# Presentation: 020362

## Texas WIC ProgramFood Package Research and Nutrition Education Implications 

**Texas WIC Program****Food Package Research and Nutrition Education Implications **

## Texas WIC Program

- Texas WIC Context:
- 900,000+ WIC Participants
- 2200+ WIC Staff
- 2300+ WIC Vendors
- 80 contracted local agencies
- Numerous partners and stakeholders

## Additional Challenges

- Statewide EBT rollout will occur right before food package implementation
- Food package implementation will occur statewide August 1, 2009
- Delay between when participants receive education and the actual food package change

**Notes:**
In Texas we will finish rolling EBT out right as we start rolling out the food package changes.  There will be a group of people in the valley area that receive both WIC EBT education and new food package education at the same time. 
In Texas we issue benefits for 3 months at a time and we are going to roll out the food package all at once on August 1, 2009 – so that means we will need to start educating participants 3 months before that and they will experience a delay between when they get education on the food package and when the actual food package change occurs.  

## What are we going to do?

- 1. Get Help!
- 	Selected Burson-Marsteller a leading advertising firm through a competitive bid process
- 2. Started with research to
- Establish benchmark of overall knowledge
- Gage current perceptions of WIC and food package
- Gage potential perceptions of coming changes
- Identify potential barriers to success

**Notes:**
Since we are such a large state and we wanted a unified campaign that included all of our clinics, vendors, stakeholders and partners we knew that we would need help developing the campaign. 

## We started with research

**We started with research**

| Education Campaign Research |
| --- |
| Focus group with WIC staff |
| In-depth interviews with WIC vendors and partners |
| Two focus groups with Spanish and English speaking WIC participants  |
| Random sample phone survey with 611 WIC participants |

| State Agency Policy Research |
| --- |
| New WIC food package survey administered May 2007 |
| TexasWIC.org surveys |

| Pre/Post Implementation Survey |
| --- |
| Texas A&M baseline food behavior survey to be administered in Fall 2008 |

**Notes:**
Texas WIC has several research projects that we have conducted/are currently conducting related to the new WIC food package.  This presentation is focused on the education campaign research but in a couple of cases there are references to the New WIC Food Package survey research and the surveys done on TexasWIC.org.  

The new WIC food package survey was a survey conducted with WIC participants in the clinic in May 2007.  There were 3,192 responses.  This survey was done before the interim rule was released and focused on what participants would like to see on the new WIC food package.  

The TexasWIC.org surveys are a series of short survey we put on our TexasWIC.org website for WIC participants.  Each week 2000 WIC participants visit the site to complete their WIC class.  Participants were asked to complete the survey before they could start their WIC class.  Each survey was about 10 questions long and was on the site for 5-7 days.  Each survey had 1500 -2000 responses.  

## What research told us

- WIC staff focus group
- Positive about all of the changes
- See the changes as aligning with dietary guidelines
- Recognize the need to educate staff, partner agencies, vendors and WIC participants on the changes
- Most concerned about educating on whole grains and infant formula

***“...******Everything is going to be easy and wonderful, except explaining to mamas why they’re getting less formula.”***
***	***
***– ******WIC Staff***

## Vendor in-depth interviews

- WIC Vendors
- Are positive but concerned about their bottom line
- Asked for DVDs and online training for cashiers
- Want participants to be educated at clinic
- Think brochures and posters are a must to help educate participants
- Like labeling WIC products that are least expensive brand

***“...******I think our profits will actually go down because we have a smaller profit level on produce.”***
***	***
***– ******WIC Vendor, McAllen***

***“...******They’ll have to educate them; it’s not up to us to educate the customers when they come in.”***
***– ******WIC Vendor, Tyler***

## WIC partner in-depth interviews

- WIC partners and stakeholders
- Welcome the changes
- See opportunities to encourage breastfeeding and healthy eating habits
- Want to work hand in hand with WIC to help educate clients and families about nutrition
- Concerned that some participants may not know how to use the new foods

***“...******For us as educators, it gives us the opportunity to educate and have a deeper discussion about it.”******	***
***–******Nutrition Manager, San Antonio Food Bank***

***“...******It would be nice if we had training or the same written material WIC is going to have...If we have that we can reemphasize what WIC is telling them”***
***–******Pediatrician, Midland***

## Participants

**Participant focus groups**** **

- Very positive about fruits and vegetables
- Mostly positive about lower fat milk
- Some uncertainty about whole grains
- Negative reaction to reductions in milk, eggs, cheese and juice!

