# Presentation: 410948

## Slide 1

**Notes:**
*We will be presenting the preliminary results from the “Barriers to Retention among Infants and Children in the NYS WIC Program”. This study funded by a grant from the USDA.

*We would like to thank the USDA for funding this project. We would also like to thank the NYS DON and the 11 participating WIC agencies. Without their cooperation, this project would not be possible.  

Findings are the responsibilities of authors and may not reflect the views of funding sponsor.

## 
Barriers to Retention 
NYS WIC Infants and Children*

Presented by:  Mary Lou Woelfel
Authors:  Mary L. Woelfel, Howard Stratton, Robert Pruzek, Donald Hernandez, Gene Shackman, ShuGuang Chen 

   * A USDA WIC Special Project Grant.  Awarded to the NYS DOH DON by the U.S. Department of Agriculture, Food and Nutrition Service, Office of Analysis and Evaluation, under grant 59-3198-7-525.  Study results are sole responsibility of authors and may not reflect the view of the funding agency.      

**Barriers to Retention **
**NYS WIC Infants and Children***
**Presented by:  Mary Lou Woelfel**
**Authors:  Mary L. Woelfel, Howard Stratton, Robert Pruzek, Donald Hernandez, Gene Shackman, ShuGuang Chen **
**   ***** A USDA WIC Special Project Grant.  Awarded to the NYS DOH DON by the U.S. Department of Agriculture, Food and Nutrition Service, Office of Analysis and Evaluation, under grant 59-3198-7-525.  Study results are sole responsibility of authors and may not reflect the view of the funding agency.  **

**NYS DOH, Division of Nutrition****Evaluation and Analysis Unit**

## 
Introduction

      In U.S. and NYS WIC caseload declining slightly 

      In NY, older the child, lower the retention

      Many eligible children do not receive WIC services

**Introduction**
**      ****In U.S. and NYS WIC caseload declining slightly **
**      **
**      ****In NY, older the child, lower the retention**
**      **
**      ****Many eligible children do not receive WIC services**

**Barriers to retention, NYS WIC**

**Notes:**
*In NYS, as a child ages, retention in the WIC program decreases.  
 For example, among infants under 6 months old who enrolled in 1993, 29% did not return for their first recertification.  An additional 30% did not return for their second recertification.  

*Since retention of children is problematic, it is important to understand the experiences of the WIC participants and if these experiences may be affecting retention in the program.

*The goal of this study is to answer two questions?
1) What barriers are the parents and caretakers experiencing while on WIC? 
2) Are these barriers related to the decision to discontinue WIC services?
3) Are there race/ethnic differences in barriers to retention

## Background
 	NY 999: WIC provided services to 	   	469,000 clients on average each month

 	Approximately 290,000 are	infants or 		children

  NYS provider network: 99 agencies 		with	oversight of 570 sites   

-  	**NY 999: WIC provided services to ****	****   ****	****469,000 clients on average each month**
** ****	**
** ****	****Approximately 290,000 are****	****infants or ****	****	****children**
**  ****NYS provider network: 99 agencies ****	****	****with****	****oversight of 570 sites**

**Barriers to retention, NYS WIC**

**Notes:**
*NYS WIC Program is the third largest program in the country. Every month, the NYS WIC Program provides services to approximately  468,000 low-income pregnant of postpartum women, infants and children up to the age of five, at no cost to the participant. 
*WIC services are provided to participants through a network of 99 WIC agencies across NYS.  Every county and major metropolitan area in the state has access to a WIC agency.

