mean birth weight of 31 grams and reductions in low birth weight rates (statistically significant) and in neonatal death rates (not statistically significant). The reduction in each rate was 23 percent. WIC participation was also associated with a reduction in Medicaid costs for newborns reported within 45 days of birth amounting to $76 per participant. For every dollar spent on WIC, about 49 cents in Medicaid costs were apparently saved. However, wide 95 percent confidence intervals ($.07, $.90) make it difficult to determine precisely what impact WIC has on Federal and State budget outlays.
PMCID: PMC1477679  PMID: 3097741
7.  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
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.  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
10.  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
11.  Evaluating the Initial Impact of the Revised Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Food Packages on Dietary Intake and Home Food Availability in African American and Hispanic Families 
Public health nutrition  2013;17(1):83-93.
OBJECTIVE
The present study assessed the impact of the 2009 food packages mandated by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) on dietary intake and home food availability in low-income African American and Hispanic parent/child dyads.
DESIGN
A natural experiment was conducted to assess if the revised WIC food package altered dietary intake, home food availability, weight, and various lifestyle measures immediately (6 months) following policy implementation.
SETTING
12 WIC clinics in Chicago, USA.
SUBJECTS
273, 2–3 year old Hispanic and African American children enrolled in WIC and their mothers
RESULTS
Six months after the WIC food package revisions were implemented, we observed modest changes in dietary intake. Fruit consumption increased among Hispanic mothers (mean=0.33 servings/d, p=.04), and low-fat dairy intake increased among Hispanic mothers (0.21 servings/d, p=.02), Hispanic children (0.34 servings/d, p<.001), and African American children (0.24 servings/d, p=.02). Home food availability of low fat dairy and whole grains also increased. Dietary changes, however, varied by racial/ethnic group. Changes in home food availability were not significantly correlated with changes in diet.
CONCLUSIONS
The WIC food package revisions are one of the first efforts to modify the nutrition guidelines that govern foods provided in a federal food and nutrition assistance program. It will be important to examine the longer term impact of these changes on dietary intake and weight status.
doi:10.1017/S1368980013000761
PMCID: PMC3858404  PMID: 23544992
dietary behaviors; minority groups; food assistance; nutrition policy; obesity
12.  Impact of the Revised Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Food Package Policy on Fruit and Vegetable Prices 
Obesity is generally inversely related to income among women in the United States. Less access to healthy foods is one way lower income can influence dietary behaviors and body weight. Federal food assistance programs, such as the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), are an important source of healthy food for low-income populations. In 2009, as part of a nationwide policy revision, WIC added a fruit and vegetable (F/V) voucher to WIC food packages. This quasi-experimental study determined whether F/V prices at stores authorized to accept WIC (ie, WIC vendors) decreased after the policy revision in seven Illinois counties. It also examined cross-sectional F/V price variations by store type and neighborhood characteristics. Two pre-policy observations were conducted in 2008 and 2009; one post-policy observation was conducted in 2010. Small pre- to post-policy reductions in some F/V prices were found, particularly for canned fruit and frozen vegetables at small stores. Compared with chain supermarkets, mass merchandise stores had lower prices for fresh F/V and frozen F/V and small stores and non-chain supermarkets had higher canned and frozen F/V prices, but lower fresh F/V prices. Limited price differences were found across neighborhoods, although canned vegetables were more expensive in neighborhoods with higher concentrations of either Hispanics or blacks and fresh F/V prices were lower in neighborhoods with more Hispanics. Results suggest the WIC policy revision contributed to modest reductions in F/V prices. WIC participants’ purchasing power can differ depending on the type and neighborhood of the WIC vendor used.
doi:10.1016/j.jand.2013.08.003
PMCID: PMC4084875  PMID: 24183996
Special Supplemental Nutrition Program for Women; Infants; and Children (WIC); Food policy; Food environment; Food prices; Food assistance
13.  Weighing costs and benefits of adequate prenatal care for 12,023 births in Missouri's Medicaid program, 1988. 
Public Health Reports  1992;107(6):647-652.