***“...******Cheese is expensive.  And the eggs are going up too.”***
***	***
***– ******WIC Participant***

***“...******there is not enough to begin with so why decrease?”***
***	***
***– ******WIC Participant***

## Baby Foods

**Participant focus groups**

- Most English speakers purchased jarred baby foods, but Spanish speakers were more likely to make their own
- Confusion about why moms and breastfed babies get more food than formula fed infants
- Fluctuations in the amount of formula were confusing to participants

## Telephone survey with 600+ participants

**% of WIC Participants that “Strongly Like” each of the changes**

## Likes and Dislikes of Food Package Changes

- Some differences among Hispanic participants and males on whole foods, baby food and reducing milk, cheese and eggs (shown as % strongly like)

| Please tell me how much you like or dislike each of the following changes.   Do you...this change?
Showing % Strongly Like  | Overall | White | African- American | Hispanic | Spanish Speaking Hispanics | Spanish Survey Takers | Male |
| --- | --- | --- | --- | --- | --- | --- | --- |
| Adding fruits and vegetables  | 93 | 94 | 90 | 92 | 92 | 89 | 86 |
| Adding whole grains | 79 | 84 | 74 | 78 | 85 | 81 | 69 |
| Adding baby food | 76 | 82 | 80 | 72 | 65 | 47 | 77 |
| Switching milk to 2% fat or lower | 58 | 56 | 51 | 61 | 65 | 67 | 52 |
| Adding soy milk and tofu | 35 | 36 | 29 | 35 | 39 | 28 | 41 |
| Reducing the amounts of cheese, milk and eggs | 29 | 28 | 32 | 28 | 41 | 42 | 15 |
| Cutting juice | 21 | 21 | 15 | 22 | 31 | 17 | 20 |

## Likelihood to Use Food Package Changes

**Likelihood to Use Food Package Changes**

***Now please tell me how likely you are to use your WIC food package to add the following items to your grocery shopping.   Are you...***

## Which is closer to your view? 

**Perceptions of WIC Changes**

***Which is closer to your view?**** *

## Fruits and vegetables

- Top fruits and vegetables
- Participants requested fresh, frozen and canned
- Top fresh fruit
- Apples, bananas, grapes, and watermelon
- Top fresh veggies
- Broccoli, carrots, potatoes, and tomatoes
- Avocados ranked first among Hispanics and Spanish speakers

## Fruits and vegetables

- Top frozen fruit
- Strawberries, mixed fruit, peaches, pineapple, and mangos
- Top frozen veggies
- Broccoli, mixed vegetables, and corn
- Top canned fruits
- Applesauce, fruit cocktail, peaches, and pineapple
- Top canned veggies
- Corn, green beans and tomatoes

##  Baby Foods

** ****Baby Foods**

**Among participants with infants between the ages of 6 and 12 months a majority currently purchase baby foods for their infant****  **

***AMONG THOSE WITH INFANTS 6-12 MONTHS: Do you regularly buy baby foods for your baby?***

| AMONG THOSE SAYING NO: Why not? | Overall | White | African-American | Hispanic |
| --- | --- | --- | --- | --- |
| My baby is too young | 31 | 8 | 19 | 50 |
| Make my own for the baby | 22 | 29 | 15 | 25 |
| My baby does not like them | 16 | 13 | 22 | 19 |
| My baby eats table food | 8 | 8 | 7 | 6 |
| My baby won't eat them | 6 | 25 | 0 | 0 |
| My baby is too old | 6 | 0 | 15 | 0 |
| Too expensive | 4 | 8 | 7 | 0 |
| Others | 6 | 8 | 15 | 0 |
| Don't Know | 0 | 0 | 0 | 0 |

**Notes:**
Of the 611 about 182 had infants between 6 to 12 months.  We really don’t have enough information to talk about specifics related to ethnicities here but we did find in the focus group that less of our Spanish Speaking participants used jarred baby foods.  However when we asked about whether they would use jarred baby foods if they were provided by WIC 94% answered yes.