## Objectives

     Identify barriers to retention 		among WIC infants and children 
     Identify barriers specific to check 	redemption patterns
     Present barriers by race/ethnicity

**     ****Identify barriers to retention ****	****	****among WIC infants and children **
**     ****Identify barriers specific to check ****	****redemption patterns**
**     ****Present barriers by race/ethnicity**

**Barriers to retention, NYS WIC**

## Methods
Focus groups with WIC participants, guidance team, lit. review used to identify potential barriers
Identified barriers used to design 20-minute survey
Survey administered one-on-one at WIC sites 
Outsourced to ensure candid response
From perspective of WIC participant 
11 volunteer agencies; 41 sites
3167 parents/caretakers of WIC infants/children

**Focus groups with WIC participants, guidance team, lit. review used to identify potential barriers**
**Identified barriers used to design 20-minute survey**
**Survey administered one-on-one at WIC sites **
**Outsourced to ensure candid response**
**From perspective of WIC participant **
**11 volunteer agencies; 41 sites**
**3167 parents/caretakers of WIC infants/children**

**Barriers to retention, NYS WIC**

**Notes:**
.  
*The survey questions regarding potential barriers, were identified from the results of 5 focus groups with current and former WIC participants, the research literature and a guidance team discussion.  Priority was given to those barriers identified in the focus groups for inclusion in the survey. 

*A 20 minute survey was conducted with parents and caretakers of WIC enrolled infants and children at 11 WIC agencies across NYS.  The interviews were conducted by outside personnel to insure confidentiality and candid responses.  

## Data collection and data analysis

  Response rate 80%; completion rate; 94% 
  Data collected March through Dec 1999
  Informed consent obtained 
  Representative of 11 agencies
  Chi-square, logistic regression

**  **
**  ****Response rate 80%; completion rate; 94% **
**  ****Data collected March through Dec 1999**
**  ****Informed consent obtained **
**  ****Representative of 11 agencies**
**  ****Chi-square, logistic regression**
**  **  ** **

**Barriers to retention, NYS WIC**

**Notes:**
80% response rate; 94% completion rate. 

Differences between sample and agency characteristics minor, can make inferences to 11 agencies. Sample not representative of state as a whole, cannot make inferences about the state.  

Cross-tabulation and logistic regression results significant  at the <.01  level. 

We collected 3167 surveys. The sample was collected to ensure we could determine if there were any differences by race and ethnicity or age of child enrolled in WIC.  So, the data was collected to guarantee at least  10% of the sample was Black and 10% Hispanic.  In addition, the sample slightly over-represents the percentage of  parents and caretakers of children over 12 months in the populations. 

*We analyzed 116 variables with regard to to race and ethnicity.  The cross-tabulation results presented are statistically significant  at the <.01  level. 

##    Measured variables
  Demographic and economic 		
	Public assistance programs
	Fast food consumption 
	Food insecurity
	Employed due to welfare reform
	Benefits of WIC
	68 individual level barriers
	Dependent variables 
  Cashing or picking up checks

**  ****Demographic and economic ****	****	**
**	****Public assistance programs**
**	****Fast food consumption **
**	****Food insecurity**
**	****Employed due to welfare reform**
**	****Benefits of WIC**
**	*****68 individual level barriers***
- 	**Dependent variables**** **
**  *****Cashing or picking up checks***
**	**

**Barriers to retention, NYS WIC**

## Figure 1.  Barriers by organization category

**Agency**
**staff**

**General****Bureaucracy**

**Food procurement**** **

**Facility**

**Getting **
**there**

**Food package**** **

**Waiting**

**Certifi-****cation**

**Nutrition****Education**

**Figure 1.  Barriers by organization category**

**Notes:**
68 barriers to retention were identified and grouped by organizational category by consensus among WIC nutritionists and WIC operations staff.    

ORGANIZATIONAL CATEGORY SYSTEM LOOKS LIKE THIS.

FOR EACH CATEGORY, COLLECTED A NUMBER OF MEASURES.  

