Economic 

Research 

Service

Electronic Publications from the Food Assistance & Nutrition Research Program

Innovative WIC Practices

Profiles of 20 Programs

By Anne Gordon, Heather Hartline-Grafton, and Renée Nogales,

Mathematica Policy Research, Inc.

ERS project representative: Victor Oliveira, 202-694-5434, 

victoro@ers.usda.gov

Abstract

WIC provides supplemental food, nutrition education, and social service referrals to lowincome pregnant, breastfeeding, and postpartum women, infants, and children younger than

age 5. WIC has come under increased scrutiny as it has expanded rapidly, and some have

suggested new directions for the program. This study examines a range of innovative practices at 20 State or local WIC agencies. The study focuses on practices in three main areas:

breastfeeding promotion and support (including peer counseling and programs for high-risk

groups), nutrition and health education (including obesity prevention, preventive health care,

and staff training), and service delivery (such as home and workplace visits). For each innovative program, the report provides background information and discusses the source of the

innovation, key challenges, implementation lessons learned, evidence of its success, and the

feasibility of replicating the practice.

E-FAN-04-007

June 2004

This report was prepared by Mathematica Policy Research, Inc., under a

cooperative assistance agreement with the Economic Research Service.

The views expressed are those of the authors and not necessarily those

of ERS or USDA.
ii

ACKNOWLEDGMENTS 

This project succeeded because of the cooperation of many people in the WIC community. 

We would like to thank the state directors and regional office staff who nominated programs for 

the study. We also received valuable feedback in selecting programs from Geri Henchy of 

FRAC, Laurie True of the California WIC Association, and Stephan Harvey. Our warm thanks 

go to the staff of the programs profiled in this report, who sat through long telephone interviews; 

their names are listed at the end of each profile. Traci Lundy, Jewell Stremler, Laurie Haessly, 

Gail Mask, Sherry Goode, and Terri Riemenschneider were particularly helpful in arranging and 

facilitating our visits at the five programs we visited in person. We are grateful to the many 

program staff who took time from their busy schedules for in-person interviews and to let us 

observe their programs. Our interview and site visit respondents also reviewed drafts of the 

write-ups on their programs and provided very helpful comments. 

We are grateful to the USDA Economic Research Service for funding this study and 

appreciate feedback during program selection and comments on the report from Vic Oliveira, 

Betsy Frazao, Mark Prell, and David Smallwood. Jay Hirschman, Pat Daniels, Ed Herzog, and 

Lisa Christie from the USDA Food and Nutrition Service also provided useful feedback. 

At Mathematica Policy Research, Inc. (MPR), we particularly want to acknowledge the 

contributions of Tania Tasse and Teresa Zavitsky, research analysts who worked with Anne 

Gordon on gathering program nominations and selecting programs for the study. Ms. Tasse also 

completed a number of telephone interviews. They left MPR before the completion of the 

project; we hope the final report does justice to the groundwork they laid. We also wish to thank 

Barbara Devaney, who helped develop the idea for the project and advised on program selection, 

and Robert Whitaker, who reviewed the final report and helped shape the conclusions. Bill 

Garrett expertly produced the report, which was edited by Walt Brower and Patricia Ciaccio. 
iii 

CONTENTS 

Chapter Page 

 EXECUTIVE SUMMARY.......................................................................................... vii 

 I INTRODUCTION ..........................................................................................................1 

A. GOALS OF STUDY................................................................................................3 

B. RESEARCH METHODS ........................................................................................4 

C. PREVIEW OF MAJOR THEMES ..........................................................................5 

 II BREAST-FEEDING SUPPORT PROGRAMS .............................................................9 

A. PEER COUNSELING ...........................................................................................10 

 Breast-feeding Peer Counseling Program, Texas ..........................................11 

 Expanded Breast-feeding Peer Counselor Program, Alameda/Contra 

Costa Counties, California .............................................................................25 

 Telephone Peer Counseling by Volunteers, Southwest Pennsylvania...........33 

B. MULTIFACETED PROGRAMS WITH STRONG OUTREACH 

COMPONENTS ....................................................................................................41 

 Loving Support Breast-feeding Program, Riverside County, California.......43 

 Lactation Consultant Services, Sacramento County, California....................57 

 Breast-feeding Promotion and Support Program, Miami-Dade County, 

Florida ............................................................................................................69 

C. PROGRAMS FOR HIGH-RISK GROUPS...........................................................79 

 Breast Pumps for Mothers of Premature or Seriously Ill Infants, 

Arkansas.........................................................................................................81 

 Pumps in the Schools (PITS), Hawaii............................................................89 

 Infant Feeding Classes for Teens, Lucas County, Ohio.................................95 
CONTENTS (continued) 

Chapter Page

iv

III ENHANCING NUTRITION EDUCATION..............................................................103 

A. OBESITY PREVENTION INTERVENTIONS..................................................104 

 Get Fit With WIC, Oklahoma......................................................................105 

 Obesity Prevention Modules, Pennsylvania ................................................121 

 Mooove to Lowfat or Fat Free Milk Campaign, Florida .............................129 

B. PREVENTIVE HEALTH INTERVENTIONS ...................................................139 

 WIC Nutrition Education Model for the Prevention of Early Childhood 

Caries, Alabama...........................................................................................141 

 Cease Alcohol Related Exposure (CARE), Los Angeles and Orange 

Counties, California .....................................................................................153 

C. STAFF TRAINING: IMPROVING METHODS, NUTRITION 

KNOWLEDGE, AND CULTURAL SENSITIVITY..........................................161 

 The Learn Together Approach, Michigan....................................................163 

 WIC RD: Adjunct to Pediatric Health Care, California .............................171 

 Bilingual Training Program, Wisconsin ......................................................177 

 IV INNOVATIONS IN SERVICE DELIVERY .............................................................183 

 Coordination of WIC with Maternal and Infant Support Services, 

Northwest Lower Michigan .........................................................................185 

 Steps Ahead/WIC Coordination, Cullman County, Alabama......................197 

 WIC Services in Workplaces, Eastern Band of Cherokee Indians, 

North Carolina .............................................................................................205 

 V CONCLUSIONS.........................................................................................................211

A. SOURCES OF INNOVATION ...........................................................................211 

B. IMPLEMENTATION LESSONS .......................................................................213 

1. Lessons from Breast-Feeding Programs ......................................................213 

2. Lessons from Nutrition Education Programs...............................................215 

3. Lessons from Service Delivery Programs....................................................217 

C. FUNDING SOURCES.........................................................................................218 
CONTENTS (continued) 

Chapter Page

v

D. OPTIONS FOR EVALUATION.........................................................................221 

1. Current Evidence Concerning Outcomes.....................................................222 

2. Data Needs ...................................................................................................225 

3. Design Issues ...............................................................................................226 

E. REPLICATING AND ADAPTING WIC INITIATIVES: ISSUES AND 

CHALLENGES ...................................................................................................227 

1. Program Cost ...............................................................................................228 

2. Appropriate Setting......................................................................................228 

3. Ease of Adoption..........................................................................................229 

4. Challenges for the Future.............................................................................229 

REFERENCES............................................................................................................231 

APPENDIX A: PROCEDURES FOR SELECTING PROGRAMS AND 

COLLECTING DATA .....................................................................A.1 

APPENDIX B: PROTOCOLS...................................................................................B.1 
CONTENTS (continued) 

Chapter Page

vi

TABLES 

Table Page 

 I.1 RESEARCH QUESTIONS AND TOPICS ............................................................ 4 

 I.2 SELECTED PROGRAMS AT A GLANCE .......................................................... 6 

 II.1 BREAST-FEEDING SUPPORT SERVICES AVAILABLE IN MIAMI, 

RIVERSIDE, AND SACRAMENTO................................................................... 41 

 V.1 FUNDING SOURCES FOR WIC INITIATIVES.............................................. 220 

 V.2 EVALUATION APPROACHES USED ............................................................ 223 
vii

EXECUTIVE SUMMARY 

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) 

serves low-income pregnant, breast-feeding, and postpartum women; infants; and children 

younger than age 5. Its objective is to provide supplemental, nutritious food as an adjunct to 

good health care during critical periods of growth and development, prevent health problems, 

and improve the health status of participants. The WIC program has three components: (1) the 

food package, (2) nutrition education, and (3) health and social service referrals. 

In recent years, WIC has come under scrutiny as the program expanded rapidly. WIC is up 

for reauthorization by Congress in 2004, so it is an appropriate time to consider new directions 

for the program. Mathematica Policy Research, Inc. (MPR) proposed to the Economic Research 

Service (ERS) of the U.S. Department of Agriculture (USDA) this exploratory study, to 

document and disseminate information on the design and operation of a range of WIC 

innovations. 

The primary objective of this study was to learn about the innovations currently in place in 

state and local WIC agencies. The plan was to identify innovative practices at 20 state or local 

WIC agencies, conduct telephone interviews with staff from each program, and study 5 of these 

promising programs in more depth through site visits. The study focused on WIC practices in 

three areas: 

1. Promoting breast-feeding (including peer counseling, outreach to health care 

providers, and breast pump programs) 

2. Improving nutrition and health education (including programs to prevent or reduce 

overweight and obesity; to provide, or coordinate with, preventive health care in 

areas such as dental health; and to provide in-depth staff training)

3. Using innovative service delivery approaches, such as home visits 

Many of the programs we studied are innovative in more than one of these areas. 

Another goal was to include at least some programs that serve high-risk groups, such as 

teenagers, premature infants, immigrants, and those with alcohol or drug abuse problems. 

The following research questions guided our work:

• What innovative WIC programs and services currently exist? 

• Under what circumstances are promising WIC programs being implemented? 

• Are the programs replicable in other service areas? Is there evidence to support their 

effectiveness? 
viii

CRITERIA FOR SELECTING PROGRAMS 

This study was exploratory. The programs selected were not intended to indicate the “best” 

programs nationally, as our time to find programs and our resources were limited. Instead, we 

sought to identify promising initiatives that may be worthy of future evaluation and replication. 

For this study, we defined “innovative” as programs that are different from services that 

WIC has traditionally offered, based on the judgments of program officials. The programs 

include those that the WIC Nutrition Services Standards (U.S. Department of Agriculture 2001) 

would consider “best practices”—for example, peer counseling for breast-feeding; programs that 

received outside funding to go beyond typical WIC nutrition services (sometimes referred to as 

“WIC Plus”); and innovations that significantly change how core WIC services are delivered 

(such as training in facilitated group discussion). Most programs had operated for at least one 

year. In addition, we sought to include programs that have clear goals and adequate resources to 

achieve them and that have largely implemented the intended services. 

An important caution is that designating these programs as “innovative” does not imply that 

they have been evaluated and found to be effective in improving health outcomes for targeted 

groups. 

DATA COLLECTION 

To select programs to profile, we contacted the Food and Nutrition Service (FNS) regional 

offices, state and tribal WIC directors, and other experts to gather suggestions on promising 

programs. Based on their feedback and consultation with USDA staff, we selected 20 programs 

to contact by telephone to gather detailed information on their scope, services, and replicability 

in other settings. 

After completing the telephone interviews, we selected five of the programs for site visits. 

These visits included interviews with program staff and observations of program activities. 

Programs selected for site visits represented the topic areas described above. In each case, the 

program was sufficiently complex that a site visit enabled us to understand it much better. Three 

of the visited programs were statewide programs, for which we visited several locations and 

interviewed both state and local staff. 

WHAT TYPES OF INNOVATIVE PROGRAMS EXIST? 

Table 1 provides an overview of the selected programs. They fall into three main areas: 

(1) breast-feeding promotion and support; (2) nutrition and health education programs (including 

programs related to preventive health care, obesity prevention, and staff training); and (3) service 

delivery innovations. 
ix

TABLE 1 

SELECTED PROGRAMS AT A GLANCE 

Program Scope 

Topic Area and Program Name State 

StateLevel LocalLevel Selected for 

Site Visit 

Breast-Feeding Promotion 

Peer Counseling 

Breast-Feeding Peer Counselor Program TX 9 9 9

Expanded Breast-Feeding Peer Counselor Program—

Berkeley Area CA 9

Telephone Peer Counseling by Volunteers PA 9

Multifaceted Programs 

Loving Support Breast-Feeding Helpline— 

Riverside County CA 9 9

Lactation Consultant Services—Sacramento County CA 9

Breast-Feeding Promotion and Support Program— 

Miami-Dade County FL 9

Programs for High-Risk Groups

Breast Pumps for Mothers of Premature or 

Seriously Ill Infants AR 9

Pumps in the Schools (PITS) HI 9

Infant Feeding Classes for Pregnant Teens OH 9

Nutrition and Health Education 

Obesity Prevention 

Get Fit With WIC OK 9 9

Obesity Prevention Modules PA 9

Mooove to Lowfat or Fat Free Milk Campaign FL 9

Preventive Health Care 

WIC Nutrition Education Model for Prevention of 

Early Childhood Caries AL 9 9

Cease Alcohol Related Exposure (CARE)— 

Los Angeles area CA 9

Staff Training 

The Learn Together Approach MI 9

WIC RD: Adjunct to Pediatric Health Care CA 9

Bilingual Training Program WI 9

Service Delivery 

Coordination of WIC with Maternal and Infant Support 

Services—northwest lower Michigan MI 9a 9

Steps Ahead/WIC Coordination—Cullman County AL 9

WIC Services in the Workplace—Eastern Band of 

Cherokee Indians NC 9

a

The program is in several counties, so telephone respondent was a state WIC staff member with responsibility for 

the area.
x

Breast-Feeding Programs 

The breast-feeding support programs described in this report go beyond the required 

services, which include staff training, offering clients prenatal breast-feeding education (through 

classes and/or one-on-one contacts, and written materials and/or videos), informing clients about 

the food packages for breast-feeding mothers, and providing, or referring to, support services 

after the birth. The innovative breast-feeding programs fall into three groups: 

1. Peer Counseling. Peer counselors usually are current or former WIC clients who 

breast-fed their babies for a substantial period. Peer counselors may be volunteer or 

paid, part-time or full-time, and they may have different levels of training. The 

breast-feeding coordinator (who is a certified lactation consultant) usually trains and 

supervises the peer counselors and provides back-up support for unusual or high-risk 

situations. 

2. Multifaceted Programs. These programs include readily available individualized 

help, either by telephone or in person, complemented by extensive outreach to 

community health professionals to “sell” the idea that WIC supports breast-feeding 

and is not just a source for infant formula. Types of outreach include training for 

hospital delivery and neonatal intensive care staff, extensive visiting with local 

health care providers, “lunch and learn” presentations for health care professionals 

on why breast-feeding is best, and networking with a wide range of community 

groups. 

3. Programs for High-Risk Groups. Programs profiled target (1) mothers of premature 

or seriously ill infants, or (2) teenage mothers. Two programs facilitate use of breast 

pumps for high-risk groups, while one is a prenatal breast-feeding class that targets 

teenage expectant mothers. 

Nutrition and Health Education Programs 

WIC has always provided nutrition education and counseling to clients, often through oneon-one counseling and lecture-style classes. In recent years, many WIC programs across the 

country have reinvigorated and updated their approaches to nutrition and health education. 

Programs we examined fall into three groups—obesity prevention, preventive health care, and 

staff training—yet are all examples of strategies to strengthen and broaden the nutrition 

education and counseling provided through WIC. 

In looking at programs that offer innovative nutrition and health education, we found some 

common themes: 

• New Methods for Working with Clients. Staff members are learning to use 

approaches such as facilitated group discussions and motivational interviewing to 

help clients change their behavior. 

• Updated Education Content. Programs are working to include nutrition messages 

related to today’s main nutrition-related health concerns in a positive framework of 

healthy eating and lifestyle choices. Relevant programs include those related to 
xi

obesity prevention and healthy lifestyles for young children (including physical 

activity), preventive dental care, and screening for alcohol problems for prenatal 

participants. 

• Broader Target Audience. WIC nutrition education has traditionally focused on 

mothers, but initiatives increasingly target young children and the family as a whole. 

For example, several programs include activities for children, such as puppet shows 

and reading of children’s books related to the theme of the initiative. 

• More Staff Training. Many of the programs involve special training—some focused 

on methods, some on content, and some on new groups of staff. The study focused 

on a training program in each of these areas: the Michigan training in facilitated 

group discussion, California’s approach to training dietitians concerning infant 

formulas, and Wisconsin’s program to train bilingual staff. 

Service Delivery 

The study included three programs that are innovative because they include delivery of WIC 

services in one of two nontraditional settings: (1) clients’ homes, or (2) clients’ workplaces. 

Because of its high cost, home visiting usually implies not just services in a different location, 

but comprehensive, individualized services that target particularly high-risk clients. In both 

examples of home visiting programs in this report, WIC was collaborating with Medicaid care 

coordination for high-risk pregnant women and infants. The home visits were funded largely 

under Medicaid, although they also included some WIC services. 

Workplace visits to provide WIC services are even more rare than home visits. However, 

because more WIC mothers have entered the workforce under welfare reform, such programs 

may become more relevant. The program described here is on a rural Indian reservation with 

few employers and significant transportation barriers for clients. 

WHAT CIRCUMSTANCES SUPPORT IMPLEMENTATION OF INNOVATIVE 

PROGRAMS? 

Sources of Innovation 

Where do ideas for innovative programs come from? Most of the programs we studied were 

conceived and developed by the state or local WIC staff who administer them, although other 

stakeholders often made important contributions to program planning. In many of the state 

initiatives, state staff obtained ideas and feedback on plans from the local level: this happened 

through formal nutrition education committees consisting of local and state staff, through 

feedback provided to regional representatives in states with a regional structure, through pilot 

projects, or informally. 

In local initiatives, agency leaders innovated in varied circumstances, but two seemed most 

common: (1) to take advantage of outside funding sources to expand services, or (2) to stretch 

scarce resources further. For example, the availability of funding from the Proposition 10 
xii

tobacco tax in California, which is for programs for young children, helped inspire several of the 

California programs. In contrast, a volunteer peer counseling program in southwest 

Pennsylvania was a creative response to tight funding. 

Programs with outside funding were sometimes developed, at least in part, outside of WIC, 

or reshaped to meet the funders’ needs. For example, the Alabama dental education program 

was developed with considerable leadership from the Dental Division of the Department of 

Health, which also helped fund the program. 

Key Implementation Lessons 

Breast-Feeding Peer Counseling. USDA has targeted funds for expansion of peer 

counseling programs. As peer counseling programs expand, it will be important to define what 

exactly can be considered a peer counseling program, as great variety currently exists in the 

hours, compensation, training, and duties of peer counselors. The basic qualifications for peer 

counselors—enthusiastic current or former WIC participants with breast-feeding experience—

seem well established, but there may also be variation in additional requirements for the job. 

Peer counselors need sufficient literacy skills so that they can maintain WIC clients’ records. It 

is also important to develop a recruitment and retention strategy, clear protocols for service 

delivery and documentation, and good relations between the WIC staff and peer counselors. 

Recruiting of peer counselors has become more challenging as low-income mothers have 

increasingly taken full-time jobs. However, many peer counselors, even those who worked as 

volunteers, found they gained valuable skills in this position that allowed them to move on to 

full-time or better-paying jobs. 

Other Implementation Lessons for Breast-Feeding Programs. Most of the promising 

breast-feeding programs we studied (whether they use peer counselors or not) emphasize three 

services, above and beyond the prenatal classes and counseling that most clinics provide: 

1. Contacting the mother in-person or by telephone within the first two weeks after 

birth (often, while in the hospital). 

2. Making help available within 24 hours when a problem arises. Ideally, help is 

available by telephone 24 hours a day and in person during office hours for more 

severe problems. 

3. Providing follow-up calls to breast-feeding mothers at regular intervals after the 

birth, rather than waiting for them to call in—many mothers are too overwhelmed to 

call themselves. 

In addition to services in these three areas, outreach to community health providers is a 

desirable part of a WIC breast-feeding program, so that women receive a pro-breast-feeding 

message wherever they receive services. However, such outreach is hard to do with current WIC 

Nutrition Services and Administration (NSA) funding, even in large agencies—those programs 

most successful in doing outreach have non-WIC funding. 
xiii

Nutrition Education Approaches. Programs that seemed particularly promising were 

those that made nutrition education fun for staff and clients and those that had messages that 

were simple (such as “choose lowfat or fat free milk”) and pervasive (visible in a range of media, 

endorsed enthusiastically by staff at all levels, and reinforced through hands-on activities), yet 

conveyed in ways that recognized client experiences.

Staff Training. Direct staff training in content is useful, because the science is changing 

rapidly in many areas of nutrition, including obesity prevention, the understanding of the benefits 

of breast-feeding, and the content of new types or formulations of formula. Traditionally, 

professionals were expected to keep up with the literature more or less on their own, but many of 

the reviewed initiatives included content-focused staff training. 

To successfully introduce new training curricula or new client materials and curricula for a 

state initiative, state WIC agencies need to follow up at the local level to make sure the new 

approach, curricula, and materials are being used (and used appropriately) and to provide 

additional assistance to those who need it. Nutrition education committees made up of local staff 

can help, as they provide regular feedback to the state agency. Another way to monitor 

implementation is to adapt data systems to track how often staff use new types of nutrition 

education contacts with clients.

Service Delivery. Incorporating WIC services into Medicaid-funded home visits seems 

promising, particularly as part of a broader integration of WIC services and Medicaid-funded 

care coordination for high-risk pregnant women and infants. This collaboration may work best, 

however, when both programs are operated by the same agency and are co-located. 

Workplace delivery of WIC services may be most applicable in rural areas with few 

employers or other places where large concentrations of WIC participants work for a single 

employer. Privacy and logistics, such as having a private space to meet, can be challenges. 

However, WIC clinics have been established successfully in schools, which are the “workplaces” 

of teenage mothers—these programs may be useful models. 

Funding Sources 

The interventions and training programs described in this report have a variety of funding 

sources, but they fall into three major categories: 

1. WIC Plus—interventions with substantial outside funding (often including services 

that go beyond WIC). Such funding usually comes from local governments or 

private foundations. The programs that provide home visits in cooperation with 

Medicaid care coordination are also counted in this group, as the home visits are 

largely paid for by Medicaid funds. 

2. Interventions with special WIC funding from the state, regional office, or central 

USDA. For example, some of the programs received grants from USDA or from 

their state agency. 
xiv

3. Interventions with little or no special funding, which are generally more modest. In 

large state or local agencies, however, the scale of the WIC program overall may 

make it possible to implement more extensive WIC initiatives with only WIC NSA 

funds. 

It may be difficult for other WIC agencies to replicate programs with substantial outside or 

special WIC funding, if similar resources are not available. In some cases, however, the wellfunded initiatives have developed materials that other WIC agencies can adopt at much lower 

cost. In addition, other agencies may find specific elements of these initiatives’ services 

applicable to their needs, even if they cannot afford to implement all the services. 

PROGRAM EVALUATION AND REPLICATION 

To assess whether these interesting programs should be expanded further, it is appropriate to 

consider the quality of existing evidence for their effectiveness and what types of evaluation 

designs could be used to study program effects on nutrition and health outcomes. Before 

replicating these programs, other issues to consider include cost, feasibility, and adaptability of 

the program model to different situations. 

Evaluating Effectiveness 

Staff of many of these programs had tried to evaluate their effectiveness. Only one, 

however—the Cease Alcohol Related Exposure (CARE) program in Los Angeles—had a 

rigorous evaluation. Others cited more ad hoc before and after comparisons of outcomes such as 

breast-feeding rates and use of special infant formulas. Such comparisons are useful but do not 

generally control for other factors that might also have caused the change. The main reason is 

that WIC local agency staff often lack the resources and skills to evaluate their programs. In 

addition, their data systems usually are not set up to track outcomes, other than those they must 

report to the state and federal governments. 

Furthermore, designing evaluations to assess the effects of the initiatives described in this 

report could be challenging. Some interventions affect the entire agency or community, so that it 

is not possible to randomly assign some clients to current services and others to receive the new 

services. Other initiatives might lend themselves to evaluation more easily. 

Options for evaluation include: 

• Implementation Studies. It is important to judge a program not only by examining 

its goals and design, but also by monitoring staff use of new services or methods and 

the quality of implementation of the planners’ vision. In addition, implementation 

studies monitor how many clients actually receive the innovative services and what 

their reactions to these services are. 

• Experimental Impact Evaluations. Randomly assigning clients to two different 

types of services may be feasible in a large clinic, but it is burdensome for staff to run 
xv

two versions of WIC services. Another, less difficult, option for staff is to randomly 

assign clinics in a large agency to two different approaches. Doing this, however, is 

useful only for narrowly defined interventions (for example, the use of facilitated 

group discussion versus a lecture style for specific classes), when it is possible to 

ensure that clients otherwise receive the same services. For more comprehensive, 

community-based interventions, it is not possible to deny the new program to some 

clients. The only type of experimental evaluation that could happen in such contexts 

is random assignment of communities, which is very expensive and may not be 

feasible in terms of obtaining cooperation. 

• Nonexperimental Impact Evaluations. It may be more feasible to evaluate WIC 

initiatives using comparison groups or evaluations of outcomes before and after 

program implementation. The diversity of local WIC programs makes it more 

feasible to use existing variations in services to examine relative effectiveness of 

different approaches. By collecting data on the characteristics of the clients, clinics, 

or agencies being compared, comparison group evaluations can be strengthened. At 

the same time, even when carefully designed, these designs are weaker than an 

experimental design. Other factors than the initiative may still be influencing the 

outcome but may not be available as control variables. Nonetheless, such approaches 

are less expensive and may provide evidence of impacts, particularly if the 

differences in outcomes are large. 

Feasibility of Replication 

All the programs described in this report involve models for providing services that could be 

applied more widely. USDA or state agencies would need to consider the following issues (in 

addition to program effectiveness) before replicating any of these initiatives, either on a pilot 

basis or on a wider scale: 

• Cost. Is the program affordable, either with existing WIC resources or available 

outside funding? Does the program require an up-front investment with few costs 

afterward, or does it require long-term funding? Are the benefits of the program 

likely to be worth the costs? 

• Appropriate Setting. For what types of WIC agencies is the initiative appropriate? 

For example, is the program of most interest to urban or rural agencies? WIC is a 

highly decentralized program, and few initiatives will be appropriate in all types of 

WIC agencies and clinics. 

• Availability of Materials. Are materials for replicating the program readily 

available? Do they include materials for training staff? How much adaptation would 

state or local circumstances require? Initiatives based on written materials are easier 

to adopt, as are those that do not require extensive staff training. Many of the 

initiatives profiled have made their materials available on the Internet. 

In considering the feasibility of new initiatives, it is also important to take into account the 

following challenges for WIC in the next several years: 
xvi

• Cultural Diversity. The WIC population is becoming more diverse ethnically and 

linguistically. 

• Mothers Working. With welfare reform and the strong economy of the late 1990s, 

more WIC mothers were working. This trend may have slowed, but it is unlikely to 

reverse. One implication is that peer counseling programs that rely on volunteer or 

part-time help are less feasible now than they were 10 years ago. Another implication 

is that WIC needs to develop approaches to improve access for working parents, such 

as extended hours, more telephone contacts, or workplace WIC visits. 

• Changes in the Health Care System. Coordination between WIC and health care 

providers is often critical to the WIC initiatives profiled. However, experiences 

during the past few years suggest that such coordination becomes more difficult as 

Medicaid managed care providers serve more WIC clients. Furthermore, the privacy 

rules used to implement the Health Insurance Portability and Accountability Act 

(HIPAA), which took effect in April 2003, make coordination more difficult. 

• State and Federal Budget Crises. State and federal budget crises may lead to 

cutbacks in WIC funding and staff, which make implementation of new approaches 

more difficult.

SUMMARY 

This study shows that many innovative WIC practices exist in breast-feeding promotion, 

nutrition and health education, and service delivery. Breast-feeding practices highlighted include 

those of various peer counseling programs, as well as those of programs that combine outreach to 

health professionals with extensive client support. Innovations in nutrition education focus on 

moving from sharing information to fostering behavior change and on meeting the needs of the 

increasingly diverse WIC population. Service delivery innovations bring WIC services to clients 

at home or at work. Most innovative programs arise in response to local needs and 

circumstances; state innovations appear to be more successful if they obtain substantial local 

input. The extent of outside funding for innovative programs varies and is related to the richness 

of services provided. At the same time, many of the programs have invested extensively in 

developing materials that others could adopt at low cost. 

Few of these interventions have been rigorously evaluated. However, substantial natural 

variation in WIC services exists, and this variation could be used in more formal evaluation 

efforts. 
1

I. INTRODUCTION 

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) 

serves low-income pregnant, breast-feeding, and postpartum women; infants; and children 

younger than age 5. Its objective is to provide supplemental, nutritious food as an adjunct to 

good health care during critical periods of growth and development, to prevent health problems 

and improve the health status of participants. The WIC program has three components: (1) food 

packages tailored to the needs of each participant group, (2) nutrition education, and (3) health 

and social service referrals. The food packages include supplemental foods rich in protein, 

vitamins A and C, calcium, and iron. Nutrition education is offered to all women participants 

and parents of child participants to improve their knowledge of the relationship between diet, 

nutrition, and good health. Health and social service referrals help participants find needed 

services. 

Since its inception, the WIC program has grown dramatically. In fiscal year 1980, WIC 

served 1.9 million women and children, at a cost of $728 million. By fiscal year 2002, WIC was 

serving 7.5 million women and children, at a cost of $4.3 billion (U.S. Department of Agriculture 

2003a). From 1988 to 1998, WIC monthly enrollment levels more than doubled, and 

participation among children increased as a percentage of all WIC participants (Cole 2001). 

