GAO

United States General Accounting Office

Report to Congressional Committees

September 2000 FOOD ASSISTANCE

Activities and Use of 

Nonprogram 

Resources at Six WIC 

Agencies

GAO/RCED-00-202

Page 1 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

Contents

Letter 5

Appendixes Appendix I: Scope and Methodology 28

Appendix II: Selected Characteristics of the Six Case Study

Agencies 35

Appendix III: Additional Comparisons of the Ways the Six Agencies 

Deliver Nutrition Services and Administer the

Program 39

Appendix IV: Detailed Summaries of the Six Case Studies 42

Appendix V: Time Study Results - Percent of Staff time and Staff 

Time Costs Spent on Activities 100

Appendix VI: Time Study Results: Approximate Minutes per 

Case-Month Spent on Nutrition Services and

Administration Activities 109

Appendix VII: GAO Contacts and Staff Acknowledgments 113

Tables Table 1: Nutrition Services and Administration Activities by Cost

Category 10

Table 2: Percent of Total Staff Spent on Nutrition Services and 

Administration Activities 17

Table 3: Approximate Minutes per Case-Month Spent on Nutrition 

Services and Administration Activities 18

Table 4: Approximate Minutes per Case-Month Spent on Specific

Nutrition Education Activities Involving Direct Contact With 

Participants and Percent of Total Staff Time Spent on These 

Activities 19

Table 5: Percent of Total Staff Time and Approximate Minutes per 

Case-Month Spent on Activities Involving Direct Participant 

Contact 20

Table 6: Categories of Nonprogram Resources Used to Cover

the Costs of Providing Nutrition Services and Administering

the Program, Fiscal Year 1999 21

Table 7: Major In-kind Contributions Made by Sponsoring

Organizations 22

Table 8: Description of WIC Activities Used for Time Studies at Six

Case Study Agencies 29

Table 9: Time Span of Time Study for Each Agency 33
Contents

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Table 10: Characteristics of Case Study Agencies in Terms of 

Sponsoring Agency, Geographic Area Served, and Average 

Monthly Number Of Participants Served 35

Table 11: Characteristics of Five Local Case Study Agencies 

Compared With Local WIC Agencies Nationwide 36

Table 12: Selected Staffing Statistics for Each Case Study Agency 37

Table 13: Six Agencies’ Expenditures of WIC Program Funds,

Fiscal Year 1999 37

Table 14: Six Agencies’ Percent Distribution of WIC Program by

Budget Category, Fiscal year 1999 38

Table 15: Number of Gallatin Participants by Category, September

1998 and July 1999 46

Table 16: Frequency of Check Issuance by Participant Type at

Gallatin WIC 48

Table 17: Gallatin WIC Program Expenditures by Category, Fisca

Years 1998 and 1999 51

Table 18: Number of Grady WIC Participants by Category, 

September 1998 and November 2000 56

Table 19: Grady WIC Program Expenditures by Category, Fiscal

Years 1998 and 1999 61

Table 20: Number of Kanabec County Participants by Category, 

September 1998 and September 1999 66

Table 21: Kanabec County WIC Program Expenditures by

Category, Fiscal Years 1998 and 1999 70

Table 22: Number Participants by Category, September 1998 an

October 1999, at Long Beach WIC 74

Table 23: Category of Participant and Frequency of Voucher 

Issuance at Long Beach WIC 75

Table 24: Long Beach WIC Program Expenditures by Category, 

Fiscal Years 1998 and 1999 80

Table 25: Number of Participants by Category, September 1998 and 

November 1999, at York WIC 84

Table 26: York WIC Program Expenditures by Category, Fiscal 

Years 1998 and 1999 90

Table 27: Number of Participants by Category, September 1998 and 

September 1999, at Zuni WIC 94

Table 28: Zuni WIC Program Expenditures by Category, Fiscal

Years 1998 and 1999 98

Table 29: Percent of Staff Time and Staff Time Costs -Gallatin 100

Table 30: Percent of Staff Time and Staff Time Costs-Grady 101

Table 31: Percent of Staff Time and Staff Time Costs -Kanabec 103

Table 32: Percent of Staff Time and Staff Time Costs—Long Beach 104
Contents

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Table 33: Percent of Staff Time and Staff Time Costs—York 106

Table 34: Percent of Staff Time and Staff Time Costs -Zuni 107

Table 35: Approximate Minutes per Case-Month Spent on Participant 

Services Activities at the Six Case Study Agencies 109

Table 36: Approximate Minutes per Case-Month Spent on Nutrition 

Education Activities at the Six Case Study Agencies 110

Table 37: Approximate Minutes per Case-Month Spent on Specific 

Breastfeeding Promotion and Support Activities at the

Six Case Study Agencies 111

Table 38: Approximate Minutes per Case-Month on Specific Program 

Administration Activities at the Six Case Study Agencies 112

Figures Figure 1: Performing a Blood Test at the York WIC Agency 12

Figure 2: A Recertification Session at a Long Beach WIC Site 14

Figure 3: Bar Code Scanner and Sheet Used in Time Study 32

Figure 4: Topography of the Three County Area Served By 

Gallatin WIC and the Satellite Clinic Locations. 44

Figure 5: Grady WIC Pediatric Clinic 55

Figure 6: Kanabec WIC Clinic 65

Figure 7: Use of Videotapes in the Waiting Area of a Long Beach 

WIC Site 77

Figure 8: Use of Brochures in the Waiting Area of the Main York

WIC Clinic 87

Figure 9: Waiting Area in Zuni WIC Clinic 93
Page 4 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

Abbreviations

CPA competent professional authority

CPC Community Progress Council 

FNS Food and Nutrition Service 

GHS Grady Health System

HHS Department of Health and Human Services

ITO Indian Tribal Organization

ITCA Indian Tribal Council of Arizona

IHS Indian Health Service

NSA nutrition services and administration

USDA U.S. Department of Agriculture

WIC Special Supplemental Program for Women, Infants, and Children
Page 5 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

United States General Accounting Office

Washington, D.C. 20548

Resources, Community, and

Economic Development Division

B-286011 Letr

September 29, 2000

The Honorable Richard G. Lugar

Chairman

The Honorable Tom Harkin

Ranking Minority Member

Committee on Agriculture, Nutrition, and Forestry

United States Senate

The Honorable William F. Goodling

Chairman

The Honorable William (Bill) Clay

Ranking Minority Member

Committee on Education and the Workforce

House of Representatives

The Special Supplemental Nutrition Program for Women, Infants, and 

Children (WIC) is a federally funded nutrition assistance program 

administered by the U.S. Department of Agriculture’s (USDA) Food and 

Nutrition Service (FNS). This program provides supplemental foods and 

nutrition services to lower-income pregnant, breastfeeding, and 

postpartum women, infants, and children up to age 5 who are at nutritional 

risk. In fiscal year 1999, WIC benefits and services were provided to a 

monthly average of 7.3 million individuals. 

In fiscal year 1999, the Congress appropriated about $3.9 billion for WIC. 

Almost three-fourths of these funds ($2.8 billion) were used to provide food 

benefits to participants, typically in the form of vouchers used to obtain 

approved foods at authorized retail food stores, commonly referred to as 

vendors. The remaining funds ($1.1 billion) were used to make grants to 

states’ WIC agencies for nutrition services and administration. The 

nutrition services supported by federal grant funds are (1) participant 

services—activities, such as certifying that a woman or child is eligible to 

participate in the program, issuing food benefits, and making referrals to 

other health or social services; (2) nutrition education—providing 

individual or group education designed to improve participants’ dietary 

habits and health status; and (3) breastfeeding promotion and support—

educating women about the benefits of breastfeeding their infants and 

providing the support necessary to enable them to breastfeed. 

Administration activities supported are the typical management functions 
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Page 6 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

necessary to support program operations, such as accounting and recordkeeping.

By law, in fiscal year 1999, the federal grants for nutrition services and 

administration made to state agencies were based on a national average of 

$11.64 per participant per month.1

 In fiscal year 1999, these grants 

supported program operations at 88 state-level WIC agencies (including 

agencies in all 50 states, the District of Columbia, American Samoa, the 

Commonwealth of Puerto Rico, Guam, and the U.S. Virgin Islands, and 33 

Indian tribal organizations). Most state-level WIC agencies retain a portion 

of their grants and pass on the remaining funds to the nearly 1,800 local 

WIC agencies, which are operated by sponsoring organizations such as 

county health departments. Some of the state-level agencies—those that 

operate the program at both the state and local levels—retain all of their 

WIC grants.

In addition to federal WIC funds, other resources may be used to support 

nutrition services and administration, such as WIC funds made available by 

state or local governments, and nonprogram resources, such as in-kind 

contributions of space, made by local WIC agencies’ sponsoring 

organizations.2

 A 1988 study prepared for USDA found that at 16 WIC 

agencies, for every dollar in costs covered with program funds, about 54 

cents in additional costs were covered by nonprogram resources. 

1

 The Child Nutrition Act of 1966, as amended by section 123(a)(6) of P.L. 101-147, 103 Stat. 

898, Nov. 10, 1989.

2

 In this report, “in-kind” refers to something of value, such as office space, equipment, 

supplies, and services, that is donated from public or private sources at no cost to the WIC 

program.
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To help the Congress better understand the costs of administering WIC and 

delivering nutrition services, the William F. Goodling Nutrition 

Reauthorization Act of 1998 (P. L. 105-336) directed GAO to assess various 

cost aspects of WIC nutrition services and administration. This report is the 

second in a series responding to this request for information. The first 

report provided information on federal and nonfederal resources obtained 

and expended by state-level and local WIC agencies nationwide for 

nutrition services and administration.3

 This report provides in-depth 

information on how WIC agencies deliver nutrition services and administer 

the program and the resources they use. Specifically, it provides 

information on the (1) ways WIC agencies deliver nutrition services and 

administer the program; (2) ways staff at WIC agencies allocate their time 

delivering nutrition services and administering the program; and (3) types 

of nonprogram resources used by WIC agencies and the extent to which 

such resources are used to cover the costs of delivering nutrition services. 

Because it was not practical to obtain in-depth information regarding these 

issues from a statistically representative sample of the over 1,800 agencies 

providing services to participants, we conducted case studies at six WIC 

agencies. We chose the six agencies to provide a range of characteristics, 

such as geographic location, numbers and types of participants served, and 

type of sponsoring organization. The six WIC agencies studied included 

five local agencies: Gallatin WIC in Montana; Grady WIC in Atlanta, 

Georgia; Kanabec WIC in Minnesota; Long Beach WIC in California; and 

York WIC in Pennsylvania; and one Indian tribal organization, Zuni WIC in 

New Mexico, which functions as both a state-level and local WIC agency. In 

addressing our second objective, we conducted 1-month time studies at 

each of the case study agencies. During these studies, we recorded and 

summarized the amount of time WIC staff spent performing various 

activities. The results of our case studies are not generalizable to all WIC 

agencies. 

We performed our work from July 1999 through August 2000 in accordance 

with generally accepted government auditing standards. Appendix I 

contains a detailed description of the methodology we used to conduct this 

work.

3

 The first report in the series was Food Assistance: Financial Information on WIC Nutrition 

Services and Administrative Costs (GAO/RCED-00-66, Mar. 6, 2000). Subsequent reports will 

provide information on performance measures used to assess nutrition services and the 

impact of WIC services in the areas of nutrition education, breastfeeding promotion, and 

referrals.
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Results in Brief WIC agencies can vary considerably in the ways they deliver nutrition 

services and administer the program. For example, the six agencies we 

studied differed in the (1) manner in which they obtained health 

information, such as the results of a blood test for anemia, needed to assess 

the level of participants’ nutritional risk; (2) amount and type of nutrition 

education typically provided to participants; and (3) level and nature of 

breastfeeding support, such as visiting a new mother in the hospital after 

delivery. Factors affecting the delivery of nutrition services or 

administration included the state program’s policies and procedures, the 

characteristics of the sponsoring organization, and resource constraints.

Because WIC agencies differ in how they deliver services and administer 

the program, the amount of time WIC staff spend on specific activities can 

vary. For example, at the six agencies, our time studies found that the 

proportion of staff time spent on nutrition services activities as opposed to 

administrative activities varied greatly. At two agencies, staff spent more 

than two-thirds of their time on nutrition services activities, while the staff 

at two other agencies spent less than half of their time on these activities. 

As a result of this variation, the agencies differed in the amount of time 

spent in direct contact with participants—either in-person or over the 

telephone. Staff at one agency, for example, spent over 60 percent of their 

time on activities involving direct contact with participants, while staff at 

another agency spent about 31 percent.

The six WIC agencies we studied used a variety of nonprogram resources 

to deliver WIC services, the most common being in-kind contributions from 

their sponsoring organizations. The share of costs covered by nonprogram 

resources at the six agencies ranged from about 20 cents to 2 cents for each 

dollar in costs covered with program funds. The extent to which 

nonprogam resources were used to cover the costs of delivering WIC 

services did not approach the level of 54 cents for every dollar in costs 

covered with WIC funds that was cited in a 1988 research study. 
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Background In fiscal year 1999, state-level and local WIC agencies received 

approximately $1.1 billion in federal grants for nutrition services and 

program administration. States or local governments are not required to 

match any portion of these federal funds. However, as we reported in 

March 2000, 10 states and the District of Columbia provided additional 

funds for nutrition services and administration in fiscal year 1998—a total 

of $38 million. In addition, 29 percent of the 1,416 local WIC agencies that 

responded to a nationwide survey we conducted in 1999 reported receiving 

a combined total of about $19 million for nutrition services and 

administration from nonfederal sources in fiscal year 1998.4

 Nationwide, 

the total of these nonfederal program funds represent a very small portion 

of the program resources used for nutrition services and administration—

about 5 percent in fiscal year 1998.

In addition to program funds, the WIC program has traditionally used 

nonprogram resources, such as in-kind contributions, to fully operate the 

program. No recent information was available on the value of these 

nonprogram resources used to cover some of the costs of providing 

nutrition services and administering the program. According to a 1988 

study of 16 case study WIC agencies prepared for USDA by Abt Associates, 

for every dollar in costs covered by WIC program funds, about 54 cents in 

additional costs were covered by other resources—mostly in the form of 

contributions from WIC agencies’ sponsoring organizations.5

Local WIC agencies, which spend over three-quarters of nutrition services 

and administration program funds, are operated by a variety of types of 

public and private organizations; provide services in different types of 

geographic settings (urban, rural); and vary considerably in size in terms of 

the number of participants they serve. WIC agencies can also vary in the 

size and composition of their staff. Appendix II provides information on 

selected characteristics and the staffing at the six agencies we studied.

WIC agencies use their nutrition services and administration grants to 

support activities in four cost categories: (1) participant services, (2) 

nutrition education, (3) breastfeeding promotion and support, and (4) 

4

 We conducted the survey for our report entitled Food Assistance: Financial Information on 

WIC Nutrition Services and Administrative Costs (GAO/RCED-00-66, Mar. 6, 2000). That 

report contains a description of the survey methodology.

5 Synthesis of Case Study Findings in the WIC Program. (Abt Associates, Dec. 1988)
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program administration. Table 1 shows some of the specific activities 

conducted by these WIC agencies in each of the categories.

Table 1: Nutrition Services and Administration Activities by Cost Category

a

In addition to vouchers, food benefits can be issued in the form of checks, coupons, and 

other documents. Gallatin WIC, located in Montana, issues WIC checks instead of vouchers.

In general, WIC agencies can use program funds for nutrition services and 

administration for costs that can be classified as either direct or indirect. 

According to the program’s regulations, direct costs are those that can be 

identified specifically with WIC-related activities, such as salaries for staff 

who provide nutrition education and breastfeeding counseling. Indirect 

Cost category Activities

Participant 

services 

Certifying that individuals meet program eligibility criteria by obtaining and reviewing information regarding (1) income 

or participation in a qualifying program such as Medicaid; (2) residency; (3) pregnancy or postpartum status, childrens’ 

age; and (4) medical risks, such as anemia, and/or nutritional risk such as inadequate diet.

Explaining program policies and procedures.

Scheduling participants for nutrition services, including nutrition education, voucher pick-ups, and recertification. 

Issuing food benefits—typically in the form of vouchers to be redeemed at grocery stores.a

Referring participants to needed health care, such as immunization, and social services, such as the Food Stamp and 

Medicaid programs, as well as voter registration. 

Preparing Individual Care Plans 

Nutrition 

education 

Providing individual nutrition sessions. 

Providing group education sessions. 

Preparing or obtaining nutrition education materials, such as brochures and videotapes.

Interpreting sessions or translating material to facilitate nutrition education of non-English-speaking participants. 

Consulting with medical providers regarding nutrition education. 

Providing or receiving training regarding nutrition education promotion.

Evaluating and monitoring nutrition education.

Breastfeeding 

promotion and 

support 

Providing individual counseling sessions to promote or support breastfeeding at WIC clinics or in the hospital.

Providing group breastfeeding support sessions.

Providing telephone support to breastfeeding mothers.

Maintaining a clinic environment that encourages breastfeeding. 

Consulting with medical providers regarding breastfeeding issues.

Preparing and providing breastfeeding educational materials.

Providing or receiving training regarding breastfeeding promotion.

Monitoring and evaluating breastfeeding promotion activities.

Administration Outreach to potential participants and health care providers and social service organizations.

Clerical tasks.

Accounting, budgeting.

Personnel, including recruitment and retention of staff.

General management tasks such as planning, developing policies and procedures, and managing the use of space. 

and equipment.

Monitoring vendors.

Program reporting.
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costs are for services that benefit the program but are not easily linked 

specifically to WIC, such as purchasing, communications, and accounting 

services. 

WIC Agencies Varied in 

How They Provided 

Nutrition Services and 

Administer Their 

Programs 

WIC agencies can vary considerably in the ways they deliver nutrition 

services and administer the program. The five local agencies and Indian 

tribal organization we studied all provided the three types of nutrition 

services—participant services, nutrition education, and breastfeeding 

promotion and support—and conducted administration activities; however, 

they differed in some of the ways they delivered these services and 

administered the program. The following provides examples of this 

variation. 

Participant Services • Long Beach staff did not routinely measure participants’ height and 

weight and test blood for anemia, as was typically done at the other 

agencies to obtain required medical information (see fig. 1). Instead, 

Long Beach obtained this information from participants’ health care 

providers.

• Gallatin and Kanabec staff routinely prepared individual care plans for 

all participants while staff at the other agencies did so only for 

participants considered to be high risk.6,7

• Kanabec issued vouchers to adult participants who were not considered 

to be at high nutritional risk every 3 months, while the other agencies 

issued vouchers or checks to such participants at least every 2 months.

• Five of the six agencies—Gallatin, Grady, Long Beach, York and Zuni—

to varying degrees, offered services during scheduled evening hours. 

For example, Long Beach’s main site had extended hours from 6:00 p.m. 

to 7:00 p.m. on Mondays and Tuesdays, while York’s main clinic stayed 

open until 6:30 p.m. 3 days a month. Gallatin and Long Beach also 

6

Program regulations give agencies discretion to determine which participants must have 

plans. However, regulations do require that plans must be prepared for participants 

requesting them. 

7

State WIC agencies use varying criteria to determine which participants are considered to 

be high-risk.
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offered scheduled weekend hours.

• Grady, Long Beach, York, and Zuni staff routinely asked participants of 

their interest in registering to vote; Long Beach, York, and Zuni 

maintained a record of the offer. For example, at York, in accordance 

with state policy, staff recorded information regarding voter registration 

in the participant’s record, on a data collection form, and in the data 

system, and assisted the participant in completing the form. At Gallatin 

and Kanabec, staff simply made voter registration forms available to 

participants. 

Figure 1: Performing a Blood Test at the York WIC Agency
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Nutrition Education • Nutrition education was typically provided at all six agencies during the 

participant’s certification and/or recertification session (see fig. 2). The 

sessions that we observed, which included nutrition education, lasted 

from 10 minutes at Grady to more than 60 minutes at Gallatin.

• In addition to these sessions, Long Beach provided nutrition education 

through about a dozen classes daily at each of its clinics. Gallatin, Grady, 

and Zuni also offered weekly, bimonthly, or monthly classes, while York 

and Kanabec did not offer nutrition education classes at all.

• Grady staff, when needed, provided nutrition education that involved 

medical nutrition counseling (to diabetic WIC participants, for 

example), while staff at the other agencies typically referred 

participants to non-WIC dietitians if such counseling was needed.

• Only Zuni staff offered regular nutrition education to child participants, 

even though children represented at least half of the participants at five 

of the six agencies.

• Only Grady used computer technology in the form of a touch-screen 

kiosk to provide nutrition education to participants.
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Figure 2: A Recertification Session at a Long Beach WIC Site

Breastfeeding Promotion 

and Support

• Like nutrition education, breastfeeding was typically promoted during 

individual sessions. Gallatin, Grady, Long Beach, and Zuni also offered 

breastfeeding classes.

• Staff at three of the agencies—Grady, Long Beach, and Zuni—routinely 

visited participants in the hospital after childbirth to encourage and 

support breastfeeding.
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• Staff at all of the agencies were trained to promote breastfeeding. In 

addition, Grady, Zuni, and York staff included at least one certified 

lactation consultant.

Program Administration • While all of the agencies utilized an automated participant database 

system, Long Beach was the only agency to maintain minimal paper 

records. In contrast, York, because it lacked a sufficient number of 

computers, relied on paper records and data entry staff to enter 

participant information into the state’s data system.

• York staff played a major role in training and monitoring vendors and 

assisted state agency staff in approving vendors’ applications. The other 

four local agencies performed limited vendor management activities 

because this was a state-level responsibility. At Zuni—a state-level 

agency—staff were heavily involved in all aspects of vendor 

management.

• All of the agencies, except Kanabec, provided services at satellite clinics 

or sites. Gallatin, York and Zuni staff traveled to satellite clinics or sites 

to provide services, while Long Beach and Grady staff did not. Kanabec 

did not operate satellite clinics but did offer participants free or 

reduced-cost transportation, on request.

A number of factors, including state program policies, the characteristics of 

the sponsoring organization, and resource constraints, affected how the 

agencies delivered services and contributed to some of the variation we 

observed. For example, state policy strongly encourages Long Beach to 

obtain needed medical information from the participants’ health care 

providers. Similarly, staff at Gallatin prepared individual care plans for 

participants in accordance with established state program policy. 

The characteristic of the sponsoring agency also affected service delivery. 

For example, because Grady was operated by a hospital, WIC dietitians 

routinely provided medical nutrition counseling to participants in need of 

such services, rather than making referrals to non-WIC dietitians. In 

addition, staff at Zuni WIC, the only state-level agency that we studied, 

carried out some activities, such as those associated with approving 

vendors and reimbursing them for vouchers, that are not typically 

performed by local agencies.
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Finally, agency officials and staff at the five local agencies reported that 

insufficient resources affected how services were delivered. For example, 

York and Grady officials attributed the limited time staff spent providing 

nutrition education and/or breastfeeding promotion and counseling to 

insufficient staffing. Staff constraints are being exacerbated, according to 

some of the agency directors, because it is becoming increasingly difficult 

to retain and recruit staff with the salaries and benefits the program is able 

to offer. For example, according to the York WIC Director, the agency 

offers a nutritionist or dietitian half the hourly rate offered at the area 

hospital. 

Appendix III contains additional information on variations we found in the 

ways the agencies delivered nutrition services and administered the 

program, and appendix IV summarizes these activities for each agency. 

The Amount of Time 

WIC Staff Devoted to 

Different Nutrition 

Services and 

Administration 

Activities Varied by 

Agency

Our time studies at the six agencies found they varied considerably in the 

amount of time staff spent on different activities. For instance, as shown in 

table 2, at Long Beach and Gallatin, staff spent over 70 percent of their time 

on nutrition services, while at two other agencies staff spent less than half 

of their time on these activities.8

 These two agencies were Zuni WIC, a 

state-level agency, and York, the only local agency with major vendor 

management responsibilities. 