Measures for each organizational category are displayed in next slideWe

## Scheduling. Inconvenient times, work problems, rescheduling, no specific appointment time, separate family appointments. 
Getting there.  Parking, neighborhood safety, transportation  
Facility.  Overcrowding, noisy, lack of children’s activities.
Waiting - Too long, > 1 hr for checks; > 1 hr to recert. 
Bureaucracy.   Rules unclear, rigid, changing food package, bringing child, paperwork, replacing checks, blood work, proxy.
Nutrition Education.  Long, boring, repetitive, useful    

**Getting there****.  Parking, neighborhood safety, transportation  **
**Facility****.  Overcrowding, noisy, lack of children’s activities.**
**Waiting**** - Too long, > 1 hr for checks; > 1 hr to recert. **
**Bureaucracy.**   **Rules unclear, rigid, changing food package, bringing child, paperwork, replacing checks, blood work, proxy.**
**Nutrition Education****.  Long, boring, repetitive, useful** **   **

**Agency staff****.  Negative treatment, customer friendly,  speaking your language, insensitive to culture, not listening, giving conflicting info. **
**Food procurement****. Store policy diff. than WIC policy, negative treatment by store staff; ****food availability****-finding food, food not in stock, not getting all WIC food. ****Food package size****-matching check to container in store, cereal box size, milk size. **
**Food package****. Variety, quantity (too little, too much of each item)   **

**Specific barrier items by organization category**

##                          (%)
 < 1 year	    26
1 year old	    22
2 year olds	    19
3 year olds	    18
4 year olds	    15
White non-H	   46
Black non-H	   34
Hispanic	   15

** ****< 1 year****	****    26**
**1 year old****	****    22**
**2 year olds****	****    19**
**3 year olds****	****    18**
**4 year olds****	****    15**
**White non-H****	****   46**
**Black non-H****	****   34**
**Hispanic****	****   15**
**	****	****	**
**	**

- 		(%)**Rent****	****	****78**
**Single****	****	****65**
**Employed****	****45**
**< 50% pov****	****28**
**< 100% pov****	****64**
**HS or less****	****64**
**Food insecure  10**

**Table 1.  Demographic/economic characteristics of study participants**

**Notes:**
The key variable here is race/ethnicnity.  In this sample, 46 percent are white, non-Hispanic, 34 percent are black, non-Hispanic and 15 percent are Hispanic.  This information is relevant since we want to look at race/ethnic differences in barriers to retention.  Also important because addressed the issue of generality. 

The race/ethnic breakdown in the sample, for example, is not representative o the state as a whole.  Statewide the distribution of the major ethnic groups are pretty much equally distributed -- about 30, 30, 30, on average.      

The majority rent, are single and are below 100 percent of poverty. 

While not a specific to this presentation, 10 percent of those interviewed reported that in the past few months, members of their household sometimes  or frequently did not have enough to eat.  This is higher in NYC than upstate (17 vs 6%).

## 			           			(%)
Medicaid						57
TANF							30
Food stamps*						40
Head Start*		 	 	 		 8
Free/Reduced lunch*					18
WIC and other food programs
	WIC only					51
	WIC plus 1 					35
	WIC plus 2 			 	 	11
	WIC plus 3 		  	 	 	 3

**Medicaid****	****	****	****	****	****	****57**
**TANF****	****	****	****	****	****	****	****30**
**Food stamps*****	****	****	****	****	****	****40**
**Head Start*****	****	**** ****	**** ****	**** ****	****	**** 8**
**Free/Reduced lunch*****	****	****	****	****	****18**
**WIC and other food programs**
**	****WIC only****	****	****	****	****	****51**
**	****WIC plus 1 ****	****	****	****	****	****35**
**	****WIC plus 2 ****	****	****	**** ****	**** ****	****11**
**	****WIC plus 3 ****	****	****  ****	**** ****	**** ****	**** 3**

**Table 2.  Public assistance  **

**Notes:**
This slide shows that the majority in this study population are on Medicaid but the majority are not on each of the other public assistance programs.  

In terms of food programs, 51 percent of those interviewed received only WIC.  Or, looking at it another way,  49 percent received WIC and at least one other food program.   