In recent years, WIC has come under scrutiny as the program expanded rapidly. WIC is up 

for reauthorization by Congress in 2004, so it is an appropriate time to consider new directions 

for the program. A substantial body of evidence exists on the effectiveness of WIC (Rush et al. 

1988; Devaney et al. 1992; Gordon and Nelson 1995; and Rose et al. 1998). However, a recent 

critique of this research questioned the extent to which the empirical evidence supports the WIC 

program expansion (Besharov and Germanis 2001). Besharov and Germanis also suggested 

program design and operational options, including the six listed here: 

1. Targeting benefits and services to fewer, needier families 

2. Adding a focus on overweight and obesity prevention 

3. Offering more intensive WIC services (such as home visits) and higher levels of 

benefits for selected groups 

4. Serving children older than age 4 

5. Using alternative service providers and co-locating WIC and other health care 

services 

6. Increasing directive counseling to bring about behavioral change 

The first recommendation (to the extent it calls for serving fewer families), the third 

recommendation (where it refers to benefits), and the fourth recommendation refer to options 

that current WIC rules do not allow. Similarly, WIC rules do not allow agencies to require 

participation in specific services as a condition for receiving benefits (part of what Besharov and 
2

 

Germanis mean by directive counseling). Nonetheless, at the March 2002 meeting of the 

National WIC Association, where Besharov and Germanis presented these ideas, many state and 

local WIC directors reported that some local WIC programs were already implementing 

innovative nutrition services along the lines of recommendations 1 (targeting services to highrisk groups), 2 (obesity prevention), 3 (more intensive services), 5 (coordination and colocation), and 6 (more focus on behavioral change). However, policymakers have little 

information about many of these innovative WIC practices. As a result, Mathematica Policy 

Research, Inc. (MPR) proposed to the Economic Research Service (ERS) of the U.S. 

Department of Agriculture (USDA) that MPR could help fill this gap by documenting and 

disseminating information on the design and operation of a range of WIC innovations. 

The Besharov and Germanis critique occurred when federal WIC policy had already moved 

to improve WIC nutrition services in several areas. It had (1) targeted funds for breast-feeding 

promotion and support, (2) started an initiative to revitalize nutrition education, and (3) funded a 

large research study of obesity prevention programs. 

Since 1989, a portion of WIC Nutrition Services and Administration (NSA) funding has 

been designated by law for breast-feeding promotion and support. The existence of this assured 

funding stream for more than a decade implies that breast-feeding programs, including the most 

innovative, tend to be more fully developed and implemented than other types of nutrition 

education reforms. Core services related to breast-feeding promotion and support include 

(1) designating breast-feeding coordinators at the state and local levels; (2) training staff in 

breast-feeding promotion and support; (3) integrating breast-feeding promotion into prenatal 

education contacts and assessing women’s knowledge, concerns, and attitudes about breastfeeding; and (4) making all prenatal participants aware of the special food packages for breastfeeding women.1

 Core services postpartum include the food packages and provision of, or 

referral to, support for breast-feeding mothers. Many local WIC agencies also have at least one 

certified lactation consultant or educator on staff. 

In 1999, USDA’s Food and Nutrition Service (FNS) began an initiative for “Revitalizing 

Quality Nutrition Services” (RQNS) in WIC. This initiative has two key components. First, 

FNS worked with the WIC community to update the Nutrition Services Standards to provide a 

tool for state and local staff to monitor the quality of their services (U.S. Department of 

Agriculture 2001). Second, FNS has targeted annual Special Project Grants to state agencies 

since fiscal year 1995 to plan and implement model programs and share materials from these 

programs with others. The WIC Works Web site [www.nal.usda.gov/wicworks] is also part of 

this effort—it provides resources for WIC nutrition educators online and allows state and local 

staff to share their experiences. 

USDA has also recognized growing concerns about child obesity. In fiscal year 1999, FNS 

awarded Special Project Grants to five states to develop and test WIC programs that targeted 

prevention of childhood obesity. We did not study these “FIT WIC” projects for this report, 

1

 We include as “core” WIC services those that the WIC Nutrition Services Standards 

identify as mandatory or recommended. 
3

 

since an implementation report on them was recently completed (U.S. Department of Agriculture 

2003) and a final report is forthcoming. 

A. GOALS OF STUDY 

The primary objective of this study was to learn about the innovations currently in place in 

state and local WIC agencies. We sought to identify innovative practices at 20 state or local 

WIC agencies and to study 5 promising programs in more depth through site visits. We focused 

on WIC practices that (1) promote breast-feeding and appropriate infant feeding practices (such 

as proper use of special formulas, appropriate timing for introduction of solid foods, and healthy 

feeding relationships); (2) improve nutrition and preventive health education through new 

approaches and staff training in these approaches; and (3) use innovative service delivery 

approaches, such as home visits. Many of the programs studied are innovative in more than one 

of these areas. In addition, we looked for some programs that serve high-risk groups, such as 

teenagers, premature infants, immigrants, and those with alcohol or drug abuse problems. 

For this study, we defined “innovative” as programs that are different from services that 

WIC has traditionally offered (a somewhat deliberately vague definition, because we wanted 

WIC officials we contacted for nominations to give us their perspective on what was innovative). 

The initiatives we ultimately identified as innovative include those that the WIC Nutrition 

Services Standards (U.S. Department of Agriculture 2001) would consider “best practices”—for 

example, peer counseling for breast-feeding; services that go beyond typical WIC nutrition 

services (sometimes referred to as “WIC Plus”)—such as dental education; and innovations that 

significantly change how core WIC services are delivered (such as training in facilitated group 

discussion).2

 Preferably, the program would have operated for at least one year, have 

demonstrated some evidence of its effectiveness, and have potential for being replicated. In 

terms of potential effectiveness and replicability, we were looking for preliminary indications 

that suggested the programs were worth investigating, while recognizing that further 

investigation of the programs would be needed to assess these issues more fully. Furthermore, 

we were judging effectiveness in terms of clear goals, adequate resources to achieve these goals, 

and progress toward implementing the intended services, not in terms of the ultimate impacts of 

the program on the health of mothers and children. 

An important caution is that this definition of “innovative” does not imply that these 

programs have been evaluated and found to be effective in improving health outcomes for 

targeted groups. Instead, this preliminary study sought to identify promising initiatives that may 

be worthy of future evaluation. 

The following core research questions guided our work:

• What innovative WIC programs and services currently exist? 

2

 We would also consider services delivered to a broader population than WIC participants 

(for example, a breast-feeding hotline available to all new mothers) to be “WIC Plus.” 
4

• Under what circumstances are promising WIC programs being implemented? 

• Are the programs replicable in other service areas? Is there evidence to support their 

effectiveness? 

Table I.1 lists these overarching questions, along with specific topics covered in the 

interviews and site visits that are related to each question.

B. RESEARCH METHODS 

Limited information is available on innovative practices that local agencies use, or, indeed, 

on what constitutes WIC program services “as usual.” Therefore, this study is exploratory. The 

programs selected are not intended to indicate the “best” programs nationally, as our time to find 

programs and our sources were limited, and the programs nominated are not necessarily 

TABLE I.1 

RESEARCH QUESTIONS AND TOPICS 

Research Questions Specific Topics 

What innovative WIC programs and services 

currently exist? 

• Program history and goals 

• Services provided 

• Target population(s) 

• Frequency and intensity of services 

• Reasons for innovation 

Under what circumstances are promising WIC 

programs being implemented? 

• Community contexts 

• Start-up efforts and development 

• Types of staff and necessary training 

• Eligibility requirements 

• Outreach efforts 

• Participation rates 

• Associated costs and funding sources 

Are the programs replicable in other service areas? 

Is there evidence to support their effectiveness?

• Applicability in a range of settings 

• Critical factors for success 

• Implementation challenges and lessons 

learned 

• Evidence of promising outcomes 

• Evaluation possibilities 
5

representative. They are interesting programs, however, and suggest practices that may be 

worthy of further study and may be useful for WIC policymakers and program officials to 

explore.

To select programs to profile, we first contacted the FNS regional offices, state and tribal 

WIC directors, and other experts to gather suggestions on promising programs. Based on their 

feedback and consultation with USDA staff, we selected about 20 programs to contact by 

telephone to gather detailed information on their scope, services, and probability of replication in 

other settings. The telephone interviews were conducted by senior project staff and generally 

involved interviewing the program’s senior manager or managers. The interviews followed a 

detailed protocol and took one to two hours. 

After completing these interviews and preparing detailed notes on the programs, we selected 

five of the programs to study in depth through site visits, which included interviews with 

program staff and observations of program activities. One or two MPR staff members conducted 

the site visits, which lasted one to two days, depending on the complexity and geographical 

scope of the program. Programs selected for site visits represented the major topic areas: they 

included two breast-feeding programs, one preventive health education initiative, one nutrition 

education program that focused on obesity prevention, and one service delivery initiative. In 

each case, the programs were sufficiently complex that a site visit could help us to understand 

them better. Three of the visited programs were statewide programs, for which we sought to 

visit several locations and interview both state and local staff. 

Appendix A describes in more detail the steps we took to obtain an initial set of programs 

for consideration, the criteria we used in selecting programs, and the procedures we used in 

collecting data on the programs. Table I.2 provides an overview of the selected programs.

C. PREVIEW OF MAJOR THEMES 

The next three chapters describe three groups of innovative programs: those concerned with 

breast-feeding promotion, with other aspects of nutrition education, and with innovative service 

delivery approaches. In each of these areas, we distinguish several major themes. 

Innovations in breast-feeding promotion described in Chapter II fall into four major groups: 

(1) peer counseling programs, (2) multifaceted programs with a strong focus on outreach to 

health providers, (3) breast pump programs that go beyond what most WIC agencies provide, 

and (4) programs that target teenage WIC mothers. Peer counseling programs are widespread 

but vary greatly. We describe three long-standing programs (in California, Pennsylvania, and 

Texas) that illustrate variation in the use of paid versus volunteer counselors and in the specific 

roles that peer counselors fill. Some large WIC agencies offer a wide range of breast-feeding 

services but focus on telephone helplines and extensive outreach to community health 

professionals (Riverside County, California, and Miami-Dade County, Florida). Increasing 

access to breast pumps for high-risk groups is the focus of an Arkansas program for mothers of 

premature or ill babies and a Hawaii program to provide breast pumps in schools for teenage 

mothers. In Ohio, another program for teenagers provides special infant feeding classes for 

pregnant teenagers both in and outside of school. 
6

TABLE I.2 

SELECTED PROGRAMS AT A GLANCE 

Program Scope 

Topic Area and Program Name State 

StateLevel LocalLevel Selected for 

Site Visit 

Breast-Feeding Promotion (Chapter II) 

Peer Counseling 

Breast-Feeding Peer Counselor Program TX 9 9 9

Expanded Breast-Feeding Peer Counselor Program—

Berkeley Area CA 9

Telephone Peer Counseling by Volunteers PA 9

Multifaceted Programs 

Loving Support Breast-Feeding Helpline— 

Riverside County CA 9 9

Lactation Consultant Services—Sacramento County CA 9

Breast-Feeding Promotion and Support Program— 

Miami-Dade County FL 9

Programs for High-Risk Groups

Breast Pumps for Mothers of Premature or 

Seriously Ill Infants AR 9

Pumps in the Schools (PITS) HI 9

Infant Feeding Classes for Pregnant Teens OH 9

Nutrition and Health Education (Chapter III) 

Obesity Prevention 

Get Fit With WIC OK 9 9

Obesity Prevention Modules PA 9

Mooove to Lowfat or Fat Free Milk Campaign FL 9

Preventive Health Care 

WIC Nutrition Education Model for Prevention of 

Early Childhood Caries AL 9 9

Cease Alcohol Related Exposure (CARE)— 

Los Angeles area CA 9

Staff Training 

The Learn Together Approach MI 9

WIC RD: Adjunct to Pediatric Health Care CA 9

Bilingual Training Program WI 9

Service Delivery (Chapter IV) 

Coordination of WIC with Maternal and Infant Support 

Services—northwest lower Michigan MI 9a 9

Steps Ahead/WIC Coordination—Cullman County AL 9

WIC Services in the Workplace—Eastern Band of 

Cherokee Indians NC 9

a The program is in several counties, so telephone respondent was a state WIC staff member with responsibility for 

the area. 
7

Other types of innovations in nutrition education, described in Chapter III, cover three major 

areas: obesity prevention initiatives, initiatives that coordinate with or provide preventive health 

services, and new or enhanced staff training. Nutrition education in WIC has traditionally 

focused on providing information to pregnant women and mothers as the first step to achieving 

behavioral change. In most cases, information was presented through brief, individualized 

counseling (generally 15 minutes or less) or lecture-style classes. The innovative programs 

presented in this chapter typically include one or more of the following: 

• New Methods. Some programs focus on motivating client behavior change through 

facilitated group discussion and other interactive approaches. In some situations, 

incentives are used to reinforce program messages (see box below). 

• Updated Content. Several innovative programs focus on obesity prevention; others 

add material on nutrition-related health behaviors, such as alcohol consumption 

during pregnancy and preventive dental care. 

• Broader Target Audience. Interventions that target the entire family, or specifically 

the preschool children, are expanding nutrition education’s audience. 

• More Staff Training. Many states are providing more in-depth, ongoing training for 

staff or providing more training in special topics such as breast-feeding promotion or 

obesity prevention. 

A Note for WIC Staff: The Use of Incentives in WIC

Incentives for Participants

Some of the programs described in this report use incentive items to reinforce healthy behaviors in WIC 

participants. These inexpensive items, such as water bottles or balls, are given for the accomplishment of 

specific tasks, or to reinforce learning in the nutrition education elements of the programs. FNS wishes 

readers of this report to understand WIC policy with regard to such incentives. WIC Policy 

Memorandum #95-5, issued 12-21-94, provides guidelines on purchasing such items with WIC funds. 

Program incentive items for participants and/or staff are allowable if they are considered to be reasonable 

and necessary costs that promote the specific program purpose. 

Incentives for Staff

In some programs, clinic staff may occasionally receive the same items as participants, because the staff 

may participate in cooperative functions with the WIC target population. According to WIC Policy 

Memorandum #95-5, “...it may occasionally be appropriate to distribute some types of program incentive 

items to program staff. The items must present a WIC outreach or nutrition education message as 

opposed to an agency logo, and must be ones which would be expected to be widely seen by the general 

population or the target population.” 

Need More Information?

The State agency should refer to WIC Policy Memorandum #95-5, as well as to OMB Circulars A087 and 

A-122, and check with the Regional FNS office if it has any questions regarding the use of program 

incentive items. Local agencies should contact their State agencies for assistance. 
8

The final three programs (described in Chapter IV) are innovative in where services are 

provided and how they are coordinated with other programs. All three are in rural areas, where 

lack of transportation can be a barrier. In particular, we studied two programs that integrate WIC 

services with Medicaid-funded care coordination for low-income pregnant women. Because the 

Medicaid program supports home visits, some WIC services can be provided through home visits 

in these areas. Another program provides WIC services at worksites, with cooperation from 

employers. 

The concluding chapter discusses cross-cutting issues—the sources of the ideas and funding 

for these programs, implementation lessons learned, their potential for replication, the strength of 

evidence for their success, and possibilities for further evaluation. 
9

II. BREAST-FEEDING SUPPORT PROGRAMS 

WIC agencies are required by federal regulations to promote and support breast-feeding 

among their clients. This is accomplished through staff training, offering clients prenatal breastfeeding education (through classes and/or one-on-one contacts, and written materials and/or 

videos), informing clients about the food packages for breast-feeding mothers, and providing or 

referring to support services after the birth. Agencies receive targeted funding for these 

activities. They can also use either food funds or Nutrition Services and Administration (NSA) 

funds to purchase breast pumps to give or lend to breast-feeding mothers, and most agencies now 

have a breast pump program. In addition, many agencies have at least one lactation consultant 

(generally an International Board Certified Lactation Consultant, or IBCLC) on staff. 

The breast-feeding support programs described in this chapter go beyond the required 

services. They have three main themes: 

1. Peer Counseling. Peer counselors are generally current or former WIC clients who 

breast-fed their babies for a substantial period. Peer counselors may be volunteer or 

paid, part-time or full-time, and they may have different levels of training. 

Generally, the breast-feeding coordinator (who is a certified lactation consultant) 

trains and supervises them and provides backup support for unusual or high-risk 

situations. 

2. Multifaceted Programs that emphasize individual assistance and outreach to health 

professionals. The programs profiled also provide a wide range of other services for 

breast-feeding mothers. 

3. Programs for High-Risk Groups. Programs profiled are targeted at mothers of 

premature or seriously ill infants or teenage mothers. 
10

 

A. PEER COUNSELING 

Over the past several years, peer counseling programs have become more common in the 

WIC program, although they are not yet standard. Because the FY 2004 appropriation for the 

WIC program provides funding for peer counselors, these programs are currently of considerable 

policy interest. USDA considers them to be a “best practice” in the Nutrition Support Standards, 

but the standards do not provide any guidance on what makes a good peer counseling program. 

Most programs require peer counselors to be current or former WIC participants who have 

breast-fed at least one child, generally for six months or more. However, the programs we 

studied varied in their service structure along the following dimensions: 

• Training and quality control: the length of training varies, as does the frequency with 

which the peer counselor is monitored. 

• Compensation—from unpaid to well-paid. 

• Hours—from very part-time to full-time (4 to 40 hours per week). 

• Services provided: responsibilities of peer counselors may include prenatal 

counseling, teaching or assisting with prenatal classes, hospital bedside counseling, 

telephone counseling, in-person counseling in clinics, administering pump programs, 

leading or assisting with support groups, and translating (if bilingual). 

Sometimes, WIC agencies incorporate peer counselors into their services in part because 

they cannot afford more qualified staff, such as lactation consultants. Other agencies believe 

strongly that peer counselors are better able than professional staff to motivate mothers to breastfeed and to continue breast-feeding, as clients may feel more comfortable with discussing 

breast-feeding issues with someone “just like them.” 

We profile three programs that illustrate some of this variation. Texas, a pioneer in peer 

counseling programs, runs statewide training in how to establish peer counseling programs and 

train peer counselors. At the same time, Texas allows a lot of local autonomy in defining the 

programs. The program in Berkeley, California, and the surrounding area receives substantial 

outside funding and pays peer counselors competitive wages. It uses peer counselors from 

diverse backgrounds to serve its multi-ethnic clientele. In contrast, the peer counseling program 

in Washington and Greene counties in southwestern Pennsylvania operated for 10 years with 

volunteer peer counselors who provided counseling by telephone out of their homes.1

1

 Two of the comprehensive breast-feeding programs described in Section B (Sacramento 

and Miami) also use peer counselors. 
11

BREAST-FEEDING PEER COUNSELOR PROGRAM2

TEXAS 

OVERVIEW 

Location: Statewide, available in 61 of 80 local WIC agencies 

Start Date: April 1991 

Target Population: Pregnant and breast-feeding WIC clients are the primary targets for this 

initiative; however, non-WIC clients are served in hospitals. 

Purpose: To improve infant health by increasing breast-feeding rates through breast-feeding 

promotion, education, support, and assistance. 

Services: Peer counselor services vary at the local level, and can include one-on-one assistance 

in WIC clinics, hospitals, the home, or over the phone; breast-feeding and prenatal classes; breast 

pump programs; and referrals to other social services. 

Funding: The Texas peer counselor program received $1.3 million in U.S. Department of 

Agriculture (USDA) operational adjustment funds for fiscal year 2003.3

 Many local agencies 

also use a portion of their regular WIC funding to support their peer counselor programs. 

Why Program Was Chosen: This program was one of the first Breastfeeding Peer Counselor 

(BFPC) Programs in the country, and it has been used as a model by other states. Moreover, 

through the Peer Dads Program, it has attempted to slowly expand into nontraditional venues. It 

can serve as a model for other agencies to enhance breast-feeding promotion efforts by 

implementing Texas’ intensive breast-feeding trainings for program staff, WIC staff, and health 

professionals. 

Key Challenges: Staff turnover has been a challenge at some WIC clinics. Counselors may 

leave, for example, because they can no longer bring their infants to work after their first 

birthday or because they need to find a full-time job. In addition, it is challenging for a statewide 

program to maintain quality control and ensure that peer counselors give consistent, good-quality 

services and accurate information to clients. 

 2

 Telephone interview: April 1 and 7, 2003; site visit: September 16-17, 2003. 

3

 Operational adjustment grants are awarded by Food and Nutrition Service (FNS) regional 

offices, often through a competitive process. FNS regional offices retain 10 percent of Nutrition 

Services and Administration (NSA) funds allocated to state agencies for these grants. 
12

 

BACKGROUND 

State Characteristics. Texas, with over 21 million residents in 2001, is one of the largest 

states in the nation by land area and population. In 2002, 52 percent of the state was white and 

12 percent was African American, lower than the national average. About 32 percent of the 

state’s population is of Hispanic or Latino origin, compared to 13 percent for the U.S. as a 

whole. More than 31 percent of the population speaks a language other than English in the 

home. In 1999, over 15 percent of residents lived below the poverty line.4

WIC Program Background. The Texas WIC program is the second-largest program in the 

country, serving 800,000 to 850,000 clients a month in fiscal year 2003. In September 2003, 

51 percent of clients were children, 25 percent infants, 11 percent pregnant women, 7 percent 

postpartum women, and 6 percent breast-feeding mothers. WIC clients in Texas all have access 

to basic WIC services, but supplemental services depend on the specific agency, with some 

offering free immunizations and the USDA’s Farmer’s Market Nutrition Program (FMNP). 

According to program staff, there are multiple barriers to breast-feeding among the Texas 

WIC population. Some mothers believe common breast-feeding myths, including constant pain, 

the inability to go back to work or school, and lack of father-infant bonding. Breast-feeding 

while returning to work can be very difficult for WIC clients, as certain work environments are 

less flexible than others. For example, service jobs often do not have private space for breastfeeding mothers. Additional barriers include a lack of confidence and support, a family history 

of formula feeding, and receipt of inaccurate information from health professionals who may not 

have the expertise to support breast-feeding or who view formula feeding as a safety net. 

Program History and Objectives. In 1989, when state WIC agencies were mandated to 

name a state Breastfeeding Coordinator, the Texas Breastfeeding Coordinator conducted a needs 

assessment of local WIC agencies to identify successful practices in promoting breast-feeding, 

concentrating particularly on those sites with the highest breast-feeding rates. Staff from two of 

the most successful agencies reported doing something that resembled peer counseling. For 

example, one agency paid a $10 stipend to program participants to speak about their breastfeeding experiences with other clients. 

Based on these findings, the BFPC Program was developed from the state level with input 

from the local La Leche League International chapter and has been operating since April 1991. 

The state Breastfeeding Coordinator (who later became the state Peer Counselor Coordinator) 

collaborated with a team leader from La Leche League to write the first proposal and develop 

training materials. Initially, the program was piloted in Travis County, Houston, and Harris 

County. Having successfully implemented and refined these pilot programs, program officials 

gained support from WIC stakeholders and were able to promote the initiative across the state. 

4

 Unless noted otherwise, state and county characteristics throughout this report are from 

quickfacts.census.gov. 
13

 

The BFPC Program mission is to improve infant health by increasing breast-feeding rates. Goals 

include (1) increasing the number of WIC mothers who breast-feed, (2) providing follow-up 

support to mothers who start to breast-feed, and (3) creating long-term networks of breastfeeding support in low-income neighborhoods. The core philosophy of peer counseling is that 

WIC mothers with breast-feeding experience have a perspective to offer expectant and new 

mothers that health professionals do not. Building on their own experience, peer counselors 

incorporate current research and knowledge from breast-feeding experts into information they 

share with their clients. Another important element is having a network of specialists, such as 

WIC nutritionists and nurses, local breast-feeding coordinators, lactation consultants, and clients’ 

physicians, to whom the peer counselor can refer the mother. 

Target Population. WIC clients who are pregnant or breast-feeding are eligible to 

participate in the program. In addition, non-WIC women often receive BFPC services in local 

hospitals. In a few pilot sites, fathers of WIC infants can be counseled by “peer dads” (see box). 

PROFILE OF INNOVATIVE PROGRAM 

Services Provided. Since WIC agencies have autonomy and flexibility in program 

implementation at the local level, services vary from agency to agency. At many agencies, peer 

counselors serve as role models by breast-feeding their infants (either during a private counseling 

session or in the waiting room) and discussing their experiences, often with women who have 

never seen a baby being breast-fed or talked to a mother who has breast-fed. One peer counselor 

remarked that peer counselors are “regular people, regular moms,” which is different from 

having WIC staff convey the benefits of breast-feeding to clients. 

In general, peer counselors teach or co-teach breast-feeding and pump classes, and facilitate 

or co-facilitate breast-feeding discussion and support groups.5

 In some agencies, they teach 

prenatal and general nutrition education classes.6

 Classes, which often rotate between English 

and Spanish, last for 30 minutes. Peer counselors might teach small or large classes, depending 

on the agency. For example, at one of the Houston clinics, classes are held in an auditorium that 

was formerly a movie theater. There, it is not unusual for a peer counselor to teach a class of 100 

women. As of August 1, 2003, the state permits breast-feeding discussion groups in lieu of 

breast-feeding classes. Local staff must develop an objective, provide an evaluation component, 

and select a major topic for discussion. Some agencies open the event to non-WIC mothers.

5 The program has had limited success with support groups unless they are held as nutrition 

education encounters at the time of voucher issuance. 

6 Peer counselors must complete a set of modules in order to teach nutrition education 

classes other than breast-feeding. 
14

PEER DADS PROGRAM 

The peer-counseling program for fathers (hereafter referred to as “peer dads”) started in 

fiscal year 2002 in four pilot sites (Austin, Brownsville, El Paso, Houston). State WIC officials 

were aware that WIC needed to better incorporate fathers into program services. Research also 

indicates that the father influences a mother’s decision to breast-feed (Peregrin 2002, Arora et 

al. 2000). Therefore, the Peer Dads Program was designed to arm fathers with information, 

education, and support, so that they have the skills and knowledge to help their partner breastfeed successfully. 

To become a peer dad, a father must have a breast-fed baby who is currently enrolled or was 

previously enrolled in WIC. Local Breastfeeding Coordinators and their staff train the peer dads 

in an eight-hour workshop using the state agency developed WIC Father-to-Father Breastfeeding 

Support Training Manual, Training Dads to Help Dads, and Becoming a Father: How to 

Nurture & Enjoy Your Family (Sears, Gotsch, and Froelich 2003).

Peer dads’ schedules vary from 4 to 20 hours per week. Services can be conducted in the 

WIC clinics or over the telephone. Peer dads attend breast-feeding classes to inform prenatal and 

postpartum women about the program and to encourage their partners to seek counsel. They also 

approach fathers in the waiting room to see if they would be interested in talking about breastfeeding, and on occasion have attended health fairs. Common topics for discussion with fathers 

include the benefits of colostrum, the advantages of breast milk over formula, and ways fathers 

can be supportive of their baby’s mother during the breast-feeding experience. Sessions last 

about 20 minutes. If the peer dad is faced with a question that he cannot address, he refers the 

father to a peer counselor, nutritionist, lactation consultant, or WIC supervisor. The most 

frequent referral is to the peer counselor. 

One pilot site has been very successful since beginning the initiative, with more WIC fathers 

coming to the clinic and receiving the services of the peer dads each month. Specifically, peer 

dad contacts increased from 2 in May 2002 to 89 by October 2002. In exit interviews, fathers 

have rated the services of the peer dad as “very important” and said the information they 

received from peer dads would help them support their babies’ mothers with breast-feeding and 

help them to be better fathers. Other peer dad pilot sites have so far met with limited success 

because of the low volume of males in the clinic and problems in recruiting and retaining peer 

dads. For example, the state Peer Counselor Coordinator noted difficulty in getting peer dads to 

plan time to come into clinics around their regular work schedule. Despite implementation 

challenges, local WIC agencies that sponsor peer dads are excited about the pilot. They like the 

concept of fathers helping fathers and are working hard to make the program work.
15

 

In addition, peer counselors provide one-on-one counseling and assistance to pregnant 

women and new mothers in hospitals, in WIC clinics, and over the telephone.7

 In some 

hospitals, there are staff contacts that identify potential clients for peer counselors to visit. Some 

hospitals provide peer counselors with a printout of breast-feeding clients, so that they know 

which rooms to visit. Typically, the local WIC clinic generates a monthly maternity list of 

expectant mothers. Peer counselors try to call the mother within three weeks of delivery to 

answer any questions about breast-feeding, offer encouragement, and remind the mother to call 

the clinic or peer counselor upon delivery with breast-feeding questions or concerns. If they 

cannot reach the mother by telephone, they send a letter to the home. Peer counselors will 

follow up with breast-feeding WIC mothers for as long as there is a need for individual 

assistance. 

Some peer counselors issue breast pumps, answer local breast-feeding hotlines, answer a 

statewide toll-free hotline at Mom’s Place in Austin (see box), make home visits, distribute 

pamphlets in WIC waiting rooms and hospitals, prepare bulletin boards, participate in health 

fairs, train WIC staff, make presentations to health care professionals, and perform other WIC 

duties. Some local agencies provide WIC certification services on site in the hospitals. There 

are often “reverse referrals” when a peer counselor connects with a mother in the hospital who is 

eligible for WIC but is not enrolled. At most hospitals, peer counselors simply call the local 

agency and make a certification appointment for the mother while she is in the hospital. Peer 

counselors also refer clients to local lactation consultants, Mom’s Place, or other social services. 