8

In addition to examining the percent of staff time spent on each activity, we analyzed the 

percent of staff time costs that were devoted to each activity. We did this by using 

information on the amount of time that each individual spent on an activity as well as the 

individual’s hourly wage rate. We found there was little difference between the percent of 

staff time and the percent of staff time costs for the various activities. Staff time and staff 

time costs percentages are reported in app. V.
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Table 2: Percent of Total Staff Spent on Nutrition Services and Administration 

Activities

Note: Totals may not add due to rounding. 

a

Zuni WIC was the only state-level agency. Some staff time at Zuni WIC was spent on 

activities normally performed at state-level agencies, such as developing program plans and 

reimbursing vendors. Our time study did not distinguish between state- and local-level 

activities at Zuni WIC.

Because the agencies varied somewhat in their participant-to-staff ratios—

the number of participants served per full-time-equivalent staff—we also 

analyzed the results of our time studies in terms of the minutes per 

participant per month spent on the various activities. (Hereafter, per 

participant per month is referred to as per case-month.) Table 3 shows the 

results of our time studies in terms of the approximate number of minutes 

spent per case-month. Again, there is considerable variation among the 

agencies. Additionally, this table, in combination with table 2, shows that 

agencies devoting similar percentages of staff time to an activity can differ 

in the absolute amount of time spent on that activity. For example, while 

Gallatin and Long Beach staff both spent about 28 percent of their time on 

administrative activities, this amounted to 8.9 minutes per case-month at 

Gallatin and 5.2 minutes at Long Beach. This is because the two agencies 

differed in the total amount of staff time per case-month that was available 

to perform all nutrition services and administrative activities.

Percent of total staff time spent on

Nutrition services activities

Agency

Participant

services

Nutrition

education

Breastfeeding

promotion

and support

Total

nutrition

services

Administration

activities

Gallatin 52.8 13.6 5.0 71.4 28.6

Grady 43.2 8.8 6.7 58.7 41.3

Kanabec 37.9 9.0 5.4 52.3 47.7

Long 

Beach

48.8 19.2 3.4 71.4 28.7

York 39.0 4.8 .8 44.6 55.5

Zuni a 23.6 12.9 7.6 44.1 55.8
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Table 3: Approximate Minutes per Case-Month Spent on Nutrition Services and Administration Activities

Note: Totals may not add due to rounding.

a

Represents all staff time available to perform nutrition services and administration 

activities, including that of administrative and support staff.

b

Zuni WIC was the only state-level agency. Some staff time at Zuni WIC was spent on 

activities normally performed at state-level agencies, such as developing program plans 

and reimbursing vendors. Our time study did not distinguish between state- and local-level 

activities at Zuni WIC.

As might be expected, the amount of time spent on specific activities 

within each of the four categories of activities—participant services, 

nutrition education, breastfeeding promotion and support, and 

administration—also varied among the agencies. This variation is 

illustrated in the amount of time spent on providing nutrition education and 

breastfeeding promotion and support directly to participants in one-on-one 

or group sessions. Table 4 shows that Gallatin staff spent 4.5 minutes per 

case-month on these activities, while York and Kanabec spent less than 1 

minute.9

 This table also points out that the amount of time spent providing 

nutrition and breastfeeding education directly to participants, especially at 

the five local agencies, was quite limited. (App. V contains information on 

the percentage of staff time and the percentage of staff time costs spent on 

specific activities in each of the four cost categories. App. VI contains 

Approximate minutes per case-month 

Spent on nutrition services activities

Agency

Participant

services

Nutrition

education

Breastfeeding

promotion and

support

Total spent

on nutrition

services

Spent on

administration

activities

Total time

available for all

nutrition services

and

administration

activitiesa

Gallatin 16.4 4.2 1.6 22.2 8.9 31

Grady 10.8 2.2 1.7 14.7 10.3 25

Kanabec 8.0 1.9 1.1 11.0 10.0 21

Long Beach 8.8 3.5 .6 12.9 5.2 18

York 12.5 1.5 .3 14.3 17.8 32

Zunib 17.0 9.3 5.5 31.8 40.2 72

9

The time spent on these specific activities during our time study period at Kanabec was 

probably less than typically spent because the WIC coordinator attended a training course 

related to nutrition education, during the study, which reduced the time normally spent 

providing nutrition education and breastfeeding education to participants.
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Page 19 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

information on the approximate number of minutes per case-month spent 

on the specific activities.) 

Table 4: Approximate Minutes per Case-Month Spent on Specific Nutrition 

Education Activities Involving Direct Contact With Participants and Percent of Total 

Staff Time Spent on These Activities 

a

A description of each nutrition education activity can be found in app. I.

b

Zuni WIC was the only state-level agency. Some staff time at Zuni WIC was spent on activities 

normally performed at state-level agencies, such as developing program plans and reimbursing 

vendors. Our time study did not distinguish between state- and local-level activities at Zuni WIC.

c

We observed, and some staff reported to us, that some individual nutrition education and 

breastfeeding promotion/counseling occurred during nutrition assessment. Since nutrition assessment 

was considered to be a participant service activity in our time study, our results might underreport the 

amount of time spent on nutrition education and breastfeeding promotion and support. For example, if 

25 percent of the reported time spent on nutrition assessment involved individual nutrition education or 

breastfeeding promotion and support, then the total time spent on these specific activities at Gallatin, 

Grady, Kanabec, Long Beach, York, and Zuni would be increased by 1.0, .7, .8, .4, .5, and .4 minutes, 

respectively.

The variation in how agencies deliver WIC services affects how much time 

WIC staff spend in direct contact with WIC participants. Table 5 shows the 

percent of staff time and minutes per case month spent on activities 

involving direct participant contact—in person or over the telephone. As 

shown in the table, the five local agencies varied widely in both the percent 

Approximate minutes per case-month and the percent 

of staff time

Nutrition education and 

breastfeeding promotion 

activitya Gallatin Grady Kanabec

Long

Beach York Zunib

Providing one-on-one 

nutrition education or 

counseling

2.9 1.1 .5 2.2 .8 2.0

Providing group nutrition 

education

.2 <.1 0 .5 0 3.3

Providing one-on-one 

breastfeeding education or 

counseling

1.4 .8 .1 .5 .1 3.2

Providing group education 

breastfeeding or counseling

<.1 .1 0 <.1 0 .1

Total time spent on these 

specific activitiesc 4.5 2.0 .6 3.3 .9 8.6

Percent of available staff 

time spent on these 

activities. 

15% 8% 3% 18% 3% 12%
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Page 20 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

of total time and the minutes per case-month spent in activities involving 

direct participant contact. Percent of time ranged from a high of 62.5 

percent to a low of 26.9 percent and, in terms of minutes per case-month, 

from 19.4 to 7.0. While Zuni staff spent the most time in terms of minutes 

per case-month in direct contact with participants, they spent the lowest 

percent of total time on such activities, in large part because, as a statelevel agency, Zuni WIC used some staff resources for a variety of program 

planning and management activities not typically performed by local 

agencies, such as developing and updating a state WIC plan and approving 

and reimbursing vendors. 

Table 5: Percent of Total Staff Time and Approximate Minutes per Case-Month Spent 

on Activities Involving Direct Participant Contact 

a

Zuni WIC was the only state-level agency. Some staff time at Zuni WIC was spent on activities 

normally performed at state-level agencies, such as developing program plans and reimbursing 

vendors. Our time study did not distinguish between state- and local-level activities at Zuni WIC.

Agencies Used 

Nonprogram 

Resources to Cover 

Some Costs, but the 

Share of Costs Covered 

Did Not Approach the 

Level Cited in a 1988 

USDA Study

The six agencies we studied used a variety of nonprogram resources to 

cover some of the costs of delivering nutrition services and administering 

the program. Most of the nonprogram resources we identified were in-kind 

contributions made by the agencies’ sponsoring organizations, and some 

were provided by other organizations, individuals, or grants. The share of 

costs covered by these resources at the agencies we studied did not 

approach the level cited in a 1988 USDA study.

Agency

Percent total

staff time

Approximate minutes

per case-month

Gallatin 58.5 18.1

Grady 41.2 10.3

Kanabec 34.3 7.2

Long Beach 62.5 11.3

York 31.4 10.0

Zunia 26.9 19.4
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Page 21 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

Agencies Used a Variety of 

Nonprogram Resources 

In fiscal year 1999, the six agencies we studied used a variety of 

nonprogram resources to cover some costs: (1) in-kind contributions from 

their sponsoring organizations, (2) in-kind contributions from other 

organizations or individuals, and (3) grants from other organizations. Most 

of the nonprogram resources we identified were in the first category. Table 

6 shows the categories of nonprogram resources used at each agency. 

Table 6: Categories of Nonprogram Resources Used to Cover the Costs of Providing 

Nutrition Services and Administering the Program, Fiscal Year 1999

The following provides information on the nature of nonprogram resources 

for each category.

In-Kind Contributions by 

Sponsoring Organizations 

Table 7 describes the major types of in-kind contributions we identified 

that were made by each agency’s sponsoring organization.

Agency

In-kind contributions

by sponsoring

organization

In-kind contributions

by other

organizations or

individuals

Grants from other

organizations

Gallatin X X

Grady X

Kanabec X X

Long 

Beach

X

York XXX

Zuni WIC XXX
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Page 22 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

Table 7: Major In-kind Contributions Made by Sponsoring Organizations

In-kind Contributions Made by 

Other Organizations 

Four agencies—Gallatin, Kanabec, York, and Zuni—received contributions 

from other public entities and private businesses. Again, donated space 

was a common contribution. For instance, Gallatin, which serves not only 

Gallatin County but also two adjacent counties, received donated space for 

three of its four satellite clinics from these counties. Two public high 

schools in Zuni donated space for WIC staff to issue vouchers to teenage 

WIC mothers, while a grocer in a neighboring town provided Zuni WIC with 

space for the issuance of vouchers to Navajo participants. Similarly, the 

private landlord for York’s main clinic charged the program a below-market 

rate for rent.

WIC agencies also received other types of in-kind contributions from public 

and private sources. For instance, the Grady Director indicated that its 

dietitians received free continuing education via teleconference courses 

sponsored by the Centers for Disease Control and Prevention. A local 

medical practice provided the waiting room furniture for York’s main clinic, 

while a national medical supply company donated infant feeding supplies 

to Kanabec.

Agency Major in-kind contributions made by sponsoring organization 

Gallatin Shared space—the waiting area, examination room and classroom space for the main clinic is shared with other 

county programs and is provided at no cost to the program.

General administrative support—utilities, administrative personnel.

Grady Space—the space for the six clinic locations provided at no cost to the program.

Indirect costs—the program was not charged for any indirect costs incurred to operate it. 

Personnel—the costs of some staff providing WIC services were not charged to the program.

Employee benefits—some of the costs of benefits for WIC staff were not charged to the program.

Kanabec Space—all space used by the program, including the clinic, was provided at no cost to the program. 

Personnel—health care staff provided some nutrition education, in conjunction with prenatal care, to WIC participants.

General administrative support—supplies/materials, equipment, and administrative personnel.

Long Beach Space—the space used at two sites was provided at no cost to the program.

Indirect costs—the sponsoring organization did not charge the program for all indirect costs it incurred to operate the 

program.

General administrative support—utilities for two sites, furniture, equipment, and translation services.

York Indirect costs—the sponsoring organization did not charge the program for all indirect costs it incurred to operate the 

program.

Personnel—one part-time administrative support staff provided at no cost to the program.

General administrative support—furniture and supplies.

Zuni Space—the land on which the main clinic structure—a trailer—is situated.
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Page 23 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

Grants Three of the agencies, Zuni, Grady, and York, recently received small grants 

from public and private sources to support program services. In 1999, Zuni 

received a $500 grant from a U.S. Indian Health Service diabetes prevention 

program to distribute toys to encourage children’s physical activity. In 

fiscal year 1999 York WIC used $2,000 in grant funds from the city of York 

to educate mothers on baby bottle tooth decay. Lastly, Grady received 

$2,000 in 1998 from the March of Dimes for breastfeeding supplies and 

educational materials. 

The Share of Costs Covered 

by Nonprogram Resources 

Did Not Approach the Level 

Previously Cited 

The share of costs covered by nonprogram resources at the six agencies we 

studied did not approach the level cited by Abt Associates in its 1988 study 

for USDA—54 cents for every dollar in costs covered with WIC funds. For 

example, at Grady, where the nonprogram resources we identified covered 

the largest share of costs, the share of costs covered by these resources 

amounted to 20 cents for each dollar in costs covered with WIC funds. 

More specifically, the major nonprogram resources we identified at Grady 

in fiscal year 1999 were the sponsoring organization’s in-kind contributions, 

which had a total value of approximately $99,000. According to information 

provided by an official of the sponsoring organization, an estimated $88,000 

of this total was in the form of indirect costs incurred by the sponsoring 

organization that were not charged to the program and about $4,000 was to 

subsidize the benefits for WIC employees. According to information 

provided by the WIC Director, nutrition and clerical staff support provided 

by the sponsoring organization was valued at about $7,000. (The $7,000 in 

salary costs for these staff was covered by other federal grant funds.) The 

$99,300 in total contributions represents approximately 20 percent of 

Grady’s 1999 WIC program expenditures, or about 20 cents for every dollar 

in costs covered with program funds. 

We identified the following nonprogram resources at the other five 

agencies: 

• Long Beach. The major nonprogram resources used in fiscal year 1998 

had a total value of approximately $333,000 and were in-kind 

contributions made by the sponsoring organization.10 According to 

information provided by an official of the agency’s sponsoring 

organization, about $273,000 of the amount was for indirect costs not 

10Fiscal year 1998 was the most recent year for which information on the indirect costs for 

the WIC program was readily available. 
B-286011

Page 24 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

charged to the program and $60,000 was for the value of the space 

provided to the program at no charge. The estimated $333,000 value of 

nonprogram resources represented about 11 percent of program 

expenditures in fiscal year 1998, or 11 cents for every dollar in costs 

covered with program funds.

• York. The major nonprogram resources used in fiscal year 1999 had a 

total value of approximately $58,400. According to information provided 

by officials of the sponsoring organization, about $36,400 of this amount 

was the approximate value of its in-kind contributions. About $31,000 of 

this amount was for indirect costs incurred by the sponsor but not 

charged to the program, and about $5,400 was for the wages of one parttime administrative staff person assigned to the program at no cost. (In 

both instances, the costs of the contributions made by the sponsor were 

covered by other federal program funds—a Community Services Block 

Grant and a grant from the Department of Labor.) An additional $20,000 

in nonprogram resources was, according to the WIC Director, the 

approximate value of the discounted lease amount the landlord charged 

the program for the space at the main clinic. The remaining $2,000 was a 

grant from the city of York to educate mothers on baby bottle tooth 

decay. In total, the value of these nonprogram resources ($58,400) 

represented approximately 11 percent of program expenditures in fiscal 

year 1999, or 11 cents for every dollar in costs covered with program 

funds. 

• Gallatin. The major nonprogram resources used to cover the costs of 

providing nutrition services and administering the program in fiscal year 

1999 were in-kind contributions by both the sponsoring and other 

organizations. The sponsoring organization estimated the value of the 

in-kind contributions of shared space and support from administrative 

personnel to be $10,720. The program also received donated space for 

three of its four satellite clinics from Madison and Park counties. The 

WIC Director estimated the value of space contributed by these adjacent 

counties was about $1,200 per year. The combined total value for the 

major in-kind contributions, $11,920, represented about 8 percent of 

Gallatin’s WIC program expenditures in fiscal year 1999, or about 8 cents 

for every dollar in costs covered by program funds. 

• ⋅Kanabec. The major nonprogram resources in fiscal year 1999 used to 

cover program costs had a value of $3,000. According to a sponsoring 

agency official, in-kind contributions were made by the sponsoring 

organization of dedicated space for the WIC office, use of equipment, 
B-286011

Page 25 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

and support from health care staff. The $3,000 represented about 6 

percent of program expenditures, or about 6 cents for every dollar in 

costs covered by program funds.

• Zuni. The major nonprogram resources Zuni WIC used to cover 

program costs in fiscal year 1999 had a value of about $5,500. According 

to an official of the sponsoring agency, $5,000 was in the form of an inkind contribution of rent-free land on which the WIC facility was 

located. In addition, the WIC program received a $500 Indian Health 

Service grant to distribute toys to improve children’s physical activity. 

The $5,500 represented about 2 percent of Zuni WIC’s program 

expenditures in fiscal year 1999, or about 2 cents for every dollar in 

costs covered by program funds.

Agency Comments We provided a draft of this report to USDA’s Food and Nutrition Service for 

review and comment. We met with Food and Nutrition Service officials, 

including the Director of the Grants Management Division. The agency 

officials generally agreed with the information presented in this report. 

They provided some technical comments, which we incorporated as 

appropriate. We also provided the case study agencies, their sponsoring 

organizations, and the state-level WIC agencies with the opportunity to 

review a draft of those sections of the report pertaining to their operation. 

These organizations provided us with a number of technical corrections, 

which we incorporated as appropriate. 

We are sending copies of this report to the appropriate congressional 

committees; interested Members of Congress; the Honorable Dan 

Glickman, Secretary of Agriculture; and other interested parties. We will 

also make copies available upon request.
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Page 26 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

If you or your staff have any questions about this report, please contact me 

or Thomas E. Slomba at (202) 512-5138. Key contributors to this report are 

listed in appendix VII.

Robert E. Robertson

Associate Director, Food and

Agriculture Issues
Page 27 GAO/RCED-00-202 Activities and Use of Nonprogram Resources
Page 28 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

Appendix I

Scope and Methodology ApApenednxidexiIs

This report provides information on the (1) approaches WIC agencies use 

to deliver nutrition services and administer the program; (2) way staff at 

WIC agencies allocate their time delivering nutrition services and 

administering the program; and (3) types of nonprogram resources used by 

WIC agencies and the extent to which such resources are used to cover the 

costs of delivering nutrition services.

To address these issues, we conducted case studies at six judgmentally 

selected WIC agencies. The case study approach enabled us to provide 

detailed information on agency procedures and operations. The case 

studies are not intended to be a statistically valid sample. Consequently, 

our observations and results are not generalizable to all WIC agencies.

In judgmentally selecting individual case study agencies, we sought to 

identify a set of case studies that represented a wide range of agency 

characteristics. Towards that end, we considered over a dozen agency 

characteristics, including WIC enrollment levels, type of sponsoring 

agency, geographic location, rural versus urban operating environments, 

frequency of food instrument issuance, racial/ethnic diversity, and poverty 

levels. The six WIC agencies selected included five local agencies: Gallatin 

WIC in Montana; Grady WIC in Atlanta, Georgia; Kanabec WIC in 

Minnesota; Long Beach WIC in California; and York WIC in Pennsylvania; 

and one Indian tribal organization, Zuni WIC, in New Mexico, which 

functions as both a state- and local-level WIC agency. 

To determine how nutrition services and administration activities are 

performed at each of the case study agencies, we conducted on-site 

interviews with WIC agency management and staff as well as with officials 

and staff of the respective sponsoring organizations and state WIC 

agencies. Interviews were conducted using a standardized interview guide. 

During our site visits, which ranged from 4 to 5 days in length, we observed 

staff perform the various nutrition services and administrative activities, 

including individual and group nutrition education sessions. We also 

gathered and reviewed pertinent documents, including agency policies, 

staff rosters, clinic schedules, and financial and budget documents. After 

our on-site visits, we followed-up as necessary with agency, state, and 

sponsoring organization officials to obtain additional information as 

needed. We did not evaluate whether the local agencies followed state 

and/or federal WIC or grant management guidelines. 

To determine the amount of time that the WIC staff spent performing 

various activities, we conducted time studies at each of agencies. To 
Appendix I

Scope and Methodology

Page 29 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

develop the activity categories used in our time studies we reviewed Food 

and Nutrition Service (FNS) documentation, recent WIC research and 

examples of WIC time studies from several states in order to identify and 

categorize the nutrition services and administration (NSA) activities to 

track during the time study. Table 8 lists the activity categories and 

subcategories that we monitored in our review. 

Table 8: Description of WIC Activity Categories Used for Time Studies at Six Case Study Agencies

WIC activity category Description of activities in each activity subcategory

Participant services 

Scheduling participantsa Scheduling appointments, providing phone or in-person reminders, following up on missed 

appointments, and rescheduling.

Determining participants’ eligibilitya

 Determining eligibility (income, category, residence); obtaining necessary documentation 

and copying it; completing forms or computer screens; having support staff obtain 

anthropometrics and blood work for the purpose of determining eligibility; obtaining and 

recording immunization data; handling complaints.

Assessing participants’ nutritional riska Having competent professional authoritiesb

 obtain physical measurements, such as height 

and weight, and bloodwork for the purpose of assessing risk or intervention level, 

completing assessments and tests, determining appropriate risk factors, assessing 

immunization status, completing forms or computer screens, discussing nutrition and 

breastfeeding, developing a care plan, developing a food package, reviewing charts and 

filing, entering progress notes.

Making referrals and following upa Assisting participants in obtaining other health or social services (such as public health 

services, immunizations, Medicaid, food stamps, and voter registration) or transferring to 

another WIC agency.

Explaining benefits and procedures to 

participantsa

Explaining WIC procedures, rights and benefits.

Issuing food benefitsa Issuing checks or vouchers, training participants in using vouchers in a store, voiding 

vouchers.

Providing or receiving training or other 

professional development

Training staff or volunteers or receiving training in procedures for certification, eligibility, 

scheduling, WIC client benefits and rights, and client services; reading related professional 

materials; attending or holding workshops, meetings, and conferences. Professional 

development refers to time spent by WIC staff either receiving training, or in providing 

training to other WIC support staff (such as peer counselors, volunteers, clerical staff) on 

WIC procedures, policy or related technical issues.

Making record notations Making chart notations after client has left clinic: completing or revising nutritional notes, 

care plan, or other participant information.

Nutrition education

Providing one-on-one nutrition education or 

counselinga

Providing a one-on-one counseling/education session that occurs outside of 

certification/recertification process, explaining WIC foods and food preparation, following 

up, and documenting meetings. Includes phone calls and visits to, for example, the home or 

a hospital.

Providing group nutrition educationa Providing group counseling/education sessions.
Appendix I

Scope and Methodology

Page 30 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

Developing educational materials Researching, developing, ordering, and reviewing materials; planning and conducting 

activities, sending out mailings.

Consulting with medical providers regarding 

nutrition education of individual participants 

Communicating with medical providers regarding the nutrition education of individual 

participants. Includes phone calls, mailings, visits, meetings, and in-services.

Providing or receiving training or other 

professional development 

Reading professional materials, attending workshops and other meetings; developing and 

presenting in-services; training other staff or volunteers. 

Monitoring and evaluating nutrition 

education activities

Monitoring and evaluating nutrition education activities; compiling and analyzing data; 

revising policies and procedures.

Breastfeeding promotion and support

Providing one-on-one breastfeeding 

Instruction/counselinga

Providing a one-on-one breastfeeding counseling/education session that occurs outside of 

certification/recertification process. 

Providing group breastfeeding 

instruction/counselinga

Providing group breastfeeding counseling/education. 

Developing breastfeeding promotion 

materials

Researching, developing, ordering, and reviewing materials; planning and conducting 

activities (e.g., incentive awards), mailings. 

Consulting with medical providers regarding 

breastfeeding issues

Communicating with medical providers regarding breastfeeding promotion and support or 

coordination of services. Includes phone calls, mailings, home visits, hospital or medical 

center visits, meetings, and in-services.

Providing or receiving training or other 

professional development 

Reading professional materials, attending workshops or other meetings; developing and 

presenting in-services, training peer counselors or volunteers. 

Monitoring and evaluating breastfeeding 

promotion activities

Monitoring and evaluating breastfeeding promotion and support activities and 

breastfeeding rates; compiling and analyzing data; revising policies and procedures.

Administration

Outreach to potential participantsa Providing WIC information to potential participants.

Outreach to health care providers and other 

organizations

All communication (such as phone, meetings, and mailings) with health care providers, 

social service agencies, schools, public officials, and others; encouraging referrals to the 

WIC program; nutrition education or breast feeding promotion; developing and distributing 

outreach materials; arranging for advertising or notification; developing or conducting 

demonstrations.