## 								(%)
Number in household on WIC 
	1   on WIC						56
	2  on WIC						33
	3  on WIC				  		  9
	4  or more		  				  2
WIC composition
	Infant only	  					24
	Child only	    					60
	Infant & child					16
Missed pickup/cash checks				46	

**Number in household on WIC **
**	****1   on WIC****	****	****	****	****	****	****56**
**	****2  on WIC****	****	****	****	****	****	****33**
**	****3  on WIC****	****	****	****	****  ****	****	****  9**
**	****4  or more****	****	****  ****	****	****	****	****  2**
**WIC composition**
**	****Infant only****	****  ****	****	****	****	****	****24**
**	****Child only****	****    ****	****	****	****	****	****60**
**	****Infant & child****	****	****	****	****	****16**
**Missed pickup/cash checks****	****	****	****	****46****	**

**Table 3.  Number and participant type on WIC**** **

**Notes:**
In this sample, 24 percent are only an infant on the program, 76 percent had at least one child on WIC.  

Key point here is that 46 percent reported not cashing or picking up all their checks.  

## 						W	B	H						(%)	(%)	(%)
Rent					69	85	91
Single					54	79	72
<   50%  poverty				22	32	28
< 100% poverty				58	67	72	
Employed				45	50	34
HS or less				63	61	71
Medicaid					52	61	63	
TANF					19	39	46
Food stamps				31	49	51
Free/Red lunch				17	21	15
Food insecurity				   8	  8	18	
Missed pickup/cash checks			44	50	41	

**Rent****	****	****	****	****	****69****	****85****	****91**
**Single****	****	****	****	****	****54****	****79****	****72**
**<   50%  poverty****	****	****	****	****22****	****32****	****28**
**< 100% poverty****	****	****	****	****58****	****67****	****72****	**
**Employed****	****	****	****	****45****	****50****	****34**
**HS or less****	****	****	****	****63****	****61****	****71**
**Medicaid****	****	****	****	****	****52****	****61****	****63****	**
**TANF****	****	****	****	****	****19****	****39****	****46**
**Food stamps****	****	****	****	****31****	****49****	****51**
**Free/Red lunch****	****	****	****	****17****	****21****	****15**
**Food insecurity****	****	****	****	****   8****	****  8****	****18****	**
**Missed pickup/cash checks****	****	****	****44****	****50****	****41****	**

**Table 4.  Socio-demographics by race/ethnicity.  NYS WIC**** **

**Notes:**
This slide is not a focus of this presentation, but include interesting data that we will be addressing in future analysis.  For example, 18 percent of  Hispanics report food insecurity.  That is, 18 percent responded that they often or frequently do not have enough to eat.      

## Barriers to retention, NYS WIC

**Results**** ****	****	****	****GO LA STAFF!**
**In upstate and NYC, across all**
**organization categories, local **
**WIC agency staff received the **
**highest ratings.****     **
**       ****      **
** **

**Barriers to retention, NYS WIC**

**Notes:**
Examining barriers by organizational category; that is, on how WIC is organized, the organizational unit with the fewest barriers to retention and therefore the highest marks is the LA WIC staff.  LA Agency staff interface well with WIC participants.  This results hold in upstate and in NYC.

According to NYC participants and upstate participants, LA staff are culturally sensitive, listen to them, they are customer friendly, they don’t give out conflicting information, not treated negatively.    

## Barriers to retention, NYS WIC

**       ****The  most important benefit of WIC ****	****	****participation from participant’s  ****	****	****	****perspective**
**In Upstate: Good nutrition and formula**
**In NYC:****	**** Formula and milk**
**      **
** **

**Barriers to retention, NYS WIC**

**Notes:**
Slide looks at most important benefit of WIC from perspective of  participant.  In upstate, the most important benefit reported was good nutrition and formula.  In NYC, the most important benefit was milk and formula.