##  Soy Milk / Tofu

**Two thirds say they would not use soy milk or tofu and would continue to use only cow’s milk.  More Hispanic participants said they would be likely to add soy milk or tofu to replace some cow’s milk.  **

| If WIC offered tofu or soy milk as a choice in place of all or some of the cow s milk, which would you most likely choose? | Overall | White | African- American | Hispanic | Spanish Speaking Hispanics |
| --- | --- | --- | --- | --- | --- |
| Tofu only | 1 | 0 | 0 | 1 | 3 |
| Soy milk only | 9 | 7 | 9 | 9 | 7 |
| Both tofu and soy milk | 3 | 1 | 1 | 4 | 10 |
| Tofu and cow's milk | 5 | 5 | 1 | 4 | 7 |
| Soy milk and cow's milk | 16 | 11 | 13 | 19 | 17 |
| Neither tofu or soy milk; I would keep using only cow's milk. | 64 | 71 | 73 | 61 | 50 |
| Don't know  | 2 | 5 | 3 | 1 | 7 |

** ****Soy Milk / Tofu**

**Notes:**
The results are shown in percentages.  The results are fairly similar to California with 65% of participants wanting only cow’s milk. The results seem somewhat culturally specific. We didn’t have enough Asian responses to break that category out separately here.  Across the board people in Texas are less familiar with tofu than soy milk. 

For more information on what type of food packages to develop with soy and tofu we did a survey on TexasWIC.org with 1,627 participants.  Only 5.9% reported drinking soy milk and only 2.5% reported using tofu.  Thus the percentage of participants who currently consume soy milk or tofu is a much smaller then the percentage that said they were “interested” in selecting soy milk or tofu in the phone poll.  

We are not sure what the implication is from this – it’s possible that more participants are interested in trying soy milk or tofu than currently consume soy milk or tofu.  This also means that while there is initial interest the actual number of participants who would actually want soy milk or tofu may be much lower.  

## Whole Grains

**When it comes to whole grains, two-thirds or more say they are very confident in choosing whole grain products and nearly more than 3 in 4 say they already consume whole wheat or whole grain bread at least once a week.  **

| How confident are you that you can select a whole grain product? | Overall | White | African- American | Hispanic |
| --- | --- | --- | --- | --- |
| CONFIDENT | 95 | 97 | 93 | 94 |
| Very confident | 72 | 80 | 80 | 67 |
| Somewhat confident | 23 | 17 | 13 | 27 |

| How often do you eat whole wheat or whole grain bread? | Overall | White | African- American | Hispanic |
| --- | --- | --- | --- | --- |
| Daily | 43 | 41 | 36 | 45 |
| Weekly | 34 | 32 | 34 | 38 |
| Monthly | 10 | 9 | 14 | 8 |
| A few times a year | 6 | 10 | 8 | 4 |
| Never | 7 | 7 | 9 | 5 |
| Don't know  | 0 | 0 | 0 | 0 |

***Confidence In Choosing Whole Grains***

***Current Usage of Whole Grains***

**Whole Grains**

## Most prevalent responses by grain.
Whole wheat or whole grain bread (daily-45.6%)
Reason: “It is healthy for me and my family” (74%)
White bread (weekly-38.0%)
Reason: “My family likes the taste” (41.6%)
Brown rice (never -38.6%)
Reason: “I have never tried it” (56.4%)
Oatmeal (weekly-33.5)
Reason: “It is healthy for me and my family (52.6%)
Whole wheat tortillas (never-54.4%)
Reason: “I have never tried it” (54.6%)
Corn tortillas (monthly-31.2%)
Flour tortillas (monthly-37%)
Many significant differences in frequency related to ethnicity