Clerical tasks Filing, photocopying, ordering supplies and equipment; purchasing, renting or repairing 

equipment; handling correspondence and data entry; setting up the clinic; assigning space 

for group sessions, maintaining state or local licenses, bondage or insurance; maintaining 

voucher issuance records; maintaining lists of authorized vendors; voiding vouchers; 

inventorying vouchers; printing vouchers; and maintaining voucher stock.

Travel Preparing for travel—such as loading equipment; traveling to clinics or other-WIC related 

destinations; preparing travel expense reports; and checking on airfares, hotels, and other 

travel needs. 

Personnel tasks Completing timesheets; processing payroll; hiring and terminating staff; orientating new 

personnel; supervising staff; non-WIC staff training.

Accounting and finance Processing invoices, preparing reports; developing and reviewing budgets; auditing.

Vendor management Training vendors; responding to complaints; conducting on-site visits; monitoring; 

disqualifying vendors; corresponding with vendors; maintaining vendor records; authorizing 

vendors.

(Continued From Previous Page)

WIC activity category Description of activities in each activity subcategory
Appendix I

Scope and Methodology

Page 31 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

a

Activity involved direct contact with participant, or in the case of outreach with potential 

participants, either in person or by telephone. 

b

A competent professional authority is, according to program regulations, an individual on 

the staff of a local agency who is authorized to determine nutritional risk and prescribe 

supplemental foods. Individuals who can be designated as a CPA include nutritionists, 

dietitians, nurses, and medically trained health officials. 

We used two techniques to record and summarize the amounts of time 

individual staff spent on these various activity categories. At five agencies 

we employed a contractor, Work Management Institute, Ltd. of Arlington, 

Virginia, which had developed a recording system utilizing bar code 

technology. Rather than having WIC agency staff manually record how they 

spent their time using traditional timesheets, the bar code technology 

allowed participating staff to sweep a credit-card size bar code scanner 

over specific bar codes as they began each activity throughout the day (see 

fig. 3). The technology and associated procedures were intended not only 

to ease the WIC staffs’ data entry burden but also to increase the accuracy 

of the data. The contractor provided training to the staff and subsequent 

monitoring to ensure that the bar code procedures were followed properly. 

Each evening, the data were uploaded to the contractor who collated and 

analyzed the data. The contractor provided reports to each staff member 

the next day for verification. We used the bar code technology to conduct a 

1-month (20 to 22 workdays) time study at five of the WIC case study 

agencies: Gallatin, Grady, Kanabec, York, and Zuni. 

Management Attending staff meetings; conducting general evaluation of WIC activities; developing 

policies and procedures; reviewing reports; scheduling clinic operations.

Organize self/work Setting priorities for the day’s work; turning computers on/off; organizing desk at end of day.

Miscellaneous Time spent on WIC related activity that did not fit under other defined activity.

(Continued From Previous Page)

WIC activity category Description of activities in each activity subcategory
Appendix I

Scope and Methodology

Page 32 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

Figure 3: Bar Code Scanner and Sheet Used in Time Study

We did not use the bar code technology for the sixth case study—Long 

Beach—because of the increased costs associated with deploying the 

system for the significantly larger number of staff located at the agency. 

Instead we used a paper-and-pencil timesheet approach, which 

incorporated many of the features of the bar code approach. Specifically, 

Long Beach staff used the same activity coding system as the agencies 

using the bar code technology, and agency staff members received on-site 

training from GAO staff members. WIC staff recorded on timesheets how 

they spent their time 1-day a week, over a 5-week period. The days for timeuse recording were pre-assigned, so that staff recorded their times once on 

each day of the week (i.e., once on a Monday, once on a Tuesday). In 

addition, on any given day approximately one-fifth of the staff recorded 

time use. If a staff member could not record times on the assigned day, 

GAO assigned a substitute day. Complete data (5 days) were obtained for 

51 of the 53 staff members. The recording sheet of each staff member was 

reviewed once it was received, and any problems or concerns about the 

way times were recorded were discussed with the staff member. Table 9 

shows the time span of each of the six time studies.
Appendix I

Scope and Methodology

Page 33 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

Table 9: Time Span of Time Study for Each Agency

To arrive at the minutes per case-month spent on an activity category at an 

agency, we multiplied the percent of all time staff time spent on a given 

activity category by the approximate number of minutes of staff time, 

including that of administrative and support staff, available to perform all 

nutrition services and administrative activities. To arrive at the 

approximate number of minutes available for all nutrition services and 

administrative activities for each agency, we (1) calculated the number of 

full-time equivalent staff at each agency at the time of our study; (2) divided 

the agency’s average monthly participation for fiscal year 1999 by the 

number of full-time equivalent staff to arrive at an approximation of the 

number of participants served per full-time equivalent staff; (3) assumed 

each full-time equivalent staff had approximately 1,920 hours available 

each year and divided 1,920 by the number of participants served per fulltime equivalent staff to arrive at the number of hours of staff time available 

per participant per year; (4) divided the number of hours available per year 

by 12 and converted the result to minutes to arrive at the approximate 

number of minutes available per participant per month—referred to as per 

case-month. 

To calculate the percent of staff time costs spent on the various activity 

categories we used the loaded hourly wage rate (pay plus benefits) for 

employees at all agencies except Long Beach where we used the unloaded 

hourly wage rate (benefits not included). The time an individual staff 

member spent on an activity category was multiplied by that individual’s 

wage rate. The sum of staff costs for an activity category and the sum of 

costs for all activity categories were used to calculate the percentage of 

staff time costs for each activity category. 

Finally, to determine the types of nonprogram resources and the extent to 

which agencies used such resources to cover costs, we requested detailed 

Agency Time span of time study

Gallatin October 10, 1999 through November 17, 1999

Grady February 28, 2000 through April 3, 2000

Kanabec October 25, 1999 through November 22, 1999

Long Beach January 18, 2000 through February 18, 2000

York March 13, 2000 through April 12, 2000

Zuni February 10, 2000 through March 16, 2000
Appendix I

Scope and Methodology

Page 34 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

information during our interviews with officials of the WIC agencies and 

their sponsoring officials regarding all nonprogram resources used to 

provide WIC services. We then worked with the officials to establish a 

value for each of the major nonprogram resources used, relying where 

possible on records such as existing indirect cost allocation plans. 
Page 35 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

Appendix II

Selected Characteristics of the Six Case Study 

Agencies ApendxiI

This appendix presents five tables on selected characteristics of the case 

study agencies.

Table 10 shows the characteristics of the six case study agencies in terms 

of sponsoring organization, and geographic areas served, and average 

monthly number of participants served in fiscal year 1999. 

Table 10: Characteristics of Case Study Agencies in Terms of Sponsoring Agency, 

Geographic Area Served, and Average Monthly Number Of Participants Served 

a

Gallatin is operated by a single county but provides nutrition services to three counties.

Table 11 compares the characteristics of the five local case study agencies 

with those of local agencies nationwide. The characteristics of the local 

agencies are based on information provided by 1,416 local WIC agencies 

that responded to a nationwide survey we conducted in 1999.1

Agency 

Sponsoring 

organization 

Geographic area 

served

Average monthly

participation, fiscal

year 1999

Gallatina Single county health 

agency

Rural 1,018

Grady Public hospital Urban 4,852

Kanabec Single county health 

agency

Rural 313

Long Beach City health 

department

Urban 28,452

York Community action 

agency

Urban 4,859

Zuni Indian tribal 

organization 

Rural 857

1

We conducted the survey for our report entitled Food Assistance: Financial Information on 

WIC Nutrition Services and Administrative Costs (GAO/RCED-00-66, Mar. 6, 2000). That 

report contains a description of the survey methodology.
Appendix II

Selected Characteristics of the Six Case 

Study Agencies

Page 36 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

Table 11: Characteristics of Five Local Case Study Agencies Compared With Local 

WIC Agencies Nationwide

a

Gallatin is operated by a single county but provides nutrition services to three counties

Table 12 shows the number of full-time equivalent staff and the participantto-staff ratio at the time of our study.

Agency setting 

Percent of local

agencies

nationwide Case study agency 

State health agency 3

District health agency 7.6

Multicounty health agency 8.6

Single county health agency 40.6 Kanabec, Gallatina

Municipal health agency 2.9 Long Beach

Community health agency 15.7

Community action agency 7.3 York

Indian health agency 2.3

Public hospital 3.5 Grady

Private voluntary hospital 1.8

Private proprietary hospital 0.6

Other 5.3

Geographic service area

Urban 24.3 Long Beach, Grady, York

Suburban 7.6

Rural 56.1 Gallatin, Kanabec

Mixed 10.5

Average monthly caseload 

500 or less 19.8 Kanabec 

501-999 15.7

1,000—2,499 26.5 Gallatin

2,500—4,999 17.7 Grady, York 

5,000—9,999 11.4

10,000 or more 8.2 Long Beach 

Unknown 0.6
Appendix II

Selected Characteristics of the Six Case 

Study Agencies

Page 37 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

Table 12: Selected Staffing Statistics for Each Case Study Agency 

Table 13 shows the amount of WIC program resources the six agencies 

used to provide nutrition services and administer the program in fiscal year 

1999. These expenditures are expressed as expenditures per participant 

per month. The variation among the agencies is due in large part to the 

amount of funding per case-month that flows from USDA to the state-level 

WIC agencies, and from these state-level agencies to the local agencies.

Table 13: Six Agencies’ Expenditures of WIC Program Funds, Fiscal Year 1999 

Notes: The WIC program expenditures refer to the local agency expenditure of federal and, in the case 

of Kanabec, federal and state WIC program funds. The per-participant per case-month expenditures 

for the five local agencies do not include program expenditures made at the state level. Some statelevel expenditures directly support local agency operations. The expenditures for Zuni WIC, the only 

state-level agency, include both state-and local-level expenditures. 

Table 14 shows the percent of WIC program funds expended on personnel, 

space, indirect costs, and all other costs for each of the six agencies in 

fiscal year 1999. 

Agency 

Number of

full-time

equivalent

staff

Number of

registered

dietitians on

staff

Number of

registered

nurses on

staff

Participants

per staff

Gallatin 3.3 1 0 308

Grady 12.8 8 0 381

Kanabec .7 0 1 460

Long Beach 52.2 16 0 545

York 16.3 0 2 300

Zuni 6.6 1 0 134

Agency

Expenditure per

participant per month

Gallatin $12.54

Kanabec $8.09

Long Beach $8.43

Grady $8.37

York $9.47

Zuni $25.71
Appendix II

Selected Characteristics of the Six Case 

Study Agencies

Page 38 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

Table 14: Six Agencies’ Percent Distribution of WIC Program by Budget Category, 

Fiscal year 1999 

a Zuni WIC was the only state-level agency. Some Zuni WIC expenditures were for statelevel costs.

Budget category Gallatin Grady Kanabec

Long

Beach York Zunia

Personnel and benefits, 

excluding expenditures 

for contracted personnel 

79% 96% 89% 50% 84% 68%

Contracted personnel 0 0 0 26 0 0

Facilities and related 

expenses 

70 2782

Equipment and supplies 3 4 2 2 1 4

Indirect 4 0 6 5 4 14

All others 7 <1 1 10 3 12

Total 100% 100% 100% 100% 100% 100%
Page 39 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

Appendix III

Additional Comparisons of the Ways the Six 

Agencies Deliver Nutrition Services and 

Administer the Program ApendxiI

This appendix provides additional comparisons of agencies’ approaches in 

areas of participant services, nutrition education, breastfeeding promotion, 

and program administration. 

Participant Services • Managing participants’ waiting time. The six agencies used a variety 

of strategies to try to schedule participants’ appointments, thus affecting 

the amount of time participants waited to be seen. For example, Gallatin 

and Kanabec saw their participants in the order of their scheduled 

appointment times, and participants typically waited 5 to 10 minutes for 

service. In contrast, while Long Beach scheduled most appointments, 

participants were seen on a “first-come, first-served” basis, regardless of 

whether or not they had an appointment; under this system, participants 

experienced waiting times of about 30 minutes. 

• Handling missed appointments. The agencies used various strategies 

to deal with the problem of missed appointments. At two agencies—

Kanabec and York—staff routinely called participants to remind them of 

upcoming appointments but did not call them if they had missed 

appointments. In contrast, Grady, Gallatin, and Zuni only made followup phone calls or sent post cards to participants who missed an 

appointment. Long Beach uses an automated telephone calling system 

to make recorded calls to remind participants of upcoming 

appointments and to remind them to reschedule a missed appointment.

• Referring participants to other service providers. The agencies 

varied somewhat in how they referred participants to other service 

providers, but no agency consistently followed up on whether 

participants had acted on the referral. Participants may be referred to a 

variety of health and social service providers, such as the public health 

nurse for immunizations or the Medicaid or food stamp offices. In 

particular, for referrals to public health providers, three agencies—

Gallatin, Kanabec, and Zuni—used a referral form. For other types of 

referrals at these three agencies and for all referrals at the other three 

agencies, staff typically provided participants with information orally 

and in written form, such as a brochure or printed list that identified the 

provider or providers of the needed service. At all of the agencies but 

Long Beach, staff noted the referral in the participant’s record. 
Appendix III

Additional Comparisons of the Ways the Six 

Agencies Deliver Nutrition Services and 

Administer the Program

Page 40 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

Nutrition Education • Content of instruction. The six agencies most often provided 

nutrition education to adult participants or caregivers through one-onone discussions. The information provided during these sessions varied 

considerably. We observed that the content of these initial discussions 

ranged from a few general sentences to in-depth explanations and 

medical nutritional counseling.1

• Other methods used to provide nutrition education. The agencies 

varied in the extent to which they used strategies, other than one-on-one 

sessions or classes, to provide nutrition education. For example, Zuni, 

which had a kitchen in its facility, was the only agency to incorporate 

cooking demonstrations into group sessions. All the agencies also used 

brochures and other education material to provide general nutrition 

information. At Zuni, participants were asked to study a display and 

answer questions that they reviewed with WIC staff. Videotapes on 

nutrition were typically played in waiting rooms at Long Beach, York,2

and Zuni. 

• Tailoring nutrition education to meet participants’ language 

needs. Several agencies tailored the nutrition education they provided 

to meet the language needs of specific groups of participants. For 

instance, four agencies—Long Beach, Zuni, Grady, and York—operated 

in ethnically diverse communities and hired bilingual staff to provide 

nutrition education to non-English speaking participants. Long Beach 

staff developed its own brochures to serve its Cambodian population. In 

contrast, the Grady Director told us that the program lacked funding for 

nutrition education materials in languages to serve some segments of 

the agency’s participant population. 

Breastfeeding 

Promotion and Support

• Content of breastfeeding one-on-one sessions. As with nutrition 

education, the content and the duration of the breastfeeding counseling 

ranged from a brief exchange about whether a woman intended to 

breastfeed to a 45-minute breastfeeding appointment. 

1

Medical nutrition counseling addresses medical nutrition issues such as gestational 

diabetes. Gallatin, Kanabec, Long Beach, and Zuni referred participants who needed 

medical nutrition counseling to non-WIC dietitians. 

2

 During our visit the York videotape machine was out of order.
Appendix III

Additional Comparisons of the Ways the Six 

Agencies Deliver Nutrition Services and 

Administer the Program

Page 41 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

• Using other strategies to promote breastfeeding. In order to 

sustain breastfeeding once the mothers are at home, three agencies—

Kanabec, Grady, and Zuni—offered telephone support to mothers 

calling with questions or concerns. To make breastfeeding convenient 

while mothers were visiting WIC offices, two agencies—Long Beach and 

Zuni—dedicated private space for this purpose. In addition, staff from 

three agencies, Zuni, Gallatin, and Long Beach, committed their local 

WIC funding or time volunteered by staff to develop breastfeeding 

promotion material—videos and brochures—for use not only by their 

own agency but also for other agencies in their area. 

Administration • Conducting outreach. Outreach generally includes those activities 

undertaken to attract eligible participants and to ensure that they 

continue to receive the benefits to which they are entitled. All of the 

agencies but Grady described distributing WIC materials to area medical 

providers, community groups, or social service providers, and at area 

health fairs. Several agencies mentioned that they distributed material 

to area schools and/or the Head Start program. The Kanabec WIC 

Director indicated that participants also typically heard about the WIC 

program through friends and family. The Gallatin WIC Director said that 

the effectiveness of the agency’s outreach was limited because staff 

were not trained in outreach strategies, and the agency lacked the 

resources to provide such training. Grady WIC conducted minimal 

outreach because it did not have a defined service area and did not want 

to take participants from neighboring WIC agencies. Outreach activities 

were confined to the WIC caseload, hospital-based patients, and 

hospital-sponsored events, such as an open house meant to inform 

expectant mothers on available hospital services.
Page 42 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

Appendix IV

Detailed Summaries of the Six Case Studies ApendxiIV

This appendix provides a detailed summary of each of the six case study 

agencies. It includes an overview of the state-level WIC program and 

describes the geographic area served by the agency, the sponsoring 

organization, staffing, clinic operations, the approaches used to deliver 

major nutrition services and administer the program, and the nature of 

nonprogram resources used to provide WIC services.

Gallatin County, 

Montana, WIC Program 

Overview of the Montana 

State WIC Program 

The Gallatin County WIC program is one of 43 local agencies providing WIC 

services in Montana. In fiscal year 1999, the average monthly number of 

participants served by these 43 agencies was 21,346. According to our 1999 

national survey of local WIC agencies, most of these agencies operate in 

rural settings and over half are run by a single county public health agency.1

In fiscal year 1999, the Montana WIC program expended federal Nutrition 

Services and Administration (NSA) grant funds totaling $4,178,202, or 

about $16.31 per participant per month (per case-month). Montana 

provided no state funds for WIC nutrition services and administration. 

About 24 percent of the NSA expenditures ($986,655) was made at the state 

level. The remaining 76 percent ($3,211,547) was expended by the local 

agencies. Montana distributes WIC program funds to local agencies on the 

basis of served caseload bands, or “per capita funding.” The funding 

allocation is based on the average of actual participants served in the most 

recent 6 or 12 months of participation, whichever is greater. For example, 

in fiscal year 1998, Gallatin WIC received $180 per participant per year for 

the first 100 participants, $139 per participant per year for the next 101 to 

500 participants, and $133 per participant above 500. 

The Montana WIC program supports the local agencies by providing a 

statewide participant database system, which became fully operational in 

1995. The state conducts a nightly upload of the participant certification 

data from the local agencies’ computers. The statewide automated system 

1

 We conducted the survey for our report entitled Food Assistance: Financial Information on 

WIC Nutrition Services and Administrative Costs (GAO/RCED-00-66, Mar. 6, 2000). This 

report describes the survey methodology. 
Appendix IV

Detailed Summaries of the Six Case Studies

Page 43 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

is used to schedule appointments and collect and record information 

obtained during participant certification and recertification, including 

nutrition risk assessments. It is also used to create custom food packages, 

calculate the value of each food package or food check, and print food 

checks on demand. Local agency staff can also use laptop computers to 

print food checks on demand at satellite clinics.

The Montana WIC program also supports the local agencies by providing 

program guidance; nutrition and breastfeeding materials, training; peer 

training on breastfeeding; travel and lodging needed to attend training; 

equipment purchases, such as blood-testing equipment and supplies; 

automated data processing equipment and support, including three toll-free 

800 telephone numbers for technical support.

Characteristics of the 

Geographic Area Served by 

the Gallatin County WIC 

Program

The Gallatin County WIC program is located in Bozeman, Montana, and 

serves the residents of Gallatin, Park, and Madison counties. The 

population in Gallatin County grew over 2 percent in just 1 year, from 

61,196 in 1997 to an estimated 62,545 in 1998. Bozeman is the fifth largest 

city in the state, with an estimated population of 29,936 in 1998. It is 

situated in southwestern Montana, in a large valley surrounded by rugged 

mountains. The climate varies with the elevation. Higher elevations bring 

lower temperatures and higher snowfalls that can make travel difficult at 

times. Figure 4 shows the topography of the tri-county area served by 

Gallatin WIC.
Appendix IV

Detailed Summaries of the Six Case Studies

Page 44 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

Figure 4: Topography of the Three County Area Served By Gallatin WIC and the Satellite Clinic Locations.

Source: Gallatin City-County Health Department, Bozeman, MT.

In 1993 about 13 percent of Gallatin County’s population was at or below 

the poverty level. The recent population growth has made Bozeman more 

expensive to live in, and as a result, low-income individuals and families 

have moved farther from the town’s center. Gallatin County is 

predominantly white, with minorities (African-Americans, American 

Indians, Eskimos and Aleuts, Asian/Pacific Islanders, and Hispanics) 

representing 3.7 percent of the total population in 1996.

Yellowstone

National

Park

State of Montana

MADISON

COUNTY

PARK

COUNTY

GALLATIN

COUNTY

West

Yellowstone

Ennis

Bozeman Livingston

Three Forks

505

Roads

County boundary
Appendix IV

Detailed Summaries of the Six Case Studies

Page 45 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

Local Agency’s Program 

Characteristics 

Sponsoring Organization Gallatin WIC has operated under the auspices of the Gallatin City-County 

Health Department, a single county health agency, since 1976. In addition to 

the WIC program, the Health Department operates adult and child 

immunization clinics, a school nursing program, a well-child clinic, a 

breastfeeding support and education program, and the Maternal/Child 

Health Home Visitation program. The Department provides an integrated 

service model that provides “one-stop-shopping” for those seeking health 

services in Gallatin County.

The county charges the WIC program for indirect costs such as accounting, 

data processing, and personnel. Total indirect costs charged to the WIC 

program are based on cost allocation among the various programs. In fiscal 

year 1999 the program was charged for indirect costs that represented 3.9 

percent of program expenditures. The health department provides WIC 

with in-kind contributions of shared space for a waiting room, a classroom, 

storage space, and an examination room used by the main clinic, as well as 

utilities and support from administrative personnel. 

WIC Clinics The main Gallatin WIC clinic is in Bozeman and is collocated with the other 

Gallatin health department programs. At the time of our study, the normal 

hours for the main clinic were Monday through Friday, 8:00 a.m. to 5:00 

p.m. Gallatin WIC offered limited extended hours at the main clinic—

evening hours on three to four Wednesdays per month and during the lunch 

hour on Tuesdays. In July 1999, over 700 of the 1,045 Gallatin WIC 

participants were receiving services at this clinic.

To make services more convenient for participants with limited 

transportation, Gallatin WIC opened four additional sites—Three Forks 

and West Yellowstone in Gallatin County, Ennis in Madison County and 

Livingston in Park County (see fig. 4). The distance from the main site in 

Bozeman to the satellite sites ranges from 28 to 90 miles. The farthest three 

satellite clinics are located on the other side of mountain ranges. The 

satellite sites all share space with other public or health agencies—Three 

Forks in the City Hall, Livingston and Ennis in public health clinics, and 

West Yellowstone in a community services building. Services at Livingston 

are provided every Friday and two Wednesdays and one Saturday per 

month; at Ennis, Three Forks, and West Yellowstone, services are provided 

one day a month and a second consecutive day at West Yellowstone, if 
Appendix IV

Detailed Summaries of the Six Case Studies

Page 46 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

needed. In July 1999, the satellite clinics served between 28 and 202 

participants.

Staffing At the time of our study, Gallatin WIC had four staff—three of whom 

worked part-time—for a total of 3.3 full-time equivalent staff. The WIC 

Director is a registered dietitian who has been with the program since 1988. 

She has the only full-time, salaried position. The three part-time employees 

were all competent professional authorities (CPAs)2

 with bachelor degrees 

in home economics. Gallatin had no support staff—the service staff carried 

out support activities.

Number of Participants Served The Gallatin County WIC program, which served a monthly average of 990 

participants in fiscal year 1998, is one of the largest local WIC agencies in 

the state. In fiscal year 1999, the monthly average participation had grown 

to 1,018. Table 15 shows the number of participants by category served in 

September 1998 and July 1999. In April 2000, 64 percent of the participants 

being served were considered to be high-risk. 