Numerous studies have shown that the receipt of adequate prenatal care is associated with improvements in pregnancy outcome, particularly a reduction in the risk of low birth weight. Since medical costs for these low birth weight infants are several times higher than for normal birth weight infants, one would expect that medical costs for newborns would be lower for babies whose mothers have had adequate prenatal care than for those with inadequate prenatal care. Explored in this paper is whether the reduction in Medicaid costs for newborn and post-partum maternal care is greater than the increase in prenatal costs for a Medicaid population. The analysis used a file of 12,023 Missouri Medicaid records linked with the corresponding 1988 birth certificates. A modified version of the Kessner index was used to define the adequacy of prenatal care. Prenatal care costs were $233 higher for pregnancies with adequate prenatal care than for those in which prenatal care was inadequate. Newborn and post-partum costs starting within 60 days after the birth were $347 lower for the adequate prenatal care pregnancies, resulting in a savings of $1.49 for each extra $1 spent on prenatal care. Among the other factors studied in determining this benefit to cost ratio were global billing, Supplemental Food Program for Women, Infants, and Children (WIC), and participation in Medicaid under the expanded eligibility provisions that were effective in Missouri in 1988.
PMCID: PMC1403715  PMID: 1454976
14.  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
15.  A community based prevention of weight gain intervention (Mothers In Motion) among young low-income overweight and obese mothers: design and rationale 
BMC Public Health  2014;14:280.
Background
Over 45% of American women 20–39 years old are at risk for type 2 diabetes, cardiovascular disease, and other health conditions because they are overweight or obese. The prevalence of overweight and obesity is disproportionately high among low-income women. This paper describes the study design and rationale of a community based intervention (Mothers In Motion, MIM) aimed to prevent weight gain among low-income overweight and obese mothers18-39 years old by promoting stress management, healthy eating, and physical activity.
Methods/Design
Peer recruiters approach participants from 5 Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in Michigan. The MIM delivers theory-based, culturally-sensitive intervention messages via a combination of DVDs and peer support group teleconferences (PSGTs). The DVD features African American and white overweight and obese WIC mothers who participated in a healthy lifestyle intervention patterned after MIM. The PSGTs are led by paraprofessionals from Michigan State University Extension and WIC providers in Michigan who are trained in motivational interviewing and group facilitation skills. Participants are randomly assigned to an intervention (n = 350) or comparison group (n = 175). The intervention group receives a 16-week intervention on a weekly or bi-weekly basis. Participants are asked to watch 10 MIM DVD chapters at home and join 10 PSGT sessions by phone. The comparison group receives printed educational materials. The primary outcome is body weight. Secondary outcomes include dietary fat, fruit, and vegetable intake; physical activity; stress, and affect. Mediators are self-efficacy, emotional coping response, social support, and autonomous motivation. Telephone interviews and in-person data collection at WIC offices occur at 3 time points: baseline, immediately, and 3 months after the 16-week intervention.
Discussion
If MIM shows effectiveness, it could have a favorable impact on public health and community programs. The DVDs and PSGTs will be disseminated in WIC, Extension, clinical practice that promote healthy lifestyles for similar target audiences to make a broad contribution to the prevention of weight gain in low-income mothers. Also, our methodology can be adapted by researchers and community stakeholders to help other low-income populations prevent weight gain.
Trial registration
Clinical Trials Number: NCT01839708.
doi:10.1186/1471-2458-14-280
PMCID: PMC3987655  PMID: 24666633
Obesity prevention; Stress management; Healthy eating; Physical activity; Low-income women
16.  The 18-Month Impact of Special Supplemental Nutrition Program for Women, Infants, and Children Food Package Revisions on Diets of Recipient Families 
Background
Beginning in 2009, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) revised its food packages and provided more whole grains, fruits, and vegetables, and fewer foods with high saturated fat content. However, knowledge of the impact of this policy shift on the diets of WIC participants remains limited.
Purpose
To examine the longer-term impact of the 2009 WIC food package change on nutrient and food group intake and overall diet quality among African American and Hispanic WIC child participants and their mothers/caregivers.
Methods
In this natural experiment, 24-hour dietary recalls were collected in the summer of 2009, immediately before WIC food package revisions occurred in Chicago, Illinois, and at 18 months following the food package change (winter/spring 2011). Generalized estimating equation models were used to compare dietary intake at these two time points. Data were analyzed in July 2013.
Results
Eighteen months following the WIC food package revisions, significant decreases in total fat (p=0.002) and saturated fat (p=0.0004) and increases in dietary fiber (p=0.03), and overall diet quality (p=0.02) were observed among Hispanic children only. No significant changes in nutrient intake or diet quality were observed for any other group. The prevalence of reduced-fat milk intake significantly increased for African American and Hispanic children, whereas the prevalence of whole milk intake significantly decreased for all groups.