- Whole wheat or whole grain bread (daily-45.6%)
- Reason: “It is healthy for me and my family” (74%)
- White bread (weekly-38.0%)
- Reason: “My family likes the taste” (41.6%)
- Brown rice (never -38.6%)
- Reason: “I have never tried it” (56.4%)
- Oatmeal (weekly-33.5)
- Reason: “It is healthy for me and my family (52.6%)
- Whole wheat tortillas (never-54.4%)
- Reason: “I have never tried it” (54.6%)
- Corn tortillas (monthly-31.2%)
- Flour tortillas (monthly-37%)
- Many significant differences in frequency related to ethnicity

**Choosing New Food Items – Whole Grains**

**To get more in-depth information we surveyed participants via TexasWIC.org **

**Notes:**
Participants were asked how frequently they ate certain grain products, the reasons for eating them if they responded daily or weekly, and if the product was never eaten, the reasons why.

## Change from whole to lower fat milk

| If you drink cow’s milk, what type do you usually drink?  
(% of responses) |  |  |
| --- | --- | --- |
| 1% low fat milk |  | 4.4% |
| 2% reduced fat milk |  | 38.4% |
| Buttermilk |  | 0.2% |
| None |  | 1.8% |
| Skim or non-fat milk |  | 3.6% |
| Whole milk (Vitamin D milk) |  | 51.5% |
|  |  |  |

**Notes:**
These results are again similar to California with over 50% drinking Whole Milk.  
Important to remember that 78% said they are likely to drink 2% or lower fat milk if that is what WIC offers.

More in-depth analysis found that African American participants have greater odds of reporting that they usually drink whole milk compared to White-Caucasians.  Paricipants in PHR 8 (San Antonio) have greater odds of reporting that they usually drink whole milk compared to PHR 11 (South Texas-Harlingen).  Hispanic participants have lower odds of reporting that they drink whole milk compared to non-Hispanic participants as did those with greater levels of education (i.e., some college and those with a Bachelor's degree) compared to those with only a high school degree.						

## Educating Participants 

**Educating Participants**** **

***Please tell me how helpful each of the following would be to learn about changes. Would this be...Showing % Very Helpful ***

## Educating Participants 

**Educating Participants **

| Please tell me how helpful each of the following would be to learn about changes. Would this be...
Showing % Very Helpful  | Overall | White | African- American | Hispanic | Spanish Speaking Hispanics | Spanish Survey Takers | Male |
| --- | --- | --- | --- | --- | --- | --- | --- |
| A fold-out guide with pictures of the new food items and quantities  | 89 | 91 | 89 | 88 | 85 | 89 | 79 |
| Information sent directly to your house.  | 85 | 84 | 81 | 87 | 85 | 86 | 86 |
| One-on-one contact with WIC staff  | 76 | 71 | 72 | 80 | 80 | 86 | 71 |
| Pamphlets or brochures  | 73 | 69 | 73 | 74 | 70 | 78 | 60 |
| Flyers at the point of purchasing groceries  | 65 | 61 | 66 | 66 | 62 | 75 | 59 |
| Materials from your doctor’s office | 65 | 58 | 69 | 68 | 73 | 69 | 75 |
| An in-store tasting of foods prepared with the new WIC foods  | 64 | 58 | 62 | 66 | 73 | 78 | 62 |
| Group classes at WIC  | 64 | 50 | 63 | 70 | 79 | 81 | 56 |
| Take home DVD  | 61 | 51 | 64 | 65 | 68 | 56 | 57 |
| Cooking demonstrations at the WIC clinic  | 61 | 50 | 55 | 68 | 80 | 86 | 49 |
| Online WIC classes  | 59 | 53 | 66 | 59 | 48 | 33 | 44 |
| Information via the internet, a website or email  | 57 | 54 | 64 | 56 | 45 | 47 | 51 |

** ****Spanish speaking participants see internet tools such as online classes and information via the web as less helpful.  Alternatively these audiences are more welcoming to learning through in-store tastings, group classes and cooking demonstrations.**

**Notes:**
Appears to be some striking differences along racial and ethnic lines.  Might need different approaches for different groups.