Clients often see a peer counselor for at least two breast-feeding contacts, including one 

breast-feeding class and one individual counseling session, which frequently takes place on the 

day the client is being certified. However, the number and length of contacts with a specific 

client vary. For example, one local agency requires its peer counselors who counsel mothers in 

hospitals to follow up with five telephone calls. Most issues that surface during one-on-one 

counseling, whether in person or over the phone, are common, such as latch-on challenges, sore 

nipples, and engorged breasts. Often non-breast-feeding issues arise, such as frustrations with a 

partner or the challenges of being a new mother. Complex breast-feeding issues are rarer, but if 

one does come up, peer counselors can refer WIC clients to a lactation consultant, a site 

supervisor, the Breastfeeding Coordinator, a nurse, a nutritionist, the mother’s physician, or 

another designated health professional. Many local agencies have Internationally Board 

Certified Lactation Consultants (IBCLCs). In Austin and Central Texas, peer counselors often 

refer mothers who need extra attention to Mom’s Place. Most hospitals have lactation 

consultants that see high-risk mothers or mothers with problems beyond the peer counselors’ 

scope of practice or knowledge. Peer counselors are trained to make immediate referrals for 

7

 In WIC clinics, staff members refer clients to a peer counselor for breast-feeding 

assistance. Some WIC agencies have more funding than ever before, but not enough to meet 

peer counselor demand. As a solution, agencies have scheduled certification appointments and 

prenatal and breast-feeding classes when peer counselors are scheduled at the clinic, so that they 

can target WIC clients who would most likely benefit from peer counselor services. Some peer 

counselors have their own office space, while others do not. In many clinics, the breast-feeding 

room and the peer counselor’s office are the same. 
16

MOM’S PLACE 

Mom’s Place is the Texas WIC Breastfeeding Resource Center. Located in the capital, 

Austin, this centralized resource center and WIC lactation clinic provides assistance through a 

statewide toll-free breast-feeding hotline (operating during regular business hours), individual 

assistance by appointment for complicated breast-feeding cases, and breast pumps. The director, 

who is an IBCLC and a nurse, as well as at least two peer counselors from the BFPC Program, 

staff the center. Mom’s Place deals with complex issues relating to premature infants, infants in 

the neonatal intensive care unit, congenital abnormalities (such as cleft lip, cleft palate), digestive 

disorders, neurological disorders, mastitis, poor range of tongue motion, physical injury to 

mother, sore nipples, and failure to thrive. The peer counselors primarily answer routine breastfeeding questions on the hotline, issue breast pumps, and handle clerical tasks, whereas the 

director provides one-on-one assistance for mothers with more complex issues. 

Generally, the three main sources of referrals are hospital lactation consultants, peer 

counselors, and other WIC staff. A WIC clinic is attached to Mom’s Place, and sometimes staff 

bring walk-ins over to the center. In turn, Mom’s Place staff often provide reverse referrals to 

clients who are probably eligible for but not enrolled in WIC. It is also common for former 

clients to refer friends and relatives to Mom’s Place. 

Aside from functioning as a central breast-feeding resource center, Mom’s Place serves as a 

training facility for the Texas Department of Health’s dietetic internship program. Pediatric 

residents also come to Mom’s Place for one of their public health rotations, along with nursing 

students from the University of Texas, Austin Community College, and Baylor College of 

Medicine. Written into the Mom’s Place grant is a continuing education stipend program 

requiring that 40 WIC staff receive three days of training at Mom’s Place each year. In addition, 

the director conducts several in-services and trainings for the Texas Department of Health, local 

health departments, and community organizations. 

The Mom’s Place grant totaled $189,000 in fiscal year 2003. This comprised the entire 

operating budget for the clinic, which employs a staff of four who worked a total of three FTEs. 

During fiscal year 2003, there were 2,104 telephone consultations through the hotline, 

2,167 local calls, and 8 electronic mail messages. Of these 4,279 contacts, 2,402 were from WIC 

clients and 709 were from professionals requesting breast-feeding information. In addition, 

39 medical and health students received brief training at Mom’s Place. Forty-four WIC staff 

received training as well. As for clinic consultations, there were 1,124 appointments for 

819 clients (801 were WIC clients). Of the mothers seen, 80 percent were still breast-feeding 

one month after the first clinic visit to Mom’s Place. 
17

problems outside the normal breast-feeding experience (for example, severe pain or failure to 

thrive), breast-feeding problems that are not resolved within 24 hours of the peer counselors’ 

intervention, or problems in an area other than breast-feeding. 

Participation. The BFPC Program is available statewide, but it is not mandatory that local 

agencies participate. There are 80 local agencies, with 61 offering the program. The majority of 

local WIC agencies without peer counselors are small. Peer counselors also work in 

30 participating hospitals. At most hospitals, peer counselors do not try to differentiate between 

WIC and non-WIC mothers, because it would be too cumbersome and time-consuming to select 

specific mothers for peer counselors to visit. 

Coordination and Collaboration. The La Leche League plays an important role in 

promoting the program, giving referrals to WIC clients, receiving referrals for non-WIC clients, 

and helping with staff training. Moreover, the organization assisted with initial program 

development. The state professional liaison of the local chapter formally gave her support for 

the initiative. To the state Peer Counselor Coordinator, this “stamp of approval” from a 

reputable breast-feeding advocacy group was beneficial in garnering support. 

Publicity and Outreach Efforts. Program participants often have their first contact with 

the BFPC Program through a local WIC agency that offers these services. Ideally, a peer 

counselor connects with a client when she is pregnant and being certified for WIC services. 

While a client is waiting for vouchers, peer counselors often introduce themselves or have the 

WIC staff introduce them. In this way, they have time to work with the mother, addressing 

concerns and educating her about the benefits of breast-feeding well before delivery. Some 

clinics require that pregnant women meet with a peer counselor. 

Local agencies have implemented a range of publicity strategies to promote the program, 

such as putting up displays in waiting rooms. Some peer counselors have spoken about breastfeeding on radio and television shows. In addition, to raise awareness about the program, they 

give presentations to health professionals and visit social service agencies and health fairs. 

ORGANIZATION AND MANAGEMENT 

Staff and Organizational Structure. The state Peer Counselor Coordinator is the main 

contact for the BFPC Program, fielding questions that cannot be handled at the local level and 

facilitating the Peer Counselor Trainer Workshop. Local Breastfeeding Coordinators recruit, 

train, and supervise the peer counselors. Many of these coordinators have degrees in nutrition 

and are IBCLCs. About 300 peer counselors are employed in 123 full-time equivalent positions 

and work about 20,000 hours a month. 

Local agencies have their own recruiting and hiring practices for peer counselors. 

Nevertheless, state BFPC policy requires that peer counselors be current or previous WIC 

participants, be successful in having breast-fed at least one infant, be enthusiastic about breastfeeding, and have access to a telephone and transportation. Some local agencies set other 

criteria, based on their own needs and hiring practices. For example, some agencies require that 

staff be bilingual in Spanish. However, this can become a problem when needy clients miss out 
18

on services while the local agency waits for an appropriate bilingual applicant. Some agencies 

try to hire peer counselors whose ethnic and cultural background is similar to that of clients. 

Peer counselors are often recruited through WIC staff, other peer counselors, or posters in 

the clinics. After completing an application and an interview, they are hired as regular 

employees, temporary employees, or contractors, depending on local policies. The state Peer 

Counselor Coordinator originally envisioned peer counselors working four hours a week so that 

they did not earn a salary that would make them ineligible for certain social service benefits. 

However, over the years, their hours of work have expanded. Some WIC agencies have full-time 

and/or part-time peer counselors working anywhere from 4 to 40 hours a week. Some part-time 

peer counselors have another part-time position, such as intake clerk, within the local health 

department or WIC agency. 

As previously mentioned, agencies develop local policies on how their programs are 

structured. For example, at one agency, peer counselors may be allowed to work in hospitals, 

usually for longer hours, after gaining experience in the clinic for one year. At another agency, 

peer counselors might be required to attend additional state-sponsored training before working in 

the hospital. Other agencies might allow peer counselors to work in the hospitals immediately 

after the initial training program. 

DESIGNING A PEER COUNSELOR PROGRAM 

The Training Moms to Help Moms manual provides answers to the following questions for 

WIC staff that want to begin a BFPC Program:

• How do you choose peer counselors? 

• What are the responsibilities of the peer counselor? 

• How many peer counselors do you need? 

• How many peer counselors should you recruit and train? 

• Why is peer counselor training required? 

• Where will you hold the training? 

• How will you schedule the training? 

• How will you conduct the training? 

• Do you need a graduation? 

• What is the role of the lactation consultant? 

• What are the costs? 

• How are peer counselor costs funded?
19

Training and Quality Assurance. Training for the BFPC program occurs at two levels: 

training professionals to train the peer counselors, and training the peer counselors locally. The 

state Peer Counselor Coordinator collaborated with a La Leche League team leader—a nurse and 

IBCLC—to develop training manuals. They wrote the WIC BFPC Training Manual—Moms 

Helping Moms to train the peer counselors, along with Training Moms to Help Moms for the 

Peer Counselor Trainer Workshop. 

The state Peer Counselor Coordinator and other staff usually facilitate the train-the-trainer 

workshop, which is held three times a year in Austin. Participants include local Breastfeeding 

Coordinators, lactation consultants and educators, nurses, WIC staff, La Leche League team 

leaders, teen-parent educators, health educators, and experienced peer counselors. The workshop 

gives an overview of the approaches to peer counseling, how to design a peer counselor program 

and advocate for one in their agency, and how to conduct effective peer counselor training (see 

box). The training also presents detailed lesson plans, including topics to be covered, handouts, 

videos and books needed, and questions to address with the class. Panels of local Breastfeeding 

Coordinators and peer counselors provide additional insight and guidance. 

Local peer counselor training is designed to be five classes of four hours each. This 

schedule can be modified to meet trainer or participant needs, but the initial training should total 

20 hours. Like other elements of the BFPC Program, the frequency of trainings varies from 

agency to agency. Travis County’s Breastfeeding Coordinator holds a training whenever there 

are 6 to 10 interested people, usually two or three times a year. Some agencies have little peer 

counselor turnover, so training sessions may occur less frequently. Program officials 

recommend holding training outside the clinic or after clinic hours to avoid interruptions, and to 

ask community advocates, peer counselors, or WIC staff to co-facilitate. Most agencies allow 

participants to bring their breast-feeding infants. 

The content of the actual peer counselor training focuses on enabling peer counselors to help 

with routine breast-feeding issues (such as latch-on problems) and answer “real-life” questions. 

Specific topics include the advantages of breast-feeding, the amazing breast (anatomy, 

physiology), comparing breast milk with substitutes, the immunological qualities of breast milk, 

prenatal care, basic how-to’s of breast-feeding (such as latch-on and positioning), common 

concerns, starting solids, weaning, parenting skills, barriers to breast-feeding, cultural 

considerations, counseling techniques, including the father and family in the breast-feeding 

process, special circumstances, referrals, mother/infant separation, breast pumps, and peer 

counselors at work. Participants receive copies of The La Leche League International 

Breastfeeding Answer Book to use as a reference tool while working with clients (Mohrbacher 

and Stock 2003). The Texas BFPC Program has trained about 2,500 breast-feeding mothers as 

PCs since its inception in 1991. 

The extent to which additional, on-the-job training is implemented varies from site to site as 

local agencies develop their own orientation and mentoring/training plans. For new staff, some 

agencies use a formal “Peer Counselor Skills Check-Off” list of the various observations and 

activities staff must perform before they are permitted to work on their own in counseling 

mothers or teaching classes. Other agencies have informal procedures but require similar 

activities. In Travis County, new peer counselors must observe the counseling, teaching, and 

documentation of other peer counselors. The new counselors, while being observed by WIC 
20

staff or the Breastfeeding Coordinator, must also (1) counsel a prenatal mother, (2) co-teach or 

teach a breast-feeding class, (3) counsel a mother in person or over the phone, and (4) create or 

help design a bulletin board promoting breast-feeding or the peer-counseling services. Finally, 

the peer counselor in training must locate various resources in the clinics (such as pamphlets, 

breast pumps), weigh an infant, conduct an inventory of the breast pumps, visit Mom’s Place, 

and meet with the local Breastfeeding Coordinator and WIC supervisors before qualifying to 

work independently.

Peer Counselors have the opportunity to attend other training sponsored by the agency, state, 

or community organization. For example, the program includes a monthly in-service session that 

lasts about an hour. Usually, local staff review and discuss actual case studies and/or peer 

counselors receive an update or training session on a breast-feeding topic from the agency’s 

Breastfeeding Coordinator, the lactation consultant, or an invited speaker. 

Many peer counselors also undergo the same state agency-sponsored training that breastfeeding staff and health care professionals receive. The Texas Department of Health 

Breastfeeding Promotion Section and the Texas Association of WIC Directors have coordinated 

a statewide effort to train professionals on breast-feeding information so that WIC clients are 

receiving consistent messages. Training courses include “Principles of Lactation Management” 

and “Counseling and Problem Solving.” These two training sessions last for 15 hours over two 

full-day sessions. Other classes available by request for health care providers include “Mini 

Breastfeeding Management Program I and II” and the “Physicians’ Breastfeeding Course.” 

For quality assurance, local Breastfeeding Coordinators frequently observe peer counselors, 

especially new hires, and provide feedback. They also rely on the site supervisor to monitor peer 

counselors. Annual audits require observations of WIC staff doing counseling, including peer 

counselors. 

Record Keeping and Data Systems. In the WIC clinics, peer counselors fill out 

standardized tracking forms for individual counseling. These forms are flagged for any 

necessary followup and inserted into the client’s chart. The Breastfeeding Counseling Form 

includes basic contact information, the reason for the call or visit, a series of questions about the 

infant and mother (frequency of feedings, number of wet diapers, positioning, milk supply, 

health problems), the peer counselor’s response, pamphlets given, and any referrals made. The 

Prenatal Breastfeeding Counseling Form includes basic contact information, questions to prompt 

a discussion about breast-feeding (for example, Does the mother know anyone who is breastfeeding? Does she have a support system in place?), a checklist of topics discussed (for 

example, latch-on, positioning, engorgement), the peer counselor’s response, and pamphlets 

given. Furthermore, at some agencies, peer counselors maintain class attendance and telephone 

logs. While counselors do not insert written documentation into the patient’s charts in hospitals, 

they report verbally to the nurse in charge, who will document their comments.

Funding. In fiscal year 2003, the Texas BFPC Program received $1.3 million in operational 

adjustment funds through USDA for a budget that includes the cost of the peer counselor 

salaries, staff training, and training materials. Many local agencies also use a portion of their 

regular WIC funding to support their peer counselor programs. Other sources of funding cover 

food and child care provided at the local and statewide training. In addition, one of the initial 
21

 

pilots was funded through the Office of Childhood Services of the U.S. Department of Health 

and Human Services. 

ASSESSMENT AND LESSONS LEARNED 

Program Strengths. Some research indicates that women are more likely to breast-feed 

after hospital discharge with the support of peer counselors, whether through phone calls or 

through individual counseling (Gross et al. 1999; and Shaw and Kaczorowski 1999). The peer 

counselor provides woman-to-woman support and is often seen as a friend, a personal 

cheerleader, or a sister. In Texas, breast-feeding rates have increased at all WIC agencies that 

have implemented peer counselor programs. Specifically, 98,338 infants born to WIC mothers 

were breast-fed in July 2001. By July 2002, the number was 106,250, and by July 2003, it was 

112,691. The proportion of breast-feeding mothers to total infants was 7.5 percent in 1990, and 

over 20 percent in 2003. Texas uses a multifaceted approach to breast-feeding promotion, 

including peer counselor services, WIC staff training, and health professional training. 

Therefore, it is hard to say to what degree each component contributed to the increase, since the 

components were implemented simultaneously. 

Success is also evident at the local level. For example, Travis County was a pilot site for the 

peer counselor program. The breast-feeding rate was 16.7 percent in April 1991, but by June 

1992, a little over a year into the pilot, the rate was 21.2 percent. These percentages reflect the 

ratio of breastfeeding mothers to the total number of infants participating in the program. In 

fiscal year 2003 this ratio was 41 percent at the Travis County WIC Program.8

A secondary outcome is that peer counselors have gained the skills and self-esteem to 

pursue other employment. For many peer counselors, the program is their initial entrance into 

the workforce. Since 1991, local agencies have hired more than 200 peer counselors into other 

staff positions. Some have gone on to pursue higher education; several have passed the IBCLC 

exam and now work as lactation consultants. Many local agencies have instituted career ladders, 

so that an experienced peer counselor can become a senior peer counselor, then a Peer Counselor 

Coordinator, and eventually an assistant Breastfeeding Coordinator. Several smaller agencies 

have moved experienced peer counselors into Breastfeeding Coordinator positions. 

Many hospital staff members see the value and success of having someone address breastfeeding needs upon delivery. Hospitals have even started to hire their own lactation consultants. 

Several hospitals have hired WIC peer counselors into Breastfeeding Counselor positions paid 

for by the hospital. While this structural change reduces the number of peer counselors needed 

at the hospital, another benefit is that hospitals are becoming “breast-feeding friendly.” 

8

 Over the years, Texas began to take a closer look at breastfeeding initiation rates among 

infants of mothers who were on the WIC Program during pregnancy and therefore available to 

receive breastfeeding information and encouragement from WIC. In September 1999 the 

breastfeeding initiation rate among infants born to a mother who had been served by WIC during 

pregnancy at the Austin/Travis WIC Program was 70.4 percent. By December 2003 the 

initiation rate at Austin/Travis had increased to 83 percent. 
22

 

Key Challenges. Peer counselor turnover has affected the BFPC Program. Most agencies 

allow peer counselors to bring their breast-feeding infants to work up to 1 year of age. A prime 

time for peer counselors to resign is after this first year. Also, many peer counselors are from 

socioeconomic circumstances that may produce a higher-than-average incidence of family and 

financial issues that disrupt their ability to continue their job. With this in mind, local 

Breastfeeding Coordinators recommend recruiting more peer counselors than a local agency 

thinks it will need. Furthermore, there are pros and cons in allowing peer counselors to bring 

their breast-feeding infants to work. The main advantage is that peer counselors can model 

breast-feeding for clients. At the same time, even though the WIC clinics are full of infants and 

children under the age of 5 every day, some agencies may consider it a liability that an infant 

brought to work by his mother might become injured or ill. 

All peer counselors have a unique style in how they interact with clients, which can be 

perceived as both a challenge and a benefit. Despite their preferences, personalities, and varying 

education backgrounds, they must provide consistent information, as well as document and 

communicate appropriately.9

 With a statewide program, achieving this level of quality control 

can be difficult. In particular, some bilingual peer counselors struggle with documentation 

because they have trouble expressing themselves in writing in either English or Spanish. 

Peer counselors’ schedules vary from 4 to 40 hours per week. When peer counselors are 

hired for part-time jobs, applicants must understand how their income could affect their 

eligibility for services and benefits. If their income is too high, they may lose benefits such as 

WIC and Medicaid. Some women must choose between having a reduced workload and losing 

benefits in order to pursue a valuable position within the WIC program. 

Lessons Learned. To maximize the effectiveness of the BFPC Program for pregnant and 

postpartum women who choose to breast-feed, WIC staff must have a clear understanding, 

preferably gained in a meeting or training before the initiative begins, of the roles and 

responsibilities of peer counselors. This is especially important so that peer counselors are not 

pulled away from their service delivery duties to assist with regular WIC administrative tasks. 

One common misconception among WIC staff is that a peer counselor in the waiting room is 

“hanging out” and not working. However, she is actually modeling and discussing breastfeeding and gaining the trust of clients. Moreover, site coordinators should make it clear that 

peer counselors are in the clinics to provide breast-feeding support to WIC clients, not to take 

over WIC staff positions. Peer counselors actually decrease the workload and improve service 

delivery, since breast-feeding support can be time-intensive. WIC staff do not usually have time 

to provide routine breast-feeding support in the context of a busy clinic schedule. 

Experience has demonstrated that the program works best when WIC staff (1) include peer 

counselors in staff meetings, (2) treat them like one of the team and recognize that the position is 

a “real job,” (3) respect the work they are doing and acknowledge that it is different from what 

9

 Peer counselors have a wide range of educational credentials, ranging from high school to 

college degrees. 
23

other staff do, and (4) mentor peer counselors. In addition, WIC staff are more likely to support 

the program when they assist in peer counselor recruitment and training and attend state agencysponsored breast-feeding trainings. WIC staff also have greater confidence in the program when 

program officials regularly observe and monitor the activities of peer counselors to make sure 

they are providing textbook information rather than relying on personal experience alone. 

Overall, the BFPC Program has rejuvenated the enthusiasm of WIC staff for promoting 

breast-feeding, and clinic staff appreciate the services that peer counselors provide. The state 

Peer Counselor Coordinator thinks that the program can be replicated, especially since the 

training manual walks interested stakeholders through program implementation step by step. In 

fact, the front section of the manual explains in detail how to design a peer-counseling program. 

CONTACT INFORMATION 

Jewell Stremler, CLE 

State Peer Counselor Coordinator 

Texas Department of Health 

Bureau of Nutrition Services 

7785 NW 48th Street, Suite 300 

Austin, TX 33166 

Phone: 512-341-4400 x2303 

Fax: 512-341-4422 

E-mail: Jewell.Stremler@tdh.state.tx.us 

www.tdh.state.tx.us/lactate/peer.htm 

25

EXPANDED BREAST-FEEDING PEER COUNSELOR PROGRAM10

ALAMEDA/CONTRA COSTA COUNTIES, CALIFORNIA 

OVERVIEW 

Location: Northern Alameda County and parts of Contra Costa County (Berkeley and 

environs), California 

Start Date: 2001 

Target Population: WIC clients and other low-income women 

Purpose: To increase breast-feeding initiation and duration rates by providing support and 

assistance to pregnant and postpartum women. 

Services: Peer counselors (PCs) provide one-on-one assistance in hospitals, homes, and WIC 

clinics, as well as over the phone, to pregnant and breast-feeding women. 

Funding: $500,000 grant from the California Endowment, plus an additional 50 cents for every 

$1 spent on the grant from the California Nutrition Network.11 The WIC program provides some 

funding as well. 

Why Program Was Chosen: This program provides services in the hospital immediately after 

delivery and over the telephone for one year, or until breast-feeding ceases. The program has 

also tried to meet the language and cultural needs of its diverse clientele, many of whom do not 

speak English, by hiring bilingual and multicultural staff members. 

Key Challenges: It is a challenge for one lactation consultant to provide adequate supervision 

for the PCs. In addition, the program initially did not have office space, so many counselors 

worked from home, adding to the challenge of providing adequate supervision. Turnover has 

also been a concern. 

 10 Telephone interview, April 25, 2003. 

11 Founded in 1996, the California Endowment is a private health foundation that resulted 

from the creation by Blue Cross of California of the for-profit WellPoint Health Networks 

Corporation. With $3 billion in assets, the organization provides grants to local community 

organizations in the state. 
26

 

BACKGROUND 

County Characteristics. Alameda County has a population of 1.5 million, based on an 

estimate for 2001. In 2000, 41 percent of the population was white, 20 percent Asian, 20 percent 

Hispanic, and 15 percent African American; the last three figures are higher than the state 

average. Over one-third of the population speaks a language other than English in the home. 

Out of 58 counties in the state, Alameda ranks 46th in poverty and 45th in childhood poverty, 

with 11 percent of the population below the poverty level in 2000, compared to the state average 

of 14 percent (rankings from California Food Policy Advocates 2003). 

Contra Costa County has a population of almost 1 million. In 2000, 58 percent of residents 

were white, 18 percent Hispanic, 11 percent Asian, and 9 percent African American. About 

26 percent of the population speaks a language other than English in the home. About 8 percent 

of the county lives below poverty, lower than the state average. 

Program History and Objectives. In 1989, the City of Berkeley WIC Director started a 

peer-counseling program (the precursor to the current program), after learning about the concept 

during a breast-feeding session at a National Association of WIC Directors conference. WIC 

mothers were identified as potential PCs if they had exclusively breast-fed an infant for at least 

seven months and had an interest in becoming a PC.12 At that point, it seemed there would not 

be enough funding to pay the PCs, but women were interested anyway. At the start, 35 women 

voiced interest in the program, 15 attended the training, 10 completed the training, and 6 were 

hired on a temporary basis at an hourly wage. A small amount of funding came from the WIC 

budget and Chez Panisse, a Berkeley restaurant that gives the WIC program money for 

emergency food for clients. The restaurant agreed that some of these emergency food funds 

could be used to pay PCs. This program, targeting Berkeley WIC clients, operated for several 

years. However, WIC funding was reduced as WIC participation declined, and the program did 

not have enough funds to sustain itself. 

Around the time the breast-feeding program was in danger of being eliminated due to 

reduced WIC funding, the WIC Director learned about grant funding through the California 

Endowment. In order to receive funding, however, she had to expand the peer-counseling 

program beyond the Berkeley WIC clientele into the community, including the hospitals. It took 

about a year to apply for and receive funding. In 2001, the City of Berkeley received $500,000 

to operate the expanded project until September 30, 2003.13

12 Exclusive breast-feeding is used here to mean giving no formula, but would include 

feeding solids as appropriate. 

13 This profile discusses activities prior to September 30, 2003, when the California 

Endowment grant formally ended. As of October 1, 2003, the program is continuing on a 

smaller scale. There is some unspent money from the California Endowment, which is funding 

the lactation consultant and two of the PCs. This money continues to be matched by the 

California Nutrition Network. Program officials anticipate that this money will last until funding 

from the $15 million earmarked by the U.S. Department of Agriculture (USDA) for breastfeeding PC programs becomes available. In addition, three WIC Programs are paying for some 

of the PCs’ time. 
27

Target Population. As part of the grant, City of Berkeley PCs serve all WIC clients and 

low-income residents of northern Alameda County and some parts of Contra Costa County. PCs 

also provide services at Alta Bates Hospital, which is in Alameda County but serves non-county 

residents also. 

WIC Program Background. Alameda County has seven WIC clinics, with a total monthly 

caseload of 33,650 participants. The county has one mobile outreach unit that provides WIC 

services at social service agencies, hospitals, and at private obstetricians’ and pediatricians’ 

offices throughout the county. The WIC program sponsors a Farmer’s Market Nutrition Program 

(FMNP) for pregnant women. The program has also worked to increase the ethnic, gender, and 

language diversity of the staff. In addition, they have increased participation by providing 

Saturday services at the Hayward WIC site in the southern portion of the county. 

In Alameda County’s Berkeley program, 9 percent of participants are pregnant, 13 percent 

breast-feeding, 4 percent non-breast-feeding postpartum, 23 percent infants, and 50 percent 

children. The Berkeley program offers two breast-feeding classes to prenatal clients in English 

or Spanish. The first class covers the advantages of breast-feeding; the second discusses breastfeeding techniques. There is also a postpartum breast-feeding class. Clients have access to an 

electric pump loan program, a breast-feeding “warmline,” and an incentive program for longterm breast-feeding. 

The Contra Costa County WIC program has four clinics that provide basic WIC services in 

English, Spanish, Vietnamese, Laotian, Tagalog, and Igbo. The program serves 16,500 

participants. Of these, 11 percent are prenatal, 12 percent breast-feeding, 6 percent non-breastfeeding postpartum, 25 percent infants, and 46 percent children. The program provides two 

prenatal breast-feeding classes and a Spanish-speaking support group. To promote long-term 

breast-feeding, there is an incentive program that recognizes mothers who breast-feed 

exclusively for 6 and 12 months. In addition, the program has an electric pump loan program 

and a toll-free warmline. The WIC program collaborates with the Child Abuse Prevention 

Council to provide discharge bags with gifts and information for breast-feeding moms in the 

hospital. Staff provide referrals to the PC program and in-person lactation assistance. 

PROFILE OF INNOVATIVE PROGRAM 

Services Provided. PCs contact and counsel clients primarily in the hospital and over the 

telephone. They call from home or from the breast-feeding office when making telephone 

contacts. The PCs typically provide one-on-one counseling, referrals, some written material, and 

electric or manual pumps if needed. They address current breast-feeding status, combination 

feedings, common problems (such as engorgement, sore nipples), and length and frequency of 

feedings. They also discuss the mother’s diet and the use of vitamin supplements. PCs use a 

protocol to refer complicated cases to a lactation consultant or other medical authority. The PCs 

distribute their home phone numbers and will identify the best time to call a client. Home visits 

and appointments at the WIC clinic are less common and are made when clients are having 

breast-feeding difficulties, in which case lactation consultants are responsible for the 
28

consultation. However, the PCs are encouraged to be present at the consultations to increase 

their counseling skills. 

All City of Berkeley prenatal WIC clients are enrolled in the program. Ideally, PCs contact 

Berkeley prenatal WIC clients during the seventh month of pregnancy. Other WIC clients and 

non-WIC clients are enrolled in the hospital, where PCs make rounds six days a week to identify 

and assist WIC clients or other low-income women. The latter can often be identified because 

they participate in MediCal. The hospital lactation consultant assists the PCs in targeting the 

appropriate women. Specifically, the PCs identify WIC and low-income clients from a list they 

receive of hospital patients. 