Conclusions
Positive dietary changes were observed at 18-months post-policy implementation, with the effects most pronounced among Hispanic children.
doi:10.1016/j.amepre.2014.01.021
PMCID: PMC4028606  PMID: 24842730
17.  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
18.  Assessing the Validity and Reliability of Three Indicators Self-Reported on the Pregnancy Risk Assessment Monitoring System Survey 
Public Health Reports  2013;128(6):527-536.
Objectives
We investigated the reliability and validity of three self-reported indicators from the Pregnancy Risk Assessment Monitoring System (PRAMS) survey.
Methods
We used 2008 PRAMS (n=15,646) data from 12 states that had implemented the 2003 revised U.S. Certificate of Live Birth. We estimated reliability by kappa coefficient and validity by sensitivity and specificity using the birth certificate data as the reference for the following: prenatal participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); Medicaid payment for delivery; and breastfeeding initiation. These indicators were examined across several demographic subgroups.
Results
The reliability was high for all three measures: 0.81 for WIC participation, 0.67 for Medicaid payment of delivery, and 0.72 for breastfeeding initiation. The validity of PRAMS indicators was also high: WIC participation (sensitivity = 90.8%, specificity = 90.6%), Medicaid payment for delivery (sensitivity = 82.4%, specificity = 85.6%), and breastfeeding initiation (sensitivity = 94.3%, specificity = 76.0%). The prevalence estimates were higher on PRAMS than the birth certificate for each of the indicators except Medicaid-paid delivery among non-Hispanic black women. Kappa values within most subgroups remained in the moderate range (0.40–0.80). Sensitivity and specificity values were lower for Hispanic women who responded to the PRAMS survey in Spanish and for breastfeeding initiation among women who delivered very low birthweight and very preterm infants.
Conclusion
The validity and reliability of the PRAMS data for measures assessed were high. Our findings support the use of PRAMS data for epidemiological surveillance, research, and planning.
PMCID: PMC3804096  PMID: 24179264
19.  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
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.  The influence of maternal health literacy and child’s age on participation in social welfare programs 
Maternal and child health journal  2014;18(5):1176-1189.
Objective
To determine the influence of maternal health literacy and child’s age on participation in social welfare programs benefiting children.
Methods
In a longitudinal prospective cohort study of 560 Medicaid-eligible mother-infant dyads recruited in Philadelphia, maternal health literacy was assessed using the Test of Functional Health Literacy in Adults (short version). Participation in social welfare programs (Temporary Assistance to Needy Families [TANF], Supplemental Nutrition Assistance Program [SNAP], Special Supplemental Nutrition Program for Women, Infants, and Children [WIC], child care subsidy, and public housing) was self-reported at child’s birth, and at the 6, 12, 18, 24 month follow-up interviews. Generalized estimating equations quantified the strength of maternal health literacy as an estimator of program participation.
Results
The mothers were primarily African-Americans (83%), single (87%), with multiple children (62%). Nearly 24% of the mothers had inadequate or marginal health literacy. Children whose mothers had inadequate health literacy were less likely to receive child care subsidy (adjusted OR= 0.54, 95% CI: 0.34–0.85) than children whose mothers had adequate health literacy. Health literacy was not a significant predictor for TANF, SNAP, WIC or housing assistance. The predicted probability for participation in all programs decreased from birth to 24 months. Most notably, predicted WIC participation declined rapidly after age one.
Conclusions
During the first 24 months, mothers with inadequate health literacy could benefit from simplified or facilitated child care subsidy application processes. Targeted outreach and enrollment efforts conducted by social welfare programs need to take into account the changing needs of families as children age.
doi:10.1007/s10995-013-1348-0
PMCID: PMC3938979  PMID: 23990157
health literacy; enrollment; social welfare programs
22.  The Effect of the WIC Program on the Health of Newborns 
Health Services Research  2010;45(4):1083-1104.
Objective
To determine the effect of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) on birth outcomes.
Data Source
The Child Development Supplement (CDS) of the Panel Study of Income Dynamics (PSID). The PSID provides extensive data on the income and well-being of a representative sample of U.S. families from 1968 to present. The CDS collects information on the children in PSID families ranging from cognitive, behavioral, and health status to their family and neighborhood environment. The first two waves of the CDS were conducted in 1997 and 2002, respectively. We use information on 3,181 children and their mothers.