Table 15: Number of Gallatin Participants by Category, September 1998 and July 

1999

Montana State University students represent about 30 to 40 percent of the 

agency’s participants, but this figure fluctuates throughout the academic 

2

 A competent professional authority (CPA), according to program regulations, is an 

individual on the staff of a local agency who is authorized to determine nutritional risk and 

prescribe supplemental foods. Individuals who can be designated as a CPA include 

nutritionists, dietitians, nurses, and medically trained health officials.

Number of participants

Participant category September 1998 July 1999

Pregnant women 107 122

Breastfeeding women 97 82

Postpartum women not 

breastfeeding

52 49

Infants 252 246

Children 478 548

Total 986 1,047
Appendix IV

Detailed Summaries of the Six Case Studies

Page 47 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

year. Participation also fluctuates because the West Yellowstone satellite 

clinic serves transient seasonal service workers. 

Major Aspects of the 

Program’s Delivery of 

Nutrition Services and 

Administration

Participant Services During the certification appointments, Gallatin WIC staff routinely 

measured participants for growth and tested their blood for anemia. 

Growth was also measured during recertification and other appointments. 

Staff reported, and we observed, that some nutrition education and 

breastfeeding promotion and support was also provided during the 

nutrition assessment process. CPAs and the dietitian saw both high- and 

low-risk participants. In accordance with Montana WIC guidance, Gallatin 

developed individual care plans for both high- and low-risk participants. 

The program used individual care plans to monitor education contacts, 

track when the participant attended an appointment, record the topic 

addressed, and evaluate the participant’s progress. The care plan was kept 

in hard copy in the participant’s record, and some information on the 

participant was entered into the automated system.

Potential participants were strongly encouraged to schedule a certification 

appointment after an initial telephone or walk-in contact. In addition to 

documents such as identification and proof of income, caregivers were 

advised to bring immunization records for child participants. If an 

applicant did not have the required documentation, as much of the 

appointment was completed as possible and another appointment was 

scheduled to complete the certification and issue checks. Participants were 

generally seen by appointment, unless time was available in the schedule to 

see them on a walk-in basis. The WIC Director estimated that if participants 

were not seen immediately, the waiting time to be seen was about 5 to 10 

minutes. Initial nutrition education appointments typically lasted over 45 

minutes. If a participant missed an appointment, the staff routinely made a 

follow-up call to reschedule. The program has a policy of scheduling 

monthly appointments for food check pick-ups to coincide with a nutrition/ 

breastfeeding education contact. The WIC Director implemented this 

policy in 1988 because she believed simultaneous appointments made 

better use of participants’ time at the WIC office. Table 16 shows the 

frequency of check issuance for various types of participants.
Appendix IV

Detailed Summaries of the Six Case Studies

Page 48 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

Table 16: Frequency of Check Issuance by Participant Type at Gallatin WIC

The state requires Gallatin staff to refer participants to the appropriate 

health care provider or agency as needed or requested by a participant. The 

state also requires documentation of the need for the referral and 

information on the person to whom the participant was referred and on the 

outcome of the referral. Gallatin WIC has established a formal system using 

a pre-printed referral form that is filled out by WIC staff and sent to the 

Gallatin City-County Health Department, Human Services Division for 

Public Health, Pregnancy Services, and the Follow-me Program, as 

appropriate. This formal approach enables Gallatin WIC to track whether 

the participant was seen and to confer with the nurse. Staff also 

documented the child participant’s immunization status and made 

immunization referrals. Immunization appointments were coordinated 

with WIC appointments at all sites but Three Forks. 

Gallatin WIC staff did not use a formal system when referring participants 

to other providers, such as substance abuse programs and La Leche League 

but rather simply provided a listing of providers with the necessary contact 

information. A list of the social services available in the county was also 

provided in the packet that the participants received at certification. If the 

Gallatin WIC staff refers the participant to a provider within the building, 

such as another county health department program, they will sometimes 

escort the participant to that office. In addition, referrals are made when 

the staff are unable to provide certain services, such as home visits, which 

may be provided by a county public health nurse. 

Regarding voter registration, the staff had voter registration cards on the 

WIC office desks, but they did not ask the participants whether they had 

registered.

Nutrition Education Nutrition education was typically provided in one-on-one sessions with 

participants during certification, recertification, and check pick-up 

Type of participant Frequency of check issuance 

Pregnant women Monthly 

Postpartum women Monthly first 4 months, then every 2 months

Infants Monthly first 4 months, then every 2 months

Children—high-risk Every 2 months 

Children—low-risk Every 3 months
Appendix IV

Detailed Summaries of the Six Case Studies

Page 49 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

appointments. One-on-one nutrition education discussions began during 

the nutrition assessment phase of the certification process, when the CPA 

provided feedback on the participant’s reported diet. For instance, during 

one recertification appointment, the WIC Director explained to a mother 

that her toddler was drinking twice as much milk in a day as he needed and 

that by drinking less milk he might be able to eat more meat. The 

certification and recertification appointments that we observed lasted from 

between 25 minutes to over 1 hour. Staff handed out brochures to 

supplement their nutrition education discussions, and the agency displayed 

posters illustrating general nutrition information, such as the Food 

Pyramid. The content of these individual discussions focused on the 

individual’s dietary needs and included in-depth explanations, such as 

describing the benefits of different vitamins and ways to identify vegetables 

that were good sources of particular vitamins, and strategies to improve 

their diet, such as moderating a child’s intake of juice to avoid unnecessary 

calories. However, in accordance with the state WIC policy, the WIC 

Director referred participants who needed medical nutrition counseling to 

the registered dietitian at the local hospital. In addition, the Gallatin WIC 

Director indicated that funding constraints limited the amount of time staff 

had to spend with participants. For instance, she reported that, over the 

past 2 years, the program had to schedule the staff for fewer days per 

month because of budget constraints. The Director also indicated that staff 

time or the space was not available to provide formal nutrition education to 

the child participants. She reported that the older children were frequently 

given coloring sheets with food subjects, and the WIC staff then discussed 

the sheet with the child. Two other strategies the program uses to provide 

nutrition education to participants were the following: 

• Holding monthly scheduled video sessions on a variety of nutrition and 

related topics. These topics include breastfeeding, infant care and 

development, menu planning, food selection storage and safety, infant 

and child feeding behaviors, and parenting; and 

• Sending participants to 45-minute monthly classes offered by the WIC 

program and by the public health nurses in the health department. The 

WIC staff taught classes every other week on the topics of prenatal 

nutrition, infant feeding, and breastfeeding/postpartum nutrition, and, 

twice a month, on starting your baby on solid foods. These classes were 

offered at all the WIC clinics. The public health nurses teach classes 

monthly on breastfeeding; infant care; the toddler years—nutrition, 

behavior, and discipline; pregnancy—fetal growth/development, 

nutrition, and healthy lifestyle; and labor and delivery. The classes 
Appendix IV

Detailed Summaries of the Six Case Studies

Page 50 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

taught by the public health nurses are offered monthly and were 

developed in collaboration with the WIC program.

Breastfeeding Promotion and 

Support

Gallatin’s WIC Director also served as the breastfeeding coordinator, 

although all of the staff received breastfeeding training. The agency’s policy 

was to encourage all mothers to try breastfeeding at least once. This effort 

was made in one-on-one sessions with pregnant women; during the 

prenatal nutrition and monthly breastfeeding classes; in videos; and 

through promotional materials, including infant feeding review and infant 

nutrition questionnaires. The Gallatin Director developed breastfeeding 

promotion and other WIC-related brochures for use not only by her own 

agency but also by the rest of the state. 

In 1998, the program had a breastfeeding initiation rate of 83 percent.3

 In 

1998, the breastfeeding initiation rate for the state of Montana was 73 

percent. 

Administration Maintaining participants’ records. The statewide automated system is 

used to schedule appointments, collect and record information obtained 

during participant certification and recertification, including nutrition risk 

assessments, create custom food packages, calculate the value of each 

food package or food check and print food checks on demand. While a 

substantial amount of participant and program data is maintained on the 

system, individual hard-copy participant records were also maintained.

Managing vendors. Gallatin WIC staff played little role in vendor selection 

and compliance activities because these were handled by the state WIC 

agency. The staff’s involvement in vendor management was typically 

limited to vendor training and monitoring, such as referring any problems 

that came to their attention to the state agency. 

Outreach. Gallatin WIC is primarily responsible for running outreach 

campaigns at the local level. It has conducted outreach to the following: the 

annual Head Start carnival; local school officials; area physicians; a 

homeless service provider (in Bozeman, a shelter is in the planning stage); 

other social service providers; and professional groups. The program 

provided notices or advertisements in local newspapers, television public 

service announcements, radio public service announcements, display 

3

 The percentage of breastfed infants may be inflated because the infants whose style of 

feeding has not been identified are averaged into the breastfeeding average. 
Appendix IV

Detailed Summaries of the Six Case Studies

Page 51 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

booths or tables at community fairs; mailed program literature to 

interested persons; and encouraged referrals by participants. The Director 

indicated that effective outreach requires specialized training that the local 

agencies do not have and lack the money or time to acquire.

Travel. All of the Gallatin staff traveled to the four satellite clinics to 

provide services. Travel to some clinics, across mountain ranges, can be 

difficult, especially in winter, when roads close because of bad weather.

Retaining and recruiting personnel. The WIC Director reported having 

some problems maintaining an adequate staffing level. She believed the 

state WIC’s policy prohibiting medical nutrition counseling served as a 

disincentive to prospective applicants who were registered dietitians. 

Expenditures of Program 

Funds and Use of 

Nonprogram Resources

Gallatin’s expenditures per participant per month in fiscal year 1999 was 

$12.54. Table 17 shows the fiscal year 1998 and 1999 program expenditures 

the agency made by category. 

Table 17: Gallatin WIC Program Expenditures by Category, Fiscal Years 1998 and 1999

Note: Percents may not total to 100 percent due to rounding. 

The major nonprogram resources used to cover the costs of providing 

nutrition services and administering the program were in-kind 

contributions by both the sponsoring organization and the government 

agencies in Madison and Park counties. The Health Officer for Gallatin 

County estimated the value of the in-kind contributions of shared space 

Fiscal Year 1998 Fiscal Year 1999

Category Amount Percent of total Amount Percent of total

Personnel and benefits excluding 

expenditures for contracted personnel

$118,789.56 77% $121,404.93 79%

Contracted personnel 380.00 0% 105.12 0%

Equipment and supplies 19,596.25 13% 5,327.10 3%

Facilities and related expenses including 

utilities, maintenance, rent and telephone

9,268.86 6% 10,604.09 7%

Indirect costs 5,280.00 3% 5,757.50 4%

All other 0 0% 10,017.16 7%

Total $153,314.67 100% $153,215.90 100%
Appendix IV

Detailed Summaries of the Six Case Studies

Page 52 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

and support from administrative personnel to be $10,720. The program also 

received donated space for three of its four satellite clinics from Madison 

and Park counties. The WIC Director estimated that the value of space 

contributed by these counties to be about $1,200 per year. The combined 

total value for the in-kind contributions, $11,920, represents about 8 

percent of Gallatin’s WIC program expenditures in fiscal year 1999, or 

about 8 cents for every dollar in costs covered by program funds. 

Other minor in-kind contributions from other public or health agencies 

include utilities, furniture, and equipment. We did not obtain an estimate 

for the value of these contributions. 

Grady WIC, Atlanta, 

Georgia

Overview of the Georgia 

State WIC Program

Grady WIC is one of 21 local agencies providing WIC services in Georgia. In 

fiscal year 1999, the average monthly number of participants served by 

these 21 agencies was 224,031. The local agencies ranged in size from 1,488 

to 17,346 participants in an average month. According to Georgia WIC 

officials, 19 of the 21 WIC agencies are administered by district health 

officials and 2 are administered by hospitals. Of the 15 Georgia local 

agencies that responded to our 1999 national survey of local WIC agencies, 

7 operated in rural settings, 3 in urban areas, 2 in suburban areas, and 3 in 

mixed geographic settings. 

In fiscal year 1999, the Georgia WIC program expended $30,839,839 in 

federal NSA grant funds, or about $11.47 per participant per month. 

According to state WIC officials, Georgia provided no appropriated funds 

for WIC nutrition services and administration. About 16.5 percent of the 

NSA expenditures ($5,080,115) were made at the state level, and the 

remaining 83.5 percent ($25,759,724) at the local agency level. In fiscal year 

1999, Georgia distributed WIC program funds to local agencies on the basis 

of a flat calculation of yearly cost per participant per month. Funding was 

allocated to local agencies twice a year. In fiscal year 1999, the per 

participant per month cost was $8.55. 

The Georgia WIC began automating recordkeeping of participant data by 

local agencies in 1991. The state agency staff can provide the local agencies 

with both standard and customized reports. Local agency program staff can 
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call state computer staff for assistance with issues such as installing 

hardware and software, and maintenance. State WIC computer staff will 

also travel to the local agency to resolve system problems. In February 

2000, a state WIC official reported that the local agencies used five separate 

automated systems, in addition to the system developed by the state 

program. The local agency systems are not integrated with each other, but 

each can interact with the third-party data processor. Grady WIC and two 

other local agencies use one of the five local agency systems—Grady since 

1992. Grady WIC’s system has the capability to enroll participants and issue 

food instruments. It operates in real time and has the capability to print 

both standard and customized reports. Grady WIC’s participant data are 

uploaded to the state’s third party processor system and a voucher printing 

contractor on a daily basis. According to a state WIC official, Grady’s 

system is scheduled to be upgraded during 2000 to print vouchers on 

demand. 

Other types of support the Georgia state WIC agency provided to local 

agencies included general program policy as well as nutrition education 

and breastfeeding guidance and materials, and vendor management. 

Characteristics of the 

Geographic Area Served by 

the Grady WIC Program

The Grady WIC program is located in Atlanta, Georgia’s capital and the 

government seat of Fulton County. Atlanta is mostly in Fulton County, with 

about 8 percent of its population in DeKalb County. Grady WIC provides 

services to residents from throughout Georgia, although its service area 

primarily overlaps with Fulton and DeKalb counties’ WIC agencies. Fulton 

County had a total population of about 722,540 in 1997, and in 1999, Atlanta 

had a population of 431,126. 

According to 1993 Census data, 23 percent of all Fulton County residents 

lived below the poverty level. In 1999, 67.8 percent of Atlanta’s population 

was nonwhite. In November 1999, about 61 percent of the Grady WIC 

participants were African-American; 37 percent, Hispanic; and 2 percent, 

other. The WIC Director estimated that about one-third of Grady WIC 

participants do not speak English as their primary language. Grady WIC 

staff reported a high incidence of obesity among the population they serve.

Local Agency’s Program 

Characteristics
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Sponsoring Organization Since 1983, the Grady WIC program has operated under the auspices of the 

Fulton-DeKalb Hospital Authority. The authority is responsible for 

administering the Grady Health System (GHS), which includes Grady 

Memorial Hospital, Hughes Spalding Children’s Hospital, a nursing facility, 

various health and trauma centers, and a managed care organization. Grady 

Memorial Hospital, a public, nonprofit hospital, aims to provide healthcare 

services for medically underserved and indigent citizens in the community. 

The Grady WIC program is located within the hospital’s Maternal Child 

Health Nutrition Department. As one of the two contract WIC agencies in 

Georgia operated by hospitals, Grady WIC can enroll participants in its 

program or in any of the other WIC programs in the state. 

GHS provides the WIC program with several types of in-kind contributions. 

First, GHS does not charge the WIC program for any indirect or space costs 

associated with operating the program. Second, the system provides the 

WIC program with some clerical and staff support. Lastly, GHS partially 

pays for the benefits for WIC staff—the WIC program was charged 17.5 

percent of personnel salaries for employees’ benefits, although the actual 

cost for the benefits was 18.6 percent.

WIC Clinics To make services more convenient to participants with limited 

transportation, Grady WIC operated, at the time of our study, a total of six 

clinics located in GHS-operated facilities in Atlanta. The WIC maternal and 

infant clinics are collocated with Grady Hospital. The pediatric WIC clinic 

is located in the children’s hospital (see fig. 5), two blocks from Grady 

Hospital. Another clinic, Lindbergh, is collocated with a health clinic in a 

shopping center, about 6 miles from Grady Hospital. It is Grady WIC’s 

largest clinic, serving 1,403 participants in January 2000. Another clinic is 

located at a facility dedicated to HIV patients, and one clinic, Boat Rock, 

was in a health center in a low-income residential building, about 15 miles 

from Grady Hospital. In January 2000, the clinics served between 116 and 

1,403 participants. The Boat Rock clinic was closed in April 2000 because 

the health center closed. 
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Figure 5: Grady WIC Pediatric Clinic

At the time of our study, five of the satellite clinics were open Monday 

through Friday, with hours of operation starting between 8 a.m. and 9 a.m. 

and closing between 4 p.m. and 5 p.m. The Boat Rock clinic was only open 

on Tuesdays and Thursdays. On Wednesdays, the Lindbergh clinic operated 

from 10 a.m. to 6:30 p.m. 

Staffing At the time of our study, Grady WIC had 16 staff: seven worked full-time for 

WIC, and 9 worked part-time for WIC and part-time for other hospital 

programs. This equated to 12.8 full-time equivalent staff. The WIC Director 

at the time of our study had been with the program for about 7 years and 

was a registered dietitian who had coauthored several research papers on 

nutrition education and breastfeeding. The 10 CPAs on staff consisted of 8 

registered dietitians and 2 nutritionists. A CPA was in charge of each of the 

six clinics. The CPAs conducted eligibility certifications, obtained health 

measurements, provided nutrition education and breastfeeding promotion 

and support, maintained logs of nutrition education, and monitored 

participants’ nutrition education statistics. Two of the five clerks at the 

agency also provided informal breastfeeding counseling and support. Five 

of the staff were bilingual.
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Number of Participants Served In fiscal year 1999, Grady WIC’s average monthly caseload was 4,852. Table 

18 shows the number of participants by category served in January 2000. 

The WIC Director estimated that 90 to 95 percent of the participants served 

were from the metropolitan Atlanta area. Approximately 79 percent of the 

participants served in November 1999 were considered to be high-risk.

From April 1999 to October 1999, according to the WIC Director, the 

caseload dropped significantly, by almost 400 participants. The Director 

attributed this decrease to a new requirement that applicants document 

their family income and residency.4

Table 18: Number of Grady WIC Participants by Category, September 1998 and 

November 2000

Major Aspects of the 

Program’s Delivery of 

Nutrition Services and 

Administration

Participant Services During certification or recertification sessions, Grady CPAs will most often 

measure the participant’s height and weight and test blood for anemia, 

according to the WIC Director. However, if a new participant had recently 

been admitted to the hospital or if a participant had just delivered a baby in 

the hospital, WIC staff will have access to the participant’s hospital chart, 

4

USDA regulations require documentation of family income for individuals not participating 

in a qualifying program, such as the Food Stamp Program or Medicaid.

Number of participants 

Participant category September 1998 November 2000

Pregnant women 1,473 1,052

Breastfeeding women 256 207

Postpartum women not 

breastfeeding

415 392

Infants 1,457 1,360

Children 1,398 1,323

Total 4,999 4,334
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which will have the needed information. Grady’s computer system can also 

access the hospital’s laboratory results database; if a patient has recently 

been seen, staff can get blood test results from the database instead of 

doing another blood test. While staff could occasionally save time in 

assessing participants, the Director indicated recent program changes had 

increased the time and the number of forms required to certify participants.

For the initial assessment, both the dietitians and nutritionists saw 

participants considered to be at high-risk. An individual care plan—

developed for all high-risk participants—was used to record the physical 

information obtained during assessment. For example, in the case of a 

child participant, this information would include whether the child had 

been immunized, the nutrition topics discussed, the handouts provided, 

and the notations regarding follow-up activities. The care plan was kept in 

the participant’s WIC record, and some information on the participant was 

entered into the automated system.

All participants were typically issued vouchers on a bimonthly basis. The 

Grady WIC clinics made appointments and accepted walk-ins for voucher 

pick-up, and certification and recertification sessions. All of the satellite 

clinics attempted to coordinate the WIC recertification appointments with 

the participants’ other medical appointments. At the time of our study, 

Grady WIC was short-staffed, and therefore the clerks did not have time to 

contact participants who missed appointments. When the clerks had time, 

they made follow-up calls or sent post-cards to such participants. In 

February 2000, the WIC Director estimated that about 10 percent of 

participants missed their appointments. 

In accordance with state guidelines, during certification and recertification 

sessions, Grady WIC staff asked if child participants were current on 

immunizations and recorded the information provided by the caregiver. 

However, staff were not required to ask for documentation of 

immunization status. In making referrals to other service providers, staff 

typically provided the participant with the telephone number of the 

provider or a booklet describing Atlanta area service providers. However, 

when making referrals for health service within the hospital, staff reported 

that, depending on the seriousness of the situation, they sometimes 

escorted participants to service providers. Typically, Grady WIC staff did 

not refer participants to non-WIC staff to address any nutrition education 

or breastfeeding issues. Staff recorded some referral information in the 

participant data system and attempted to follow up with participants at the 

next scheduled appointment regarding the outcome of the referral. 
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Regarding voter registration, according to the WIC Director, staff will 

inquire if adult participants are registered to vote. If not, staff will provide 

participants with the registration paperwork and help them fill it out if 

necessary. The program does not track whether participants have been 

asked about voter registration. 

Nutrition Education According to the WIC Director, although the agency used several different 

methods to provide nutrition education, the primary method was one-onone counseling during certification, recertification, and voucher pick-up 

appointments. The certification and recertification appointments that we 

observed lasted from 10 to 40 minutes. Grady WIC staff did not 

differentiate between nutrition education and counseling but provided little 

extensive counseling. The topics discussed during a nutrition education or 

counseling sessions depended on a participant’s particular needs. For 

instance, we observed a one-on-one session in which staff explained to a 

father who reported giving his obese 6-month-old baby soft drinks that 

plain water was a better choice. 

High-risk participants are typically allotted 10 minutes for a nutrition 

education session, according to the WIC Director. Because of a staff 

shortage, the nutrition education for low-risk participants typically 

consisted of providing a nutrition brochure or having them watch a video. 

The Director indicated that although a daily nutrition education class was 

scheduled at the maternal WIC clinic, it was often not held because 

participants would not come in at the designated class times. 

Grady WIC also provided nutrition education via brochures, videotapes, 

group sessions or a touch screen computer kiosk. The touch screen 

computer kiosk, which the state provided, was located at the maternal 

clinic. It offered a self-paced narrated program to educate the participant 

on how the WIC program works and to discuss various nutrition education 

and breastfeeding issues. Grady WIC also displayed a few posters 

illustrating general nutrition information at some of the clinics.

To serve its multilingual population, Grady WIC offered materials and 

classes in English and Spanish and some written materials in other 

languages. However, the WIC Director said that the program did not have 

funding for enough nutrition education materials translated into other 

languages. She also said that Grady did not have nutrition education 

classes geared toward the child participants because it did not have 

sufficient space or staff.
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In response to the need of some WIC participants for more nutrition 

education than could be provided by the WIC program, GHS’ Maternal and 

Child Health Nutrition Department received federal funding from two other 

programs providing nutrition services that benefited many WIC 

participants. The Department’s support to the prenatal, obstetric, and HIV 

clinics is funded by two Department of Health and Human Services (HHS) 

grants. Since so many of the high-risk maternity and infant patients are 

eligible for WIC services, the WIC dietitians and the HHS-funded dietitians 

closely coordinated their efforts to provide this supplemental education. 

The Grady WIC Director indicated that the loss of these complementary 

services would significantly affect the demands placed on WIC staff and 

thus the quality of WIC’s nutritional services.