In the hospitals, the PCs go from room to room explaining the program and checking 

whether the woman is eligible based on income and residence. If she is eligible and would like 

to participate, then she is enrolled in the program and given bedside assistance. The enrollment 

forms are returned to the WIC lactation office, and the WIC lactation consultant considers age, 

location, language, and ethnicity to match the client with a PC to provide followup. The hospital 

lactation consultant supervises the counselors while they are in the hospital. The PCs will refer 

clients who need additional assistance to the hospital lactation consultant. The two positions 

work together, and the PCs are considered part of the health care team. 

After delivery, all clients are followed for one year or until they stop breast-feeding. The 

goal is to have contacts with breast-feeding clients at 2–3 days, 5–7 days, 10–14 days, 1 month, 

3 months, 6 months, 9 months, and 1 year after delivery. These contacts are primarily over the 

telephone. 

The grant requires that program staff include bilingual and multicultural PCs to meet the 

needs of clients from different cultures and of those who do not speak English. The program has 

PCs who speak Arabic, Spanish, and various dialects of Chinese, Vietnamese, and Korean. In 

the hospital, PCs try to identify monolingual women in need of assistance in their own language, 

regardless of their income. 

Participation. The grant from the California Endowment specifies that 2,250 women a year 

should be served; however, the program has been averaging about 1,600 a year. 

Coordination and Collaboration. The Alta Bates Hospital agreed to have PCs provide 

breast-feeding support and information to their patients. 

Publicity and Outreach Efforts. A hospital lactation consultant and the PCs publicize the 

program by word of mouth and through handouts. Most of the physicians that see the Medi-Cal 

and low-income clients know about and refer patients to the program as well. 
29

 

ORGANIZATION AND MANAGEMENT 

Staff and Organizational Structure. One lactation consultant and 17 PCs staff the 

program, including the 6 original PCs from 1989.14 Of these, 15 are paid $18 an hour and 

2 volunteer their services. The PCs are temporary employees who have breast-fed their own 

children, have an interest in being a PC, and are flexible and willing to work evenings and 

weekends.15 Potential candidates complete an application and are interviewed. Some are then 

selected to participate in the training, without compensation. After completing the training, 

candidates take an exam. The results are used, in part, to determine who is hired. The number of 

hours they work varies a great deal with their language abilities, as some languages are in 

demand more than others. Some of the PCs work other part-time or full-time jobs as well, 

sometimes even for the WIC peer-counseling programs of other counties. 

Training and Quality Assurance. Initially, the program contracted with the La Leche 

League to conduct train-the-trainer sessions for lactation consultants, lactation educators, and 

WIC nutritionists. After trying this and using various training curricula, program officials 

developed their own PC training manual and curriculum. The WIC lactation consultant 

facilitates the 24-hour training, which addresses anatomy, common breast-feeding problems and 

how to help, cultural differences, and nutrition. Since receiving the California Endowment grant, 

there have been two trainings for PCs. In addition, PCs receive in-service training at a biweekly 

staff meeting. For quality assurance, the lactation consultant regularly observes PC activities and 

reviews charts. 

Record Keeping and Data Systems. The WIC Director provides the California 

Endowment with program updates every six months, as the grant requires. PCs are expected to 

document every client contact. Standardized forms, in triplicate, are used. One copy goes to the 

hospital, one goes to the PC, and one is sent for centralized processing into the WIC computer 

system.

Funding. The California Endowment grant is for $500,000. Since 2001, the California 

Nutrition Network has given 50 cents for every $1 spent of the California Endowment funding, 

increasing the total by almost another 50 percent. Most salaries are covered in the grant, but two 

are paid with WIC funds. The main cost of the program is the salaries of the PCs. 

ASSESSMENT AND LESSONS LEARNED 

Program Strengths. When the grant was submitted in 2001, the exclusively breast-feeding 

rate in Berkeley was 29 percent.16 As of November 2003, it was 35 percent, which was the goal 

14 In addition, an hourly lactation consultant is available when the full-time consultant is on 

vacation. 

15 In most cases, PCs have breast-fed a child for at least seven months, but program officials 

do make some exceptions. 

16 A PC program was already in place at this time in Berkeley. 
30

outlined in the grant. The state rate was 10.8 percent in November 2003. These results are 

promising, although it is not possible to say definitively that this is attributable to the peercounseling program. In addition, the WIC Director has noticed that exclusive breast-feeding 

almost always leads to breast-feeding for a year or more. 

The program’s success reflects the PCs and the support they receive from the lactation 

consultant. It is critical to have a full-time lactation consultant on-call after-hours to provide 

support and assistance to the PCs. It is also essential that breast-feeding education start early, 

even before a woman becomes pregnant. In general, clients give positive feedback about the 

program and look forward to receiving a call from their PC. In addition, PCs have an 

opportunity for career growth with the program. For example, one of the original PCs is now a 

supervising lactation consultant. 

Key Challenges. Staffing was difficult at first, as many of the new PCs required significant 

support and training. In addition, there was only one lactation consultant to meet this need. 

Having two lactation consultants supervising the program would be ideal so that there would be 

more time to review the PCs’ case notes, monitor and observe activities, and schedule individual 

meetings with the PCs. It is also a challenge to supervise a staff that works primarily from home, 

though biweekly PC staff meetings enhance communication. Staff turnover has been an issue as 

well. Some PCs have been terminated because they did not like to do paperwork or were 

providing inaccurate information. Others resigned because they felt “burned out” from being on 

the phone so much with clients, or they had personal issues to deal with. The WIC Director finds 

that her most stable PCs are married and have support at home to do this work. 

Quality control and assurance has been a major challenge. PCs did not have office space 

until after the first year of implementation. During that time, PCs had no choice but to work 

from home without direct supervision. Some staff members took advantage of this system and 

were terminated. The WIC Director remarks that it is “extremely important” to have adequate 

space, telephones, furniture, and equipment in place before the PCs are hired, as well as to have 

the proper ratio of professional staff to PCs.

Lessons Learned. The WIC Director believes that this project can be replicated at other 

agencies, but she recommends that someone with experience in implementing a PC program be 

consulted. It is critical to get support and buy-in from the WIC agency and community 

stakeholders. The hospital component is very important, too, so that women can be contacted 

immediately after delivery, when establishing breast-feeding relationships is critical. The WIC 

Director also recommends paying the PCs a “decent” salary. Other counties that have started 

similar programs have lost PCs because the pay was inadequate. Finally, the WIC Director 

suggests following clients for six months after delivery and then providing them with contact 

information if they have questions or problems. It is difficult to follow clients for more than six 

months, especially as the PCs are busy enrolling new clients and so many old ones are becoming 

unreachable. 
31

CONTACT INFORMATION 

Ellen Sirbu, MS, RD 

WIC Director 

City of Berkeley 

830 University Avenue 

Berkeley CA 94710 

Phone: 510-981-5131 

Fax: 510-981-5385

E-mail: esirbu@ci.berkeley.ca.us 

33

TELEPHONE PEER COUNSELING BY VOLUNTEERS17

SOUTHWEST PENNSYLVANIA 

OVERVIEW 

Location: Washington and Greene Counties, Pennsylvania 

Start Date: 1993 

Target Population: Pregnant and breast-feeding WIC participants 

Purpose: To encourage mothers to breast-feed and provide them with regular breast-feeding 

support after they start. 

Services: The program trained volunteer breast-feeding peer counselors (PCs) to contact WIC 

participants during pregnancy and after birth, and to continue regular followup as long as they 

are breast-feeding. They provide support, routine breast-feeding assistance, and referrals to other 

sources of care, with supervision and backup from a lactation consultant. 

Funding: The program, which cost very little, was paid for out of WIC breast-feeding funds. 

Why Program Was Chosen: This program is unusual in that, over a period of 10 years, breastfeeding peer counseling was conducted by volunteers only. The PCs were trained and 

supervised by a lactation consultant. All services were provided by telephone from the 

counselors’ homes, so that PCs could integrate their work with their home responsibilities. 

Although this type of program seems a useful model for agencies with tight funding, the agency 

is now moving to the use of paid PCs, because of the challenges noted. 

Key Challenges: It became increasingly difficult to recruit volunteers. The limited availability 

of volunteers and the limited number of hours they could work meant the program could not 

serve all breast-feeding clients and that PCs contacted pregnant women only once. 

 17 Telephone interview, May 24, 2003. 
34

BACKGROUND 

Community Characteristics. Washington County is part of the Pittsburgh metropolitan 

area and adjoins Allegheny County. Its 2001 population was 200,000. Greene County is a rural 

(nonmetropolitan) county with a population of just over 40,000. It has a high poverty rate 

(15.9 percent in 1999 versus 11 percent for Pennsylvania as a whole). The populations of both 

counties are 95 percent white. 

WIC Program Background. The WIC agency for Washington and Greene Counties is 

Community Action Southwest, a large community action agency that also sponsors Head Start 

and other family literacy programs, as well as the Child and Adult Care Food Program, among 

others. The program sponsors 13 WIC clinics throughout the area, one open 5 days a week, two 

open 3 days a week, two open 2 days a week, and others open less often (ranging from one day a 

week to once every two months). The less-frequent clinics are in locations like community 

centers and church basements. Fourteen full-time WIC staff and 3 part-time staff move around 

between the various locations. Each month the agency serves 4,800 WIC participants and has about 

125 prenatal participants giving birth.

Program History and Objectives. The objectives of the Telephone Peer Counseling 

Program are to encourage breast-feeding initiation and duration by providing mothers with 

support from knowledgeable mothers in their own community. The program began in 1993, 

when the Breastfeeding Coordinator (who is now both the Breastfeeding Coordinator and the 

Nutrition Services Director [WIC local agency director]—hereafter, the Director) heard about the 

Texas peer-counseling program and, to save scarce WIC funds, decided to try something similar 

with volunteers. Before the peer-counseling program started, the Director saw mothers at the 

WIC clinics who needed help, took phone calls from mothers with breast-feeding questions, and 

worked with mothers with breast-feeding problems who were referred by WIC staff. She also 

tried to call prenatal participants soon before delivery to talk about breast-feeding and to provide 

support to mothers who breast-fed after birth, but she could not call everyone. 

The Director led the development of the program. She attended the Texas Peer Counselor 

training, which gave her useful background. She developed the idea of volunteer PCs who were 

WIC mothers (or former WIC mothers) working out of their own homes. The program would 

provide a monthly stipend of $25 to PCs to cover the cost of the phone and occasional trips to the 

WIC office for meetings. She also decided that PCs would serve only clients in their local 

calling areas, so they would not have to pay for toll calls. 

She then recruited PCs. The original group was recruited through ads in the WIC program 

newsletter and recommendations from WIC staff—mostly the latter. The first training lasted 

three full days and was conducted in person. Ten women started the training, and six completed 

it and became PCs. 

PROFILE OF INNOVATIVE PROGRAM 

Services Provided. PCs made an initial call to prenatal participants four to six weeks 

before their due date. Using open-ended questions, they asked the expectant mother how she felt 

about breast-feeding, and told her they were available to help if she decided to breast-feed. The 
35

PCs gave pregnant women their home phone number. If a woman was adamant that she would 

not breast-feed, they did not call back, but if she wanted to breast-feed or was unsure, they tried 

to call as soon as possible after the birth. Sometimes, they heard of the delivery from WIC staff, 

but otherwise they tried calling around the due date to see how things were going, and called 

back if the mother had not yet delivered. 

Although PCs gave out their home phone numbers, clients rarely called them. Instead, the 

PCs initiated most calls. The program’s goal was that a PC would call a breast-feeding mother 

two or three times a week in the first month after birth, once a week in the second month, and 

about once a month thereafter, until weaning. However, they adjusted this schedule based on 

what worked for each mother—if she was experienced, she may have needed only occasional 

calls from the start; if she was having problems, she may have needed a call every day. Clients 

were often too overwhelmed to ask for help, but they were very appreciative when the PCs 

checked on them. 

The PCs were also trained to give referrals and to alert mothers when a problem might be 

serious enough to require the doctor. PCs referred complex breast-feeding problems to the 

Director. They also made referrals to community agencies for services such as counseling for 

depression, women’s shelters for domestic violence, help with getting a crib or diapers, and so 

forth. Each PC came to know the resources in her area well. If a mother was referred to a doctor 

in an emergency situation, the Coordinator was also notified—but this happened only a few times in 

10 years. 

Coordination and Collaboration. There was no formal collaboration between the 

volunteer program and other programs, but the community has become more supportive of 

breast-feeding over time. When the PC program started, the WIC Director was the only 

Internationally Board Certified Lactation Consultant (IBCLC) in the area. Hospitals did not have 

“rooming in” of babies with their mothers, and very little breast-feeding support was available. The 

A PROGRAM IN TRANSITION 

Community Action Southwest has recently moved to paid PCs, with the hope that they can 

serve more mothers. The agency joined a consortium with two other local WIC agencies and 

received U.S. Department of Agriculture (USDA) funding for two PCs, who will each work 10 

hours a week in an office setting. Two of the volunteer PCs were hired as the first paid PCs at 

the agency, so they needed minimal training. The PCs are now covered by a union contract and 

were hired under union rules. 

Our interview with the Director took place one month before these changes went into effect. 

At that time, the Director expected to discontinue using the volunteer PCs, because of union 

rules and because the paid counselors may be able to handle the full caseload. She also hoped 

the paid PCs will be able to make more prenatal contacts, to try to increase breast-feeding 

initiation as well as duration.
36

level of support has changed a great deal in the past 10 years. All but one of the local hospitals have 

lactation consultants, all have rooming in, and a lot more support is available in the community. 

Participation. The peer-counseling program reached about half of new mothers in the two 

counties (a little over 60 a month), largely because not all mothers were in the local calling areas 

of one of the PCs. The Director used to call expectant and breast-feeding mothers in areas 

without PCs, but she has not been able to since she became the Nutrition Services Director three 

years ago. Thus, the more rural areas, which are less likely to have PCs, tend to be underserved. 

About 30 percent of WIC mothers choose breast-feeding (about 20 a month among those 

contacted) and receive additional follow-up calls from the PCs as described above. 

Publicity/Outreach. The agency has not done publicity or outreach for the peer-counseling 

program, because they have never had enough PCs to cover all WIC women giving birth. 

However, there is a brief description of the peer-counseling program on the WIC part of the 

Community Action Southwest Website.

ORGANIZATION AND MANAGEMENT 

Staff and Organizational Structure. The Director supervised the program; she recruited 

the PCs, trained them, and reviewed their work. In the volunteer program, there have generally 

been seven to nine PCs at a time. During the early years, PCs tended to stay 4 to 5 years (and 

one stayed 10 years), but now they stay about 2 years. In part, the shorter tenures reflect welfare 

reform and increased pressure to take a paid job. In addition, PC experience motivates some 

mothers to move into the workforce, particularly as their children get older. Some PCs, 

however, continue peer counseling after they start paid work, but handle fewer cases. 

PCs must have breast-fed a child for at least 6 months (all the current PCs breast-fed over a 

year) and have children no younger than 6 months old. They have to be former or current WIC 

participants. Women interested in becoming PCs filled out an application form and a survey in 

which they described their breast-feeding experience. The PCs received a $25 monthly stipend 

for months in which they worked at least five hours. The PCs set their own hours, with the 

stipulation that they should call clients only between 9:30 A.M. and 8 P.M., unless clients gave 

them permission to call at another time. Most worked 5 to 10 hours a month. 

The WIC agency used the computer to assign prenatal clients who will deliver soon to PCs 

in their local calling area. Each PC was assigned 15 to 20 pregnant clients a month, of whom 

about 5 would breast-feed. The contact lists were mailed to the PCs. 

Training for Peer Counselors and Quality Control. The Director developed the original 

training and has updated it regularly. Initially, it was based on the training materials of the Texas 

peer-counseling program. Later, she changed it to include the same breast-feeding material used 

in training WIC staff. The Director had helped develop this statewide curriculum. The training 

also covers issues related to confidentiality, material on maternal and child nutrition, and a 

section on making referrals: when to refer to the Director (who is an IBCLC), WIC staff, and 

community agencies, and especially when to tell the mother to call the doctor, with procedures 

for following up to make sure the doctor was contacted. The Director also does most of the 

training, but sometimes other WIC staff have delivered parts related to child nutrition or WIC 
37

 

procedures. The training initially was in a small group, but has increasingly been one on one, as 

new counselors joined the program one at a time as previous counselors left. 

When a new counselor joins the program, the training includes only 12 hours of in-person 

training, and then from 8 to 15 hours of telephone training, in which the Director role-plays 

being the client. The Director trains the new PCs on how to handle introductory calls (including 

what to do if people are rude or hang up), and on how to handle the most common breast-feeding 

problems. Practicing counseling over the telephone works much better than practicing in person, 

as the PCs are forced to practice giving explanations and instructions without visual aids—for 

example, explaining the proper way to get the baby to latch on to the breast. 

The Director was in frequent contact with trainees during their first month—she was often 

on the phone with each of them for two to three hours a week. Afterwards, she found they 

needed little supervision; she just called them once a month to check in. She tried to meet with 

the PCs at least quarterly, but met with them less frequently in the past year, because of the press 

of her other duties. 

The Director received contact forms (discussed below) from PCs when the baby was 

weaned. She called about six randomly selected mothers who had weaned each quarter and 

asked them how it was to work with the PC. This provided a form of quality control. 

Record Keeping. The Director designed a contact sheet for counselors to fill out for each 

client. It had basic contact information on the mother, and a section in which to enter data on the 

baby after the birth. It also included a checklist for types of contacts and issues PCs often 

encounter. On the back was an infant assessment that the PCs reviewed with the mother to 

determine whether the baby was having any trouble. This assessment, which included questions 

such as how many wet diapers the baby had per day, was used during every call for the first two 

months after birth, and sometimes later if needed.18 At the end of the form, the PCs attached 

notes on each contact. They mailed the form back to WIC when the baby was weaned. 

Funding. The only concrete cost for the program (when operating as a volunteer program) 

was the PC stipends, which came to $2,000 to $3,000 a year. The stipends were funded out of 

WIC breast-feeding funds. (Some of the counselors worked fewer than 5 hours a month and thus 

did not get stipends.) The Director’s time was not really an extra cost—she would have been 

calling mothers herself if she had not had PCs to do it. She spent only about one day a month 

checking in on PCs, except during training periods. If anything, the WIC agency may have 

saved money from having PCs, as they handled the more routine breast-feeding issues, so the 

Director did not have to. 

18 The Director noted that the assessment was especially important when mothers did not see the 

pediatrician until two weeks after birth. Now, babies have a three-day checkup visit, which helps in 

catching early feeding problems.
38

ASSESSMENT AND LESSONS LEARNED 

Program Strengths. The program is interesting because it is an example of a successful 

peer-counseling program implemented in a largely rural area. In addition, it has been staffed by 

volunteers, which has kept the cost very low. 

There is some evidence that the PCs have succeeded in improving the duration of breastfeeding among WIC mothers who initiated it, but they do not seem to have affected initiation 

rates. In particular, in the early years of the program, the Director monitored breast-feeding 

initiation and duration rates among clients in each clinic her agency ran. Average breast-feeding 

durations were much longer in clinics with PCs in the area than in clinics with no PCs (12 to 

18 weeks versus 4 weeks), but initiation rates were no different (about 30 percent throughout the 

area). Lately, she has not monitored these rates, because of her additional responsibilities and 

because of a recent switch to a new computer system. Because the PCs have had the resources to 

make only one contact during pregnancy, the Director believes they have not affected initiation rates. 

Clients are very positive about their PCs. When the director calls to get feedback on the 

PCs, she often hears comments from mothers such as that they could not have breast-fed as long 

without the support of the counselor. Other typical comments include how the counselor did not 

make them feel bad for weaning, but praised them for breast-feeding as long as they did. 

Another positive outcome of the program was the PCs’ increased self-confidence and new 

skills learned, which have helped them to pursue further education or to enter the workforce. 

Key Challenges. The major challenges this program faced included the difficulty finding 

volunteers in the more rural parts of the counties and the limited hours that most volunteers were 

willing to work. These problems limited the ability of the program to serve all women giving 

birth in the two counties. They also meant that the program did not have the resources to contact 

pregnant women more than once. Now that they have a regular, paid staff, the WIC agency 

hopes to increase its contacts with pregnant women. Another issue has been the limited time 

available for the Director to supervise the program, as funding constraints have forced her to take 

responsibility for both the overall administration of the WIC program and for the coordination of 

breast-feeding promotion. Additional funding for WIC nutrition services or funding from other 

sources would alleviate these problems. (As noted, outside funding was received for the move to 

paid PCs.) 

Lessons Learned. The WIC Director for Washington and Greene counties believes that 

volunteer breast-feeding PCs could be useful in an agency that is short of funding, but that they 

could not be expected to stay as long as her original group did. Her experience was that once the 

counselors were trained, she did not need to spend much time monitoring them. 

The program is unusual in that it allows PCs to work out of their homes, but the results 

suggest that this model can work. Telephone counseling out of the home seems of particular 

value in a rural area, where transportation is not always available. The use of telephone training 

to help counselors prepare to provide assistance over the telephone may be of interest to other 

programs. The restriction of the PCs to local calls was a concern; other agencies might want to 

explore different options for telephone connections. 
39

CONTACT INFORMATION 

Rosa Snyder-Boyd, IBCLC 

Nutrition Services Director 

Community Action Southwest WIC Program 

150 W. Beau St., Ste. 304 

Washington, PA 15301 

Phone: 724-225-9550, ext. 441 

Fax: 724-228-8975 

E-mail: rsnyderboyd@caswg.org 

41

B. MULTIFACETED PROGRAMS WITH STRONG OUTREACH COMPONENTS 

This section describes programs that include readily available individualized help, either by 

phone or in-person, complemented by extensive outreach to community health professionals to 

“sell” the idea that WIC supports breast-feeding and is not just a source for infant formula. Two 

of the programs (Riverside and Miami) provide the support largely through a hotline with inperson meetings as a backup, while one (Sacramento) provides support largely through clinic 

appointments with lactation consultants. These programs also include a wide range of other 

services, which are summarized in Table II.1. 

TABLE II.1 

BREAST-FEEDING SUPPORT SERVICES AVAILABLE IN 

MIAMI, RIVERSIDE, AND SACRAMENTO 

Services Miami Riverside Sacramento 

Training programs for WIC staff and/or other health professionals X X X 

Incentives for mothers X X 

Support groups X X 

In-hospital counseling and/or support to hospital staff X X 

In-person counseling in WIC clinics available daily X X 

Breast pump program with a large stock of pumps available X X X 

Calling mothers at regular intervals X X 

24-hour helpline Xa X 

Home visits X 

Peer counseling X X 

a

In Miami, the helpline is staffed during the day, and an answering machine is used at night and on weekends. The 

machine is only checked occasionally, so the helpline does not have full 24-hour coverage.

Two of these programs (in Riverside and Sacramento) have extensive outside funding. The 

Riverside program serves all women in the county, which clearly makes it a “WIC Plus” 

program for which outside funding is appropriate. The Miami program, which does not have 

non-WIC funding, is a good example of comprehensive services in a more constrained budgetary 

environment. 

43

LOVING SUPPORT BREAST-FEEDING PROGRAM19

RIVERSIDE COUNTY, CALIFORNIA 

OVERVIEW 

Location: Riverside County, California 

Start Date: Breast-feeding services have been available since 1982 to WIC clients, a 24-hour 

telephone helpline began in 1997 for WIC clients, and helpline services were expanded to all 

Riverside County residents in 2000. 

Target Population: All pregnant and breast-feeding women who live in Riverside County. 

Purpose: To meet the Healthy People 2010 breast-feeding objectives by providing help and 

support to breast-feeding women and collaborating with the health professionals that care for 

them. 

Services: 24-hour helpline, individual assistance, prenatal education, educational materials and 

incentives, breast pump program, outreach to the medical community, training of health 

professionals, outreach to employers. 

Funding: $480,000 from California’s Proposition 10 Tobacco Tax Initiative, and several 

hundred thousand more in special grants from the state WIC agency, plus some smaller grants 

and in-kind contributions. 

Why Program Was Chosen: This program offers breast-feeding support 24 hours a day, 7 days 

a week, 365 days a year to all county residents through a helpline. Focusing outreach on one key 

message, “contact the helpline if you need breast-feeding assistance,” is one key to the program’s 

success. In addition, Breastfeeding Representatives, who are responsible for a geographical 

territory, conduct outreach similar to that done by formula company representatives. The rich 

menu of services and extensive outreach and training offered to health care professionals work 

together, yet some subset may be useful to other agencies with less-generous funding. 

Key Challenges: At first, it was challenging to convince community health professionals to 

refer patients to the breast-feeding helpline, but extensive outreach has largely overcome their 

reluctance. At this point, an important challenge is to keep a high level of services as the 

popularity of the program grows. The geographic dispersion of the county’s population is also a 

challenge. 

 19 Telephone interview, May 13, 2003; site visit, August 12-13, 2003. 
44

BACKGROUND 

County Characteristics. Riverside County is one of the fastest growing counties in the 

United States. In 2001, the population was 1.6 million, with a 5.9 percent increase between 

April 1, 2000, and July 1, 2001. The population is growing as people migrate to the county for 

the lower cost of housing and living. In addition, businesses are relocating from Los Angeles 

and San Diego to the county because of lower real estate costs. It is also a large county in land 

area, comprising 7,207 square miles, about half of which is desert, and extending from Orange 

County to the Arizona border. According to 2000 figures, 66 percent of the population is white 

and 19 percent report some other race, both of which are higher than the California average. In 

addition, about 6 percent of the population is African American and 4 percent is Asian; both 

figures are lower than the state average. Regardless of race, 36 percent are of Hispanic or Latino 

origin. In 1999, 14 percent of the population of both California and Riverside County lived 

below the poverty level, higher than the national average.

WIC Program Background. The Nutrition Services Branch of the Riverside County 

Department of Health (which is the local WIC agency) has a $9.3 million annual budget and 

170 staff, including 40 dietitians. Funding streams include the U.S. Department of Agriculture 

(USDA), Proposition 10, California Nutrition Network, California Health and Disability 

Prevention Program, and medical nutrition therapy insurance reimbursement. The department is 

responsible for WIC, Loving Support, and a range of other nutrition programs. 

The caseload that Riverside WIC handles is larger than or comparable to that of some states. 

The WIC program serves 60,000 clients a month in 18 clinics. According to August 2003 

figures, 75 percent of participants are Hispanic, 53 percent speak English, about 10 percent are 

prenatal women, and 5 percent are breast-feeding mothers. Monthly clinic census ranges from 

800 in the smallest clinics to 10,000 in the larger ones. Proposition 10 funds allowed WIC to 

expand clinic hours to some evenings and weekends, and to serve an additional 3,000 clients 

each month. The WIC Customer Service Center is a centralized call center that answers a tollfree number for people inquiring about WIC or scheduling a clinic appointment. On average, the 

call center receives 10,000 to 14,000 calls a month. 

Program History and Objectives. Since 1982, the Riverside WIC program has provided 

comprehensive prenatal education, lactation education, and breast-feeding support groups for 

WIC clients, as well as extensive staff training. However, WIC staff did not have the time to 

provide much individualized counseling and help with breast-feeding. The breast-feeding 

helpline began in 1997, but at that time, it was available only to WIC clients and operated only 

during regular business hours. The helpline came into being because WIC staff members saw 

that by the time women came to enroll their infant in WIC, it was too late to address breastfeeding problems, since many mothers, lacking support and assistance, had already stopped 

breast-feeding. In addition, women who were not enrolled in or eligible for WIC received 

limited, if any, information and support. 

California voters passed the Proposition 10 Tobacco Tax Initiative, part of the Children and 

Families Act, in November 1998. The proposition increased tax on cigarettes and tobacco 

products to fund intervention services for young children and their families. The Nutrition 

Services Branch applied for and was awarded Proposition 10 funds from the First 5 Riverside 
45

 

Commission to expand and enhance the existing breast-feeding services to all Riverside County 

residents, not just WIC participants. Upon receiving the funding in 2000, program officials 

classified all breast-feeding supportive services under the umbrella name “Loving Support 

Breastfeeding Program.”20 The program also began extensive community outreach at this time, 

with both clients and health care professionals. 

Loving Support is committed to meeting the Healthy People 2010 objectives pertaining to 

breast-feeding: (1) 75 percent of new mothers must leave the hospital breast-feeding after 

delivering their babies; (2) 50 percent of new mothers must continue to breast-feed their babies 

for the first six months of life; and (3) 25 percent of new mothers must continue to breast-feed 

their babies for at least one year. 

To meet these goals, Loving Support developed five “Standards for Success”: (1) increased 

numbers of pregnant women will receive accurate and reliable information regarding the 

importance of and how to initiate breast-feeding; (2) increased numbers of newly delivered 

mothers will receive information, support, and help for breast-feeding in the immediate 

postpartum period; (3) increased numbers of women will be successful at breast-feeding their 

babies through at least the first year of life; (4) increased numbers of mothers will continue to 

breast-feed after returning to work or school; and (5) standardized reports using collected data 

will be generated on a quarterly basis to demonstrate the successes in the first four standards. 

Target Population. Loving Support targets all pregnant and breast-feeding women in 

Riverside County. WIC also offers additional breast-feeding services only for WIC clients. The 

program also conducts substantial community outreach targeting health care providers and 

employers. 

PROFILE OF INNOVATIVE PROGRAM 

Loving Support offers a wide range of breast-feeding services for all county residents, but 

the WIC clinics provide additional breast-feeding services to WIC clients. Although Loving 

Support and WIC are separate programs, they are very integrated. Because the line is difficult to 

draw, and the WIC services would at any rate be important in context, we discuss the full range 

of breast-feeding support services offered by the Riverside County Department of Public Health 

in this section, indicating when services differ for WIC clients and others. 