## Supplemental Materials Welcomed

| Which of the following are you interested in receiving along with materials explaining the WIC food program change? Please select all that apply. MULTIPLE RESPONSE | Overall | White | African- American | Hispanic | Spanish Speaking Hispanics | Spanish Survey Takers | Male |
| --- | --- | --- | --- | --- | --- | --- | --- |
| Recipes | 86 | 89 | 82 | 86 | 83 | 75 | 80 |
| Materials geared toward children | 84 | 84 | 80 | 86 | 83 | 89 | 75 |
| Cooking tips | 81 | 82 | 78 | 81 | 82 | 69 | 75 |
| Nutrition tips | 81 | 80 | 80 | 81 | 80 | 72 | 73 |
| Health tips | 79 | 78 | 81 | 78 | 75 | 69 | 76 |
| Exercise recommendations | 78 | 75 | 77 | 80 | 80 | 78 | 67 |
| None - not interested in any of the above | 1 | 2 | 1 | 1 | 0 | 0 | 5 |
| Don't know  | 1 | 1 | 2 | 0 | 0 | 0 | 1 |

**Supplemental Materials Welcomed**

## Interest in Children’s Materials

**Interest in Children’s Materials**

** ****DVDs, coloring sheets, story books and stickers get the most positive response in terms of children’s materials.**

| IF INTERESTED IN MATERIALS FOR CHILDREN: What specific topics or types of material do you personally feel would be helpful to help children learn about the new WIC food package? 
MULTIPLE RESPONSE | Overall | White | African American | Hispanic | Spanish Speaking Hispanics | Spanish Survey Takers | Male |
| --- | --- | --- | --- | --- | --- | --- | --- |
| DVDs with characters geared toward kids | 86 | 84 | 88 | 86 | 86 | 81 | 79 |
| Coloring sheets | 83 | 82 | 87 | 81 | 80 | 78 | 76 |
| Story books about drinking low fat milk or eating whole grains | 83 | 85 | 87 | 82 | 80 | 66 | 73 |
| Stickers | 76 | 76 | 80 | 74 | 80 | 75 | 63 |
| Other  | 5 | 6 | 4 | 4 | 0 | 3 | 4 |
| Don't know  | 1 | 1 | 0 | 0 | 0 | 0 | 0 |

## Summary of research findings

**Overall Findings**
- WIC staff and partners welcome the changes
- WIC participants are positive but are concerned about decreases and are somewhat resistant to lower fat milk
- WIC vendors see the changes as positive for participants but are concerned about their bottom line
- There are cultural differences for some food items
**Food Specific Findings**
- Over 50% of participants drink whole milk
- WIC participants are somewhat familiar with whole grains
- Changes in the infant food package are confusing

## After the research

- Brand platform/messaging
- Using research to develop brand platform and key messages
- Next step is to develop communications plan and materials
- Materials will be tested with vendors, partners, staff and participants

## Key Challenges

**Overall Takeaways**

- Explaining the changes and reasons behind the changes
- Creating culturally specific and relevant materials
- Ensuring our staff, partners and vendors are all on the same page and have similar materials to use with participants
- Key Opportunities
- Recast WIC as a modern program that provides the foundation for a healthy lifestyle
- Broader outreach to WIC partners and vendors to amplify healthy diet and nutrition messages
- Impact beyond the food package

## For more information

- contact Amanda Hovis at _[amanda.hovis@dshs.state.tx.us](mailto:amanda.hovis@dshs.state.tx.us)__ or (512) 458-7111 ext 3411_