Breastfeeding Promotion and 

Support

Grady WIC promotes breastfeeding through classes, support groups, 

telephone contacts and on-call services. All pregnant participants received 

breastfeeding information at certification. The WIC breastfeeding 

coordinator was a focal point and resource for breastfeeding information in 

Grady Hospital. For instance, she provided in-service training to the 

hospital’s health professionals. The coordinator and two CPAs, were also 

certified lactation consultants. The coordinator spent the largest portion of 

her time providing one-on-one breastfeeding assistance to WIC participants 

who were in the hospital. One of the lactation consultants taught a 

breastfeeding class in Spanish twice a month and in English twice a week, 

as well as a teen breastfeeding class once or twice a month. In addition to 

visits conducted by the coordinator, a WIC nutritionist visited the maternity 

ward daily. The program also trained and utilized volunteer breastfeeding 

peer counselors, who conducted the telephone contacts and met with 

participants in the WIC clinics. 

Grady had one of the highest breastfeeding initiation rates in the Georgia 

WIC program, about 57 percent for fiscal year 1998. However, because of 

funding constraints, Grady had fewer staff to provide individual 

breastfeeding counseling and follow-up than it had in the past. 

Consequently, the breastfeeding coordinator had observed a decrease in 

the initiation rate; in January 2000, the rate was 50 percent. 

Administration Maintaining participants’ records. Grady WIC used a local database 

system that created a participant record and tracked participant data. The 

local system printed the first set of vouchers at certification. Grady’s 

participant data were uploaded daily to the state’s third party data 

processor and a state printing contractor. The state’s printing contractor 

sent preprinted vouchers to Grady for issuance to participants at 
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subsequent appointments. The staff documented information such as the 

participant’s diet, nutrition risk factors, and physical measurements on 

paper. Because they rely on preprinted vouchers rather than printing 

vouchers on demand, Grady staff need time to enter and download 

participant data to a state contractor, and they had to void and reconcile 

preprinted vouchers when participants did not pick them up. Although 

Grady’s participant data system generated various reports, staff often took 

data off the system and generated reports using off-the-shelf software 

because the system did not perform the kind of data analysis needed. 

Managing vendors. Unlike the other local WIC agencies in Georgia, Grady 

played little role in vendor management activities because it was located at 

a hospital. Instead, vendor activities were typically limited to referring any 

problems that came to the staff’s attention to the state WIC agency.

Outreach. According to the WIC Director, Grady WIC conducted minimal 

outreach because it did not have a defined service area and did not want to 

take participants from neighboring WIC agencies. Outreach activities were 

confined to the WIC caseload, hospital-based patients, and hospitalsponsored events, such as an open house meant to inform expectant 

mothers about available hospital services. Grady WIC had recently 

experienced a decrease in caseload. The WIC Director attributed this 

decrease to recent program changes, which she believed made qualifying 

for the WIC program more difficult. Given the decrease in caseload, the 

short-term outreach goal was to maintain and increase caseload. 

Travel. The staff normally did not travel from site to site to provide 

services. Travel expenses were provided for attending conferences and 

training.

Retaining and recruiting personnel. Because of level funding over the 

last 3 years, the WIC Director reported that Grady had recently eliminated 

two positions, a part-time nutritionist and a lactation assistant, and had 

three unfilled positions, for one nutritionist and two support staff. She 

indicated that hiring personnel takes 5 to 6 months because the hospital 

human resources office is short-staffed and procedures are slow. The 

eliminated nutritionist position provided on-call support to participants, 

while the lactation assistant supported breastfeeding promotion. Because 

the program was short one nutritionist, the Director had pulled the 

designated lactation consultant from her breastfeeding promotion and 

support duties in order certify eligible participants. The reassignment of 

the consultant and the elimination of the lactation assistant position had 
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resulted in Grady’s reducing its breastfeeding promotion and support 

efforts. In addition, the Director reported that management and 

nutritionists had to spend more time in clinics performing clerical duties, 

leaving little time for professional development, consultations, and chart 

notations. To cover vacancies in the clerical positions, the remaining clerks 

were working overtime on a regular basis. 

Expenditures of Program 

Funds and Use of 

Nonprogram Resources 

Table 19 shows the fiscal years 1998 and 1999 program expenditures the 

agency made by category. In fiscal year 1999, the expenditure per 

participant per month was $8.37. Ninety-six percent of Grady’s 

expenditures were for personnel. In fiscal years 1998 and 1999, Grady 

expended no program funds for space or indirect costs. 

Table 19: Grady WIC Program Expenditures by Category, Fiscal Years 1998 and 1999

Note: Percents do not total to 100 due to rounding. 

The major nonprogram resources used by the program were in-kind 

contributions to cover all of the indirect costs incurred to operate the 

program, some nutrition and clerical staff support, and to subsidize a 

portion of the costs to provide benefits to WIC staff. According to 

information provided by a sponsoring agency official, the indirect costs 

GHS incurs to operate the program—including the space provided at no 

charge—would be about 18 percent of program expenditures, or about 

$88,000 in fiscal year 1999. The WIC Director reported that the value of the 

GHS-provided nutrition and clerical staff support to be about $7,000. In 

Fiscal year 1998 Fiscal year 1999

Category Amount

Percent of

total Amount

Percent of

total

Personnel and benefits 

excluding expenditures for 

contracted personnel

$453,365 92% $467,205 96%

Equipment and supplies 31,530 6% 17,993 4%

Facilities and related 

expenses including utilities, 

maintenance, rent and 

telephone

0 0% 0 0%

Indirect costs 0 0% 0 0%

All other 5,393 1% 1,989 <1%

Total $490,288 100% $487,187 100%
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addition, the sponsoring organization subsidized WIC employee benefits in 

1999 for a total of about $4,000. Taken together, these contributions 

(amounting to about $99,000) represented about 20 percent of program 

expenditures, or about 20 cents for every dollar in costs covered with 

program funds. 

In addition to the nonprogram resources provided by the sponsoring 

organization, Grady received a small grant ($2,000) from the March of 

Dimes in fiscal year 1998 for breastfeeding supplies and educational 

materials, and WIC dietitians received free continuing education via 

monthly teleconferences on nutrition issues provided by the Centers for 

Disease Control.

Kanabec County, 

Minnesota, WIC 

Program

Overview of the Minnesota 

State WIC Program

Kanabec County’s WIC program is one of 70 local agencies providing WIC 

services in Minnesota. In fiscal year 1999, the average monthly 

participation at these agencies was 90,200. According to our 1999 national 

survey of local WIC agencies, these local agencies averaged between 35 to 

18,309 participants monthly in fiscal year 1998. Over half of the Minnesota 

local agencies responding to our survey were operated by single county 

health agencies, and over three-quarters operated in rural areas.

In fiscal year 1999, the state WIC program expended federal NSA grant 

funds totaling $13,064,382, or about $12.07 per participant per month. Since 

1987, the state has also provided funding of about $3.7 million per year. In 

fiscal years 1998 and 1999 all the state funds were used for grants to local 

agencies. In fiscal year 1999, the amount of state funds expended for 

nutrition services and administration was $3,999,906, bringing the total 

expended (federal and state funds) for nutrition services and 

administration to $17,064,287. (Statewide, state funds covered about 31 

cents in NSA costs for every dollar in costs covered with federal funds). 

About 39 percent of the total NSA expenditures, or $6,681,038, was made at 

the state level. The remaining 61 percent, or $10,343,249, in expenditures 

was made by the local WIC agencies. Minnesota distributes WIC program 

funds to local agencies on the basis of a cost per participant that is the 
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same for all local agencies. In fiscal year 1999, the rate was $8.74 per 

participant. The state agency has a mechanism to recover and reallocate 

unspent funds on a quarterly basis. The state Director noted that another 

source of funding for some local agencies are the local tax revenues that 

the sponsoring agencies allocate to the program to cover NSA costs not 

covered by state or federal funding. She estimated that in 1999 local 

sponsoring agencies, statewide, contributed about $300,000 to local WIC 

agencies.

Minnesota’s WIC participant database system was fully automated in 1998. 

It is used to record and track participant information, generate predefined 

reports, and issue vouchers on demand. The state uploads the participant 

certification data from the local agencies’ computers. At the time of our 

study, the state’s ability to print reports was limited because the system 

could not search by specific data fields and run reports, such as a report on 

all participants by birth date. The state anticipates the system will have that 

capability in the future. Local agency program staff can obtain assistance 

with equipment maintenance, reports, and other questions via the statefunded WIC help desk.

The state WIC program provides most of the training for local agency 

employees, including introductory sessions on basic WIC operations and 

conferences on nutrition education and breastfeeding promotion and 

support, and other program functions. The state WIC program provides one 

basic training class for new local agency staff. This training focuses on 

basic WIC program operations, such as certification and the use of the 

computer system, and nutrition education. In addition, the state WIC 

program holds an annual conference on nutrition education and 

breastfeeding promotion and administration; the conference offers training 

on issues such as working with the computer system, voucher issuance, 

and policy changes. The state WIC agency also funds operational and 

nutrition consultants to provide technical assistance to local agencies in 

the consultants’ assigned geographic areas. Other types of support the state 

agency provides to local agencies include nutrition and breastfeeding 

materials, voucher stock, and statewide multimedia campaigns.

Characteristics of the 

Geographic Area Served by 

Kanabec County WIC 

Program

The Kanabec County WIC program is located in Mora, Minnesota, and 

serves residents of Kanabec County, which had a population of about 

14,000 in 1999. Mora is a small rural town with a population of about 3,100 

in 1999, located approximately 60 miles north of Minneapolis. The area’s 

terrain is flat and forested and contains several lakes. Snowfall during 
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December and January averages about 10 inches a month, which can 

sometimes make travel difficult.

Although the county’s unemployment rate is low, a significant portion of its 

residents are poor. Kanabec County is the fifth poorest county in the state. 

In 1997, about 19 percent of its children were estimated to live in poverty, 

and the estimated average annual unemployment rate was 7.7 percent. In 

addition, between 1995 and 1997, Kanabec County’s birthrate for teenagers 

ages 18 and 19 was over twice that of the rest of Minnesota. The county’s 

population is predominantly white, with an estimated minority population 

of 1.3 percent (African-Americans, American Indians, Eskimos and Aleuts, 

and Asian/Pacific Islanders).

Local Agency’s Program 

Characteristics

Sponsoring Organization The Kanabec County WIC program is sponsored by a single county health 

agency—the Kanabec County Public Health Department. Established in 

1976, the WIC program operates in conjunction with other health 

department programs, such as those providing health check-ups, family 

planning, meals, and other community services. Agency officials consider 

the WIC program part of an integrated care management approach to 

public health. For example, WIC participants often stop to see the public 

health nurse and obtain their immunizations before going to the WIC office.

The department charges the WIC program for indirect costs, such as 

services provided by the sponsoring organization’s auditor and treasurer. In 

fiscal year 1999, the indirect costs charged the program were based on a 

cost allocation plan. The Department provides WIC with in-kind 

contributions, including dedicated space for the WIC office; the use of 

equipment; and support from health care staff, who provided some 

nutrition education, in conjunction with pre-natal care, to WIC participants. 

WIC Clinics The program provided all WIC services at one location, the Kanabec 

County Health Department building in Mora. Normal hours of operation 

were Tuesday through Thursday, 8:00 a.m. to 4:00 p.m. The clinic was open 

during lunch hours and stayed open later than normal hours, if needed. 

Mondays were reserved for other WIC duties. All of the WIC operations are 

conducted in the coordinator’s office. (See fig. 6.) Participants typically 

waited in the hallway outside of the office for their appointment. On 
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occasion, participants could view videotapes in the adjoining team room. 

Although Kanabec did not have satellite clinics, it did offer, on request, free 

or reduced-cost transportation to WIC participants. 

Figure 6: Kanabec WIC Clinic

Staffing At the time of our study, the program employed one part-time staff 

member—a registered nurse—who serves as the WIC coordinator and is 

the CPA. (This is equivalent to a staff of .7 full time employees.) The WIC 

Coordinator was responsible for daily nutrition services and administration 

activities. Staff of the sponsoring organization provide minimal 

administrative or management support. (Another county nurse was 
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certified to issue vouchers if the WIC Coordinator was unavailable.) The 

WIC Coordinator has been a registered nurse for 28 years and has been 

with the program for 5 years. She is paid on an hourly basis. 

Number of Participants Served The Kanabec WIC is one of the smallest local agencies in the state. In fiscal 

year 1998, it served a monthly average of 300 participants, and in fiscal year 

1999, a monthly average of 313 participants. Table 20 shows the number of 

participants by category served in September 1998 and September 1999. 

According to data from the state WIC agency, approximately 54 percent of 

the Kanabec participants in October 1999 were considered high-risk. 

Table 20: Number of Kanabec County Participants by Category, September 1998 and 

September 1999

Major Aspects of the 

Program’s Delivery of 

Nutrition Services and 

Administration

Participant Services During the certification or recertification session, the Coordinator 

routinely measured participants’ height and weight and tested blood for 

anemia. If a participant was pregnant, she was asked to prospectively fill 

out the infant feeding survey indicating whether or not she planned to 

breastfeed. The WIC coordinator typically developed individual care plans 

for both low- and high-risk participants. The care plan specified behaviorrelated goals, the nutrition education provided, and documentation of 

follow-up visits.

Number of participants in:

Participant category September 1998 September 1999

Pregnant women 6 20

Breastfeeding women 11 16

Postpartum women not 

breastfeeding

50 30

Infants 24 73

Children 253 187

Total 344 326
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Potential participants were typically scheduled for a certification session 

after pre-screening for eligibility. If the Coordinator determined that the 

applicant was eligible for WIC benefits, she scheduled the applicant for an 

appointment and either sent or gave the forms to the applicant. Kanabec 

had a policy of scheduling separate appointments for certification and 

voucher pick-ups to manage the daily flow of participants and keep waiting 

times to 5 to 10 minutes. It was not common for participants to be seen on a 

walk-in basis. Because only the Coordinator handles certifications and 

other appointments, she scheduled 6 to 8 days per month for certification 

and 8 days a month for voucher pick-up. For other days, she scheduled 

appointments with participants who required more of her time, such as 

those with more in-depth nutritional needs. She attempted to schedule WIC 

appointments for participants who also participated in the Maternal Child 

and Health Program to coincide with appointments for that program. The 

Coordinator routinely called participants to remind them of upcoming 

appointments. 

In response to the loss of clerical support, the Coordinator decided to 

change the monthly flow of participants by changing voucher issuance for 

low-risk participants to every 3 months. According to the WIC coordinator, 

tri-monthly issuance of vouchers provided some benefits to participants by 

reducing the amount of travel to the clinic, which is especially important 

during bad winter weather. This, in turn, has decreased the number of 

broken appointments. Vouchers were issued to high-risk participants 

monthly or bimonthly. The Coordinator typically did not call participants to 

follow up on missed appointments.

Kanabec WIC made referrals on an as-needed basis. As required by the 

state, the Coordinator fills out forms when making health care referrals. 

The referrals to the county maternal child and health nurse were also 

tracked manually. Every 6 months the Coordinator asked whether the child 

participant had received the proper immunizations. If the child needed 

immunizations, she referred the child to the public health nurse and 

coordinated the WIC appointment with the immunization appointment. 

Kanabec did not use a form when referring participants to other providers, 

such as social services, but rather provided a listing of providers with the 

necessary contact information. If applicants were not eligible for the WIC 

program, the coordinator referred them to a community food program. 

Although the community food program did not offer nutrition education, it 

did provide children and mothers with extra food for up to 1 year. The WIC 

Coordinator will typically follow up on the outcome of a referral to the 

county public health nurse. With regard to voter registration, the 
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Coordinator had the voter registration cards visible in the office, but did 

not ask the participants whether they had registered.

Nutrition Education Nutrition education was typically provided during 15- to 20-minute one-onone sessions during certification, recertification, and voucher pick-up 

appointments. The certification appointment that we observed lasted about 

30 minutes. The Coordinator reported, and we observed, that some 

nutrition education and breastfeeding promotion and support were also 

provided during the nutrition assessment process when the Coordinator 

provided feedback on the participant’s reported diet. The contents of 

individual nutrition education sessions were tailored in response to such 

information as diet, weight, and height. For instance, she explained to the 

mother of a formula-fed newborn that the baby did not need to be given 

water, juice or any other food. The Coordinator assessed the participant’s 

diet and weekly food intake record to determine the areas for focus during 

counseling. She referred participants needing medical nutrition counseling 

to the registered dietitian at local hospital. She also provided brochures to 

supplement the nutrition education discussions, and the agency displayed 

posters illustrating general nutrition information. In addition, nutrition 

education was delivered via promotional displays, newsletters, and 

videotapes. The WIC Coordinator generally directed the discussion to the 

caregiver, although she would sometimes ask children what they ate.

Since the staff of the sponsoring public health agency carries out most 

program management responsibilities, the WIC Coordinator could spend 

more time providing nutrition services. However, she indicated that the 

agency did not have sufficient resources to carry out the program’s 

nutrition education requirements. For instance, she had not provided group 

counseling sessions since she assumed additional administrative tasks 

following the loss of a part-time clerk and had to spend time automating the 

certification process.

Breastfeeding Promotion and 

Support

The WIC Coordinator, who is also the breastfeeding coordinator, provides 

breastfeeding promotion and support services, usually in one-on-one 

counseling, to both pre-natal and postpartum mothers, during certification, 

recertification, or voucher pick-up appointments. In addition, the 

Coordinator distributes breastfeeding promotional materials and provides 

space at the clinic for breastfeeding, if needed. Although the Coordinator 

has received breastfeeding training, she is not a certified lactation 

consultant. The nearest consultant, who works for another local WIC 

agency, is approximately 30 miles away. The content of breastfeeding 

counseling includes the advantages, myths about, and barriers to 
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breastfeeding, such as the barriers mothers face when returning to work. In 

particular, the coordinator will review the survey that she gives to all of the 

prenatal mothers and use the responses as a basis for discussion. In order 

to sustain the mother’s breastfeeding, the Kanabec Coordinator followed 

up on the status of the mother’s breastfeeding during the next appointment 

or, if she had time, called. 

In August 1999, Kanabec WIC had a breastfeeding initiation rate of 35.1 

percent and 8.5 percent for infants about 3 to 6 months old. The sponsoring 

agency official noted that this percentage can vary greatly from month to 

month because of the small number of participants overall. In December 

1999, Minnesota WIC reported a breastfeeding initiation rate of over 57 

percent statewide.

Program Administration Maintaining participants’ records. Until a computer system was 

installed in May 1998, the WIC Coordinator collected and maintained all of 

the participant information by hand. Kanabec WIC now maintains 

participant information in both the computer and in paper files. At the time 

of our study, the computer system collected all the information to certify 

and recertify participants, evaluated the information to determine 

eligibility, set the nutritional risk level for the participants, and printed 

vouchers. Information still maintained in paper records included 

participants’ responses to standard questions regarding infant feeding and 

participants’ diet, and notations of the nutrition education provided. The 

Coordinator could also use the system to generate a few simple reports. 

More sophisticated reports required the help of skilled state employees. 

Managing vendors. Kanabec reported having little or no role in vendor 

management. The WIC Coordinator tried to resolve the few vendor or 

participant complaints that she received each year. 

Outreach. The Kanabec WIC coordinator conducted outreach by 

distributing WIC brochures at the hospital and annual county fairs, as well 

as to local organizations that serve the homeless and to local community 

groups. Participants also typically heard about the WIC program through 

friends and family, from other social service programs, and from the local 

family planning clinic collocated with the WIC agency.

Travel. The Coordinator did not have to travel to provide nutrition services 

to participants. Travel expenditures were made for trips to state 

conferences or training.
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Retaining and recruiting personnel. The WIC coordinator reported 

having some problems maintaining an adequate staffing level. As a result of 

a cut in funding, Kanabec reduced the scheduled hours for its clerk, who 

subsequently resigned in May 1999, in part, because of the reduction in 

hours. After this resignation, the WIC Coordinator took on some of the 

clerical duties, leaving less time for nutrition education and counseling.

Expenditures of Program 

Funds and Use of 

Nonprogram Resources

Table 21 shows the agency’s fiscal years 1998 and 1999 program 

expenditures by category.

Table 21: Kanabec County WIC Program Expenditures by Category, Fiscal Years 1998 and 1999

Kanabec’s program expenditures include both federal and state WIC 

program funds. Its expenditure per participant per month in fiscal year 

1999 was $8.09.

The program’s major nonprogram resources were in-kind contributions 

from the sponsoring organization of dedicated space for the WIC office, the 

use of equipment, and support from health care staff. The county health 

official estimated the value of these contributions to be $3,000 for fiscal 

year 1999. This represented about 6 percent of program expenditures, or 

about 6 cents for every dollar in costs covered by program funds.

In addition, staff from the sponsoring organization spent up to several 

hours a month providing general administrative support to Kanabec WIC. 

Fiscal year 1998 Fiscal year 1999

Category Amount Percent of total Amount Percent of total

Personnel and benefits excluding 

expenditures for contracted personnel

$35,279.07 89% $27,006.30 89%

Contracted personnel 0 0% 0 0%

Equipment and supplies 500.28 1% 601.35 2%

Facilities and related expenses including 

utilities, maintenance, rent and telephone

970.11 2% 568.27 2%

Indirect costs 2,211.99 6% 1,866.15 6%

All other 762.09 2% 346.82 1%

Total $39,723.54 100% $30,388.89 100%
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Other minor support from the sponsoring organization, not covered by 

indirect costs, were supplies and materials. In addition, a national medical 

supply company donated infant feeding supplies. No estimate was available 

of the value of these additional nonprogram resources.

Long Beach, California, 

WIC Program

Overview of the California 

State WIC Program 

Long Beach WIC is one of 83 local agencies providing WIC services in 

California. In fiscal year 1999, the average monthly number of participants 

served by these local agencies was 1,229,495. According to our 1999 

national survey of local WIC agencies, the local WIC agencies in California 

range in size from about 400 to 307,000 average monthly participants. Of 

the 67 California local WIC agencies that responded to our survey, 25 

operated in urban settings, 20 in rural settings, 10 in suburban settings, and 

12 in mixed geographic settings. 

In fiscal year 1999, the California WIC program expended about 

$170,805,225 in federal NSA grant funds, or about $11.58 per participant per 

month. California provided no state funds for nutrition services and 

administration. About 25 percent of NSA expenditures, or $43,101,972, 

were made at the state level. Of this amount, about three-quarters was used 

for state-level operations and about one-quarter was used for costs 

associated with providing state support to local agencies, primarily for 

operating the state’s case management information system and for 

purchasing the nutrition education materials provided to local agencies. 

The remaining $127,703,253, or 75 percent, of California’s WIC 

expenditures was made by the local WIC agencies. California distributes 

funds to local agencies using a formula that results in smaller agencies 

receiving more per participant per month than larger agencies. The formula 

has two elements: (1) a base allocation that depends on an agency’s 

caseload and (2) a per participant per month cost rate. 

The California WIC program implemented its statewide integrated 

automated participant and vendor information system in 1995. The 

computer system is an on-line real-time system. Once local agency 

employees log onto it, they have immediate access to all information, 

restricted only by their level of clearance. Local agency staff enter 

information obtained from participants during certification and follow-up 
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meetings. They use the system to calculate income eligibility, determine 

nutritional risk priority, recommend a food package tailored to 

participants’ needs and preferences, schedule appointments, and interface 

with Medi-Cal, California’s Medicaid system. The system also assists staff 

with referrals to other public assistance programs for which the applicant 

may be eligible. An advantage to an on-line, real-time system is that if 

someone attempts to enroll at one agency while actively enrolled at 

another agency elsewhere in the state, the system recognizes this attempt 

and alerts the WIC staff. 

The state-level agency provides hardware and software, computer support, 

technical assistance, and the training necessary for the local agencies to 

use the system. It also provides local agencies with nutrition education and 

breastfeeding promotion materials, training, and assistance in fraud and 

abuse prevention efforts, and conducts statewide outreach campaigns. 

Characteristics of the 

Geographic Area Served by 

the Long Beach WIC 

Program

The Long Beach WIC program serves the city of Long Beach, which is 

located on the southern California coast in Los Angeles County, with a 1997 

estimated population of about 437,800. 