Services Provided to Parents/Caregivers 

Helpline. A toll-free breast-feeding helpline is available to all Riverside County residents. 

Support, encouragement, and technical assistance are provided 24 hours a day, 7 days a week, 

365 days a year. Two full-time Helpline Counselors, who are lactation educators, manage the 

calls during weekday business hours. The Breastfeeding Representatives and the Breastfeeding 

20 The program purchased the rights to use the Loving Support logo and name from Best 

Start Social Marketing of Florida. 
46

 

Coordinator rotate on-call after-hours duty for the helpline weekly.21 After-hours calls are 

returned within 30 minutes. 

The helpline addresses a variety of concerns: breast abrasions, infant thrush, medication 

safety, alcohol consumption, latch on, infant weight loss, jaundice, weaning, and pumping due to 

mother and infant separation. Some mothers receive so little support from family and friends 

that often they simply need a friendly voice to encourage rather than criticize them. The 

Helpline Counselors use the La Leche League International’s Breastfeeding Answer Book

protocols, which are available in English and Spanish and on CD-ROM (Mohrbacher and Stock 

2003). 

In addition to receiving incoming calls, Helpline Counselors call mothers who fill out and 

mail postage-paid postcards requesting enrollment in the Loving Support Program. WIC 

participants receive a postcard, included in a WIC Last Trimester Help Bag, during their lasttrimester counseling session. To reach additional mothers, Certified Nurse Assistants and other 

medical staff members distribute these postcards to new mothers in hospitals after delivery. 

Riverside County Public Health Nurses, the Tobacco Free Families Health Education Program, 

and the Black Infant Health Program also distribute the postcards to pregnant women. These 

postcards include the mother’s name, contact information, and a request to receive a call from a 

Helpline Counselor and join the program. Calls are made upon receipt and allow the Helpline 

Counselors to provide education, help, and support to new mothers to ensure that breast-feeding 

gets off to a good start. Helpline Counselors also do follow-up calls to all Loving Support 

Program mothers at critical milestones in the infant’s development (3 weeks, 6 weeks, 3 months, 

6 months, 9 months, and 12 months; or until weaning) in order to offer anticipatory guidance 

regarding growth spurts, returning to work, teething, introduction to solid foods, and weaning 

advice from family or friends. 

In some situations, a Helpline Counselor is unable to provide over the telephone the 

assistance the mother needs. If a serious medical situation is apparent, the Helpline Counselor 

will suggest that the mother seek medical assistance from her physician or, in life-threatening 

situations, go directly to a hospital or call 911. Typically, however, the Helpline Counselor will 

refer a client to a Breastfeeding Representative in the client’s geographical area. 

The average number of calls and the average call length varies, but in a typical day, the 

Helpline Counselor will receive 20 calls and complete 30 follow-up calls. Call length can vary 

from a few minutes to an hour, depending on the need or the number of questions. 

Individual Assistance. Breastfeeding Representatives provide individual assistance to 

mothers primarily in WIC clinics, hospitals, and over the telephone, and to a lesser extent in 

doctor’s offices or in the home. When a Breastfeeding Representative receives a referral from 

the Helpline Counselor, she calls the client to discuss the problem or breast pump need over the 

21 A bilingual Helpline Counselor is teamed with a Breastfeeding Representative for on-call 

duty, if the latter is not bilingual. Staff members are paid for 1 hour for every 8 hours on call but 

not active, and bank compensatory time-and-a-half for time spent responding to calls. 
47

phone and, if needed, schedules a meeting time and place, often at a WIC clinic. Often a mother 

knows what to do but needs in-person reassurance that she is doing everything correctly. In 

other situations, a breast-feeding mother may have pain that warrants intensive assistance. 

Breastfeeding representatives can arrange to see mothers at WIC clinics; some have walk-in 

hours, and others require an appointment, which will be scheduled either the same day or the 

next day. As a standard procedure, after Breastfeeding Representatives provide individual 

assistance, the Helpline Counselors will conduct the follow-up calls. However, some 

Breastfeeding Representatives conduct their own follow-up calls. In general, immediate followup is provided to mothers having serious problems. 

A goal of Loving Support is to help all the county’s 14 hospitals become “baby-friendly,” 

not only by having Breastfeeding Representatives provide bedside counseling to postpartum 

women, but also by training medical staff to provide such support. In general, the Breastfeeding 

Representative trains medical staff members to provide bedside assistance, and the Breastfeeding 

Representative counsels a patient only if a staff member feels it is necessary. In particular, the 

Riverside County Regional Medical Center (RCRMC) nurses in the neonatal intensive care unit 

(NICU) and Obstetrics, Labor, and Delivery unit work with the Breastfeeding Representative to 

ensure that all mothers receive bedside counseling and information on breast-feeding from either 

the Breastfeeding Representative or a nurse. For example, one week after an infant is discharged 

from the NICU, the Breastfeeding Representative and a NICU nurse assess the breast-feeding 

mother and infant. In addition, the hospital has collaborated with Loving Support to offer a 

weekly walk-in lactation clinic for any breast-feeding mother needing assistance. 

Prenatal Education. Prenatal education classes are available only to WIC clients, and are 

facilitated by WIC staff members at the clinics. There are three components in the prenatal 

breast-feeding education efforts: (1) group education topic one month after prenatal enrollment: 

“What have you heard about breast-feeding?” (2) group education topic two months before 

delivery: “What to expect in the hospital,” and (3) individualized consultation and distribution 

of the WIC Last Trimester Help Bags. 

Breast Pump Program. Breast pumps are available on loan to women, including 

teenagers, who are working, going to school, or separated from their infants. Pumps can be 

obtained at WIC clinics, or a Breastfeeding Representative may deliver them to the hospital or 

home. Non-WIC mothers give a $30 deposit, but attachments are given for free from Loving 

Support as part of the Proposition 10 funding. All mothers borrowing a pump sign a pump loan 

agreement. The completed agreements are mailed or faxed to the central Loving Support office 

for input into a pump distribution database. The hard copy of the agreement is kept at the clinic 

or hospital where the pump was distributed. A daily printout, entitled the “Breast Pump 

Availability Report,” is generated and distributed to Loving Support staff to identify which 

clients and clinics have pumps. WIC mothers with breast pumps are flagged in the WIC 

Integrated Statewide Information System so that WIC staff members know to follow up. 

Support Groups. Support groups are available each month at all WIC sites for WIC 

participants and weekly at two hospitals for anyone who is interested. Lactation educators who 

are located in the WIC clinics facilitate the WIC groups. Breastfeeding Representatives, along 

with hospital staff that have been trained by Loving Support, facilitate the hospital-based support 

groups. Topics for discussion include adjusting to parenthood, breast-feeding: a family 
48

experience, returning to work, breast-feeding the older baby, weaning with love, and wearing 

your baby (that is, using a baby sling). Each group has about 20 people, and 2,500 people attend 

support groups each month. 

Materials and Incentives. A Loving Support Prenatal Breastfeeding Education Package is 

sent to all pregnant women who call the helpline to enroll in the Loving Support Program. This 

package includes the pamphlets “Is Breastfeeding Right for Me?”; “Ten Healthy Habits While 

You Are Breastfeeding”; “Ten Ways to Relax While Breastfeeding”; “Ten Tips on How Dad 

Can Help with the Baby”; and “Eat 5 a Day the California Way.” A Loving Support 

introductory letter and refrigerator magnet with the helpline number is included.

WIC participants receive, to take to the hospital for delivery, a WIC Last Trimester Help 

Bag that contains a “Breastfeeding: The Best Start” pamphlet, a 10-day diaper log, a “Dear 

WIC, I had my baby...” postcard, a “Wear Your Love!” necklace flyer, a “No Bottles” sticker, 

and a Loving Support refrigerator magnet. In January 2003, Wear Your Love necklaces were 

added as an incentive for WIC participants to breast-feed exclusively and to attend monthly 

breast-feeding support or nutrition education sessions. The necklace has a baby head charm of 

the appropriate gender, race, and ethnicity, and mothers who breast-feed exclusively receive a 

bead for the necklace when they attend a support group or nutrition education session. 

Loving Support mails inspirational cards to encourage, congratulate, and honor breastfeeding mothers at critical milestones in the baby’s development (3 weeks; 3, 6, 9, and 

12 months). In addition, displays in physician’s offices include a “Take-Away” card that offers 

up-to-date breast-feeding information, helpful hints, and support resources. 

Community Outreach to Medical Professionals 

Loving Support wants to ensure that health care providers have the knowledge and resources 

necessary to help their patients choose and continue to breast-feed. The seven Breastfeeding 

Representatives visit 300 prenatal, pediatric, and family practice care providers and 14 hospitals 

on a monthly or biweekly basis. During a visit, the Breastfeeding Representative will ask staff if 

they have any material or training needs, or any general questions about breast-feeding. The 

Breastfeeding Representatives will also restock educational materials, displays, and take-away 

cards at this time. There are different displays for the obstetricians’/gynecologists’ (OB/GYN) 

and pediatricians’/family practitioners’ offices. Both provide bilingual displays with a Loving 

Support business card, but the former also contains a pamphlet with more details on breastfeeding and Loving Support. Each office receives either the Loving Support Resource Guide for 

OB/GYNs or the Loving Support Resource Guide for Pediatricians/Family Practitioners. Both 

contain information on the Loving Support and WIC programs, the breast-feeding policy 

statement of the American Academy of Pediatrics and the Family Practice Association, 

resources, camera-ready patient handouts, and a section on current research. These guides, 

particularly the current research section, are updated on a monthly basis when Breastfeeding 

Representatives visit offices. In addition, a quarterly Baby-to-Breast newsletter is distributed to 

all partnering health professionals with up-to-date information and resources on breast-feeding. 

In addition, hospitals are provided Loving Support crib cards to replace the pharmaceutical 

companies’ crib cards.
49

Community Outreach to Employers 

In 2002, the Loving Support staff developed the “Breastfeeding Friendly Workplace” 

package to help local businesses comply with California’s AB1025-Lactation Accommodation 

Law, which imposes requirements upon employers concerning safety, work conditions, and time 

to accommodate employees who desire to express breast milk. Loving Support offers to come to 

the workplace and provide technical assistance. 

Participation 

Loving Support wants to reach at least 50 percent of mothers who give birth in Riverside 

County, a challenge considering that there are more than 24,000 infants born each year in the 

county. In the first year of the program, the Loving Support program counseled 5,150 mothers 

between July 2001 and June 2002. Now, on average, Loving Support counsels 4,000 to 5,000 

clients, and the helpline receives or returns 4,000 to 5,000, calls each quarter. Specifically, the 

helpline received or returned 4,412 total calls in April through June 2003. Of those calls, 1,730 

were initial calls and 2,682 were follow-up or repeat calls, representing 2,724 individual 

mothers. During the quarter July–September 2003 the Helpline Counselors received or returned 

4,743 total calls. Of those calls, 1,804 were initial calls and 2,939 were follow-up calls.

The typical helpline client varies, but the helpline receives many calls from first-time or 

young mothers who do not know much about breast-feeding. Most calls are from WIC 

participants, and many initial calls are from new mothers in the hospital who received literature 

or a referral from medical staff. Fathers or male partners will occasionally call on behalf of the 

mother, as will other relatives. It is also common for medical providers to call the helpline for 

information to assist their patients. About 3 percent of calls are from mothers who do not live in 

the county. Loving Support tries to help these mothers over the phone. If the caller needs inperson assistance, Loving Support either refers them elsewhere, if such help exists, or will try to 

meet them at a clinic. 

Coordination and Collaboration 

Loving Support maintains extensive collaborations with agencies and organizations in the 

county, including area hospitals, doctor’s offices, and pharmacies. For example: 

• Loving Support provides referrals to and receives referrals from the La Leche League 

so that breast-feeding mothers receive as much support as possible. 

• Loving Support has worked with one pharmacy to display breast-feeding supplies in a 

special section and has supplied the reference book Medications & Mothers’ Milk

(Hale 2002) to 18 pharmacies. 

• In addition, Breastfeeding Representatives participate in and often organize regional 

breast-feeding networks and coalitions comprising professionals, mothers, and other 

interested persons. 

These are only some of Loving Support’s extensive collaborations. 
50

Publicity and Outreach Efforts

The main message for all publicity efforts is simple: anyone in Riverside County can call 

the Loving Support Breastfeeding helpline 24 hours a day for breast-feeding assistance. The 

program uses multiple mediums to publicize this message, including displays in OB/GYN and 

pediatricians’/family practitioners’ offices, the Baby-to-Breast newsletter, magnets, business 

cards, magazine and bus shelter advertisements, movie theater advertisements, public service 

announcements, Lunch and Learns, and prenatal education classes. World Breastfeeding Month 

in August provides additional exposure through press releases, health fairs, and a county 

proclamation. In addition, as discussed earlier, the program uses postcards at WIC and the 

hospitals, bags with magnets and other information, and outreach to health care providers to 

obtain referrals or calls to the helpline. According to program tracking forms, most clients called 

the helpline after receiving a magnet or business card at WIC or their doctor’s office. 

ORGANIZATION AND MANAGEMENT 

Staff and Organizational Structure. The Loving Support Program has 13 staff members: 

the Breastfeeding Coordinator who is the overall project coordinator, 8 Breastfeeding 

Representatives of which 1 is a Senior Nutritionist helping to oversee the project, 2 Helpline 

Counselors, 1 data entry clerk, and 1 clerical support clerk. While personal experience is not a 

requirement for a Loving Support position, all but one staff member have personal breast-feeding 

experience. The Chief of Nutrition Services and the WIC Director spend a limited amount of 

time on the program and are not funded through Proposition 10 funds. The Breastfeeding 

Coordinator supervises the Breastfeeding Representatives, Helpline Counselors, and clerks. 

The Breastfeeding Representatives have varying backgrounds, but all need to be enthusiastic 

and passionate about breast-feeding. Some are registered dietitians, others public health 

professionals, WIC staff members, or teachers. The Breastfeeding Coordinator and two 

Breastfeeding Representatives are Internationally Board Certified Lactation Consultants

(BCLCs). Breastfeeding Representatives are classified as Health Education Assistants, which 

requires a four-year degree or a two-year degree plus two years of experience. They have three 

primary responsibilities: direct client services (including pump distribution), outreach and 

technical assistance to the medical community, and training health professionals. The first two 

roles require a significant amount of travel. Breastfeeding Representatives are responsible for 

one to three hospitals, two to three WIC clinics, and all the OB/GYN and pediatricians’/family 

practitioners’ offices in their geographical region. 

The Helpline Counselors are classified as Health Service Assistants, a position that requires 

a high school degree. They must be bilingual and have an understanding of the community. 

Although WIC staff members are not funded through the Loving Support program, each 

WIC clinic has a lead lactation educator responsible for teaching breast-feeding classes, 

facilitating support groups, and managing and distributing breast pumps for their clinic 

participants. When the clinic’s Health Service Assistants, Health Education Assistants, or 

Nutritionists are unable to provide assistance to a breast-feeding mother, the lead lactation 
51

educator will try to help the mother. However, if there is a challenging case that the lead 

lactation educator is unable to manage, a Breastfeeding Representative is contacted. The WIC 

clinic lactation educators report to the supervising nutritionist in each clinic. However, they also 

meet bimonthly with the Breastfeeding Coordinator. 

Training and Quality Assurance. The Breastfeeding Coordinator developed and 

coordinates the Trained Lactation Counselor (TLC) training that takes place one or two times a 

year. The Breastfeeding Coordinator, guest speakers, and other Loving Support staff are the 

trainers. All new WIC employees, Helpline Counselors, WIC clinic lactation educators, and 

Breastfeeding Representatives attend this 40-hour training, but other health professionals can 

attend as well. WIC employees working at the Customer Service Center attend a modified oneday training. 

Monthly in-services and staff meetings for Loving Support and WIC staff members provide 

additional training opportunities. Loving Support staff members and lead lactation educators 

often attend other trainings, including Birth and Beyond courses, the La Leche League annual 

conferences, Loma Linda University’s Perinatal Services Network training, and courses offered 

at the Lactation Institute in Encino, California. 

RCRMC is the only hospital in the county with a medical resident training program that 

includes Loving Support. As part of their family practice, obstetric, pediatric or physician 

assistant’s rotation, all RCRMC residents, as well as area dietetic interns, participate in a 

mandatory three- to four-hour rotation in the walk-in help clinic, where they learn about helping 

mothers with latching on and other common problems from the Breastfeeding Representative 

assigned to RCRMC. They also observe bedside teaching. 

The Obstetrics, Labor, and Delivery unit hosts a Skills Day once a year for its nursing staff 

members. Nurses receive a hands-on “refresher” on breast-feeding by spending 30 minutes with 

the Breastfeeding Representative. In addition, it is mandatory that all this unit’s nurses receive 

training on bedside counseling; two nurses at a time spend a morning with the Breastfeeding 

Representative, and the bilingual Certified Nursing Assistant (CNAs) spend two full days with 

the Breastfeeding Representative. The Breastfeeding Representative assigned to RCRMC has 

also trained all NICU nurses. 

Training of hospital staff members is limited because Loma Linda University has a 

successful Perinatal Services Network training program that trains hospital staff, primarily 

nurses, in breast-feeding. Loving Support collaborates and coordinates efforts with the Perinatal 

Services Network to ensure that they enhance rather than duplicate the work in the hospitals. 

Specifically, Loving Support has provided some nurses the opportunity to shadow the breastfeeding representatives in bedside counseling of new mothers. Loving Support also trains all 

county-employed Public Health and Clinic Nurses in breast-feeding support through a one-day 

new-employee training and an annual one-day update. 

Record Keeping and Data Systems. The Loving Support initial call and program 

enrollment tracking form includes: name, contact information, language, infant’s name, infant’s 

birth date, where infant was born, breast-feeding or formula-feeding status, how they heard about 

Loving Support, and the type of consult (such as incoming call, called out, in-person contact). 
52

The follow-up tracking form includes similar information as the initial tracking form, with the 

addition of inquiries regarding breast-feeding termination, combination feedings, and a section 

for notes. Helpline Counselors and Breastfeeding Representatives use these forms when 

providing individual help over the phone or in person. Breastfeeding Representatives send the 

original form to the central Loving Support office for processing, often after photocopying the 

form for their records.

Funding. For fiscal year (FY) 2002–2003, Proposition 10 provided $480,000 to support, 

expand, and enhance the breast-feeding program for WIC participants and move beyond the WIC 

client base. As of November 2003, Loving Support was in its second two-year agreement with 

First 5 Riverside. This agency wants awardees like Loving Support to sustain the program on 

their own eventually. This is a challenge for Loving Support, as there is a growing need and an 

already insufficient amount of staff and community resources to meet the need. The WIC 

program currently funds one Helpline Counselor. Loving Support is considering having the 

Medi-Cal managed care program provide a Helpline Counselor, since many of the clients 

receiving services are also Medi-Cal clients. There is also a potential to bill Medi-Cal and 

insurance companies for Loving Support services in hospitals and outpatient clinics. 

LUNCH AND LEARNS 

In 2003, Loving Support conducted about 198 Lunch and Learn sessions for 873 people 

working in OB/GYNs’, pediatricians’, or family practitioners’ offices; hospitals; and other health 

clinics in the county. Funding was from a special grant from the state WIC program. A 

Breastfeeding Representative developed the Lunch and Learn facilitators’ manual, and 

Breastfeeding Representatives facilitated the actual presentations, which could last anywhere 

from 15 to 90 minutes, depending on the audience’s interest in breast-feeding and time 

constraints. 

Temporary Office Assistants were hired for this project, and each was assigned to a 

Breastfeeding Representative to assist with logistical and clerical issues. 

The Lunch and Learns discussed Loving Support services and how breast milk “stacks up” 

to formula. Regarding the latter, large colored Lego blocks, each representing a specific 

component of breast milk, were stacked to illustrate the difference in breast milk and formula. 

By the end of the demonstration, there was a tower several feet high for breast milk and a small 

stack of blocks for formula, which indicated that breast milk has more to offer than artificial 

human milk. Program officials note that the demonstration was important because at the same 

time, pharmaceutical representatives were visiting doctors’ offices to inform them of the new 

“brain development” infant formula newly supplemented with “special” lipids. A healthy lunch 

is also provided to participants. 

Loving Support is currently searching for funding to continue this well-received project. 
53

In FY 2002–2003, Loving Support received $250,000 in WIC funding, and $133,000 from a 

WIC Best Practices Grant for the Lunch and Learns (see box). The Riverside County Children 

and Families Commission also provides funding for Loving Support. Many hospitals, clinics, 

and community groups offer office or meeting space at no cost. 

ASSESSMENT AND LESSONS LEARNED 

Program Strengths. Program officials cite three significant successes. First, breastfeeding rates among WIC clients have increased. In 1999, the Riverside County WIC 

exclusively breast-feeding rate was 10 to 11 percent. The goal of Loving Support is to increase 

these rates by 1.5 percent each year so that by 2010, the Riverside County WIC exclusively 

breast-feeding rate is at 20 percent. In June 2003, the exclusively breast-feeding rate among the 

WIC population in Riverside County was 14.5 percent. It rose to 14.8 percent in August and 

15.1 percent in September. Second, there is an increased awareness and augmented support from 

community health care providers who are communicating breast-feeding as the norm to their 

clients. Third, the helpline and comprehensive outreach program has increased awareness of 

breast-feeding among the WIC population and the general public. More people in the 

community are talking about breast-feeding, and it is becoming more common and accepted. 

Families have been very appreciative of the Loving Support program’s 24-hour service and 

follow-up calls. Clients often call and send thank-you letters to Loving Support staff members. 

Program officials repeatedly hear clients say, “I wish that you had been around years ago,” or “I 

wish that I had known about this service with my first child.” Many breast-feeding women 

remark, “If you were not here, I would have quit.” 

Health care providers appreciate the services of Loving Support as well. The resources, 

training, and helpline support allow them to better meet the needs of their breast-feeding clients. 

Many carry Loving Support business cards in their lab coat pockets so they can easily make 

referrals. They see the program as especially beneficial to young and first-time mothers. 

Furthermore, WIC staff members value the quality breast-feeding services since they cannot 

spend much time with their breast-feeding clients because of busy caseloads. WIC staff 

members also have greater knowledge and confidence in discussing breast-feeding because of 

the TLC training and frequent updates from the program. 

In general, the Loving Support staff is energized and enthusiastic about what they do. They 

do whatever it takes to help a breast-feeding mother in need. 

Key Challenges. Initially, it was difficult to convince doctors and other health care 

professionals to refer their patients to the Loving Support program, or to allow outreach 

materials to be displayed in their offices. At that point, the helpline was not widely known, and 

the Breastfeeding Representatives had not yet established a credible reputation with the wider 

community. However, now doctors enthusiastically refer patients to the program, because more 

of their patients have expressed an interest in breast-feeding over the past three or four years. 

Further, it is challenging keeping up with the popularity of the program. Once a client is 

entered into the database, she will receive a series of phone calls from a Helpline Counselor. 
54

Following up with as many as seven contacts (one prenatal and six postpartum) for every client 

throughout the baby’s first year is time-consuming for staff members. Another large challenge is 

the geographic size of the county. Breastfeeding Representatives spend a significant amount of 

time traveling throughout their territories. 

At a community level, overcoming the barriers to breast-feeding is a challenge for staff 

members and clients. These barriers include embarrassment to breast-feed in public, fear that not 

enough milk is produced, and challenges in going back to school or work. In addition, some in 

the Hispanic culture believe that the first week of breast milk is “dirty,” and some Hispanic 

mothers think that formula is better because it costs more. Of greater concern is that many 

women do not have the support of their male partner, friends, or family to breast-feed. 

Lessons Learned. The extensive services provided in Riverside are clearly beyond what 

most WIC agencies can contemplate, even with outside funding. If a WIC program has minimal 

breast-feeding services, Loving Support program officials suggests that the program implement a 

24-hour helpline so that clients always have access to help. The helpline receives many calls 

from frantic mothers on Friday afternoons, on weekends, and in the middle of the night. 

However, if there was no helpline, or if the helpline was only available during business hours, 

the mother might resort to formula and give up on breast-feeding altogether. Targeting all 

outreach materials around a simple message, “Call the hotline if you need breast-feeding help,” 

seems to be an important source of the program’s success. 

Another priority for program planners is to implement a system so mothers receive support 

in the hospital immediately after delivery and a supportive call during the first few days at home 

with the new baby. Providing services in the hospital or coordinating with hospital staff is 

critical to helping mothers initiate breast-feeding. 

The idea of having “Breastfeeding Representatives” that do for breast-feeding what formula 

company representatives do to sell formula is a very creative part of the Riverside program, but 

may be more than agencies can afford without substantial outside funding. However, Riverside 

staff pointed out that a WIC agency could “get the word out” with limited funding and still 

produce an increase in enrollment rate or clients served. For example, Loving Support produced 

magnets. They were not very expensive, but many clients tell Loving Support staff members 

that they learned about the program because they picked up a magnet and put it on their 

refrigerator. Outreach to health professionals also is an important element of the Breastfeeding 

Representative’s work that other agencies could (and do) adopt in a scaled-back form.

Riverside staff commented that communication skills, flexibility, and passion are important 

attributes to look for in staff members. Different strategies work for different people, but the key 

for breast-feeding success is not to give up and to seek out help and support. 
55

CONTACT INFORMATION 

Laurie Haessly, MA, RD, IBCLC 

Supervising Nutritionist and Breastfeeding Coordinator 

Gayle Shockey Hoxter, MPH, RD 

Chief of Nutrition Services 

Riverside County Community Health Agency 

Department of Public Health 

Nutrition Services Branch 

Room 207 

P.O. Box 7600 

4065 County Circle Drive 

Riverside, CA 92503 

Phone: (909) 358-5311 

Fax: (909) 358-5472 

E-mail: ghoxter@co.riverside.ca.us; lhaessly@co.riverside.ca.us

57

LACTATION CONSULTANT SERVICES22

SACRAMENTO COUNTY, CALIFORNIA 

OVERVIEW 

Location: Sacramento County, California 

Start Date: June 2002, a three-year pilot that will continue if funding is available 

Target Population: WIC mothers within 10 days of giving birth, participants in the Birth and 

Beyond program, clients who receive county public health nursing services, and relevant health 

care professionals 

Purpose: To reduce the number of WIC mothers who discontinue breast-feeding due to a lack 

of support by providing enhanced breast-feeding services and educating health care professionals 

about the benefits of breast-feeding. 

Services: Full-time lactation consultants offer consultations in the WIC offices, technical 

assistance through a breast-feeding helpline, home visits, and a Spanish-speaking peer counselor. 

Another key component is training WIC staff, Birth and Beyond staff, Sacramento County 

Public Health Nursing Services, and community doctors and nurses about the importance of 

breast-feeding. 

Funding: $1,500,000 over three years from Proposition 10 tax revenues23

Why Program Was Chosen: Full-time professional lactation consultant services are available 

to WIC clients during office hours, along with home visits. The program also includes active 

collaboration with local organizations to promote awareness of the benefits of breast-feeding. 

Key Challenges: The county would not allow the program to hire lactation consultants as 

regular employees with benefits. It was also a challenge to gain acceptance for the program 

among regular WIC staff and other health professionals. Finally, it could be difficult to arrange 

private space for the consultants to see clients at WIC clinics. 

 22 Telephone interview, April 28 and May 2, 2003. 

23 In 1998, California voters passed Proposition 10, which levied a tax on cigarettes to 

generate funding for children’s health programs. 
58

 

BACKGROUND 

County Characteristics. Sacramento County is the eighth-most-populated county in 

California, with 1,223,499 residents, 16 percent of whom are Hispanic or Latino in origin and 

64 percent of whom are white (U.S. Census Bureau 2002). It encompasses approximately 

994 square miles in the middle of the 400-mile-long Central Valley, the state’s prime agricultural 

region. In 1997, 30 percent of the population aged 0 through 4 lived in poverty, and in 1999 an 

estimated 11,272 children aged 3 to 4 lived in poverty. The number of low-birth-weight infants 

declined slightly from 1997 to 1999—6.9 to 6.6 percent. Sacramento County’s median 

household income in 2000 was $42,329, and approximately 27.5 percent of kindergarteners and 

18.9 percent of children (grades 1–8) were classified as English learners during the 1999–2000 

school year.24

WIC Program Background. Sacramento County has two WIC agencies, but only one (the 

County Department of Health and Human Services) participates in the pilot. This agency has 

four clinics. Before the pilot, Sacramento County had two part-time lactation consultants who 

each worked 17 hours a week on a caseload of 21,000 women, infants, and children. The 

consultants were overwhelmed with cases and did not have adequate private space in the WIC 

clinics to deliver services. Except for one clinic that collaborated with the Birth and Beyond 

Program for a mini-grant through a United Way agency, WIC was not able to provide lactation 

consultations through home visits. In addition, the consultants delivered training to other WIC 

staff, including both nutrition assistants and registered dieticians, to teach them about basic 

breast-feeding skills and to encourage them to refer clients to the lactation consultants whenever 

possible. 

Program History and Objectives. The pilot program seeks to make professional lactation 

services available through Internationally Board Certified Lactation Consultants (IBCLCs) to 

reduce the number of mothers who discontinue breast-feeding due to challenges (such as sore 

nipples) and/or a lack of support. According to the project director, health care professionals 

often do not have the time or training to understand or appreciate the benefits of breast-feeding, 

and thus fail to provide mothers with the support that they need to pursue it. In her opinion, 

nurses are more likely to use formula as the immediate solution to any problems that a new 

mother encounters when breast-feeding. While Sacramento County had lactation consulting 

services before the pilot began, WIC had only two part-time IBCLCs for a caseload of more than 

20,000 clients. Program staff knew that more should be done to encourage and support breastfeeding among WIC clients. 