## Barrier			 Percent reporting barrier

Waiting too long					48
Waiting area/no child activities			42 
Waiting area/overcrowded/noisy		36
Waiting more than 1 hr to recertify		27
Cereal box size					41
Matching check to foods				23
Too little WIC formula				38
Too little WIC juice					27
Nutrition education repetitive			33
Nutrition education boring			27
Different policies WIC/Vendor			29

**Waiting too long****	****	****	****	****	****48**
**Waiting area/no child activities****	****	****	****42 **
**Waiting area/overcrowded/noisy****	****	****36**
**Waiting more than 1 hr to recertify****	****	****27**
**Cereal box size****	****	****	****	****	****41**
**Matching check to foods****	****	****	****	****23**
**Too little WIC formula****	****	****	****	****38**
**Too little WIC juice****	****	****	****	****	****27**
**Nutrition education repetitive****	****	****	****33**
**Nutrition education boring****	****	****	****27**
**Different policies WIC/Vendor****	****	****	****29**

**Table 5.  Barriers to retention**

**Notes:**
Slide shows most frequently cited barriers to retention- includes barriers reported by at least 20% of those interviewed.  

Waiting too long is most frequently cited problem. 48% of respondents indicated waiting too long was a problem.  Waiting was followed by a lack of activities for children and not being able to get the cereal box size you want.

Will not cite every barrier.  Intent is to determine if most frequently cited barriers clustered in any of the organization categories that represent how WIC is organized.  The most frequently cited barriers to cluster as will be presented.  

## Table 6.  Most frequently cited barriers to retention by Race

**Barrier****	****White****	****Black****	****Hisp.****	****Other**
- Waiting too long	47%	50%	46%	51%
- Waiting area lacking children’s activities 	38%	50%	39%	41%
- Not getting right cereal box size	43%	41%	35%	41%
- Too little formula	36%	40%	43%	40%
- Waiting room overcrowded and noisy	31%	40%	41%	35%
- Nutrition education repetitive	34%	35%	29%	23%
- Stores having different WIC policies	26%	35%	25%	28%
- Too little juice	24%	29%	26%	30%
- Waiting more than one hour to re-certify	25%	27%	34%	29%
- Nutrition education boring 	26%	29%	25%	22%
- Matching check amount to food container	24%	24%	17%	26%

**Notes:**
*Slide addresses third objective: Are there cultural differences in barriers to retention 

There is no difference in the top 11 most frequently cited barriers to participants by race/ethnicity.  There is some difference in rank ordering.    

Although there is no difference in most frequently cited barriers, there are some statistically significant difference in reporting of some barriers, as shown in next slide.

## 	 			        	  	   	W(%)  B(%)  H(%)

Language barrier 	 		 	0	  0	  7

Inconsistent w/culture diet			3	  6	10
Too little milk					13	10	18
Too little dry beans	  	 		4	10	  9 

Getting off work				12	19	15 
Transportation		  			7	11	14
Safety			  		 	4	  3	  8

**Language barrier ****	**** ****	****	**** ****	****0****	****  0****	****  7**
**Inconsistent w/culture diet****	****	****	****3****	****  6****	****10**
**Too little milk****	****	****	****	****	****13****	****10****	****18**
**Too little dry beans****	****  ****	**** ****	****	****4****	****10****	****  9 **
**Getting off work****	****	****	****	****12****	****19****	****15 **
**Transportation****	****	****  ****	****	****	****7****	****11****	****14**
**Safety****	****	****	****  ****	****	**** ****	****4****	****  3****	****  8**

**Table 7.****  ****Barriers by race/ethnicity****Statistically significant differences among less cited barriers**

**Notes:**
Starting with 95 potential barriers and using a chi square test of significance of LT .01, there were 13 significant differences.  This slide reports only on barriers cited less often.  
(The other barriers were among those most frequently cited and include waiting too long, overcrowded, nothing for kids to do, matching box to vouchers, different store/vendor policies, wait more than 1/2 hr..  