According to 1990 Census data, 17 percent of all Long Beach residents lived 

below the poverty level. The data indicated that Long Beach was ethnically 

diverse, with 24 percent of the population Hispanic, 13 percent AfricanAmerican, and 13 percent Asian/Pacific Islander. In March 2000, the WIC 

Director reported that approximately 78 percent of Long Beach WIC 

participants do not speak English as a primary language. 

Local Agency’s Program 

Characteristics

Sponsoring Organization Long Beach WIC, which has operated in the city for more than 23 years, is 

sponsored by the city’s Department of Health and Human Services, one of 

only three independent city-operated health jurisdictions in California. The 

WIC Director described the WIC program as a gateway to the Department’s 

other programs such as lead poisoning prevention, child health and 

disability, immunization, and the prenatal clinic. 

The Department charges the WIC program for indirect costs, such as 

personnel, accounting, and postage. However, because of a state limit on 
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the amount of indirect costs that can be charged to the program, only a 

portion of the indirect costs the Department incurs are charged to the WIC 

program.5

 The Department also provides WIC with in-kind contributions of 

space for two sites. Other in-kind contributions from the sponsoring 

agency included utilities for two sites, equipment, furniture and translation 

services. 

WIC Sites In California, WIC clinics are referred to as WIC sites. This was done to 

distinguish the role of the California WIC program from the health care 

system. The main Long Beach WIC site is collocated with the Department 

of Health and Human Services and serves an average of 9,300 participants 

each month. To make services more convenient to participants with limited 

transportation, Long Beach has four other sites—on a hospital campus, in a 

stand-alone building, in a city-owned health facility, and in a strip mall. The 

number of participants being served at three of the four additional sites 

ranges from a monthly average of about 4,000 to 8,000. The fourth site 

opened in February 2000 and at that time was serving about 257 

participants. The WIC Director expected that site to serve a monthly 

average of about 5,000 participants after 3 months of operation.

The sites operated Monday through Friday. Two of the sites operated from 

7:30 a.m. to 6:00 p.m.; two from 7:30 a.m. to 5:30 p.m.; and one, the newest, 

from 8:00 a.m. to 5:00 p.m. On Monday and Tuesday, the main site had 

extended hours to 7:00 p.m., as well as every Saturday from 8:00 a.m. to 

noon. 

Staffing At the time of our study, Long Beach WIC had 53 staff, and all but 2 worked 

full-time, for a total of 52.2 full-time equivalent staff. The WIC Director is a 

registered dietitian who has been with the program since 1984. Fifteen of 

the staff were also registered dietitians. Administrative registered dietitians 

developed local agency policy and procedures as needed to implement new 

regulations, assessed staff training needs in nutrition education, and 

developed and implemented staff training programs on nutrition education. 

Twenty-one of the staff were nutrition aids or assistants who were CPAs. 

Seventeen of the staff were clerical or support staff. Of the 53 staff at the 

agency, 28 were considered contract consultants who are not permanent 

employees of the sponsoring organization and therefore did not receive 

health or vacation benefits. The sponsoring organization was exploring the 

5

 In accordance with state policy, local agencies cannot charge the WIC program for indirect 

costs in excess of 10 percent of program expenditures for personnel minus benefits.
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option of converting the contract WIC employees to city employees with 

benefits, as a means of improving staff retention. Converting these 

employees would increase personnel costs for Long Beach WIC, according 

to Department staff.

Each of the agency’s five sites had a registered dietitian as a supervisor and 

a team leader. The supervisor provided counseling to high-intervention 

participants and supervised the paraprofessional staff. The team leader 

was responsible for assisting with nutrition education by teaching classes 

and keeping education materials up-to-date.

Number of Participants Served Long Beach WIC’s monthly participation rate increased from 9,000 in 1992 

to 28,452 in October 1999. Table 22 shows the number of participants by 

category served in October 1999. In August 2000, according to the WIC 

Director, approximately 18 percent of the agency’s participants served in an 

average month were considered high-intervention.6

Table 22: Number Participants by Category, September 1998 and October 1999, at 

Long Beach WIC

Major Aspects of the 

Program’s Delivery of 

Nutrition Services and 

Administration

6

 In California, high-risk is referred to as high intervention level.

Number of participants

Participant category September 1998 October 1999

Pregnant women 2,842 2,639

Breastfeeding women 1,699 1,725

Postpartum women not 

breastfeeding

2,100 2,007

Infants 6,136 6,063

Children 17,231 16,018

Total 30,008 28,452
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Participant Services Long Beach WIC, in accordance with California WIC policies, strongly 

encouraged participants to obtain their physical measurements (such as 

height and weight) and the results of blood tests from their Medi-Cal 

provider, the state’s Medicaid program, or private physician, thus 

decreasing the amount of time WIC staff need for this activity. In California, 

WIC staff do not do blood work to assess medical conditions such as 

anemia. Requiring this information from a medical provider has several 

advantages: it encourages the applicant to visit a medical provider, requires 

less staff time, and eliminates the need for specialized staff. If an applicant 

does not have all of the information needed to determine eligibility, the 

applicant is typically approved for 1 month’s participation and must bring 

the needed information at the next visit. Initially, all participants are seen 

by a CPA. Participants determined to be high-intervention are typically 

seen the following month by a registered dietitian. In some instances, a 

registered dietitian would see high-intervention participants the same day. 

Long Beach, in accordance with state requirements, required that a 

nutritionist or a registered dietitian develop an individual care plan for all 

high-intervention participants.

Since Long Beach schedules appointments in blocks of time, staff report 

that participants are seen on a “first-come, first-served” basis, contributing 

to a typical 30-minute waiting time. One site reported about 25 percent of 

its appointments were walk-ins, and another reported that as much as 40 

percent were walk-ins. Long Beach uses an automated telephone calling 

system to make recorded calls reminding participants of upcoming 

appointments and to reschedule missed appointments. According to the 

WIC Director, the missed appointment rate at the end of any given month is 

less than 10 percent. 

The frequency of voucher issuance varies by participant type and risk 

category as shown in Table 23. 

Table 23: Category of Participant and Frequency of Voucher Issuance at Long Beach 

WIC

Type of participant Frequency of voucher issuance

Pregnant woman Monthly

Infant, first 2 months Monthly

Infant, 3 to 12 months Monthly/bimonthly

Child Monthly/bimonthly
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Long Beach WIC typically refers its participants to other service providers 

by giving them access to a listing of providers. Two of Long Beach’s sites 

have a binder of referral information available at the reception desk for use 

by applicants and participants. Staff note the immunization status of child 

participants in their case record and refer participants to immunization 

services as necessary. In addition, they offer a class on the benefits of 

immunizations. Long Beach also distributes a referral guide to participants 

that lists services such as low-cost health clinics. WIC does not provide the 

names of, or recommendations to, specific doctors. In addition to 

counselors, receptionists answer questions and provide brochures and 

pamphlets as requested on a variety of topics, including child care and 

parenting. Long Beach staff are not expected to note in the participant data 

system to whom the participant was referred. The staff indicated that they 

did not always follow-up with the participant on referrals.

Regarding voter registration, staff asked participants whether they were 

registered to vote during the enrollment appointment and noted the answer 

on the back of the participant’s file folder. The program also has voter 

registration forms available.

Nutrition Education Long Beach WIC presented some type or level of nutrition education at 

almost every participant contact. One-on-one nutrition education 

discussions began during the nutrition assessment phase of the 

certification process, when the dietitian provided feedback on the 

participant’s reported diet. The certification appointment that we observed 

lasted about 45 minutes. Staff typically discussed aspects of nutrition 

information and diet informally during the certification or recertification 

process or during any other contact with a participant and handed out 

brochures to supplement the discussion. The registered dietitians provided 

nutrition education to high-intervention participants during one-on-one 

counseling sessions. They also referred participants who needed medical 

nutritional counseling to registered dietitians in medical settings. Long 

Beach WIC also provided nutrition education, particularly to lowintervention participants, through 15-minute classes that addressed nearly 

40 different topics. These classes were offered both to individuals and to 

groups of between 5 and 20 participants. For instance, during an individual 

class given to the mother of a 2-month old infant, the CPA advised the 

mother to avoid the ready-to-feed formula that was giving the baby diarrhea 

and use the powdered formula instead. In November 1999, these short 

High-intervention Monthly/bimonthly
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classes were being offered about 12 times per day at each of the sites. 

According to the nutrition education coordinator, about 55 percent of the 

nutrition education is provided in one-on-one sessions, and the remaining 

45 percent is provided in group sessions. She indicated that there was 

inadequate time to develop new classes.

Long Beach WIC also provided nutrition education through brochures and 

pamphlets, educational displays relating to nutrition such as posters 

illustrating general nutrition information such as the Food Pyramid, and 

videos. Pamphlet and booklet topics included nutrition during pregnancy 

and infant feeding. Nutrition education was also provided by playing WIC 

or nutrition-related videotapes in the waiting rooms. (See fig. 7). Video 

topics observed at one site in Long Beach included cooking with beans and 

infant safety. 

Figure 7: Use of Videotapes in the Waiting Area of a Long Beach WIC Site

To serve its multilingual population, Long Beach WIC hired bilingual staff 

to provide nutrition education to non-English-speaking participants. 

Classes were taught in several languages, including Spanish, Khmer, 

Laotian, Vietnamese, and Hmong. Generally, classes were geared toward 
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the adult participants. Long Beach staff indicated that they recently taught 

a pilot class on nutrition geared to children 1 to 5 that was well-received by 

participants and caregivers. However, according to the nutrition education 

coordinator, the program lacked the staff to continue to teach this type of 

class. 

Breastfeeding Promotion and 

Support

All of the Long Beach WIC staff were trained to promote breastfeeding. 

Breastfeeding information and education is provided to all pregnant 

participants at the first appointment and staff distributed promotional 

materials to the participant at that time. The state agency requires local 

agencies to provide breastfeeding education and to make at least two 

contacts with the new mother after delivery to encourage breastfeeding. 

Long Beach WIC staff visited two hospitals in the city once a week to 

provide breastfeeding support to all new mothers. Long Beach WIC also 

used its own staff to develop breastfeeding and nutrition education 

brochures for its Cambodian participants. 

In fiscal year 1999, about 7 percent of Long Beach’s infant participants were 

exclusively breastfed and about 20 percent were partially breastfed. In 

March 1999, California WIC staff reported that the statewide average rates 

for exclusively and partially breastfed WIC infants were 10 and 24 percent, 

respectively.

Program Administration Maintaining participants’ records. Long Beach WIC tracks participant 

data on a real-time basis and issues food vouchers using the state system. 

Because of the system, the agency needs to maintain only minimal paper 

records. During a participant’s initial visit, staff enter all participant 

information into their computer system to establish a participant record. 

The system automatically identifies the participants’ level of nutritional 

need (intervention level) on the basis of this information. According to the 

WIC Director and staff, the state system has significantly improved the 

workflow at the sites and reduced participants’ waiting times. However, on 

occasion, the system goes down. When this happens, participants return to 

the site later to pick up their food vouchers or wait at the site for vouchers 

to be issued by hand or for the computer to come back on line. To minimize 

the time participants spend at the site during a return visit, staff issued 

participants a special pass that allows them to get served immediately. 

Managing vendors. Local agencies in California have no role in vendor 

management. Long Beach staff will send participant complaints about 

vendors to the state and to the individual vendors.
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Outreach. In fiscal year 1998, staff contacted local school officials, other 

social service providers, officials at local hospitals or medical centers, area 

physicians, local community groups, and local health associations or 

professional groups. They also used display booths or tables at community 

fairs, mailed program literature to interested persons, and encouraged 

referrals by participants. Long Beach WIC also had written agreements, in 

1999, with six other Department of Health and Human Services programs 

and other organizations. These agreements included provisions for the 

mutual referral of participants, inclusion of medical data when appropriate 

in referrals, and regular planned reviews of referral outcomes.

Travel. WIC staff are typically assigned to work at one site location and do 

not travel among the sites to deliver program services. However, staff do on 

occasion travel to other sites to attend training.

Retaining and recruiting personnel. The WIC Director indicated that 

the program had several unfilled positions and had difficulty identifying 

candidates for the positions because it was unable to offer competitive 

salaries. Salaries for registered dietitians and nutritionists at the Long 

Beach WIC are not competitive with salaries offered by private sector, 

according to the Director. In order to stretch the funds available for 

personnel, Long Beach WIC began, over 20 years ago, to employ contract 

employees, who do not receive health or vacation benefits. As mentioned 

above, 28 of the staff were contract employees. The WIC Director also 

reported having some problems maintaining an adequate staffing level and 

a staff turnover rate of about 15 percent. According to sponsoring 

organization officials, the WIC program has become a training ground for 

nutritionists, who then leave for higher-paying jobs. To improve staff 

retention, the sponsoring agency was exploring the option of converting 

the contract employees to city employees with benefits.

Expenditures of Program 

Funds and Use of 

Nonprogram Resources

Table 24 shows the fiscal years 1998 and 1999 program expenditures made 

by Long Beach WIC by category. The program expenditure per participant 

per month in fiscal year 1999 was $8.43.
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Table 24: Long Beach WIC Program Expenditures by Category, Fiscal Years 1998 

and 1999

Note: Totals may not add to 100% due to rounding. 

During fiscal years 1998 and 1999, Long Beach WIC also received a grant of 

about $238,000 from the California WIC program for a 2-year smoking 

cessation program.

The program’s major nonprogram resources were in-kind contributions 

from the sponsoring organization, a portion of the indirect costs incurred 

to operate the program, and space. Regarding the indirect costs, according 

to the sponsoring organization’s cost allocation plan for 1998, the indirect 

cost rate for WIC was 15 percent of total direct operating expenses, or 

$415,504. In accordance with state WIC regulations, which limit indirect 

costs to 10 percent of expenditures for personnel excluding benefits, Long 

Beach WIC paid $142,500 in indirect costs in fiscal year 1998. The 

Department of Health and Human Services covered the balance of the 

indirect costs the Long Beach WIC incurred to operate the program—

$273,004. Regarding the space contribution, the sponsoring organization’s 

in-kind contributions of space at two sites were valued at $60,000. The total 

of these two contributions, approximately $333,000, represented about 11 

percent of program expenditures in fiscal year 1998, or about 11 cents in 

nonprogram resources for every dollar in costs covered with program 

funds. 

We did not obtain estimates of the value of other nonprogram resources, 

such as equipment, furniture, and translation services.

Fiscal year 1998 Fiscal year 1999

Category Amount

Percent

of total Amount

Percent

of total

Personnel and benefits, excluding 

contracted personnel

$1,362,422 47% $1,470,586 50%

Contracted personnel 942,968 33% 770,045 26%

Equipment and supplies 31,086 1% 69,240 2%

Facilities rental, including utilities, 

maintenance, and telephone

147,466 5% 200,726 7%

Indirect costs 142,500 5% 147,500 5%

All other 272,003 9% 286,817 10%

Total $2,898,444 100% $2,944,914 100%
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York, Pennsylvania, 

WIC Program

Overview of the 

Pennsylvania State WIC 

Program 

York WIC is one of 25 local agencies providing WIC services in 

Pennsylvania. In fiscal year 1999, the average monthly number of 

participants served by these agencies was 238,203. That year, the agencies 

ranged in size from about 1,400 to 48,000 participants, on average, each 

month. Of the 24 Pennsylvania local agencies that responded to our 1999 

nationwide survey of local WIC agencies, 14 were operated by county or 

community health agencies, 5 by community action agencies, 2 by 

hospitals, and 3 by other types of organizations. Ten of the agencies 

responding to the survey operated in rural settings, 4 in urban, 2 in 

suburban, and 8 in mixed geographic settings. 

In fiscal year 1999, Pennsylvania expended federal NSA grant funds totaling 

$35,315,599, or about $12.35 per participant per month. Pennsylvania 

provided no state funds for WIC nutrition services and administration. 

About 24 percent, or $8,571,993, of NSA expenditures were made at the 

state level. The remaining 76 percent, or $26,743,606, was made by the local 

WIC agencies. 

Pennsylvania distributes WIC program funds to local agencies each year 

largely on the basis of a formula that uses three per participant per month 

rates. The first and highest rate is for the first 15,000 participants served by 

an agency. Successively lower rates are used for the next 10,000 

participants and for over 25,000 participants, respectively. Such a formula 

provides somewhat lower per participant per year funding to agencies with 

caseloads over 15,000. In fiscal year 2000, only 3 of the state’s 25 local 

agencies had caseloads over 15,000. Some program funds are distributed to 

local agencies to cover special needs, such as migrant programs or clinic 

relocations. 

The Pennsylvania WIC participant database system was first automated in 

1983 and upgraded in 1991. The statewide-automated system is used, 

among other things, to record and track participant information, assign 

nutritional risk codes to participants, track immunization status, track 

referrals, run reports, create custom food packages and print food 

instruments. The state conducts nightly batch processing of the participant 

information uploaded from the local agencies’ computers. Local agency 
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program staff can obtain system technical assistance and support from the 

state WIC agency, such as assistance with managing reports and system 

development.

The types of support the state agency provides to local agencies include 

guidance on state policies and procedures; forms; brochures in several 

languages; technical assistance, such as handling participant abuses (e.g., 

dual participation); and nutrition and breastfeeding guidance. The state 

program also provides training to local agency directors through statewide 

meetings held three times a year. 

Characteristics of the 

Geographic Area Served by 

the York County WIC 

Program

York WIC serves the county of York, which is located in south-central 

Pennsylvania. The topography of York County consists primarily of rolling 

hills, bordered on the east by the Susquehanna River. The county is a 

combination of urban and rural communities. Its estimated population in 

1997 was 370,518, while the estimated population for the City of York was 

40,087. The average unemployment rate for York County was 3.7 percent in 

1998, while the rate for the City of York was reported in 1999 to be about 2 

percent higher than the county rate. 

In 1995, about 6.5 percent of the county population was living below the 

poverty level. The per capita income for York County in 1996 was $23,610, 

while the City of York’s per capita income was $10,485. In 1996, an 

estimated 16.4 percent of the families and 31.2 percent of the children in 

the City of York lived in poverty. According to 1997 estimates, about 72 

percent of City of York residents were white, about 21 percent AfricanAmerican, and about 8 percent Hispanic. In April 1999, approximately 70 

percent of York’s WIC participants were white, about 14 percent were 

African-American and about 15 percent were Hispanic.

Local Agency’s Program 

Characteristics

Sponsoring Organization The York WIC program is administered by the Community Progress 

Council (CPC), a community action agency. Chartered in 1965, CPC is 

governed by a board of Directors representing low-income, business sector, 

and elected community members. In addition to the WIC program, which it 

has operated since 1975, CPC operates Head Start of York County; the 

Foster Grandparents program, a Welfare-to-Work program, a Case 
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Management program, a Department of Community Centers, and the 

Senior Community Services Employment Program. (The Case Management 

program provides homeless and low-income families and individuals with 

assessment, referral, and follow-up services aimed at building selfsufficiency and increasing community involvement.)

CPC charges the WIC program for some of its indirect operational costs, 

including costs related to management and administrative personnel, 

auditing, and postage. In fiscal year 1999, the indirect costs the sponsoring 

organization charged the program were based on a rate of 6.3 percent of 

program expenditures for personnel, excluding benefits. According to the 

Executive Director of CPC, the amount charged to the program 

represented only part of the indirect costs incurred to operate it. The 

remaining indirect costs were covered by CPC’s Community Services Block 

Grant. CPC also provided WIC with in-kind contributions in the form of one 

part-time administrative support staff whose pay was covered by stipends 

from a Department of Labor grant. The sponsoring organization also 

provided some miscellaneous contributions, such as office furniture and 

supplies. 

WIC Clinics To provide WIC services throughout York county, York WIC operated nine 

clinics. The main clinic is collocated with CPC’s Case Management 

program in downtown City of York. In addition to the main clinic, the York 

County WIC program operated eight satellite clinic sites. One, referred to 

as Noell, is located in the City of York, and seven are located in the 

boroughs of Delta, Dillsburg, Dover, Hanover, Lewisberry, New Freedom, 

and Red Lion. Normal hours of operation for the main clinic were 8:00 a.m. 

to 5:00 p.m., 5 days a week. To provide extended hours for participants, the 

main clinic was also open 3 days a month until 6:30 p.m. The York Director 

said it was a hardship for one of her staff to work evening hours because 

the amount she paid for childcare during the evening was more than she 

earned for those hours. Most of the program’s participants receive services 

at the main City of York site. The hours of operation at the satellite sites 

varied, with most operating 1 or 2 days a month.

The satellite sites all share space with other health and social service 

programs, such as a local food pantry, a family health clinic, an 

immunization clinic, and a clothing bank. Staff noted that some 

participants who travel to satellite offices feel that there is a lack of privacy 

in these settings because several nutritionists are working with participants 

in the same space, at the same time, and discussions can be overhead. 
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Staffing At the time of our study, York WIC had 20 staff: 10 full-time and 10 parttime, for a total of 16.2 full time-equivalent staff. The WIC Director has 

worked for WIC since 1975 and has a B.S. in Nutrition. In addition to the 

Director, eight staff members, including a nutrition education coordinator, 

four nutritionists, two nurses, and one lactation consultant, were CPAs. 

Other staff included an administrative assistant, a secretary, four nutrition 

assistants, four clerks, and a janitor. The WIC Director is the only salaried 

employee; the rest of the staff are paid hourly. Staff are assigned to provide 

services at the satellite sites on a rotating basis.

Number of Participants Served In fiscal year 1999, the average monthly participation was 4,859 

participants. Table 25 shows the number of participants by category served 

in September 1998 and November 1999. The WIC Director was not able to 

provide an estimate of the percent of participants considered high-risk in 

an average month in fiscal year 1999. Although participants are identified 

as high-risk in their individual paper records, the data system does not 

identify risk category. 

Table 25: Number of Participants by Category, September 1998 and November 1999, 

at York WIC

Major Aspects of the 

Program’s Delivery of 

Nutrition Services and 

Administration

Number of participants

Participant category September 1998 November 1999

Pregnant women 534 554

Breastfeeding women 133 107

Postpartum women not breastfeeding 508 462

Infants 1,369 1,417

Children 2,320 2,297

Total 4,864 4,837
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Participant Services During certification and recertification sessions, participants were seen by 

a CPA, but the nutrition assistant in some instances collected the income 

and residency information, measured height and weight, and tested blood 

for anemia. (Both CPAs and nutrition assistants were able to perform blood 

tests.) During the initial sessions, a CPA would typically assess the 

participant’s medical or nutritional risk, and, if the applicant was eligible, 

prescribe a food package, explain program policies and procedures, and 

provide some nutrition education. One senior staff member indicated that 

in performing the assessment she only reviewed the participant’s diet 

through a diet recall protocol if she could not find a medical reason to 

establish eligibility or if the participant had questions about her diet. 

During the initial session, either a CPA or nutrition assistant also checked 

on and recorded the immunization status of child participants and issued 

vouchers. Staff reported, and we observed, that some nutrition education 

and breastfeeding promotion and support was also provided during the 

nutrition assessment process. 

According to the nutrition education coordinator, a nutritionist was 

required to develop an individual care plan for all high-risk participants. 

These plans included information on the nutrition education topics 

addressed, the materials provided to the participant, and specific reasons 

for any change in a participant’s risk status. These plans, according to the 

nutrition education coordinator, were typically communicated to the 

participant in a combination of written and/or oral suggestions. The care 

plan is kept in hard copy in the participant’s file.

Vouchers were typically issued to all participants on a bimonthly basis. The 

CPAs manually created the first set of vouchers for new participants. 

Subsequent vouchers were printed in advance of the next scheduled pickup appointment by the participant data system. 

The staff typically scheduled appointments for certification and 

recertification sessions. Walk-ins were typically scheduled for a 

certification session at a later date because applicants may not have all the 

required documentation needed for certification. The main clinic 

frequently got walk-ins for voucher pick-up, but staff discouraged the 

practice. Staff indicated that waiting times ranged from 10 minutes to an 

hour, depending on the number of staff working on a given day. When time 

was available, staff called new participants to remind them of upcoming 

appointments and sent reminder postcards to participants who missed 

appointments. York WIC, as required by the state, tracked the “no-show” 

rate for recertification and voucher pick-up appointments. Recent no-show 
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rates for recertification and voucher pick-ups were about 8 percent and 10 

percent in November 1999 and May 2000, respectively.