To fund the pilot, county officials relied on Proposition 10 funding. The California WIC 

Association encouraged local agencies to develop ways that they could use the revenues in 

anticipation of a future request for proposal, which eventually was released in 2000. In writing 

the proposal for Sacramento County, the senior health program coordinator—who would become 

the project director—conferred with the county’s breast-feeding coordinator to gauge the service 

24 Unless indicated, all data are taken from the Sacramento County portion of California 

Report Card 2001: Factors for School Success, prepared by Children Now, a California 

children’s advocacy group, November 2001. 
59

 

needs in the WIC community. The coordinator stressed that increasing the number of 

professional lactation consultants would be the most effective use of additional resources. 

Before the pilot, it was difficult for WIC mothers to breast-feed successfully because they lacked 

a readily available, well-staffed support network. Thus, hiring additional IBCLCs became the 

core component of the county’s grant proposal. 

Between 1995 and 2000, the Sacramento WIC program used several peer counselors to offer 

general support to breast-feeding mothers or pregnant clients who expressed an interest in breastfeeding. However, program officials concluded that peer counselors required too much training 

and supervision, and that IBCLCs would be a better use of funding. Instead of referring a client 

to a lactation consultant when appropriate, sometimes a peer counselor tried to address the 

problem herself, often sharing inaccurate information. According to the project director, if a 

lactation professional is not available, it can be discouraging for clients and “set some of them up 

for failure.” By the time the pilot began, most counselors had left WIC through attrition. The 

only peer counselor remaining travels to different clinics as needed to translate when a lactation 

consultant who does not speak Spanish has a Spanish-speaking client. 

Program officials note that because it is easier to recruit bilingual counselors as opposed to 

IBCLCs, peer counselors serve as a critical link to Spanish-speaking clients. Furthermore, they 

can assume responsibility for tracking pumps, making follow-up telephone calls, and 

communicating with the rest of the clinic’s staff, which grants the lactation consultants more 

time to provide technical assistance. The project director noted that, in an ideal world, there 

would be as many peer counselors as languages spoken among clients who need breast-feeding 

services. 

Target Population. Program officials target services to WIC mothers within 10 days of the 

birth, the critical period when breast-feeding relationships are established. However, technical 

assistance is available at any time while a mother is breast-feeding. Participants in the Birth and 

Beyond program and those who receive assistance from Public Health Nursing Services through 

the county are also eligible.25 Assistance from Public Health Nursing Services is available to 

parents of medically high-risk infants, such as premature and low-birth-weight infants. In 

addition, the pilot includes educating Birth and Beyond staff, Public Health Nursing Services 

nurses, and community doctors and nurses about the importance of breast-feeding so that 

mothers receive the critical support they need.

25 Birth and Beyond is a multidisciplinary home visitation program for families who have a 

pregnant woman or an infant with one or more specific factors, such as substance abuse, that put 

them at an increased risk of child abuse. It provides family support services to pregnant women 

and families with new babies up through three months of age, though families may continue to 

participate until their youngest child reaches age five. The program’s goals are to help build 

strong families, meet the needs of developing infants, and ensure that every baby in the county 

receives medical care. Priority is given to teen mothers and single parents. There are nine Birth 

and Beyond sites in Sacramento County. A multidisciplinary team staffs each location, which 

houses a family resource center. 
60

 

PROFILE OF INNOVATIVE PROGRAM 

Services Provided. The pilot has expanded lactation technical assistance in Sacramento 

County to reduce the number of women who discontinue breast-feeding. Instead of two parttime IBCLCs, all four participating clinics have consultants available 40 hours each week. One 

outlying clinic—with the smallest caseload—provides an IBCLC two or three days a week.26 

The Spanish-speaking peer counselor is available to translate at all clinics. 

WIC clients can receive consultations from IBCLCs either in the clinics or at home. Three 

of the four clinics have private offices for one-on-one consultations, which typically last one 

hour; home visits last between one and two hours. To receive a home visit, WIC participants 

must enroll in the Birth and Beyond Program. In addition, there is a breast-feeding helpline 

answered by a recording, with messages returned by an IBCLC during regular office hours on 

the same or the next business day. Messages left after hours are returned the next business day, 

although messages that indicate a breast-feeding crisis late in the day on Friday or over the 

weekend are returned during the weekend. 

The grant also paid for neonatal scales to measure how much breast milk infants consume, 

along with nursing bras. WIC staff do not distribute the bras as incentives, but rather as medical 

aids to help prevent breast infections. Frequently, clients who cannot afford to replace their illfitting under-wire bras are at a greater risk of developing plugged ducts that can lead to breast 

infection. 

Occasionally, lactation consultants work with a client in the hospital, if the infant is sick and 

the mother needs support. Most of their work with the Birth and Beyond program occurs 

through home visits. An IBCLC accompanies a Birth and Beyond staff member on the first visit 

and can elect to conduct any follow-up visits by herself.

Participation. Only one of the two WIC agencies in Sacramento County participates in the 

enhanced lactation consultant services pilot. That agency’s total monthly caseload is 21,000, of 

which women make up 25 percent, infants make up 25 percent, and children aged 1 to 4 make up 

50 percent; the other agency has 12,000 clients. While the pilot is geared primarily toward WIC 

clients, women who are enrolled in the Birth and Beyond program or receive assistance from 

Public Health Nursing Services also have access to the lactation consultants (some women may 

be enrolled in multiple programs). Each month there are 5,000 births—25 percent of all births in 

Sacramento County—to mothers who participate in at least one of these three services 

(Sacramento County Public Health Advisory Board 2001). 

In March 2003, there was a total of 900 contacts through WIC lactation consultants. Of 

these, 504 were telephone contacts, 204 were breast-feeding class contacts, 141 were individual 

clinic consultation sessions, 46 were home visits, and 4 were referrals from Public Health 

26 If a mother at this outlying clinic needs immediate assistance, she can speak to one of the 

other lactation consultants. If she is willing to travel, she can get an appointment at one of the 

other sites by the next business day. A lactation consultant may be available on the schedule to 

make a home visit. 
61

 

Nursing Services. These figures do not include contacts with the Spanish-speaking peer 

counselor—82 breast-feeding class contacts, 69 telephone contacts, 20 individual clinic sessions, 

and two Birth and Beyond Home visits. In April 2003, the project director observed that the 

demand for lactation consultants had “really skyrocketed.” The IBCLCs were not overwhelmed 

in April of 2003, but their caseloads have since reached a saturation point. According to the 

WIC program director, they have a need for 1 or 2 more lactation consultants and another 

bilingual peer counselor. An estimated 5 percent of total pilot participants who receive services 

are not enrolled in WIC.

Coordination and Collaboration. According to the breast-feeding promotion coordinator, 

the WIC program has developed good relationships with community organizations and agencies 

over the years. She noted that Birth and Beyond is an excellent collaborative partner. Since the 

pilot began, lactation assistance has become an integral part of the home visits through the Birth 

and Beyond program. The coordinator serves on its steering committee and attends its 

stakeholder meetings. The two programs share breast-feeding data and success stories, and 

consultants often attend trainings sponsored by Birth and Beyond, such as one on mandated 

reporting for child abuse. 

In addition, the pilot enhances the overall collaboration between WIC, Birth and Beyond, 

and Public Health Nursing Services by making the lactation consultants a key part of the 

multidisciplinary team that becomes active during the prenatal period for any given client.27 The 

team includes drug and alcohol counselors, social workers from Child Protective Services, child 

development specialists, Medi-Cal staff, Birth and Beyond home visitors and team leaders, and 

WIC lactation consultants. A different team serves each Birth and Beyond site and meets weekly 

to discuss specific cases and issues. Teams intervene with any client enrolled in Birth and 

Beyond, regardless of whether that client is on WIC. While the lactation consultants offer 

breast-feeding technical assistance, nurses visit the family to ensure that growth and 

development is progressing and that the family is receiving adequate medical care.

Publicity and Outreach Efforts. WIC clients and other eligible women learn about the 

lactation consulting services from within WIC and from outside organizations.28 WIC staff 

inform their clients about the breast-feeding helpline when they enroll, and staff also refer clients 

who disclose problems with breast-feeding during their nutrition contact. If a lactation 

consultant is available, she can meet with the client immediately. Otherwise, the nutritionist 

delivers a message to the consultant, who then calls the client at home and counsels over the 

phone or schedules a clinic appointment. Staff also contact the lactation consultant if a client is 

27 These teams fall under the oversight of the county Department of Health and Human 

Services. 

28 The WIC office conducted a survey with the University of California at Davis for a time 

utilization report. Of a sample of 316 clients who had received lactation consultation during six 

weeks in September and October 2002, 42 percent were self-referred (after receiving information 

from WIC counselors, prenatal classes), 28 percent were referred by WIC staff, 12 percent were 

referred from Birth and Beyond, 10 percent were contacted directly by a lactation consultant, and 

7 percent were referred from community health care providers. 
62

 

considering breast-feeding but is skeptical. The consultant will in turn call the client to discuss 

the decision. WIC staff inform clients about the enhanced lactation consultant services during 

breast-feeding classes, and the IBCLCs occasionally teach a prenatal or postpartum class. 

Moreover, a lactation consultant tries to call all pregnant women enrolled in WIC to 

introduce herself, explain the support services that are available, and ask if they intend to breastfeed. This contact establishes a relationship between client and consultant, building a foundation 

of trust that can encourage the mother to consider breast milk carefully as an alternative to 

formula. 

Apart from WIC, the pilot works to build the community’s capacity to support breastfeeding by working with as many health staff as possible to increase their awareness of available 

resources and services to support breast-feeding mothers in Sacramento County. For example, 

private lactation consultants who work in local hospitals routinely refer patients to WIC for 

breast-feeding support. ALTA, the regional professional organization for IBCLCs, often 

sponsors booths at community events and distributes information about WIC’s lactation 

consulting services.

ORGANIZATION AND MANAGEMENT 

Staff and Organizational Structure. Currently, an equivalent of five full-time IBCLCs 

provide lactation consultations. In addition, a bilingual peer counselor interprets and also 

provides direct services for Spanish-speaking WIC clients; she is equivalent to a nutrition 

education assistant in the county’s salary rating system.29 She also has responsibilities to support 

and translate for other WIC staff. 

Day-to-day management of the pilot falls under the breast-feeding promotion coordinator 

(project coordinator), a WIC dietitian who obtained her IBCLC certification after developing an 

interest in breast-feeding. She oversees the six part-time lactation consultants and the peer 

counselor. The project coordinator also provides breast-feeding training for WIC staff, breastfeeding training for Birth and Beyond staff and public health nurses, and training to anyone in 

the community with an interest in learning about breast-feeding and lactation consultants, such as 

doctors and social workers (see training section below for more details). In addition, she 

oversees all WIC breast-feeding activities, teaches some classes, and assists with class design. 

The pilot consumes nearly 10 percent of the coordinator’s schedule. The project director 

oversees the project coordinator and general coordination of the pilot. She allocated most of her 

staff time to developing the pilot and securing Proposition 10 funding. Currently, about 

5 percent of her schedule is set aside for the pilot. 

29 There was a county hiring freeze at that time, and WIC was forced to eliminate one 

regular staff member (nutrition assistant) to accommodate the inclusion of a Spanish peer 

counselor for the pilot program. 
63

 

Training. A training component supplements the services that lactation consultants 

provide. The project coordinator sent the lactation consultants to a “train-the-trainer” session. 

The consultants, in turn, train WIC staff, Birth and Beyond home visitor staff, public health 

nurses, and other community health care providers to enable them to support, refer, and problemsolve directly with mothers of newborns. Public nurse trainings take place approximately 

monthly, and members of the Birth and Beyond staff are offered sessions about 10 times a year. 

The project coordinator estimated that at least 130 people from WIC, Birth and Beyond, and 

Public Health Nursing Services have been trained since the pilot began in June 2002.

For the county’s public health nurses and Birth and Beyond staff, lactation consultants and 

the breast-feeding coordinator have delivered a three-day training on the basics of breast-feeding 

and when it is appropriate to refer patients to the lactation consultants. Specific topics include 

normal infant behavior, feeding cues, the consequences of giving bottles and pacifiers before the 

mother’s milk is established, sore nipples, insufficient milk supply, and helping mothers develop 

a back-to-school or back-to-work plan. In addition, once a year there is a follow-up training on 

“hot topics,” such as how to support a breast-feeding mother whose baby is jaundiced.

WIC staff have received similar breast-feeding trainings. For example, lactation consultants 

held an in-service day for WIC staff on breast-feeding premature infants. Trainers passed around 

dolls of varying weights so that WIC staff could compare growth stages. They presented a video 

tape and placed drops of breast milk in a test tube to illustrate a normal amount for a micropreemie to drink during one feeding. It is important for WIC staff to share accurate information 

with their clients so that they are on the same page with the lactation consultants. 

Breast-feeding education also extends to the wider community. The program coordinator is 

involved with the Breastfeeding Coalition for the Greater Sacramento Area. The coalition asked 

lactation consultants to conduct a one-day training session for a group of doctors and nurses on 

breast-feeding topics. WIC also collaborated with Pfizer to host a doctors’ dinner, for which the 

pharmaceutical company covered all costs.30 WIC invited speakers from across the country, 

including a well-known neonatalist and expert on breast milk. Representatives from Pfizer were 

pleasantly surprised that 48 out of 50 slots were filled, an unusually high turnout for such an 

event, and they hope to host the doctors’ dinner annually. 

Funding. The pilot provides $500,000 annually for three years from Proposition 10 tax 

revenues. To receive such a large amount of outside funding for a WIC project is unusual. In 

the project director’s opinion, a WIC agency cannot provide adequate breast-feeding assistance 

unless it also receives outside funding to supplement its regular budget. 

It is too soon for program officials to determine whether the enhanced lactation consultant 

services will extend beyond the pilot period. California is facing a severe budget shortfall, and 

the project director remarked that the county is proposing to relinquish its WIC contract back to 

the state, which would in turn contract for WIC services with a nonprofit agency. 

30 WIC selected Pfizer because of an ethics clause stating that it can collaborate only with 

drug companies that do not produce baby formula. 
64

The project coordinator is working on a project proposal that would enable her WIC agency 

to expand its lactation consultant services even further and link the IBCLCs more closely with 

peer counselors, perhaps “working in teams of two like a doctor and nurse.” The project would 

also fund one additional Spanish-speaking peer counselor to work in the outlying clinics. 

ASSESSMENT AND LESSONS LEARNED 

Program Strengths. An indicator of success for the pilot has been higher breast-feeding 

rates. In the first nine months of the pilot, breast-feeding rates increased as follows: 

8 weeks 5 to 6 months 11 months 

June 2002 46.6% 30.4% 24.3% 

February 2003 50.7% 34.3% 25.6% 

The project director thinks that the home visits can make a significant difference in raising 

breast-feeding rates. Many mothers find it difficult to transport their infants to the WIC clinic. 

Home visits are much more convenient for the mother and baby.

Lactation consultants distribute surveys to health care professionals three months after 

training to determine to what extent the professionals have altered their service delivery because 

of the breast-feeding training. Further, the project coordinator and the lactation consultants also 

have collected questionnaires after some of the training sessions. Another outcome indicator is 

the number of professionals and paraprofessionals who have received breast-feeding education.31

Since the pilot began, the project coordinator, each quarter, calls to get feedback from 

approximately 25 clients who met with lactation consultants. Responses are “glowing” and 

“there has not been one complaint.” Many WIC mothers have told the coordinator that they 

would not have been able to breast-feed without lactation consultant services in place. Learning 

how to hold a baby during feeding and how to latch on properly are common responses when she 

asks what information from the lactation consultants was most helpful. 

The pilot seems to have had a significant impact on regular WIC staff. Before the pilot, staff 

were “timid” in promoting breast-feeding. Since limited lactation consultant services were 

available, staff were reluctant to encourage WIC mothers to breast-feed, because they did not 

have the technical knowledge to address problems that emerged if the lactation consultant was 

not available.32 Before the pilot, WIC staff often struggled with questions like “Should I give 

 31 In addition, the Proposition 10 Committee is coordinating a formal evaluation, which will 

be conducted by a local private company at the end of the pilot. 

32 In the outlying clinic, an IBCLC came on site only 4 hours each week. 
65

 

this mother formula or not?” However, since enhanced lactation consultant services began, WIC 

staff actively promote breast-feeding, because there are professionals who can provide the 

necessary information and support when needed. Now, a lactation consultant can determine 

whether, for example, it would be appropriate to supplement with formula, lend out an electric 

pump, and see the mother for a lactation consultation. WIC staff are grateful that they no longer 

have to make tough decisions that they are not qualified to make.

Because of the training received by regular WIC staff, the staff has an enhanced sense of 

knowing what to say to their clients about breast-feeding, they are more likely to refer clients to 

the helpline and lactation consultants, and they are more aware of the health risks of using 

formula. According to the project director, WIC employees chose this profession because they 

enjoy helping people. Anything that enables them to do their job better—like receiving breastfeeding training—gives them self-esteem and gratification. The breast-feeding training, which is 

mandatory, is integral to the total training plan for all new and ongoing WIC staff.

Finally, one success of the pilot is the infants the IBCLCs save. Consultants are frequently 

the first people to see the mother after delivery and before her first postpartum doctor’s 

appointment. They may visit a WIC client at home two or three days after delivery and conclude 

that the infant is sick and needs immediate medical care. The lactation consultant contacts the 

doctor’s office to make an expedited appointment or helps transport the mother to the hospital. 

In 2003, there were three infants who were hospitalized the same day as the home visit. The 

breast-feeding coordinator noted that the babies could have died if they had not received 

immediate medical attention. 

Key Challenges. Program staff encountered several challenges, both during the planning 

phase and during implementation. The project director encountered difficulties in obtaining 

approval from county officials for contracts for the IBCLCs. Ideally, she would have preferred 

to designate the consultants as regular county employees with full benefits, but officials were 

reluctant to grant a special job classification. Moreover, they insisted that the lactation 

consultants each purchase a $1 million liability insurance policy. 

In addition, the receipt of the Proposition 10 dollars was delayed. Although the First 5 

Sacramento Commission33 approved funding quickly, it took the Sacramento County Board of 

Supervisors almost a year to transfer the funding to the WIC program. The project director 

observed that the county can sometimes be resistant to procedural changes, and also is concerned 

about the possibility of legal challenges initiated by employee unions and the community at large 

that may arise from contracting out services. As a result of a lawsuit filed several years ago, the 

county cannot contract out for a service unless it can be demonstrated that county employees 

cannot provide it. 

33 The First 5 Sacramento Commission is a quasi-county agency with political independence 

from the Board of Supervisors. It is responsible for distributing Proposition 10 funds. Members 

of the Commission include a member of the County Board of Supervisors, the Chief of the 

County Public Protection Agency, the Chief of the County Department of Health and Human 

Services, and a representative from a local school district. Each California county has such a 

commission. 
66

 

Another challenge is that some WIC staff have been resistant to referring clients to the 

IBCLCs, especially those who used formula for their children. They may have feelings of guilt 

and resist the information that lactation consultants share. It is common for them to think, “If 

formula was good enough for my baby, it is fine for my clients.” Part of the training that the 

project coordinator developed distinguishes between guilt and regret. It is hoped that staff can 

embrace the latter so that they can “provide breast-feeding education with conviction” to their 

clients. Unfortunately, the project director thinks that some WIC staff members will “never be 

on the breast-feeding bandwagon.” Consequently, lactation consultants need to encourage those 

enthusiastic staff members who are committed to promoting breast-feeding. 

Space for the consultants was another hurdle for the pilot. In some cases, clinics had extra 

space to offer the lactation consultant, and in others they had to “battle” for a private office. In 

the smallest clinic, the consultant must work in whatever space is available that day. 

Though the pilot has augmented collaboration with other organizations and health 

professionals to promote breast-feeding, WIC still encountered challenges with community 

partners. Birth and Beyond staff were at the start not referring clients to lactation consultants. In 

the project coordinator’s opinion, Birth and Beyond home visitors thought that clients did not 

need help, when in fact clients needed the professional guidance of IBCLCs to breast-feed 

successfully. Birth and Beyond home visitation staff “were taking matters into their own hands” 

because they can be “protective of their clients’ families.” Eventually, WIC had to work with 

managers at Birth and Beyond to mandate that line staff refer all pregnant and postpartum 

mothers to lactation consultants, who would in turn determine whether they needed to make a 

home visit. The process now works very well.34

Similarly, the project director continues to be frustrated by the fact that not all stakeholders 

are on board with breast-feeding promotion and lactation assistance. In her opinion, some health 

care professionals are “fine with formula.” Nurses and doctors use formula as the “quick 

answer,” neglecting to try to determine exactly what might be causing the difficulty with breastfeeding. It is also difficult to get the general public to recognize the value of breast-feeding. In 

conjunction with this pilot, the project coordinator teaches a class to WIC and Birth and Beyond 

staff on the marketing strategies of formula companies. She discusses the marketing techniques 

of formula companies, the difference between guilt and regret for women who did not breastfeed, and the health risks of using formula. The latter topic is what usually “raises people’s 

eyebrows.” They are surprised that formula can (according to WIC staff) increase the risk of 

diabetes, cancer, obesity, and ear infections. 

34 The project coordinator told a story about a mother who had lost three children to Child 

Protective Services. The Birth and Beyond home visitor was certain that this mother would fail 

at breast-feeding, but in fact she thrived under the guidance of the lactation consultant, pleasantly 

surprising the home visitor. Accomplishments like this are slowly overcoming the prejudices 

against lactation consultants (that is, the belief that lactation consultants are not needed). Having 

a policy in place that would allow the lactation consultants to be “seen in action” and to be seen 

as an asset to the Birth and Beyond program has helped. 
67

Lessons Learned. Having an IBCLC who is available for private counseling sessions 

throughout the week and for home visits is sometimes the critical factor in successful breastfeeding. A survey conducted in a neighboring county asked 145 WIC mothers who had stopped 

breast-feeding, “What would have helped you to continue breast-feeding?” It found that 

65 percent selected the option of “having a staff member provide assistance in their homes.” 

Program officials think that the pilot could be replicated, and that including home visits is an 

important component of any successful program. In fact, they would like to expand the program 

by adding lactation consultants for the other WIC agency and hiring more peer counselors so that 

they can work formally in teams. 

Another key element for replication is outside funding sources. The project director noted 

that there would not have been enough funding in the general WIC budget to provide the right 

number of lactation consultants needed to support eligible breast-feeding mothers adequately in 

Sacramento. Before the pilot, two part-time lactation consultants paid for with WIC dollars were 

unable to meet service needs fully. Obtaining outside funding through Proposition 10 has been 

critical to expanding these services. 

Program officials have realized that there is still resistance to breast-feeding from different 

stakeholders. They imagine that some professionals and paraprofessionals—whether they be 

doctors, nurses, or WIC staff—will never be “won over.” At this point, WIC “just tries to win 

them over one by one.” The project director hopes that the pilot, particularly by training 

community health care providers, can begin to change attitudes about breast-feeding. WIC staff 

encounter many clients who think that breast-feeding is a “nice idea” but is only for “the 

fortunate few”: stay-at-home mothers. Moreover, some people attach a stigma to breast-feeding 

in public, which may dissuade some clients from electing this instead of formula. Ideally, WIC 

officials want breast-feeding to be perceived by the general public as the norm, and as an 

appropriate practice for women of all socioeconomic levels.

CONTACT INFORMATION 

Teri Ellison-Duarte, WIC Program Director 

Amelia Schendel, Breastfeeding Promotion Coordinator 

Sacramento County Department of Health and Human Services 

2251 Florin Road, Suite 100 

Sacramento, California 95822 

Phone: 916-427-9062 

 916-427-1134 x274 (A. Schendel) 

E-mail: duartet@saccounty.net 

 schendela@saccounty.net

69

BREAST-FEEDING PROMOTION AND SUPPORT PROGRAM35

MIAMI-DADE COUNTY, FLORIDA 

OVERVIEW 

Location: Miami-Dade County, Florida 

Start Date: Selected services began in 199736

Target Population: Current and potential WIC clients, along with health care professionals. 

Purpose: To increase breast-feeding rates among WIC clients and to help them breast-feed 

successfully. 

Services: Multifaceted services, including a breast-feeding helpline, lactation consultant 

services, peer counselors, a breast pump loan program, breast-feeding support groups, and baby 

showers. 

Funding: $400,875 for fiscal year (FY) 2002, which represents 14 percent of the total WIC 

budget. 

Why Program Was Chosen: The Miami-Dade County Breastfeeding Promotion and 

Supportive Program (BPSP) is a comprehensive program that includes a community outreach 

component with technical assistance for local health care professionals as needed. 

Key Challenges: Most obstacles have been related to peer counselor and staff recruitment and 

retention. First, program officials were unsure of the best way to recruit volunteers for the peer 

counselor program. Moreover, retention has been an ongoing issue. Because a small number of 

volunteers eventually moved into paid positions, many other volunteers left the program because 

they were unwilling to continue counseling services without compensation. In addition, low 

salaries for lactation consultants make it difficult to recruit and retain them, as many are attracted 

to higher-paying positions in private hospitals and clinics. 

 35 Telephone interview, April 8, 2003. 

36 Different program components had different start dates—breast-feeding helpline, lactation 

consultant services, and breast pump program (September 1997); peer counselor program (May 

1998); and community outreach (October 1999). 
70

 

BACKGROUND 

County Characteristics. Miami-Dade County is one of the most densely populated regions 

in Florida, with 2,289,683 inhabitants in 2001. Approximately 6.5 percent of the population are 

children under five. The majority (57.3 percent) of county residents classify themselves as 

Hispanic or Latino in origin, which is significantly higher than the state average of 16.8 percent. 

Almost 68 percent of households speak a language other than English at home, as compared to 

23.1 percent statewide. In 1999, 18 percent of the county lived below the poverty line, and the 

median household income was $35,966.

WIC Program Background. The Miami-Dade County WIC program has the third-largest 

local WIC agency in the country in terms of the numbers of participants and has the largest staff 

of all Florida WIC agencies. There are 23 clinics in the Miami-Dade County service area, as 

well as an administrative office and a central appointment office. The WIC program has 55,000-

60,000 enrolled participants per month, including infants and young children; about 11,000-

12,000 are pregnant and breast-feeding women.37

Until the BPSP began in 1997, the only breast-feeding promotion and services for WIC 

clients included breast-feeding classes taught by WIC nutritionists. Moreover, all women had 

received formula for their infants regardless of their breast-feeding patterns and preferences. The 

breast-feeding program administrator noted that most staff assumed clients would “feel like they 

were not getting something free if they did not receive formula.” 

Program History and Objectives. Soon after starting her position in July 1997, the breastfeeding program administrator concluded that the county WIC clinics were falling short of what 

they could be doing to encourage and support clients to breast-feed. Consequently, with help 

from her staff, she developed a comprehensive set of support services for clients. By the late 

nineties, the Miami-Dade County BPSP had become a multifaceted program that sought (1) to 

assist WIC clients from pregnancy through year one postpartum with breast-feeding issues, and 

(2) to promote the WIC program as a source of breast-feeding assistance to doctors’ offices, 

hospitals, community organizations, and third-party insurers. 

The program administrator decided to implement a breast-feeding helpline first, because it 

was easiest to establish. Within a few months, the WIC program began a breast pump loan 

program and lactation consultant services to further support clients in their efforts to breast-feed. 

In 1998, the administrator launched a peer counselor program, as the demand for breast-feeding 

support services—specifically culturally appropriate support—exceeded what the regular WIC 

staff could provide. Peer counselors would be more representative of the client population in 

terms of ethnicity and languages spoken, thus enabling WIC to offer effective breast-feeding 

support to a more diverse client base. 

Finally, the breast-feeding program administrator decided to incorporate community 

outreach into the BPSP’s mission. She targeted local hospitals, health care professionals, and 

37 Based on participation data supplied by the Miami-Dade County WIC program, December 

3, 2003, covering the period October 2002 to October 2003. 
71

third-party insurers to receive information on WIC’s breast-feeding support services. In her 

opinion, a fundamental goal of community outreach is to “change the image of WIC,” educate 

community stakeholders about WIC services, and encourage them to refer pregnant and 

postpartum women to lactation consultants and peer counselors. Specifically, the WIC program 

is shifting away from “where the formula is” to “WIC makes breast-feeding easy.” In fact, the 

latter statement has been incorporated into the program logo, and all hospital and outreach 

personnel wear uniforms with this slogan on the front. 

Target Population. WIC participants enrolled in a county WIC clinic are eligible for 

breast-feeding support services. Staff who work in the hospitals target low to moderate-income 

pregnant and postpartum women who are potentially eligible for WIC services in addition to 

current WIC clients. The BPSP also reaches out to community health care workers and other 

stakeholders to educate them about the benefits of breast-feeding and lactation support services 

available through WIC. 

PROFILE OF INNOVATIVE PROGRAM 

Services Provided. WIC promotes breast-feeding education for pregnant and postpartum 

women through individual breast-feeding consultations with board-certified lactation 

consultants, peer counselors, breast-feeding support groups, a breast-feeding helpline, a breast 

pump loan program, and baby showers. 

All 23 county clinics have a lactation consultant available, although at 7 of them, the 

Internationally Board Certified Lactation Consultant (IBCLC) comes in only once a week. 