Study Design
We use propensity score matching with multiple imputations to examine whether WIC program influences birth outcomes: birth weight, prematurity, maternal report of the infant's health, small for gestational age, and placement in the neonatal intensive care unit. Furthermore, we use a fixed-effects model to examine the above outcomes controlling for mother-specific unobservables.
Principal Findings
After using propensity scores to adjust for confounding factors, WIC shows no statistically significant effects for any of six outcomes. Fixed-effects models, however, reveal some effects that are statistically significant and fairly substantial in size. These involve preterm birth and birth weight.
Conclusions
Overall, the WIC program had moderate effects, but findings were sensitive to the estimation method used.
doi:10.1111/j.1475-6773.2010.01115.x
PMCID: PMC2910570  PMID: 20459450
WIC; birth outcomes; propensity score; multiple imputations; fixed-effects model
23.  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
24.  Use of Food Labels, Awareness of Nutritional Programs and Participation in the Special Supplemental Program for Women, Infants and Children (WIC): Results from the National Health and Nutrition Examination Survey (2005-6) 
Maternal & child nutrition  2011;9(3):299-308.
Background
Use of nutritional labels in choosing food is associated with healthier eating habits including lower fat intake. Current public health efforts have focused on the revamping of nutritional labels to make them easier to read and use for the consumer.
Objectives
To assess the frequency of use of nutritional labels and awareness of the United States Department of Agriculture (USDA) nutritional programs by women eligible and participating in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) as surveyed in the National Health and Nutrition Examination Survey (NHANES) 2005-6 .
Results
Many low-income women do not regularly use the nutrition facts panel information on the food label and less than half had heard of the United States Department of Agriculture’s (USDA) Dietary Guidelines for Americans (38.9%). In multivariate logistic regression, we found that WIC participation was associated with reduced use of the nutrition facts panel in choosing food products (OR 0.45, 95%CI 0.22-0.91), the health claims information (OR 0.54, 95%CI 0.32-0.28) and the information on carbohydrates when deciding to buy a product (OR 0.44, 95%CI 0.20-0.97) in comparison with WIC eligible non-participants.
Conclusions
Any intervention to improve use of nutritional labels and knowledge of the USDA’s nutritional programs needs to target low-income women, including WIC participants. Future studies should evaluate possible reasons for the low use of nutrition labels among WIC participants.
doi:10.1111/j.1740-8709.2011.00382.x
PMCID: PMC4008321  PMID: 22171961
25.  ‘Fit Moms/Mamás Activas’ internet-based weight control program with group support to reduce postpartum weight retention in low-income women: study protocol for a randomized controlled trial 
Trials  2015;16:59.
Background
High postpartum weight retention is a strong independent risk factor for lifetime obesity, cardiovascular disease, and type 2 diabetes in women. Interventions to promote postpartum weight loss have met with some success but have been limited by high attrition. Internet-based treatment has the potential to overcome this barrier and reduce postpartum weight retention, but no study has evaluated the effects of an internet-based program to prevent high postpartum weight retention in women.
Methods/Design
Fit Moms/Mamás Activas targets recruitment of 12 Women, Infants and Children (WIC) Supplemental Nutrition Program clinics with a total of 408 adult (>18 years), postpartum (<1 year) women with 14.5 kg or more weight retention or a body mass index of 25.0 kg/m2 or higher. Clinics are matched on size and randomly assigned within county to either a 12-month standard WIC intervention or to a 12-month WIC enhanced plus internet-based weight loss intervention. The intervention includes: monthly face-to-face group sessions; access to a website with weekly lessons, a web diary, instructional videos, and computer-tailored feedback; four weekly text messages; and brief reinforcement from WIC counselors. Participants are assessed at baseline, six months, and 12 months. The primary outcome is weight loss over six and 12 months; secondary outcomes include diet and physical activity behaviors, and psychosocial measures.
Discussion
Fit Moms/Mamás Activas is the first study to empirically examine the effects of an internet-based treatment program, coupled with monthly group contact at the WIC program, designed to prevent sustained postpartum weight retention in low-income women at high risk for weight gain, obesity, and related comorbidities.
Trial registration
This trial was registered with Clinicaltrials.gov (identifier: NCT01408147) on 29 July 2011.
doi:10.1186/s13063-015-0573-9
PMCID: PMC4347547  PMID: 25887964
Postpartum; WIC; Internet-based; Lifestyle intervention; Weight retention; Pregnancy

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