According to the WIC Director, at initial certification participants received 

a brochure that provided information on a number of local service 

providers. She indicated that referrals were commonly made to the state’s 

medical assistance program (Medicaid), CPC’s case management program, 

Food Stamps, cash assistance, medical providers, food pantries, and 

shelters. Typically, the participant was given the brochure and the phone 

number for a specific service provider. Staff normally entered information 

about referrals in the participants’ files as well as information related to 

eligibility for medical assistance, cash assistance, and food stamps. 

Information in the participant database could be used to track the number 

of referrals made to the different types of service providers. Staff reported 

that they did not always follow-up with the participant on the outcome of 

referrals that had been made.

Regarding voter registration, in accordance with state policy, York staff ask 

each adult participant if she is registered to vote, note the response in the 

participant’s file, record the response on a data collection form, enter the 

response into the data system, give the voter registration form to the 

participant, and assist the participant in completing it. York staff also 

deliver completed forms to the voter registration office. 

Nutrition Education Nutrition education was typically provided in one-on-one sessions with 

both low- and high-risk participants during certification, recertification, 

and voucher pick-up appointments. The certification and recertification 

appointments that we observed lasted from 20 minutes to over an hour. 

One-on-one nutrition education discussions began during the nutrition 

assessment phase of the certification process, when the CPA provided 

feedback on the participant’s reported diet. At many of the appointments 

that we observed, the content and the duration of the nutrition education 

provided were minimal. For example, participants were asked brief 

nutrition-related questions; however, there was little, if any, discussion of a 

participant’s specific nutrition situation or of general nutrition education 

issues. One nutritionist told us that because staff try to adhere to the 

allotted time of 30 minutes per certification and recertification 

appointment, not much time was available to provide education after 

dealing with eligibility, assessment, and voucher issuance issues. 

York participants also received general nutrition education from the 

brochures that staff distributed to supplement their nutrition education 
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discussions. Brochures on numerous nutrition topics and display posters 

were also available in the main clinic’s waiting area. (See fig. 8.) The WIC 

Director told us that the clinics normally played WIC orientation, nutritionrelated, or food demonstration videos in the waiting room, but, at the time 

of our study, the videotape machine was out of order. The WIC Director 

told us that the program does not offer group classes because space is not 

available at the clinics.

Figure 8: Use of Brochures in the Waiting Area of the Main York WIC Clinic

To serve non-English-speaking participants, York hired bilingual staff to 

provide nutrition education to Hispanic participants. The local hospital’s 

lactation consultants referred Hispanic patients to York WIC for 

breastfeeding services because the hospital does not have employees who 

can speak or translate Spanish. York WIC had nutrition and breastfeeding 

materials available in Spanish, Vietnamese, Laotian, and Cambodian. York 

WIC staff did not provide nutrition education directly to child participants. 

They did distribute sipper cups and toothbrushes to the children to 

promote good dental health. 
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Breastfeeding Promotion and 

Support

Breastfeeding at York WIC was typically promoted through one-on-one 

counseling and/or handouts. The breastfeeding coordinator reported that 

all of the staff—including the clerks—had been trained to promote and 

encourage breastfeeding. However, we observed that during the 

certification appointments for two pregnant women, breastfeeding 

education or counseling was minimal or did not occur at all. One of the 

women was only asked about her breastfeeding intentions while no 

mention of breastfeeding was made to the other woman. The breastfeeding 

coordinator, who is also a lactation consultant, spent much of her time 

certifying and recertifying participants. She indicated that if more staff 

were available she would be able to devote more of her time promoting 

breastfeeding. 

According to the breastfeeding coordinator, breastfeeding classes were not 

offered because of low attendance in the past. The breastfeeding 

coordinator did not conduct telephone follow-up calls to encourage and 

support breastfeeding because of the difficulty she had previously 

encountered in trying to reach participants. The breastfeeding video was 

not being shown to participants during our visit because the only videotape 

machine was out of order. Breastfeeding support groups were not offered 

because of lack of staff time and facilities. York WIC provided breast 

pumps for rent and for distribution to WIC breastfeeding mothers for a 

minimal fee.

In November 1999, about 4 percent of York WIC infant participants were 

exclusively breastfed. In December 1999, the percentage of infant 

participants at York who were partially breastfed was about 46 percent, 

compared with about 51 percent for WIC participants statewide. 

Program Administration Maintaining participants’ records. Although York WIC tracked 

participant data and issued food vouchers using the state data system, it 

relied heavily on paper records. CPAs or nutritionists first recorded 

participant’s certification and other appointment-related information on 

paper forms, then a clerk entered the data into the computer system. Staff 

had access to the statewide system through two of its computers. They 

were able to use the state system to generate a few standardized reports, 

such as breastfeeding rates or vendor lists. According to the WIC Director, 

staff would use computers more if more were available. At the time of our 

study, four computers were available for staff use. 

Managing vendors. In accordance with state guidelines, York WIC had 

significant vendor management responsibilities. At the time of our study, it 
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managed 40 vendors. One staff member, the administrative assistant, 

devoted part of her time to vendor management. Her responsibilities 

included training vendors, monitoring their adherence to program rules, 

performing inventory audits, and assisting state staff in vendor selection, 

authorization, and the performance of compliance buys. The administrative 

assistant indicated that there were insufficient resources to manage 40 

vendors effectively.

Outreach. The administrative assistant who manages York’s vendors also 

coordinates all of the outreach efforts. She reported that recent outreach 

included mailings to homeless shelters, substance abuse agencies, local 

high and middle schools, day care centers, health care groups and 

individual physicians. She served as member of two coalition groups that 

focused on community health issues. She actively coordinated with CPC’s 

Head Start program and the county’s foster care agency. 

Travel. Thirteen York staff traveled to the satellite clinics to provide 

services. York reimbursed staff for travel to the satellite clinics and state 

WIC meetings. 

Retaining and recruiting personnel. The WIC Director reported 

significant difficulty in recruiting and retaining WIC staff because she is not 

able to offer nutritionists and registered nurses salaries comparable to 

those that the county health department, local family planning 

organizations and hospitals can offer. The CPC Executive Director 

indicated that the salaries that the program is able to offer to WIC staff are 

“shameful.” The WIC Director reported that the agency offers a nutritionist 

or dietitian half of the hourly rate offered for a comparable position at the 

local hospital. She can only offer the clerical staff an hourly rate of $5.70, 

about three-quarters of the hourly rate being offered at the local fast food 

and retail stores. According to the WIC Director, one staff member pays 

more for babysitting than she makes on those evenings when she works 

extended hours. 

Expenditures of Program 

Funds and Use of 

Nonprogram Resources

The expenditure per participant per month in 1999 was $9.47. Table 26 

shows the fiscal years 1998 and 1999 program expenditures for York WIC, 

by category.
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Table 26: York WIC Program Expenditures by Category, Fiscal Years 1998 and 1999

Note: Percents may not total to 100% due to rounding. 

The major nonprogram resources used by the program were in-kind 

contributions made by the sponsoring organization and the landlord who 

leased the space for the main clinic. The in-kind contributions from the 

sponsoring organization were in the form of payment of some of the 

indirect costs incurred to operate the program and one part-time 

administrative support staff provided to the program at no cost. According 

to information provided by the sponsoring organization, in fiscal year 1999, 

about $31,000 of the indirect costs it incurred to operate the WIC program 

were covered by its Community Service Block Grant. Additionally, about 

$5,400 in Department of Labor grant funds were used to cover the costs of 

one administrative support staff assigned to WIC. The landlord’s in-kind 

contribution was in the form of a charge for the space of the main WIC 

clinic that was below the market rate. Using information provided by the 

WIC Director, we estimate that in fiscal year 1999, the value of the discount 

on the rent would be about $20,000.7

 In fiscal year 1999 York WIC also used 

$2,000 in grant funds from the city of York to educate mothers on baby 

bottle tooth decay. The total value of these nonprogram resources obtained 

from the sponsoring organization, the landlord, and the city of York in fiscal 

Fiscal year 1998 Fiscal year 1999

Category Amount

Percent of

total Amount

Percent of

total

Personnel and benefits 

excluding expenditures for 

contracted personnel

$488,050 82% $464,554 84%

Contracted personnel 0 0% 0 0%

Equipment and supplies 13,567 2% 6,623 1%

Facilities and related 

expenses including utilities, 

maintenance, rent and 

telephone

47,845 8% 42,443 8%

Indirect costs 24,668 4% 23,353 4%

All other 24,460 4% 15,360 3%

Total $598,590 100% $552,333 100%

7

 According to the WIC Director, the value of the contribution was between $10,000 and 

$30,000. For our estimate we used $20,000.
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year 1999 was about $58,400. This represented approximately 11 percent of 

program expenditures in fiscal year 1999 or about 11 cents for every dollar 

in costs covered with program funds. 

York WIC also made use of other miscellaneous nonprogram resources, 

including shared space used at its satellite locations, waiting room 

furniture in the main clinic that was donated by a local pediatric practice, 

and some office furniture donated by a local bank. We did not obtain or 

develop an estimate of the value of theses miscellaneous in-kind 

contributions. 

Zuni WIC Program

Overview of the Zuni WIC 

Program 

The Zuni WIC program is operated by the Pueblo of Zuni, a federally 

recognized Indian Tribe. It is one of 33 Indian Tribal Organizations (ITO) 

operating WIC programs nationwide that are considered to be state-level 

agencies by the U.S. Department of Agriculture (USDA). Since 1979, the 

Zuni WIC program has operated under the auspices of the Zuni Tribal 

Council, a six-member Council headed by an elected governor and 

lieutenant governor. The Governor and the Council are elected to 4-year 

terms and governed by the tribe’s own constitution. According to the WIC 

Director, the WIC program is one of the largest Zuni-run programs. In fiscal 

year 1999, Zuni provided WIC services to a monthly average of 857 

participants. According to the Governor, WIC is a major program in the 

tribe’s effort to improve community health, and the program closely 

coordinates its efforts with the Zuni Pueblo’s only medical facility—a U.S. 

Indian Health Service hospital. 

In fiscal year 1999, Zuni WIC, as a state-level agency, expended federal NSA 

grant funds totaling $264,372, or about $25.71 per participant per month. 

According to information Zuni reported to USDA, about 23 percent of NSA 

expenditures, or $60,530, was made for state-level program management 

costs. The remaining 77 percent, or $203,842, was expended for costs 

typically incurred by local agencies in providing nutrition services and 

administering the program. 

Zuni WIC’s participant database system was first automated in 1996. The 

current system was developed by the Inter-Tribal Council of Arizona 

(ITCA) and implemented at Zuni in October 1999. Its capabilities include 
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maintaining participant records, generating reports, and printing food 

vouchers. The system processes participant certification data as they are 

entered. The WIC Director described the system as user-friendly, flexible, 

and fast. She found the printed forms had a quality assurance problem and 

was working with ITCA on programming. ITCA provides technical 

assistance for the database, via telephone, and the agency has a contract 

for hardware and other software support.

The Tribal Council charges the WIC program for indirect costs, such as 

procurement, accounting, and personnel. The indirect rate for fiscal years 

1998 and 1999 was 16.7 percent of total direct costs, less capital 

expenditures, pass-through funds, and other exclusions. The Pueblo 

applied the indirect rate only to WIC administrative expenditures. The ITO 

also provides WIC with in-kind contributions of the land for the WIC trailer 

facility.

Characteristics of the 

Geographic Area Served by 

the Zuni WIC Program

Zuni Pueblo is a rural community in New Mexico with a total population of 

about 10,895 in July 1999. The main reservation is situated in a semiarid 

valley surrounded by mesas, about 150 miles southwest of Albuquerque. 

The Zuni WIC program provides service to residents within Zuni tribal 

boundaries and some Navajo tribal areas. Since only 16 of the 560 miles of 

roads maintained by the county are paved, bad weather conditions along 

rural dirt roads can make travel almost impossible and further isolate large 

portions of the population. 

In 1997, an estimated 47 percent of Zuni’s labor force was unemployed. 

According to the Governor, the Zuni population has elevated rates for 

diabetes, hypertension, and heart disease, and these need to be reduced. In 

1998, according to a report from the local Indian Health Service (IHS) 

hospital, between 35 and 60 percent of Zuni adult patients over the age of 

50 have diabetes, and about 28 percent of Zuni patients between the ages of 

2 and 4 years old were obese. Approximately 87 percent of the Zuni Pueblo 

population were members of the Zuni tribe. 

Zuni WIC Program’s 

Characteristics

WIC Clinics Zuni WIC provided nutrition services at four locations: the clinic in Zuni, a 

grocery store in a nearby town, and two local high schools. The Zuni clinic 
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provided the full range of nutrition services (see fig. 9); its normal hours of 

operation were Monday through Friday, 8:00 a.m. to 4:30 p.m. This clinic 

offered limited services during extended evening hours, which were held 

several days a month. Most of the program’s participants received services 

at the main clinic.

Figure 9: Waiting Area in Zuni WIC Clinic

The grocery store site—located in Ramah, New Mexico—was 

approximately 17 miles from Zuni. Staff set up a card table near the front of 

the store. Activities at the site were limited to issuing vouchers to low-risk 

participants. Staff were at this site every other month, from 9:00 a.m. to 3:00 

p.m. This site served from 20 to 25 participants, most of whom were 

Navajo. 

The two high schools are located in the Zuni Pueblo. WIC staff used space 

in the day care centers at the high schools. Activities at these sites were 

also limited to issuing vouchers to low-risk participants. Vouchers were 

issued at these sites twice a month. Each high school site served from 10 to 

20 teenage participants. 

Number of Participants Served In fiscal year 1999, Zuni WIC served a monthly average of 857 participants. 

Approximately 33 percent of the agency’s participants served in an average 
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month during that year were considered high-risk. Table 27 shows the 

number of participants by category served in September 1998 and 1999.

Table 27: Number of Participants by Category, September 1998 and September 1999, 

at Zuni WIC

Staffing At the time of our study, the program employed six full-time and one parttime staff, for a total of 6.4 full-time equivalent staff. The WIC Director had 

been with the program for 20 years and is an active member of the 

community. She was the former department head of the Department of 

Human Services and the current president of the board of education. The 

part-time staff member was a registered dietitian, and the only lactation 

consultant in the county. Two of the other five full-time staff and the WIC 

Director were designated as CPAs—having passed a competency-based 

test developed by registered dietitians from the New Mexico ITOs and 

approved by USDA. One of the full-time staff members was a breastfeeding 

peer counselor, and two were administrative support staff. All of the staff 

were paid on an hourly basis. 

Major Aspects of the 

Program’s Delivery of 

Nutrition Services and 

Administration

Participant Services During the certification and recertification sessions, the Zuni WIC staff 

routinely measured participants’ height and weight and tested blood for 

anemia. Zuni WIC also received a health summary from the IHS hospital 

prior to each participant’s certification or recertification visit. This 

Number of participants 

Participant category September 1998 September 1999

Pregnant women 62 53

Breastfeeding women 66 66

Postpartum women not breastfeeding 29 36

Infants 160 166

Children 544 517

Total 861 838
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summary typically included the latest information that the hospital had on 

the participant’s height, weight and immunization status. At each visit 

participants completed a form to identify the foods they were eating. Staff 

reported, and we observed, that some nutrition education and 

breastfeeding promotion and support was also provided during the 

nutrition assessment process. CPAs see the low-risk participants, while 

participants considered to be high-risk were seen by the staff dietitian as 

well as a CPA. An individual care plan is typically developed for high-risk 

Zuni participants. The Zuni WIC Director believed that the required proof 

of income is a barrier to Zuni residents applying for WIC services because 

they find it humiliating to have to prove how poor they are.

The Zuni WIC clinic schedule dedicated Mondays and Tuesdays of each 

week to updating files, preparing participant folders for those who are 

scheduled to be seen later in the week, and scheduling participants for 

upcoming appointments. Participants were scheduled for visits on 

Wednesdays and Thursdays of each week. Walk-ins were seen on 

Thursdays. Fridays were dedicated to completing any work left over from 

earlier in the week. Staff sent letters to participants who missed more than 

four appointments. If they could not reach the participants by letter, then 

they visited them at home. During the certification process, as described by 

the staff, participants returned to the waiting area at least twice while their 

case information is updated. Regarding the flow of participants through the 

main clinic, no recent information was available about the amount of time 

participants spent waiting for services. 

All staff members were responsible for issuing the food vouchers, and the 

agency tracks voucher issuance on the computer system. Food instruments 

could be printed on demand at the main clinic and were printed beforehand 

for issuance at Ramah and the local high schools. Vouchers were typically 

issued to participants every 2 months. Zuni WIC staff sometimes made 

preappointment calls, but routinely made follow-up telephone calls or sent 

postcards to participants who missed an appointment. 

In making referrals to the IHS health care providers, Zuni WIC staff 

completed a hospital referral form, recording the reason for the referral. 

Copies of the form went to IHS, the participant, and the participant’s WIC 

file. After completing the form, the WIC staff called the IHS health care 

provider and scheduled an appointment for the participant. This was done 

to help ensure that participants followed through on the referral. After 

seeing the referred WIC participant, the IHS provider returned the referral 

form to Zuni WIC, indicating the services provided. If the referred agency 
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did not return the form to WIC, staff followed-up with the participant 

during the next recertification and, if necessary, telephoned the IHS 

provider to obtain the completed form. In referring participants to other 

types of providers, such as social services, staff sent a memo notifying the 

agency that a referral has been made. For such referrals, the nature of 

referral and the date it was made was noted in the participant’s WIC record. 

With regard to voter registration, staff provided participants with 

registration forms and referred them to the county to register. The referral 

was noted in the computer system.

Nutrition Education The CPAs and the dietitian normally provide nutrition education through 

one-on-one sessions, during certification, recertification and voucher pickup appointments, because group education is less accepted culturally in 

the Zuni community. Nutrition education sessions typically involved 

reviewing the participant’s diet and addressing any identified nutrition 

deficiencies, such as low iron levels, by suggesting foods to eat. The 

recertification appointments that we observed lasted between 45 and 60 

minutes. These sessions were often supplemented with brochures dealing 

with good nutrition, such as the Food Pyramid. The WIC registered 

dietitian referred participants who needed medical nutritional counseling 

to the registered dietitian at the local IHS hospital. In order to facilitate the 

delivery of nutrition education, the program employed bilingual staff who 

spoke Zuni during all or part of the appointment. Zuni WIC staff offered 

regular nutrition education to child participants, through individual 

discussions in English and Zuni, and coordinated activities with Head Start 

and the IHS-sponsored diabetes prevention program. 

Most of the participants came to the WIC clinic for their bimonthly voucher 

pick-up, enabling staff to use this opportunity to offer classes, such as 15-

minute cooking demonstrations in the clinic’s kitchen. Furthermore, Zuni 

WIC had some interactive displays depicting general nutrition information 

that required participants to study the presentation and answer review 

questions, such as a display on juices that depicted the relative amount of 

fruit juice in locally purchased juice drinks. In addition, Zuni WIC had 

created over a dozen nutrition education brochures using graphics 

depicting Native American women and children and culturally appropriate 

foods, such as the Pueblo Food Pyramid.

Breastfeeding Promotion and 

Support

Zuni WIC offered many breastfeeding promotion and support activities, 

such as one-on-one counseling, quarterly group classes, home and hospital 

visits, breastfeeding pumps and aids, videos, promotional materials, and 

scheduled follow up. On a daily basis, the breastfeeding peer counselor 
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tracked new births at the local hospital, conducted hospital visits at the 

maternity ward in the morning and home visits in the afternoon and made 

follow-up telephone calls at regular intervals to check on a breastfeeding 

mother’s progress and provide assistance. To make breastfeeding 

convenient while mothers were visiting WIC offices, Zuni WIC dedicated 

private space for this purpose. In addition, Zuni WIC invested local 

resources to create and distribute a video that depicted Zuni and other 

Native American women and their experiences with breastfeeding. Zuni 

WIC shared this breastfeeding video and its brochures with other ITOs.

To support their efforts in this area, all of the Zuni WIC staff are trained to 

promote breastfeeding. In addition, the agency staff includes a certified 

lactation consultant, the only one in the area, and a full- time peer 

counselor. As a result of the long-term team effort, the program had, in 

fiscal year 1999, a breastfeeding initiation rate of 77 percent and a 

breastfeeding rate of 43 percent for infants 6 months and older.

Program Administration Maintaining participants’ records. While a substantial amount of 

participant and program data are maintained on the automated system, 

individual hard-copy participant records are also maintained to verify the 

accuracy of information on the new database system.

Managing vendors. Since Zuni WIC is a state-level agency, the staff are 

heavily involved in all aspects of vendor management, including selection, 

authorization, training, routine monitoring, compliance buys, inventory 

audits at participating vendors, enforcement, and payment of redeemed 

vouchers. One staff member was dedicated to vendor management and was 

supported by other staff. At the time of our study, Zuni WIC had nine 

vendors, five in the Zuni area and four in the Gallup area. Several of the 

small Zuni vendors raised concerns that their cash flow was being affected 

because of the length of time it took to get reimbursed for redeemed WIC 

vouchers, even though the program was reimbursing them within the 

contracted timeframes. The Pueblo of Zuni staff were aware of the issue 

and were attempting to speed up reimbursements. 

Outreach. The program employs an outreach specialist who coordinates 

all such efforts. The specialist reported that she had conducted outreach at 

Head Start, the local health center, the hospital, high schools, and health 

fairs. In response to recent declines in caseload, WIC staff encouraged 

participants to inform friends of WIC benefits and opened the clinic for 

extended hours to serve working WIC mothers. The outreach staff mailed 

letters to potentially eligible participants by using Head Start’s address list. 
Appendix IV

Detailed Summaries of the Six Case Studies

Page 98 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

Posters and flyers were made to recruit participants and displayed at the 

offices of the local television station. 

Travel. Zuni WIC staff traveled to three satellite sites to provide services. 

The WIC program purchased a vehicle for the staff for such purposes as 

visiting satellite sites, attending area training sessions, and responding to 

emergencies.

Retaining and recruiting personnel. There were no unfilled positions at 

the time of our study. The WIC Director did not describe any difficulties in 

hiring or retaining staff. 

Expenditures of Program 

Funds and Use of 

Nonprogram Resources

Table 28 shows the fiscal years 1998 and 1999 program expenditures the 

agency made by category. 

Table 28: Zuni WIC Program Expenditures by Category, Fiscal Years 1998 and 1999

According to the WIC Director, the current funding level for nutrition 

services and administration is insufficient because nothing is factored into 

their funding to reflect the added costs of conducting their operation out of 

their own building. 

The major nonprogram resource used by Zuni WIC in fiscal year 1999 was 

the sponsoring organization’s in-kind contribution of rent-free land and a 

Fiscal Year 1998 Fiscal Year 1999

Category Amount

Percent of

total Amount

Percent of

total

Personnel and benefits, 

excluding expenditures for 

contracted personnel

$171,587.22 67% $179,918.92 68%

Equipment and supplies 21,148.77 8% 11,270.00 4%

Facilities and related 

expenses, including 

utilities, maintenance, rent 

and telephone

4,888.72 2% 5,483.71 2%

Indirect costs 36,833.94 14% 36,187.68 14%

All other: motor vehicle 

operation, postage, printing

22,937.84 9% 31,511.69 12%

Total $257,396.49 100% 264,372.00 100%
Appendix IV

Detailed Summaries of the Six Case Studies

Page 99 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

grant from the IHS diabetes prevention program, Healthy Lifestyles, to 

distribute toys to encourage children’s’ physical activity. A Zuni tribal 

official estimated the value of the ITO’s in-kind contribution of the land for 

the WIC trailer facility at $5,000 per year. The IHS grant amount was $500. 