*Differences included
African-Americans have more difficulty getting off work-also more likely to be working.
Language and food barriers. Hispanics more likely to report language barriers and that WIC foods are inconsistent with their diet.  Hispanics more likely to report transportation and neighborhood safety problems.    

## Figure 1.  Barriers by organization category

**Agency**
**staff**

**General****Bureaucracy**

** ****Food procurement**** **

**Facility**

**Getting **
**there**

**Food package**** **

**Waiting**

**Certifi-****cation**

**Nutrition****Education**

**Figure 1.  Barriers by organization category**

- Wait too long

- Cereal box size

- Too little food

- Boring, repetitive

- Overcrowded, noisy
- nothing for kids
- to do

**Notes:**
Most frequently cited barrier categories in red.  
Waiting.  Waiting too long the most frequently cited barrier to retention.  
Local agency facility.  Overcrowded, noisy sites with no activities for children. 
Nutrition education.  Many participants reported nutrition as boring and repetitive.  85% of participants also reported nutrition education was very useful.  
Package size availability.  Cereal box size a problem and participants report difficulty matching vouchers to cereal box size.  
NYS has a minimum box size (a cost containment effort).  Increasing number of oz may affect NTE amount.   
Too little food.  Participants want more formula and juice.  
     package

## Failure to pick-up or cash checks reported by
      46% of parent/caretakers 		
Variables asso. w/failure to pick-up/cash chks   
    Child’s age  
 As child’s ages, failure to pick-up/cash checks increases  
    Parent’s age
 Younger parents more likely to fail to pick up/cash checks.
    Problems getting checks replaced
    Problems rescheduling 
    Too much milk

-       **46% of parent/caretakers**** ****	**
**Variables asso. w/failure to pick-up/cash chks****   **
-     **Child’s age  **
** ****As child’s ages, failure to pick-up/cash checks increases**
**    ****Parent’s age**
** ****Younger parents more likely to fail to pick up/cash checks.**
**    ****Problems getting checks replaced**
**    ****Problems rescheduling**** **
**    ****Too much milk**

**Table 8.  Barriers and check patterns**

**Notes:**
 age of parent/caretaker - younger theparent/caretaker, less likely cash check.   

## Barriers to retention - participant’s perspective
    	Long waits, overcrowded, noisy facilities 		with nothing for kids to do
       Nutrition education boring and repetitive 
   	Cereal box size; problems matching 			voucher to cereal box size (Cost containment 		effort)
   	Too little formula 
      Too little juice 

**    ****	****Long waits, overcrowded, noisy facilities ****	****	****with nothing for kids to do**
**       ****Nutrition education boring and repetitive**** **
**   ****	****Cereal box size; problems matching ****	****	****	****voucher to cereal box size ****(Cost containment ****	****	****effort)**
**   ****	****Too little formula **
**      ****Too little juice **

**Highlights**

## Race/ethnic similarities
  Whites, Blacks, Hispanics cite same top barriers 	  
Race/ethnic differences 
  Inconvenient hrs for employed Blacks 
  More Blacks work than whites and Hispanics. 
  Language and food barriers for Hispanics
Failure to pick up/cash checks
  Children’s food package
   Young mothers

-   **Whites, Blacks, Hispanics cite same top barriers**** ****	****  **
_***Race/ethnic differences***__* *_
**  ****Inconvenient hrs for employed Blacks**** **
-   More Blacks work than whites and Hispanics.
**  ****Language and food barriers for Hispanics**
_***Failure to pick up/cash checks***_
**  ****Children’s food package**
**   ****Young mothers**

**Highlights**

**Notes:**
A higher proportion of minorities than non-minorities report waiting, overcrowded and noisy sites.  This is probably a urban/rural difference.       

A higher proportion of African-Americans reported difficulty getting off work.   A higher proportion of African-American women in our study also worked.

Hispanics more likely to report language barriers and that WIC foods are inconsistent with their diet.  Hispanics more likely to report transportation and neighborhood safety problems.  

Check cashing

**Thank you**