Clients have access to individual lactation consultations, which typically last an hour but could 

be as long as two or three hours, depending on the mother’s need. Sometimes WIC participants 

must wait one business day to see a consultant, and occasionally they must wait a few days, but 

they can often be seen within 24 hours. Clients always access the lactation consultants through 

the helpline. Common issues include (1) sore nipples that last more than 24 hours, (2) first 

attempt at breast-feeding a premature infant, (3) breast milk supply issues, (4) breast surgery, 

(5) cleft palate and/or lip, (6) metabolic disorders, (7) inverted nipples, (8) latch-on problems, 

and (9) concerns about the infant’s weight gain.

Volunteer peer counselors supplement the support offered by lactation consultants. 

Volunteer peer counselors are available to assist primarily via telephone, while paid peer 

counselors (also known as outreach workers) work in hospital maternity wards promoting WIC 

and breast-feeding. Sometimes, they rotate to different clinics to assist with outreach events like 

health fairs. Currently, there are about 10 active volunteer peer counselors, and they volunteer 

no more than 5 hours a week. However, by December 2003, an additional 15 volunteer peer 

counselors will be trained and available. 

The breast-feeding helpline is answered weekdays from 7 A.M. to 4 P.M. by two WIC staff 

members, one of whom is an IBCLC. An answering machine operates in the evenings and on 

weekends; messages are checked once during weekday evenings and twice a day over weekends. 

The helpline is not exclusively for WIC clients. Doctors and nurses frequently call the helpline 

if they have a question or concern about a breast-feeding patient or a patient who is interested in 
72

 

breast-feeding. Program staff do not ask health care professionals if the question pertains to a 

WIC client. They simply answer any breast-feeding questions that they receive, which typically 

are on medication or specific diseases as they relate to breast-feeding. Approximately 

800 women receive assistance through the helpline each month.

A breast pump loan program is another component of the BPSP. Staff distribute electric 

pumps only to mothers who have premature or sick infants, or who face long-term separation 

from their infants. Recipients of electric pumps must be breast-feeding full-time (except for 

mothers of premature or sick infants) and cannot receive formula through WIC. Program staff 

are more liberal with mini breast pumps and usually distribute them to mothers of older babies 

(4 to 6 months old) who work or attend school. Staff lend manual pumps to anyone who 

requests one, except that pumps are not given to mothers who complain about sore nipples or 

who do not want to put the baby to the breast. In these cases, someone from the WIC breastfeeding staff will first counsel the mother and see if there is an alternate solution. Frequently, 

mothers must wait for electric pumps, but usually only for a few days. Women who request 

manual pumps tend to wait two days or so, because pumps are delivered through interoffice mail 

or regular mail from a central office. In addition, the Miami-Dade County WIC program will 

soon start a pilot electric pump program for working mothers, who will receive a free pump upon 

agreeing to complete a survey at 3, 6, and 12 months on the pump’s usefulness, degree of breastfeeding success, and overall satisfaction.

In addition, WIC sponsors breast-feeding support groups, two in English and two in 

Spanish. Classes are held monthly at a local clinic and are led by one of the paid peer

counselors. The program also sponsors baby showers for breast-feeding mothers every two 

months at two centrally located clinics. Showers provide games, gifts, distribution of food 

vouchers, and discussions about creative recipes that clients can try with WIC food. Gifts items, 

all of which are donated by various community organizations and businesses, include baby 

bouncy seats, diapers, and portable snack containers. 

Participation. During FY 2002, the program served 9,568 women through the helpline, lent 

246 double pumps, and conducted 728 individual lactation consults. The breast-feeding program 

administrator thinks that the Spanish support group is more successful and better attended than 

the English one because “Latin women really appreciate the support.” One Spanish support 

group held a birthday party for their babies and discussed the benefits of breast-feeding—all four 

of them had been breast-feeding for at least one year. 

Coordination and Collaboration. The WIC program has incorporated community 

outreach into its breast-feeding promotion efforts, particularly outreach to local doctors and 

nurses. Staff believe that building relationships with these health care providers through 

education can only benefit those WIC clients served by these doctors and nurses.38

38 WIC staff used to conduct new-employee education sessions on breast-feeding for the 

Healthy Start program in Miami-Dade County. (Healthy Start is a Medicaid expansion program 

that provides free health insurance coverage to eligible pregnant women.) However, limited time 

and staff resources led them to stop doing this training. 
73

 

Publicity and Outreach Efforts. Clients hear about the breast-feeding services from WIC 

staff, posters in the clinics, referrals, and outside agencies, as well as a breast-feeding helpline 

sticker on each WIC identification card. The sticker seems to be a very effective way to 

encourage women to access the support services. According to the breast-feeding program 

administrator, this tool is a “staple that they could not do without.” WIC receives referrals from 

hospitals, doctors, the La Leche League, and Healthy Start; it has a very good relationship with 

Healthy Start and receives many referrals from them. 

Outreach staff conduct community outreach in various ways, both for clients outside the 

clinic and for health care professionals. Currently, staff members rotate to six local hospitals 

each week, and counselors are in any given hospital for 4 to 8 hours. They talk about breastfeeding services available through the WIC program to all patients, room to room, on the 

maternity ward. They distribute WIC applications and ask patients if they have any questions or 

would like more information on breast-feeding. Outreach staff also sponsor booths at health 

fairs and work closely with a local baby supply and clothing store, teaching classes for their 

customers and attending their baby fairs monthly or every other month to distribute information. 

Moreover, staff have presented at dinners insurance companies have sponsored for physicians, 

explaining current services available through WIC, with an emphasis on breast-feeding support. 

Three dinners have been held so far, with 10 to 20 physicians attending each event.

WIC breast-feeding staff have been planning to conduct outreach to physicians’ offices. 

Because staff is limited, however, they have hosted only a few sessions.39 Generally, a WIC 

health educator cold-calls an obstetrician/gynecologist to introduce herself, talk briefly about the 

WIC program, and schedule a session. The educator meets with doctors and nurses at lunchtime 

to talk about the WIC program, the breast-feeding support services that it offers, and the ways 

WIC helps mothers succeed at breast-feeding. Visits last about 45 minutes. The educator also 

explains that WIC staff can help health care professionals with questions about non-WIC patients 

who breast-feed. She leaves several WIC applications, breast-feeding helpline posters, posters 

explaining how to enroll in WIC, and general breast-feeding materials for the health care 

providers. Staff also conduct followup with private doctors’ offices, because they do not want to 

get community stakeholders enthusiastic about breast-feeding and then “disappear.” Monthly 

followup typically includes calling someone at the obstetrician/gynecologist’s office to check 

how things are going.

ORGANIZATION AND MANAGEMENT 

Staff and Organizational Structure. The WIC breast-feeding program in Miami-Dade 

County has 12 employees (8 full-time and 4 part-time), although some play dual roles. These 

include a full-time bilingual telephone helpline operator, a full-time breast pump coordinator, 

five lactation consultants (three full-time share helpline coverage, and two half-time work only in 

the clinics), a full-time outreach coordinator, a part-time outreach worker for doctors and nurses, 

39 An outreach staff member was hired in November 2003 and will begin to make calls to set 

up sessions. The program administrator expects that these outreach sessions will become much 

more routine.
74

 

full-time and part-time administrative assistants who coordinate the outreach schedule and 

perform clerical duties, and the breast-feeding program administrator, who oversees day-to-day 

operations and policy development. The breast-feeding program administrator noted that 

95 percent of her staff started in the peer counseling program, and that peer counselors must have 

been enrolled at WIC at some point. 

Breast-feeding support staff rotate to different clinics each week since there is not enough 

staff to have a permanent worker at each clinic. Seven large clinics have a lactation consultant 

who comes in one day each week; the remaining 16 clinics have a consultant available on-site 

less frequently. Of the lactation consultants, two work almost exclusively in the field (that is, 

rotate to different clinics), three also operate the telephone helpline, and one also assists with 

community outreach. Community outreach workers visit venues like hospitals and health fairs, 

and sometimes teach breast-feeding classes to local health professionals. Volunteer peer 

counselors are available primarily to assist via telephone—occasionally they will also assist with 

the helpline—while paid peer counselors work in hospital maternity wards promoting WIC and 

breast-feeding. Peer counselors also administer pumps and can teach breast-feeding classes at 

clinics as needed. They also lead the support groups. (WIC nutrition educators are responsible 

for teaching some breast-feeding classes, but these last only about 10 minutes. Classes taught by 

breast-feeding staff are an hour long.) 

Aside from the administrative assistants and the administrator, official staff titles are either 

family support worker or health educator. Most lactation consultants have worked their way up 

from being peer counselors and have earned their IBCLC.40

Training. The Miami-Dade County WIC program provides some training opportunities for 

staff and community stakeholders to augment breast-feeding support services for clients. The 

program administrator offers a 26-hour training course for peer counselors, which she teaches 

along with another staff member. They meet once a week for 6 to 8 weeks, and two make-up 

sessions are permitted. The administrator organizes training schedules around participants’ 

needs, and sometimes classes are offered at night to accommodate participants. Topics include 

anatomy and physiology of the breast, composition of breast milk, addressing cultural 

differences, communication skills, time management of breast-feeding, normal course of breastfeeding from infancy through toddlerhood, nutrition and breast-feeding, parenting skills, and 

general baby care. On average, each session starts with 15 students, and 8 graduate. Although 

the breast-feeding program administrator used to offer the peer counselor training three or four 

times each year, she now only offers it twice annually. She estimates that there is a waiting list 

of about 20 at any given time. 

In addition, new health educators or family support workers receive 16 hours of new WIC 

employee training and a few hours of followup. The breast-feeding program administrator 

40 The breast-feeding program administrator noted that only staff who conduct individual 

consultations are required to be certified. However, some peer counselors have obtained their 

IBCLC because they are “passionate about breast-feeding.” Since the program began, six peer 

counselors obtained their lactation certification. 
75

 

conducts all trainings. Initial sessions cover basic breast-feeding management, when to refer 

clients to specialists, the breast pump program, anatomy and physiology of the breast, breast 

milk composition, the risks of artificial feeding, and proper positioning and latch-on techniques. 

Follow-up topics include fun ideas on teaching breast-feeding classes, service updates, and any 

policy updates.

As a supplemental training for peer counselors, WIC held its first all-day educational 

conference in 1998. Its purpose was to support, honor, and reinforce the knowledge of the peer 

counselors. The conference included parenting and breast-feeding panels, which addressed such 

topics as Teaching Your Client About Money, Motherhood Stress, Living on One Budget, 

Nutrition, Breast-feeding Basics, Cultural Differences, Choices in Education, Breast Pumps, and 

Making Breast-feeding Classes Fun. Peer counselors, local private practice nurses, and some 

WIC employees attended; it was open to health care providers in the community free of charge. 

The conference was so successful that the Miami-Dade County WIC office decided to host a 

yearly conference, and there have been educational conferences for the peer counselors and 

lactation consultants ever since. 

Record Keeping. All breast-feeding staff, including peer counselor volunteers, submit 

monthly reports that indicate their number of (1) classes taught, (2) pumps distributed, (3) people 

served through individual counseling sessions, and (4) telephone helpline calls made and 

received. In addition, hospitals submit information on whether patients breast-feed or not, 

whether patients are enrolled in WIC or not, the number of patients admitted, and the number of 

times that patients were seen by a doctor or nurse. Client satisfaction surveys are conducted 

regularly among clients who have received “full” breast-feeding services.41

Funding. The WIC program allocates 14 percent of its total budget, or $400,850 annually, 

for breast-feeding support services. This figure includes staff salaries. For incentive items for 

the baby showers, the program relies on donations from local companies, including children’s 

clothing stores, discount stores, caterers, bakeries, and restaurants. Doctors and other 

professionals have donated their time to speak at special events and conferences. 

ASSESSMENT AND LESSONS LEARNED 

Program Strengths. The breast-feeding program administrator said that breast-feeding 

rates have increased by about 10 percent between 1997 and 2003, and have increased each year. 

She feels that the most important success of the BPSP is that staff have implemented an “allencompassing, holistic approach,” rather than a “piecemeal” program. The breast-feeding 

helpline is key in this success, because it informs many participants about other breast-feeding 

services. It also provides breast-feeding technical assistance to health care professionals. 

Feedback from client surveys is almost always positive, and they would recommend the BPSP to 

friends and relatives (see the Lessons Learned section for survey details). Other WIC staff—

41 “Full” is defined as accessing the telephone helpline and using at least one individual 

consultation.
76

non-breast-feeding staff—are pleased that they have somewhere to refer clients who have breastfeeding questions or concerns. 

Moreover, the program administrator remarked that there have been some inspirational 

stories from peer counselors. One homeless woman with three children volunteered as a peer 

counselor for a year, was hired for the breast-feeding helpline, and eventually earned her IBCLC. 

After operating it for five years, she passed her IBCLC boards and now works for the MiamiDade County WIC program as a lactation consultant. The breast-feeding program administrator 

mentioned that 95 percent of her staff were once peer counselors, and 6 peer counselors have 

become IBCLCs, of whom 3 work as lactation consultants for the WIC program. 

Key Challenges. Several challenges have emerged while these support services have been 

implemented. At first, they were not sure how to recruit for the peer counselor program. The 

program administrator obtained a list of WIC clients who had received a breast-feeding food 

package in the past few years and called them to gauge their interest. Skeptics in the community 

(local lactation consultants not affiliated with WIC) said that the program would never succeed, 

since low-income women would not be interested in volunteering. Nonetheless, many women 

expressed interest and the volunteer peer counseling program thrived. However, they found that 

volunteers must be routinely reminded to submit their monthly service reports. 

More recently, the biggest challenge facing the BPSP has been staff retention. The breastfeeding program administrator does not feel that WIC has the capacity to serve all targeted 

women in the county who could benefit from breast-feeding services. It is especially difficult to 

keep volunteers interested in the BPSP now that some peer counselors are paid. When the peer 

counseling program began in 1998, it was fully staffed by 15 to 20 active volunteer peer 

counselors. Eventually, however, WIC secured funds to hire four counselors part-time (two fulltime equivalents), and this decision changed the climate of the program. Initially, those peer 

counselors who were not hired no longer wanted to be counselors, and the volunteer program 

almost “collapsed.” The administrator is currently increasing the number of volunteers through 

the University of Miami and Jackson Hospital, but is also seeking ways to compensate them. 

The breast-feeding program administrator noted also that the low salaries offered make it 

difficult to fill paid staff positions with people who are passionate about breast-feeding and have 

the capacity to support mothers. An additional barrier is attrition—lactation consultants are lured 

away by higher pay at private hospitals. Ideally, she would like to hire an additional 12 lactation 

consultants so that each clinic would have an IBCLC at a designated time every week.

Lessons Learned. For the breast-feeding program administrator, offering fully 

comprehensive breast-feeding services to WIC clients in a given service region can be hindered 

by a limited staff. This is also true particularly of outreach to private medical practices. Ideally, 

WIC would be able to reach more health care professionals, but her staff is small and the county 

covers a wide area. Community outreach sessions are time-consuming, each lasting about 

45 minutes, not including monthly follow-up phone calls.

Though the community outreach to private medical practices has been slow, the breastfeeding program administrator plans to continue to make it a part of the BPSP’s mission. 

Ultimately, she hopes to change WIC’s image with health care providers and the wider 
77

community to show that it is a place to get not just free infant formula but also information and 

technical assistance on breast-feeding and nutrition. The program administrator thinks that a 

breast-feeding telephone helpline is an easy, effective way to build lactation support services 

beyond traditional breast-feeding classes, not only to clients but also to community health care 

providers. She reported that many physicians appreciate the program because costs of breastfeeding support services through the private sector are high, and unaffordable to approximately 

30 percent of patients. (Lactation consultations in the private sector are about $90 and up for the 

first session, and $50 for each additional one. To borrow a breast pump, patients pay $45 per 

month, and the attachment pieces cost another $45.)

CONTACT INFORMATION 

Heidi C. Agostinho, Breastfeeding Program Administrator, IBCLC 

Breastfeeding Promotion and Support Program 

Miami-Dade County WIC and Nutrition Services 

7785 N.W. 48th Street 

Suite 300 

Miami, Florida 33166 

Phone: (786) 336-1333 

E-mail: heidil5@aol.com (please include ‘WIC’ in the subject line) 

79

C. PROGRAMS FOR HIGH-RISK GROUPS 

Besharov and Germanis (2001) suggested that WIC should target more intensive services to 

groups that are at particularly high risk for adverse health outcomes. This section highlights 

some targeted breast-feeding support programs that seem useful approaches to serving two 

(sometimes overlapping) high-risk groups: (1) teenage mothers, and (2) mothers of premature or 

seriously ill infants. 

Two of the three programs—in Arkansas and Hawaii—offer improved access to breast 

pumps for high-risk groups. Breast pumps are key tools in promoting breast-feeding initiation 

for mothers with ill or premature infants, or who otherwise must be separated from their infants. 

They can also be important tools for promoting a longer duration of breast-feeding for mothers 

returning to work or to school—and returning to school is particularly important for teen 

mothers. The third program—in the Toledo, Ohio, area—offers prenatal breast-feeding 

education classes tailored to meet the needs of pregnant teens. 

All three of these programs are inexpensive and may save WIC funds over the long term, by 

reducing costs for special formulas. Furthermore, they may improve the health of these high-risk 

infants over time. 

81

BREAST PUMPS FOR MOTHERS OF PREMATURE OR SERIOUSLY ILL INFANTS42

ARKANSAS 

OVERVIEW 

Location: Statewide 

Start Date: Spring 2000 

Target Population: Arkansas WIC mothers of premature or seriously ill infants. 

Purpose: To support breast-feeding and meet the breast-feeding needs of all Arkansas WIC 

mothers with premature or seriously ill infants by offering a low-cost, non-returnable breast 

pump. 

Services: Receipt of free electric breast pumps to keep, expedited WIC appointments to get 

certified for breast-feeding, and a toll-free number for technical assistance. 

Funding: Arkansas allocates WIC food dollars to purchase breast pumps at a bulk price of $99 

each; the pumps account for the majority of program expenses. 

Why Program Was Chosen: The program ensures that these high-risk families receive breast 

pumps quickly, and it appears to save the state money spent on special formulas and tracking 

loaner pumps. Arkansas may be the only state that sponsors a breast pump program targeting 

premature infants and seriously ill infants. Facilitating long-distance certifications in a rural state 

that has just a few, centrally located neonatal intensive care units (NICUs) is also innovative. 

Key Challenges: In the planning phase, challenges included developing and justifying the 

breast pump specifications and completing the state contract. In addition, it has sometimes been 

difficult for county health units with high caseload volume to expedite service for mothers who 

need to be certified as breast-feeding in order to receive a pump. 

 42 Telephone interview, April 2, 2003. 
82

 

BACKGROUND 

State Characteristics. The population of Arkansas in 2000 was 2,673,400, 78.6 percent of 

which were white and not of Hispanic or Latino origin. African Americans made up the largest 

minority racial group, at 15.7 percent. Most state residents speak English as their first language. 

In 1999, 15.8 percent of the population lived below the poverty level, and the median household 

income was $32,182. In 1997, one-quarter of children43 lived in poverty. An average of 84,153 

clients were enrolled in WIC each month during fiscal year (FY) 2002, approximately 3 percent 

of the total state population (U.S. Department of Agriculture 2003a).

WIC Program Background. The Arkansas WIC program is considered a single WIC 

agency, operated by the Arkansas Department of Health. The 75 county health departments—or 

units—serve as the WIC clinics. Most county health units are open Monday through Friday from 

8 A.M. to 4:30 P.M. The average monthly caseload for FY 2003 was 85,468: 3,177 breastfeeding women, 12,737 pregnant women, 7,348 postpartum women, 23,784 infants, and 38,422 

children. The average monthly breast-feeding rate was 13.3 percent.44

WIC offers lactation training for WIC staff and other health professionals, as well as 

services that promote breast-feeding and support clients who choose to breast-feed. Lactation 

specialists from the state office in Little Rock administer a toll-free breast-feeding helpline, in 

operation since 1990 and available weekdays from 8 A.M. to 4:30 P.M. Voicemail is available 

after regular office hours, on weekends, and during holidays, and calls are returned on the next 

business day. (The voicemail message includes phone numbers for other resources if immediate 

assistance is needed.) Mothers and health care professionals can ask questions about breastfeeding problems, medications, and related issues. 

In addition to the special initiative described below, the Department of Health offers less 

expensive breast pumps for mothers returning to work or school (Double Delux Small Electric 

Pumps, $45 each through a contractor or $150 retail), and manual pumps for occasional or shortterm pumping, particularly for stay-at-home mothers. A limited number of Lactina electric 

pumps are available on loan for short-term complications and medical problems. Specialized 

equipment and supplies, such as breast shields and sizing inserts, are also available.

Program History and Objectives. The Breast Pumps for Mothers of Premature or 

Seriously Ill Infants (BPMPSI) program was originally launched as a pilot to test the feasibility 

of providing non-returnable breast pumps (Pump In Style) to mothers of premature infants. 

Before then, the WIC division at the Department of Health had available for loan 200 reusable 

Lactina breast pumps, which are widely used in the United States and recommended by many 

43 Data are from www.barc.usda.gov/bhnrc/cnrg/state05.htm, accessed September 24, 2003.

44 The breast-feeding rate is calculated using a formula required by the Southwest Regional 

WIC office—the number of breast-feeding WIC clients divided by the number of all infants. 
83

 

health care professionals. However, demand for breast pumps far exceeded the supply, and 

mothers with premature infants were often placed on waiting lists.45

Not only did health officials fail to meet the demand for breast pumps, tracking and cleaning 

the reusable Lactina pumps were costly in terms of staff time and lost pumps. Frequently WIC 

staff encountered disconnected telephone numbers in trying to retrieve the pumps. Lactina 

pumps, which have a hospital-grade motor, cost $600 in 2002. 

In 1999, the U.S. Department of Agriculture (USDA) passed a regulation allowing WIC 

food funds to be used to purchase breast pumps. Before this pilot, the WIC program bought 

pumps with Nutrition Services and Administration (NSA) grants, which limited the number of 

pumps the program could purchase. With an additional funding stream available, the state WIC 

director—who was very committed to breast-feeding advocacy—approached the state breastfeeding coordinator and WIC breast-feeding nutrition consultant to explore what could be 

accomplished if more funding was allocated to breast-feeding initiatives. 

After consulting with health care professionals at Little Rock’s four tertiary hospitals that 

serve most premature infants in the state, the WIC breast-feeding coordinator and WIC breastfeeding nutrition consultant suggested the Pump In Style breast pumps, which were reusable and 

less expensive.46 Because mothers keep the pumps, WIC staff would not have to spend time 

cleaning or tracking them. Since the state could purchase pumps in greater quantities, it could 

secure a bulk price from a contractor (in the end, the state paid $99 versus $250 retail). 

Importantly, WIC staff carefully researched various pump models to develop the 

specifications, undergoing a thorough study of the pumps on the market that might meet the 

needs of their clients. For example, it was critical that the breast pump convert from electric to 

manual to account for losses in electricity due to a delinquent payment of a utility bill or a storm. 

State officials first approached the pump program as a pilot to test the feasibility of the Pump In 

Style breast pumps, but since have instituted it as a permanent part of the WIC program because 

of its success. 

Target Population. The Pump In Style breast pumps are available to Arkansas WIC 

mothers of premature or seriously ill infants. To receive a breast pump, a mother first must be 

certified as a WIC breast-feeding mother.

PROFILE OF INNOVATIVE PROGRAM 

Services Provided. WIC clients who have infants with special needs and are certified as 

breast-feeding are eligible to receive a free Pump In Style to keep. Some mothers contact the 

45 County health units, which serve as WIC sites in Arkansas, generally stopped tracking the 

number of requests for pumps when a waiting list reached 50 clients, which it often did. 

46 Doctors and nurses were very supportive of the Pump In Style pumps because their 

private-pay patients had been using them for years and were very pleased. 
84

 

helpline if they encounter a problem in getting a breast pump from their county health unit, but 

this rarely occurs.47 Each county health unit still has at least one Lactina breast pump that they 

can lend for a week or two if the need arises. As of April 2003, Arkansas had ordered 

2,000 Pump In Style pumps. 

In addition, WIC field staff grant mothers of premature or seriously ill infants expedited 

appointments to become certified for breast-feeding. Moreover, WIC staff located in Little Rock 

must accommodate clients (of premature or seriously ill infants) who are post C-section or 

staying at a neonatal intensive care unit, and who have traveled to the capital city and are far 

from their “home” WIC clinic. These women receive WIC certification as breast-feeding 

mothers at a WIC clinic near the hospital and receive a pump on the same day. Because 

Arkansas has a statewide WIC agency and automated system, this long-distance certification was 

not too hard to implement. When the mother returns home, she goes to her “home” WIC agency 

to receive vouchers. The agency checks the computer to verify her certification and issues the 

vouchers. The home agency also calls or e-mails the Little Rock unit to obtain a copy of the 

record of the mother’s certification visit, which the Little Rock staff send by mail.

Participation. The Arkansas Department of Health originally intended to administer the 

pumps to premature infants only. Soon, however, program staff learned through surveys of the 

first pump recipients that local hospitals recognized that mothers of infants with serious medical 

conditions proved to be excellent candidates for the pump program and referred them as well. 

Still, most clients have premature infants. In the initial wave of pump recipients, 7 out of 

318 infants had serious birth defects that interfered with breast-feeding. Though the babies were 

not premature, their mothers needed an effective pump for long-term use. The remaining babies 

had low birth weights.

Coordination and Collaboration. Before the state officially launched the pilot program, 

the state breast-feeding coordinator and the WIC breast-feeding nutrition consultant delivered 

brief presentations to postpartum and nursery staff at Little Rock’s hospitals with neonatal 

intensive care units: three tertiary hospitals and Children’s Hospital. The presentations included 

a description of the pilot and a demonstration of a Pump In Style pump. According to the state 

breast-feeding coordinator, staff were “eager and supportive.”

Publicity and Outreach Efforts. WIC clients generally hear about the BPMPSI program 

through health care professionals and through word of mouth from previous pump recipients. 

State officials distributed information on the program to all hospitals, clinics, and county health 

units in the state. The state breast-feeding coordinator also delivered presentations to postpartum 

and nursery staff at the main hospitals in the Little Rock area with neonatal intensive care units, 

which included a program overview and a demonstration of a Pump In Style pump. The three 

tertiary hospitals, along with the city’s Children’s Hospital, serve the majority of premature 

deliveries in the state and are where many WIC clients learn about the breast pumps. The 

coordinator observed that word of mouth is an effective and powerful means of marketing the 

47 Each month, the hotline receives between 60 and 100 calls, of which up to 10 are related 

specifically to the specialized pumps. Most of these are inquiries about how to obtain a pump. 
85

program. Using breast pumps to feed premature and seriously ill infants is a “novel” concept 

that “makes a splash” with health providers and mothers interested in breast-feeding. 

By the spring of 2002, all WIC sites and hospitals statewide were familiar with the breast 

pumps for children with special needs. The state breast-feeding coordinator reported that health 

care professionals in all parts of the state inform new hospital staff about the BPMPSI initiative 

during their employee orientations, to ensure that the new staff inform interested mothers about 

the pump program. In addition, county health units, clinics, and hospitals display program 

brochures in waiting rooms, and the Department of Health posts information on its Website.

ORGANIZATION AND MANAGEMENT 

Staff and Organizational Structure. The state breast-feeding coordinator and the WIC 

breast-feeding nutrition consultant developed and administer the BPMPSI program at the state 

level. They also are responsible for educating the statewide health care community about this 

new resource for WIC mothers. During the planning and development phase, the state WIC 

director provided counsel as needed and approved the final state contract with a pump 

manufacturer. A computer programmer from the Department of Health designed a database and 

entered results from a survey of initial recipients of the Pump In Style pumps, and two part-time 

state WIC staff members monitored those who responded to the survey to collect data on breastfeeding and using the breast pumps. (See the evaluation section for a description of the survey.) 

Program officials completed the contract with the manufacturer, distributed the first round of 

pumps to county health units, and developed a database for tracking outcomes, but, after these 

tasks were completed, little state staff time has been needed for the pump program. The state 

breast-feeding coordinator and the WIC breast-feeding nutrition consultant respond to occasional 

calls on the toll-free breast-feeding hotline, and they deliver short presentations on the program 

from time to time at health and nutrition workshops. 

Funding. Most funding is used to purchase Pump In Style pumps; very little is allocated to 

staff time or outreach. WIC uses food dollars for these breast pumps and does not receive any 

outside funding. For its first contract, the state purchased 1,000 pumps for $99 each, and the 

supply lasted about two years. An additional 1,000 have been ordered, some of which remain in 

the central supply warehouse in Little Rock, while others are stored at the county health units for 

immediate distribution. Breast pump expenditures for FY 2001 were $90,490, which represented 

less than 1 percent of its annual WIC food funds. In FY 2002, the state spent about 1 percent of 

its annual food funding, or $216,465. Because the state WIC director is a breast-feeding 

advocate and has prioritized this project, the pump program should continue as long as there is 

available federal funding.

ASSESSMENT AND LESSONS LEARNED 

Evaluation and Outcomes. State WIC officials used a written survey and follow-up 

telephone calls to gauge initial client experiences with the Pump In Style breast pumps. After 

the pumps arrived from the manufacturer, program staff inserted a survey into approximately 

500 pumps and sent one pump to each county health unit in Arkansas. In order for health units 
86

to receive additional breast pumps, officials required that the initial pump recipients complete the 

short survey that collected preliminary information for the phone survey, which local staff 

returned via fax. This approach ensured that the state office would receive immediate feedback, 

establishing a quality control mechanism that would reveal any design flaws that would require 

that the pumps be returned to the manufacturer. State officials received a total of 283 completed 

surveys. Data from the surveys included infants from 35 participating hospitals. 