The total of these nonprogram resources, $5,500, represented about 2 

percent of program expenditures in fiscal year 1999, or about 2 cents for 

every dollar in costs covered by program funds. 

Zuni WIC also received some minor nonprogram resources from other 

organizations. The two public high schools in Zuni provided shared space 

for WIC staff to deliver vouchers to teenage WIC mothers and a grocer in 

the neighboring town of Ramah also provided shared space for the delivery 

of vouchers. We did not obtain an estimated value of these nonprogram 

resources.
Page 100 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

Appendix V

Time Study Results − Percent of Staff time and 

Staff Time Costs Spent on Activities ApendxiV

This appendix presents information on the results of the time studies 

conducted at each of the six agencies. For each agency, information is 

provided on the percent of staff time as well as the percent of staff time 

costs spent on specific activity subcategories in the four broader categories 

of participant services, nutrition education, breastfeeding promotion and 

support, and administration. Information on the time span of each time 

study and the calculation of percent of staff time costs are presented in 

appendix 1. 

Table 29: Percent of Staff Time and Staff Time Costs −Gallatin

Percent of

Category/subcategory Staff time

Staff time in

category

Staff time

costs

Staff time

costs in

category

Participant services activities

Scheduling participants 13.6 25.7 13.4 26.3

Determining participants’ eligibility 8.8 16.6 8.2 16.1

Assessing participants’ nutritional risk 13.2 24.9 12.7 24.9

Making referrals and conducting follow-up 1.0 1.9 1.0 1.9

Explaining benefits and procedures to participants 1.2 2.3 1.3 2.6

Issuing checks 5.1 9.6 4.8 9.5

Providing or receiving training or other professional development 4.8 9.1 4.4 8.7

Making record notations 5.2 9.9 5.1 10.0

Total—all participant services activities 52.8 100.0 50.9 100.0

Nutrition education activities

Providing one-on-one nutrition education or counseling 9.5 69.9 8.9 65.1

Providing group nutrition education .6 4.4 .7 5.2

Developing materials and activities .9 6.4 1.1 7.9

Consulting with medical providers regarding nutrition education 

of individual participants 

.2 1.4 .2 1.5

Providing or receiving training or other professional development .8 6.0 .8 5.5

Monitoring and evaluating nutrition education activities 1.6 11.9 2.0 14.7

Total—all nutrition education activities 13.6 100.0 13.7 100.0

Breastfeeding promotion and support

Providing one-on-one breastfeeding instruction/counseling 4.6 91.2 4.3 89.8

Providing group breastfeeding instruction/counseling .1 2.2 .1 2.8

Developing materials and activities .1 2.1 .1 2.8
Appendix V

Time Study Results - Percent of Staff time 

and Staff Time Costs Spent on Activities

Page 101 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

Note: Totals may not add due to rounding.

Table 30: Percent of Staff Time and Staff Time Costs−Grady

Consulting with medical providers regarding breastfeeding 

issues

.1 1.6 .1 1.9

Providing or receiving training or other professional development .1 2.7 .1 2.5

Monitoring and evaluating breastfeeding promotion activities <.1 .2 <.1 .2

Total—all breastfeeding promotion and support activities 5.0 100.0 4.7 100.0

Administration

Outreach to potential participants .8 2.6 .8 2.4

Outreach to health care providers and other organizations 2.4 8.5 2.9 9.6

Clerical tasks 11.5 40.3 11.5 37.3

Travel 4.9 17.3 5.1 16.6

Personnel tasks .8 2.6 .8 2.5

Accounting and finance 1.9 6.5 2.3 7.6

Vendor management .1 .5 .2 .5

General management 4.3 15.1 4.9 16.0

Organize self/work .1 .3 .1 .3

Miscellaneous 1.8 6.3 2.2 7.1

Total—all administrative activities 28.6 100.0 30.7 100.0

Grand total 100.0 100.0

(Continued From Previous Page)

Percent of

Category/subcategory Staff time

Staff time in

category

Staff time

costs

Staff time

costs in

category

Participant services activities

Percent of 

Category/subcategory Staff time

Staff time in

category

Staff time

costs

Staff time

costs in

category

Participant services activities

Scheduling participants 4.3 10.0 3.4 8.5

Determining participants’ eligibility 4.9 11.4 4.9 12.4

Assessing participants’ nutritional risk 10.7 24.7 11.1 27.6

Making referrals and conducting follow-up 2.9 6.7 2.2 5.6

Explaining benefits and procedures to participants .5 1.2 .6 1.4

Issuing vouchers 9.7 22.5 7.0 17.3
Appendix V

Time Study Results - Percent of Staff time 

and Staff Time Costs Spent on Activities

Page 102 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

Note: Totals may not add due to rounding.

Providing or receiving training or other professional development 1.0 2.2 1.0 2.6

Making record notations 9.2 21.3 9.9 24.6

Total—all participant services activities 43.2 100.0 40.1 100.0

Nutrition education activities 

Providing one-on-one nutrition education or counseling 4.5 51.4 4.7 49.2

Providing group nutrition education <.1 .4 <.1 .4

Developing materials and activities .8 9.5 1.1 11.3

Consulting with medical providers regarding nutrition education 

of individual participants 

.3 3.3 .4 4.1

Providing or receiving training or other professional development 2.5 28.1 2.7 28.1

Monitoring and evaluating nutrition education activities .6 7.3 .7 6.9

Total—all nutrition education activities 8.8 100.0 9.6 100.0

Breastfeeding promotion and support

Providing one-on-one breastfeeding instruction/counseling 3.0 44.0 3.4 43.9

Providing group breastfeeding instruction/counseling .3 3.6 .3 3.6

Developing materials and activities .9 13.1 1.0 13.1

Consulting with medical providers regarding breastfeeding 

issues

.8 11.6 .9 11.5

Providing or receiving training or other professional development 1.6 24.3 1.9 24.6

Monitoring and evaluating breastfeeding promotion activities .2 3.3 .3 3.3

Total—all breastfeeding promotion and support activities 6.7 100.0 7.8 100.0

Administration

Outreach to potential participants .4 .8 .4 .9

Outreach to health care providers and other organizations .1 .3 .1 .3

Clerical tasks 28.3 68.4 25.8 61.0

Travel 3.4 8.3 3.7 8.8

Personnel tasks .9 2.1 1.2 2.8

Accounting and finance .1 .2 .1 .3

Vendor management 0 0 0 0

General management 4.8 11.6 7.0 16.5

Organize self/work 1.4 3.4 1.5 3.4

Miscellaneous 2.0 4.9 2.5 6.0

Total—all administrative activities 41.3 100.0 42.3 100.0

Grand total 100.0 100.0

(Continued From Previous Page) Percent of 

Category/subcategory Staff time

Staff time in

category

Staff time

costs

Staff time

costs in

category
Appendix V

Time Study Results - Percent of Staff time 

and Staff Time Costs Spent on Activities

Page 103 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

Table 31: Percent of Staff Time and Staff Time Costs −Kanabec 

Percent of 

Category/subcategory

Staff

time

Staff time in

category

Staff time

costs

Staff time

costs in

category

Participant services activities

Scheduling participants 5.1 13.5 5.5 13.5

Determining participants’ eligibility 4.7 12.5 5.1 12.5

Assessing participants’ nutritional risk 14.9 39.3 15.9 39.3

Making referrals and conducting follow-up .5 1.4 .6 1.4

Explaining benefits and procedures to participants 2.0 5.2 2.1 5.2

Issuing vouchers 3.5 9.2 3.7 9.2

Providing or receiving training or other professional development <.1 .1 <.1 .1

Making record notations 7.2 18.9 7.6 18.9

Total—all participant services activities 37.9 100.0 40.5 100.0

Nutrition education activities 

Providing one-on-one nutrition education or counseling 2.4 26.5 2.6 26.5

Providing group nutrition education 0 0 0 0

Developing materials and activities 1.7 18.7 1.8 18.7

Consulting with medical providers regarding nutrition education 

of individual participants 

.3 3.4 .3 3.4

Providing or receiving training or other professional development 4.6 51.4 5.0 51.4

Monitoring and evaluating nutrition education activities 0 0 0 0

Total—all nutrition education activities 9.0 100.0 9.7 100.0

Breastfeeding promotion and support

Providing one-on-one breastfeeding instruction/counseling .7 12.0 .7 12.0

Providing group breastfeeding instruction/counseling 0 0 0 0

Developing materials and activities .1 1.0 .1 1.0

Consulting with medical providers regarding breastfeeding 

issues

0000

Providing or receiving training or other professional development 4.7 87.0 5.0 87.0

Monitoring and evaluating breastfeeding promotion activities 0 0 0 0

Total—all breastfeeding promotion and support activities 5.4 100.0 5.8 100.0

Administration

Outreach to potential participants .5 .9 .5 1.1

Outreach to health care providers and other organizations <.1 .1 <.1 .1

Clerical tasks 21.2 44.5 15.2 34.4

Travel 5.5 11.5 5.9 13.3
Appendix V

Time Study Results - Percent of Staff time 

and Staff Time Costs Spent on Activities

Page 104 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

Note: Totals may not add due to rounding. 

Table 32: Percent of Staff Time and Staff Time Costs—Long Beach

Personnel tasks 2.0 4.1 2.0 4.6

Accounting and finance .5 1.1 .3 .8

Vendor management .1 .2 .1 .2

General management 10.7 22.4 12.3 28.0

Organize self/work 4.2 8.8 4.5 10.1

Miscellaneous 3.1 6.5 3.3 7.5

Total—all administrative activities 47.7 100.0 44.1 100.0

Grand total 100.0 100.0

(Continued From Previous Page)

Percent of 

Category/subcategory

Staff

time

Staff time in

category

Staff time

costs

Staff time

costs in

category

Percent of 

Category/subcategory Staff time

Staff time in

category

Staff time

costs

Staff time

costs in

category

Participant services activities

Scheduling participants 19.1 39.1 14.6 35.3

Determining participants’ eligibility 4.3 8.9 4.1 9.9

Assessing participants’ nutritional risk 9.6 19.6 9.5 22.9

Making referrals and conducting follow-up 1.1 2.2 0.9 2.2

Explaining benefits and procedures to participants 1.5 3.1 1.4 3.5

Issuing vouchers 8.6 17.7 6.5 15.6

Providing or receiving training or other professional development .5 1.1 .2 .5

Making record notations 4.1 8.3 4.2 10.1

Total—all participant services activities 48.8 100.0 41.4 100.0

Nutrition education activities 

Providing one-on-one nutrition education or counseling 12.2 63.7 12.2 56.8

Providing group nutrition education 2.6 13.3 2.2 10.4

Developing materials and activities 2.1 10.7 3.3 15.6

Consulting with medical providers regarding nutrition education 

of individual participants 

.1 .2 .1 .3

Providing or receiving training or other professional development 1.0 5.4 1.6 7.6
Appendix V

Time Study Results - Percent of Staff time 

and Staff Time Costs Spent on Activities

Page 105 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

Note: Totals may not add due to rounding.

Monitoring and evaluating nutrition education activities 1.3 6.7 2.0 9.4

Total—all nutrition education activities 19.2 100.0 21.4 100.0

Breastfeeding promotion and support activities

Providing one-on-one breastfeeding instruction/counseling 2.6 77.4 2.4 66.7

Providing group breastfeeding instruction/counseling .1 3.8 .1 3.2

Developing materials and activities .5 14.8 .8 22.1

Consulting with medical providers regarding breastfeeding 

issues

0000

Providing or receiving training or other professional development .1 2.6 .2 4.9

Monitoring and evaluating breastfeeding promotion activities <.1 1.5 .1 3.1

Total—all breastfeeding promotion and support activities 3.4 100.0 3.6 100.0

Administration

Outreach to potential participants .8 2.7 .6 1.9

Outreach to health care providers and other organizations .9 3.3 1.3 3.9

Clerical tasks 9.1 32.8 8.5 25.4

Travel 1.6 5.6 1.7 5.2

Personnel tasks .8 2.7 1.1 3.3

Accounting and finance 1.6 5.6 2.3 6.8

Vendor management .1 .1 <.1 .1

General management 8.4 29.2 11.8 35.2

Organize self/work 3.7 13.0 4.1 12.1

Miscellaneous 1.7 6.0 2.0 6.0

Total—all administrative activities 28.7 100.0 33.5 100.0

Grand total 100.0 100.0

(Continued From Previous Page)

Percent of 

Category/subcategory Staff time

Staff time in

category

Staff time

costs

Staff time

costs in

category
Appendix V

Time Study Results - Percent of Staff time 

and Staff Time Costs Spent on Activities

Page 106 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

Table 33: Percent of Staff Time and Staff Time Costs—York 

Percent of

Category/subcategories Staff time

Staff time in

category

Staff time

costs

Staff time

costs in

category

Participant services activities

Participant services activities

Scheduling participants 8.7 22.3 7.2 17.4

Determining participants’ eligibility 5.1 13.2 6.3 15.2

Assessing participants’ nutritional risk 5.5 14.1 6.9 16.6

Making referrals and conducting follow-up .4 1.0 .3 .7

Explaining benefits and procedures to participants 1.0 2.5 1.2 2.8

Issuing vouchers 7.5 19.2 7.1 17.3

Providing or receiving training or other professional 

development

3.4 8.6 4.3 10.5

Making record notations 7.5 19.2 8.1 19.5

Total—all participant services activities 39.0 100.0 41.3 100.0

Nutrition education activities 

Providing one-on-one nutrition education or counseling 2.6 54.5 2.6 49.2

Providing group nutrition education 0 0 0 0

Developing materials and activities .6 13.0 .9 16.3

Consulting with medical providers regarding nutrition education 

of individual participants 

.5 11.1 .7 13.5

Providing or receiving training or other professional 

development 

1.0 21.4 1.1 21.0

Monitoring and evaluating nutrition education activities 0 0 0 0

Total—all nutrition education activities 4.8 100.0 5.3 100.0

Breastfeeding promotion and support activities

Providing one-on-one breastfeeding instruction/counseling .4 51.9 .5 47.0

Providing group breastfeeding instruction/counseling 0 0 0 0

Developing materials and activities .2 19.2 .2 23.0

Consulting with medical providers regarding breastfeeding 

issues

<.1 3.8 <.1 3.9

Providing or receiving training or other professional 

development 

.2 25.1 .3 26.2

Monitoring and evaluating breastfeeding promotion activities 0 0 0 0

Total—all breastfeeding promotion and support activities .8 100.0 1.0 100.0

Administration

Outreach to potential participants .2 .3 .3 .6
Appendix V

Time Study Results - Percent of Staff time 

and Staff Time Costs Spent on Activities

Page 107 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

Note: Totals may not add due to rounding. 

Table 34: Percent of Staff Time and Staff Time Costs −Zuni 

Outreach to health care providers and other organizations .8 1.5 1.0 1.9

Clerical tasks 38.4 69.2 31.6 60.2

Travel 3.1 5.6 3.4 6.6

Personnel tasks .4 .7 .6 1.2

Accounting and finance .1 .2 .2 .4

Vendor management 2.5 4.5 3.2 6.1

General management 5.3 9.5 7.8 14.8

Organize self/work .5 1.0 .7 1.3

Miscellaneous 4.3 7.7 3.6 6.9

Total—all administrative activities 55.5 100.0 52.4 100.0

Grand total 100.0 100.0

(Continued From Previous Page)

Percent of

Category/subcategories Staff time

Staff time in

category

Staff time

costs

Staff time

costs in

category

Percent of :

Category/subcategories Staff time

Staff time in

category

Staff time

costs

Staff time

costs in

category

Participant services activities

Scheduling participants 3.4 14.4 2.8 12.5

Determining participants’ eligibility 2.7 11.4 2.3 10.3

Assessing participants’ nutritional risk 2.3 9.6 3.1 13.7

Making referrals and conducting follow-up .3 1.4 .4 1.7

Explaining benefits and procedures to participants .1 .5 .1 .5

Issuing vouchers 5.2 21.9 4.1 18.6

Providing or receiving training or other professional 

development

2.4 10.2 3.8 16.9

Making record notations 7.2 30.6 5.7 25.8

Total—all participant services activities 23.6 100.0 22.3 100.0

Nutrition education activities 

Providing one-on-one nutrition education or counseling 2.8 21.7 4.3 25.9

Providing group nutrition education 4.6 35.9 5.2 31.5

Developing materials and activities 3.5 27.3 3.5 21.4
Appendix V

Time Study Results - Percent of Staff time 

and Staff Time Costs Spent on Activities

Page 108 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

Note: Totals may not add due to rounding

Consulting with medical providers regarding nutrition education 

of individual participants 

.6 4.5 .9 5.7

Providing or receiving training or other professional 

development 

1.4 10.5 2.5 15.2

Monitoring and evaluating nutrition education activities <.1 .2 <.1 .3

Total—all nutrition education activities 12.9 100.0 16.4 100.0

Breastfeeding promotion and support activities

Providing one-on-one breastfeeding instruction/counseling 4.4 58.0 2.8 54.7

Providing group breastfeeding instruction/counseling .1 1.7 .2 3.1

Developing promotion materials and activities 1.0 13.5 .8 15.0

Consulting with medical providers regarding breastfeeding 

issues

.3 4.2 .2 4.1

Providing or receiving training or other professional 

development 

.8 11.0 .8 15.3

Monitoring and evaluating breastfeeding promotion activities .9 11.6 .4 7.9

Total—all breastfeeding promotion and support activities 7.6 100.0 5.2 100.0

Administration

Outreach to potential participants 1.0 1.7 1.1 1.9

Outreach to health care providers and other organizations 1.9 3.5 2.3 4.0

Clerical tasks 23.7 42.5 17.7 31.6

Travel 5.0 9.0 5.4 9.5

Personnel tasks 2.9 5.2 3.7 6.5

Accounting and finance 2.5 4.4 2.7 4.7

Vendor management 10.2 18.2 11.5 20.5

General management 5.4 9.7 8.0 14.2

Organize self/work 1.4 2.6 1.6 2.9

Miscellaneous 1.8 3.2 2.3 4.1

Total—all administrative activities 55.8 100.0 56.2 100.0

Grand total 100.0 100.0

(Continued From Previous Page)

Percent of :

Category/subcategories Staff time

Staff time in

category

Staff time

costs

Staff time

costs in

category
Page 109 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

Appendix VI

Time Study Results: Approximate Minutes per 

Case-Month Spent on Nutrition Services and 

Administration Activities ApendxiVI

This appendix presents information on the results of the time studies 

conducted at each of the six agencies. For participant services, nutrition 

education, breastfeeding promotion, and administration, the approximate 

number of minutes per case-month spent on specific activity categories are 

presented for each of the six agencies. Information on how we calculated 

the approximate number of minutes per case-month that was available to 

carry out all nutrition services and administrative activities is presented in 

appendix 1.

Table 35: Approximate Minutes per Case-Month Spent on Participant Services 

Activities at the Six Case Study Agencies 

Note: Totals may not add due to rounding.

a

A description of each participant service activity category is provided in appendix 1.

Approximate minutes per case-month:

Participant service 

activity categorya Gallatin Grady Kanabec

Long

Beach York Zuni

Scheduling participants 4.2 1.1 1.1 3.4 2.8 2.4

Determining participants’ 

eligibility

2.7 1.2 1.0 .8 1.6 1.9

Assessing participants’ 

nutritional risk 

4.1 2.7 3.1 1.7 1.8 1.7

Making referrals and 

conducting follow-up

.3 .7 .1 .2 .1 .2

Explaining benefits and 

procedures to participants 

.4 .1 .4 .3 .3 .1

Issuing vouchers 1.6 2.4 .7 1.5 2.4 3.7

Providing or receiving 

training or other 

professional development

1.5 .3 <.1 .1 1.1 1.7

Making record notations 1.6 2.3 1.5 .7 2.4 5.2

Total—all participant 

services activities 16.4 10.8 8.0 8.8 12.5 17.0
Appendix VI

Time Study Results: Approximate Minutes 

per Case-Month Spent on Nutrition Services 

and Administration Activities

Page 110 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

Table 36: Approximate Minutes per Case-Month Spent on Nutrition Education 

Activities at the Six Case Study Agencies

Note: Totals may not add due to rounding.

a

A description of each nutrition education activity category is provided in appendix 1.

Approximate minutes per case-month:

Nutrition education 

activity categorya Gallatin Grady Kanabec

Long

Beach York Zuni

Providing one-on-one 

nutrition education or 

counseling 

2.9 1.1 .5 2.2 .8 2.0

Providing group nutrition 

education

.2 <.1 0 .5 0 3.3

Developing education 

materials and activities 

.3 .2 .4 .4 .2 2.5

Consulting with medical 

providers regarding 

nutrition education of 

individual participants 

.1 .1 .1 <.1 .2 .4

Providing or receiving 

training or other 

professional development 

.2 .6 1.0 .2 .3 1.0

Monitoring and evaluating 

nutrition education 

activities

.5 .2 0 .2 0 <.1

Total—all nutrition 

education activities

4.2 2.2 1.9 3.5 1.5 9.3
Appendix VI

Time Study Results: Approximate Minutes 

per Case-Month Spent on Nutrition Services 

and Administration Activities

Page 111 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

Table 37: Approximate Minutes per Case-Month Spent on Specific Breastfeeding 

Promotion and Support Activities at the Six Case Study Agencies 

Note: Totals may not add due to rounding.

a

A description of each breastfeeding promotion and support activity category is provided in appendix 1.

Approximate minutes per case-month:

Breastfeeding promotion 

and support activity 

categorya Gallatin Grady Kanabec

Long

Beach York Zuni

Providing one-on-one 

breastfeeding 

Instruction/counseling

1.4 .8 .1 .5 .1 3.2

Providing group 

breastfeeding 

instruction/counseling

<.1 .1 0 <.1 0 .1

Developing breastfeeding 

promotion materials and 

activities 

<.1 .2 <.1 .1 .1 .7

Consulting with medical 

providers regarding 

breastfeeding issues

<.1 .2 0 0 <.1 .2

Providing or receiving 

training or other 

professional development 

<.1 .4 1.0 <.1 .1 .6

Monitoring and evaluating 

breastfeeding promotion 

activities

<.1 .1 0 <.1 0 .6

Total—all breastfeeding 

promotion and support 

activities 1.6 1.7 1.1 .6 .3 5.5
Appendix VI

Time Study Results: Approximate Minutes 

per Case-Month Spent on Nutrition Services 

and Administration Activities

Page 112 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

Table 38: Approximate Minutes per Case-Month on Specific Program Administration 

Activities at the Six Case Study Agencies

Note: Totals may not add due to rounding.

a

A description of each program administration activity category is provided in appendix 1.

Approximate minutes per case-month:

Administration activity 

categorya Gallatin Grady Kanabec

Long

Beach York Zuni

Outreach to potential 

participants

.2 .1 .1 .1 .1 .7

Outreach to health care 

providers and other 

organizations

.7 <.1 <.1 .2 .3 1.4

Clerical tasks 3.6 7.1 4.4 1.6 12.3 17.1

Travel 1.5 .9 1.2 .3 1.0 3.6

Personnel tasks .2 .2 .4 .1 .1 2.1

Accounting and finance .6 <.1 .1 .3 <.1 1.8

Vendor management <.1 0 <.1 <.1 .8 7.3

General management 1.3 1.2 2.2 1.5 1.7 3.9

Organize self/work <.1 .3 .9 .7 .2 1.0

Miscellaneous .6 .5 .7 .3 1.4 1.3

Total—all administrative 

activities 8.9 10.3 10.0 5.2 17.8 40.2
Page 113 GAO/RCED-00-202 Activities and Use of Nonprogram Resources

Appendix VII

GAO Contacts and Staff Acknowledgments ApendxiVI

GAO Contacts Robert E. Robertson (202) 512-5138

Thomas E. Slomba (202) 512-9910

Staff 

Acknowledgments

In addition to those named above, Kathy R. Alexander, Patricia Farrell 

Donahue, Judy K. Hoovler, Tina Kinney, Lynn Musser, and Carol Herrnstadt 

Shulman made key contributions to this report. 

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