As a second monitoring component, two part-time state WIC employees called surveycompleting mothers each month for as long as the mothers continued to pump breast milk. The 

follow-up calls included questions on product satisfaction, satisfaction with milk production, and 

breast-feeding duration rates. Most clients liked the Pump In Style pumps, noting that they were 

easy to use and produced adequate amounts of milk. Reasons for dissatisfaction among some 

mothers included (1) slow speed of the pump; (2) inadequate milk production; and (3) pain. The 

shortest breast-feeding duration was 4 weeks, and the longest was 83 weeks. 

Implementation Successes. As a result of the BPMPSI program, the state no longer 

maintains waiting lists for breast pumps for mothers with premature or seriously ill infants. The 

RESPONSES TO TELEPHONE FOLLOW-UP OF MOTHERS 

USING THE PUMP (PILOT PHASE) 

Number of 

Responses 

Satisfaction with the WIC Pump 

Very satisfied 520a 

Somewhat satisfied 45 

Not satisfied 12 

Satisfaction with the Amount of Milk Collected 

Very satisfied 337 

Somewhat satisfied 155 

Not satisfied 84 

Was the Pump Helpful? 

Essential to the health of my baby 332 

Helpful 212 

Somewhat helpful 23 

Not helpful 7 

a

Total responses for a particular question exceed 283—the total number of clients who received 

follow-up phone calls—because staff asked the same questions from month to month and 

aggregated the data. Therefore, we cannot determine how responses changed, if at all, over time. 
87

 

initiative ensures that mothers can receive a Pump In Style pump within a few days of delivery. 

Receiving a pump in a timely manner is crucial to initiating breast-feeding, since mothers may be 

more reluctant to begin once they have used formula. 

Based on the survey distributed to initial program participants, WIC clients have been very 

thankful for being able to provide breast milk to their premature or seriously ill infants. 

According to the state breast-feeding coordinator, mothers “love” using the Pump In Style model 

because it is easy to use and “anyone could pick it up and figure out how to use it without 

reading any instructions.”48 When asked if the breast pump made it possible for them to provide 

breast milk for their infants, clients overwhelmingly responded “yes.” 

Program officials reported that physicians and hospital staff have expressed a renewed 

appreciation for the WIC program because they understand how it helps infants with special 

needs gain access to breast milk. Moreover, WIC field staff feel empowered and relieved by 

being able to meet the clients’ needs, instead of placing them on a waiting list for pumps. 

Because the Pump In Style pumps are non-returnable, staff no longer spend time cleaning breast 

pumps and can focus on other services. In addition, the pilot part of the study suggested that 

fewer infants were prescribed expensive special formulas, which saved money. 

Key Challenges. Very few implementation challenges have been associated with the 

program. State program officials noted that the main hurdle during the planning phase was 

developing and justifying the pump specifications—such as ensuring that the pump could switch 

to manual mode in case of power outage—and finalizing the state contract. Arkansas officials 

cautioned that other states might not be able to use the Pump In Style if it is not approved for a 

state contract. They noted, however, that similar breast pumps might work just as well. 

In addition, the state breast-feeding coordinator observed that, for a few county health units 

with a heavy client flow, it has been difficult at times for WIC staff to expedite cases for mothers 

who need to be certified as breast-feeding in order to receive a pump. While it is challenging to 

juggle this immediate demand along with their regular caseloads, staff manage because they 

understand that the BPMPSI program meets a critical need for these families. Since appointment 

“show rates” are rarely 100 percent—especially for appointment slots early in the day—it is 

generally not a problem to incorporate an urgent case into the schedule. 

Lessons Learned. Program officials reported that a key element of the program’s success 

has been the support of hospital staff, particularly at Children’s Hospital in Little Rock, who 

serve as a primary source of referrals for the specialized pumps. Consequently, an agency 

implementing a similar program should know it is important to conduct outreach to area 

hospitals and health care professionals as early as possible to educate them about the breast 

pump program and encourage them to refer to WIC mothers who deliver premature or have 

seriously ill infants. If the hospitals in Little Rock were not so in favor of breast-feeding and did 

48 The survey of initial recipients revealed that only 1 of 283 clients had trouble assembling 

the pump, and only a few experienced difficulty using it. 
88

not have a history of collaborating with WIC, it may have required considerably more advocacy 

and education of health care professionals on the part of state officials. 

The state breast-feeding coordinator noted that any state could implement a pump program 

for mothers with premature or seriously ill infants, provided that funding was available to 

purchase enough pumps. A significant factor that could influence replication is the degree to 

which a state WIC director supports breast-feeding and is willing to allocate food dollars for a 

specialized pump program. In Arkansas’s experience, NSA dollars alone were not sufficient to 

eliminate waiting lists. 

For mothers who are away from home because their infants are in an NICU on an 

emergency basis, a program to certify them so that they can receive a pump may be of interest to 

other states. The statewide WIC agency in Arkansas is unusual, so other states would have to 

consider the feasibility of implementing such procedures.

CONTACT INFORMATION 

Martha Hall, State WIC Breastfeeding Coordinator 

Sandra Jones, State WIC Breastfeeding Nutrition Consultant 

Arkansas Department of Health 

WIC Nutrition and Breastfeeding 

5800 West 10th Street 

Suite 810 

Little Rock, Arkansas 72204 

Phone: 501-661-2905 

E-mail: mhall@healthyarkansas.com (Martha Hall) 

 sljones@healthyarkansas.com (Sandra Jones) 
89

PUMPS IN THE SCHOOLS (PITS)49

HAWAII 

OVERVIEW 

Location: Piloted in two high schools on the island of Oahu; the program is now operating in 

10 more schools. 

Start Date: Fall 2001 for two pilot schools; fall 2003 for expanded implementation. 

Target Population: Teenage mothers attending selected high schools and participating in the 

Graduation Reality and Dual-Role Skills (GRADS) program. 

Purpose: To make it easier for teenage mothers to continue breast-feeding after they return to 

school, and thus to extend breast-feeding duration for this high-risk group. 

Services: High-quality double pumps are made available in school, along with a private place to 

pump. Girls on WIC receive an attachment kit for free, while other girls receive one at a reduced 

price. 

Funding: The original program in two schools was funded with WIC breast-feeding funds. 

Expansion is being funded through a WIC operational adjustment grant. 

Why the Program Was Chosen: This program extends to the school setting services available 

from existing breast pump programs for WIC mothers, and targets a high-risk population 

(teenage mothers) by bringing the services to them. It would be replicable at modest cost. 

Key Challenges: The program depends heavily on the GRADS teachers to encourage 

participation; building coalitions with these teachers is critical. Young mothers face many 

challenges, such as short breaks between classes, that make breast-feeding difficult. 

 49 Telephone interview, April 21, 2003. 
90

BACKGROUND 

State WIC Program Background. In Hawaii, the WIC program serves 33,000 clients a 

month. About one-fourth are women (pregnant or postpartum). There are 16 local agencies and 

about 30 clinics. The breast-feeding initiation rate is 92 percent for the state and 75 to 94 percent 

for WIC participants, depending on the clinic and its demographics. 

Program History and Objectives. Hawaii implemented a statewide pump program in 

January 2000. This program consists of giving away manual pumps and lending hospital-quality 

double electric pumps. Part-time working and schooling mothers, partial breast-feeders 

(receiving fewer than four cans of formula a month from WIC), and some mothers with transient 

medical needs are eligible for manual pumps. The pumps on loan are for exclusively breastfeeding high-risk infants and full-time working or schooling women. Mothers who borrow the 

electric pumps receive a free attachment kit to keep. 

Returning to school is a primary barrier to breast-feeding duration among high school 

mothers, so the state’s Contracted Breastfeeding Specialist developed the idea of keeping double 

electric pumps in schools for multiple girls to use between classes. Although a breast-feeding 

WIC teen qualifies for the pump program, most do not participate. The Breastfeeding Specialist 

was concerned about teenage mothers carrying around the double pumps along with all the other 

things they need to bring to school. In addition, she wanted to make it easier for teen mothers to 

continue breast-feeding once they returned to school, since many would start but then quit when 

they went back to school. The goal of the program is to increase the duration of breast-feeding 

among teenage mothers. 

PROFILE OF INNOVATIVE PROGRAM 

Services Provided. Teen mothers at 12 public schools on Oahu, Hawaii, and Kauai are 

eligible to use the pumps. All teen mothers in the schools can use the pumps, even if they are not 

on WIC. Girls on WIC get the attachment kits for free. Girls who are not on WIC have to buy 

the kit, but are offered a reduced price by private vendors. The attachment kit can be converted 

to a manual pump for use on weekends and when the girls are not at school. 

Any girl who is interested in using the pump just has to ask the GRADS teacher. The 

teacher gives the girl a form to bring to WIC saying that she attends one of the PITS schools and 

is a parenting teen. The girl can then go to WIC and get an attachment kit. This form is useful 

because some of the girls are not very articulate and would have difficulty explaining their 

situation at the WIC clinic. 

The teachers set up special areas where the girls come to use the pump. In one pilot school, 

the area is a corner of a room that is partitioned. There is a chair, a stool, and some posters. In 

the other pilot school, the pump is in a separate room that used to be a storage room, while at 

another school it is in the health room. The key is to have a comfortable place for the girl to sit. 

They usually pump for the 10 minutes between classes, although it takes 20 minutes to pump 

fully—that is all the time they have. They are also welcome to come in at recess and lunch 

times. Sometimes two girls pump at the same time. In one of the pilot schools, the non-GRADS 

teachers have been very supportive of this program. If a mother in this school is late to class due 
91

to feeding or pumping, she is given a permission slip with no questions asked, as long as she lets 

the teacher know she will be late; this communication is handled teacher-to-teacher via cell 

phones. 

The teen mothers on WIC who breast-feed usually also get formula from WIC, but they still 

have access to the breast-pumps. In Hawaii, women generally cannot borrow an electric breast 

pump if they are using formula. Pumps are usually available only to exclusively breast-feeding 

women. However, the WIC program makes an exception for teens, because their circumstances 

are such that they cannot always use breast milk exclusively. For example, the mother may not 

be able to nurse exclusively because the baby may be with the father’s family at times, or she 

may need to leave the baby at child care while she works or attends school. In addition, because 

teen mothers have only 10 minutes between classes to pump, pumping may not be enough to 

feed the baby breast milk all the time. Furthermore, their lives are hectic, and they may have 

difficulty handling the planning needed to have pumped breast milk available at all times. 

Coordination and Collaboration. The key collaboration for this program is with the 

schools—specifically, between the teachers in the GRADS program and the nearest local WIC 

agency. GRADS is a support program for pregnant and parenting teens in school. It is designed 

to teach them life skills and help them succeed in school so they can graduate and further their 

educations. The schools in PITS each have a designated GRADS teacher. These teachers took 

on the task of getting the school principals to agree to the program. In addition, they spread the 

word about the pumps and found and decorated private spaces for pumping. The local WIC 

director or breast-feeding coordinator is asked to visit the schools with the state breast-feeding 

specialist to get to know the teachers and the students, and to establish ongoing collaboration. 

Participation. The State Breastfeeding Contractor did not have precise figures on the 

number of teen mothers who used the pumps during the pilot phase, and had even less sense of 

participation levels at the new schools. Nonetheless, based on her own interactions with the 

girls, she thought that, at the smaller pilot school, about 12 girls consistently pumped during the 

last year. Overall, because of the small numbers involved at each school, teacher reports of 

participation, although anecdotal, seem likely to be fairly accurate. 

Preliminary surveys and teacher interviews indicate that teen breast-feeding rates have 

become much higher since the program was implemented. Furthermore, teachers in the pilot 

project reported that breast-feeding durations have increased. Teachers reported that the 

program has increased breast-feeding durations from an average two to four weeks of partial 

breast-feeding postpartum, to about 80 percent breast-feeding upon return to school, which 

generally happens at six weeks postpartum. Some young mothers are now breast-feeding for six 

months to one year or longer. In one participating school, there is now only one formula-feeding 

parent, while the eight others are exclusively breast-feeding. 

Interestingly, the program is more successful when child care is available at the school. In 

fact, one Kauai high school has put the pump in the child care room, so that even if the infant is 

sleeping, the mother can pump while being near her baby, or she can pump one breast while the 

infant feeds on the other. This may also help increase “let down” and improve maternal milk 

supply. Presence of a child care center at the school also provides an indication of a supportive 

environment for teen mothers. 
92

The teen mothers who participate in PITS are of various ages and some have more than one 

child. Most have a boyfriend, and most come from families who do not believe in abortion. 

Staff report that many are normal teenagers, with a lot of pressure on them, but some are fairly 

high-risk. Like most teens, they are concerned about their image. The students involved in the 

program are from many ethnic groups: Hawaiian, Filipino, Micronesian, Caucasian, and African 

American. 

Outreach. The girls in GRADS hear about the pumps from their local WIC agency, the 

teachers, and other girls; some also see the pumping areas that have been set apart. The 

Breastfeeding Specialist also reported the program has helped change the “culture” in the 

schools. Now, students and teachers accept that pumping is what mothers do in these schools. 

Pumping and breast-feeding used to be the exception, but now have become “the thing to do.” 

Expansion Plans. The program is expanding to 10 additional schools throughout Hawaii 

during the 2003–2004 school year. The Breast-feeding Specialist will go to each site’s WIC 

agency and train the local Breastfeeding Coordinator and other staff on how to link with the 

schools to provide attachment kits to the girls. She is meeting with the GRADS teachers and the 

girls at the schools to get the program started. She expects the local Breastfeeding Coordinators 

to become involved and help keep the program running. 

ORGANIZATION AND MANAGEMENT 

Staff and Organizational Structure. The State Breastfeeding Contractor conceived the 

program and got it up and running. She conducts periodic surveys and comes to talk to the girls. 

The local WIC clinics provide attachment kits to the girls as part of their regular services. 

However, the GRADS teachers run PITS on a day-to-day basis. 

One important feature in how the program was set up is that WIC staff dealt with each 

school directly, rather than going through the state Department of Education. The GRADS 

teachers initially talked to the principals to obtain their agreement. Then the State Breastfeeding 

Consultant helped negotiate a Memorandum of Agreement between WIC and each school, which 

specifies the responsibilities of each party. For example, WIC is responsible for servicing the 

pumps, but if a pump is stolen or vandalized, it is the school’s responsibility. 

Funding. For the first two years, costs were covered by regular WIC breast-feeding funds. 

The Breastfeeding Specialist charged her time as usual to WIC. The teachers are employed by 

the school, so there is no cost to WIC for their time. WIC already had the pumps, which were 

purchased with food funds. To expand the program to 10 more schools, the state received a WIC 

Operational Assistance Fund Grant of $49,500. 

In the long run, the Breastfeeding Specialist thinks that PITS probably saves WIC money, 

because it provides a way to use one or two breast pumps for multiple clients, with minimal staff 

involvement and less likelihood of theft. 
93

ASSESSMENT AND LESSONS LEARNED 

Program Strengths. This program is straightforward to implement, has minimal costs, and 

may in fact save WIC money by reducing formula expenditures. It also offers the opportunity to 

increase breast-feeding durations for teenage mothers, whose infants are often at high risk. 

As noted above, the impressions of the teachers and the Breastfeeding Specialist are that 

usage of the pumps has been substantial. The GRADS teachers believe that PITS has improved 

breast-feeding rates and durations, decreased illnesses among the babies, and thus decreased 

absenteeism among the girls.

Even after PITS implementation, most teen mothers introduce formula at two to four weeks 

postpartum. Nonetheless, breast-feeding duration is longer among teen mothers after PITS 

implementation in their schools. More teen mothers breast-feed exclusively or feed a 

combination of breast milk and formula, rather than ceasing breast-feeding completely. Because 

of the time constraints on pumping between classes, local WIC staff have been encouraged to 

work with these young mothers to encourage as much breast-feeding as possible, while still 

being flexible about providing formula. This change in attitude, along with the availability of the 

pumps, has proven to be effective in lengthening the breast-feeding relationship, while 

supporting the young mothers based on their needs and the realities of their day. Postintervention student surveys in the pilot schools show that students view both WIC and their 

schools as much more supportive of breast-feeding than before the implementation of PITS. 

Hawaii WIC has developed new surveys for the new sites this year—they will do a “pre” 

survey before the program starts, and then a “post” survey after it has been going awhile. These 

surveys will provide a stronger basis for evaluating the program’s outcomes. 

Key Challenges. The program is very dependent on the GRADS teachers and their 

enthusiasm for encouraging participation. The Contracted Breastfeeding Specialist hopes, with 

the new grant funding, to be able to spend more time in the schools sharing information and 

assisting young mothers with any breast-feeding problems. 

Lessons Learned. The Contracted Breastfeeding Specialist advises others interested in 

starting a similar program to work closely with the teachers in school-based programs for teen 

parents and make sure they are committed to the breast pump program. They know the teen 

mothers and the realities that they face. She also recommends taking the teachers’ advice on 

how the program should work in their school. 

The initiative for the program in this case came from the state WIC agency, but they worked 

with the local schools, rather than with upper levels of the school bureaucracy, to obtain access 

to the young mothers. This type of coalition seems important in reaching teen parents, as they 

have difficulty finding time and transportation to visit the WIC agency. 
94

 

An important caveat is that the high use of the in-school breast pumps by Hawaii’s teen 

mothers may be harder to achieve in other places. Breast-feeding rates in Hawaii are very high 

in general, and the local culture is very supportive of breast-feeding.50

CONTACT INFORMATION 

Christina Shoemaker Simmons 

Contracted Breastfeeding Specialist 

WIC Services Branch 

235 S. Beretania St. 

Honolulu, HI 96813 

Phone: 808-586-8368 

Fax: 808-586-8189 

E-mail: casimmon@mail.health.state.hi.us

Or simmonc005@hawaii.rr.com

50 In contrast, we spoke with a local WIC agency that operated a similar program in a state 

with low breast-feeding rates. They found that the pumps available in the schools were hardly 

used, although other WIC services were appreciated. 
95

INFANT-FEEDING CLASSES FOR TEENS51

LUCAS COUNTY, OHIO 

OVERVIEW 

Location: Lucas County, Ohio (Toledo and environs) 

Start Date: 2000 

Target Population: Pregnant teenagers on WIC or in school programs for pregnant teens. 

Purpose: To provide breast-feeding education for pregnant teenagers that is targeted at their 

needs and concerns and thus encourages them to breast-feed their babies. 

Services: WIC staff run, for pregnant teens on WIC, a class that presents information and 

includes open-ended discussion of infant feeding from the point of view of teenagers, a video on 

breast-feeding designed for teens, information on other resources, and “goody” bags with 

incentives and informational brochures. In addition, in-depth classes are offered in local high 

schools as part of school programs for pregnant teens. 

Funding: Staff time is funded from WIC breast-feeding funds. Food and incentives were 

originally funded through small grants from the March of Dimes (MOD) and local hospital 

foundations, but the WIC agency is taking over these costs after obtaining a special waiver from 

the state agency. 

Why Program Was Chosen: The WIC class seems a good example of breast-feeding education 

targeted to a particularly high-risk group—pregnant teens—and it would be replicable in a range 

of settings at modest cost. The partnership with the schools is also of interest. 

Key Challenges: Convincing teenage mothers to breast-feed is an ongoing challenge, and it is 

difficult to affect their decisions through one class. In addition, only 15 to 20 percent attend. 

Additional contacts in the schools and in the hospital around the time of the birth are used to 

reinforce the message. 

 51 Telephone interview, May 30, 2003. 
96

BACKGROUND 

Community Characteristics. Lucas County, Ohio, contains the city of Toledo and its 

immediate environs. It is located in the northwest corner of the state, bordering Lake Erie and 

Michigan. The 2001 population of this urban county was just over 450,000. The county is 

17 percent African American, compared to 12 percent in the state as a whole, and 5 percent 

Hispanic, compared to 2 percent in the state as a whole. The 1999 poverty rate was 14 percent in 

Lucas County, much higher than the 11 percent rate in the state overall. Lucas County has the 

second-highest teen pregnancy rate in the state, and it used to have the highest rate.

WIC Program Background. The WIC agency is part of the Toledo-Lucas County Health 

Department, which operates eight WIC clinics, three or four of which are in local hospitals. The 

agency enrolls about 12,000 WIC clients a year in all categories. 

In addition to the infant-feeding classes that are the focus of this profile, the Toledo-Lucas 

WIC program offers a range of other services for breast-feeding women: 

• They can schedule appointments with the breast-feeding staff at the central WIC 

office if they need breast-feeding help; if transportation is a problem, breast-feeding 

staff will travel to other WIC clinics. 

• If pregnant WIC participants attend infant-feeding classes or otherwise express 

interest in breast-feeding, WIC staff attempt to telephone them right after the birth. If 

the mothers are having any problems, staff encourage them to bring the baby in to see 

the lactation consultants. The main WIC clinic has a very accurate scale that gauges 

the amount of milk ingested when the baby is weighed before and after nursing. 

• WIC lactation consultants coordinate with the hospital lactation consultants—the 

hospital consultants work with mothers while they are in the hospital, and WIC staff 

take over after discharge. 

• WIC has electric pumps to lend out and manual pumps to give out: (1) Lactina 

pumps are targeted at mothers with babies in the hospital, but there is a waiting list; 

(2) other, less-expensive electric pumps are provided for mothers returning to work or 

to school, with some models on loan and some that mothers can keep.

Program History and Objectives. The breast-feeding coordinator started separate classes 

for teen mothers in 2000. When conducting breast-feeding education classes for pregnant 

women that included both adults and teenagers, the coordinator noticed that the needs and 

concerns of teenagers were very different from those of older women, and she thought it would 

be more effective to offer classes targeted at teens. She wanted to present the benefits of breastfeeding in a way more meaningful to teens, and also to hold the class at a time when it would be 

easier for them to come. 

Soon after the Health Department started offering the teen classes, the breast-feeding 

coordinator received calls from the teachers of the Graduation Reality and Dual-Role Skills 

(GRADS) programs (special programs for pregnant or parenting teens) in local high schools, 
97

expressing interest in the infant-feeding classes, but also some concern that girls would skip 

school to attend them. The coordinator offered to present classes in their programs, which they 

were very happy to have. She began to visit the three area high schools regularly and give 

classes on breast-feeding—these classes have been opportunities for the teachers also to learn, 

and she reaches some girls who will not come to the WIC class (and some who are not eligible 

for WIC). 

PROFILE OF INNOVATIVE PROGRAM 

Services Provided. The breast-feeding class WIC runs is for pregnant teens on WIC. They 

all receive a postcard around their seventh month of pregnancy inviting them to the next class. 

The postcard refers to the class as an “infant-feeding class” (mention of breast-feeding may 

discourage attendance) and notes that pizza will be served. Sometimes, the postcards mention 

some of the other incentives available (described below). The WIC class is offered every six 

weeks at a local church, on Wednesday at 3:30 P.M., so teens can come after school. (At the church, 

more parking is available than at the WIC clinic; they hold classes for older mothers there, too, but at 

10 A.M.) The class, which usually lasts from 60 to 75 minutes, counts as a WIC nutrition education 

class. The girls sign in and give their WIC case number.

The class is intended to get out a few key messages: 

• Breast-feeding is best for both mother and baby. 

• WIC staff will help. They make sure the expectant mothers know how to get in touch 

with the breast-feeding coordinator and her staff. 

• Pumps and an enhanced food package are available. 

• It is possible to breast-feed and to go back to school. The breast-feeding coordinator 

has arranged private rooms for pumping at all the local high schools and colleges. 

As the teens arrive, music from one of the radio stations popular with teens plays at a low 

volume. At the start of the class, they serve pizza and drinks—it is a draw and helps to break the 

ice. Next, the coordinator shows a video that shows teens breast-feeding and talking about why 

breast-feeding is best. She shows this first partly because “teenagers tend to be late.” 

At times, the breast-feeding coordinator invites various speakers from other health 

department programs. For example, a staff member who offers smoking cessation classes may 

talk about these classes (as many pregnant teens also smoke), or another staffer may talk about 

the “Help Me Grow” program, which offers up to two home visits from a nurse after the baby is 

born. 

The most useful way to get the pregnant teens to consider breast-feeding is to have a breastfeeding teen attend the class with her baby—this has more impact than any information from the 

staff, as the breast-feeding teen can tell those in the class how breast-feeding works for her. In 

addition, the breast-feeding coordinator sometimes brings the “peer helper” who works with her 
98

at the WIC agency. She is a mother who is now 30 but who had her first child as a teen and has 

been on WIC, and she shares her experiences. 

Next, the coordinator gives out the “goody bags” that she puts together for the girls and goes 

over what they contain. The contents vary somewhat, but they tend to include: 

• Handouts with information and resources—for example, brochures on whom to call if 

they are breast-feeding and having problems, how to store breastmilk, how to know if 

the baby is getting enough milk; flyers from other organizations; and information 

from the MOD on folic acid (required as part of a MOD grant—see the discussion of 

funding). 

• Condoms—the coordinator discusses birth control and what works best while 

nursing. 

• “Onesies”—baby underwear purchased with the MOD grant. 

• Free toiletries and the American Baby magazine. 

• Magnets with numbers for the breast-feeding coordinator’s office (for breast-feeding 

help), magnets with a “Breastmilk Storage Guide,” and pens with the WIC office 

phone number. 

• A voucher for a half-price car seat if they attend a car seat class. 

The breast-feeding coordinator shows the girls different breast-feeding aids and points out 

that they can suggest them as presents to family or friends who may want to buy a gift for the 

baby; examples include breast-feeding pillows. She also discusses breast pumps, including 

which pumps are available through WIC, and which types of pumps are better than others. Many 

of the girls are interested in this information. 

Next, there is an open-ended discussion. The breast-feeding coordinator passes out a series 

of questions on laminated paper. She asks for volunteers to read the questions (as not all the 

girls can read). For example, questions include: 

• Can you breast-feed and go back to school? 

• Can you smoke and breast-feed? 

She tries to get a group discussion going, letting them express what they believe and offering 

more information. She tries to focus on the issues that concern teens, recognizing their 

immaturity, such as “Will my breasts sag if I breast-feed?” or “Can I still go out with my 

friends?” The coordinator discusses the benefits of breast-feeding from the teen mother’s point 

of view, such as: the baby is easier to take care of, she can get more sleep at night with nursing in 

bed, she does not need to take bottles when out, and she will have larger breasts. 
99

The coordinator is flexible in leading the discussion and will focus on what seems to be of 

most concern to the girls attending. The discussion lasts 50 minutes to 1 hour. She also 

encourages the girls to bond with each other; some exchange phone numbers at the end. In 

addition, there is a drawing for a baby quilt (made and donated by local volunteers) at the end of 

each class, which is another incentive for the girls to attend. 

The breast-feeding coordinator also gave classes at three local high schools in GRADS, their 

special program for pregnant/parenting teens, every six weeks. In fall 2003, the school district 

moved all pregnant and recently delivered teens to a separate school; the school has a satellite 

WIC clinic on site every three to four weeks, and she offers classes at that time. In the school 

setting, she sees the same girls repeatedly, so she covers different information each time. For 

example, one class may focus on positioning the baby on the breast, and another class may focus 

on what to do if the baby is premature (not uncommon for teen mothers). She always brings a 

few of the goody bags in case the class contains girls who are close to delivery. In spring 2003, 

there were about 10 to 15 girls in the program at each of the three high schools.

Coordination and Collaboration. In addition to the collaboration with the schools, WIC 

staff also work with the hospitals to help teenagers. The hospitals have lactation consultants on 

staff, and they will refer mothers to WIC when appropriate. In addition, the local hospitals offer 

a Teen Lamaze class, and the WIC breast-feeding coordinator works closely with the people who 

run this class. She refers WIC teens to the Lamaze class as appropriate, and the hospital staff in 

turn provide information about WIC services, including WIC’s teen classes. 

Participation. In general, about 15 girls attend each WIC class. Many are brought by 

someone else—their mother, boyfriend, or other relative—since they need a ride. Thus, 20 or 

more people typically attend. 

About 15 to 20 percent of those invited attend each class, a participation rate that is typical 

for WIC classes. Some girls may come after a second invitation, or the breast-feeding 

coordinator may reach them in the classes she gives in the schools. In a few cases, young 

women come after they have had their baby, as some deliver before the next available class. The 

coordinator told a story of a girl who came to the class with a three-day-old baby and stayed after 

to ask, “Can I still breast-feed?” She hadn’t realized how important it was. The staff stayed at 

the clinic and worked with her until she was successful in getting started. 

The classes in the schools reach a potentially wider audience—all pregnant teens in the 

school parenting programs, including some who may not qualify for WIC. However, the WIC 

classes may attract some girls who are not in school. 

Publicity/Outreach. Most WIC teens are recruited through the postcards described above 

or their contacts with WIC staff. In addition, the local hospitals and doctors offices have 

information on the breast-feeding help available through WIC to offer their patients. The breastfeeding coordinator also visits the high schools and tells teens who do not know about WIC how 

to enroll, and offers classes there as described above. 
100

ORGANIZATION AND MANAGEMENT 

Staff and Organizational Structure. The breast-feeding coordinator for the agency 

developed and runs the classes. She is a nurse and an Internationally Board Certified Lactation 

Consultant (IBCLC). Toledo-Lucas County WIC also employs two other lactation consultants 

and a peer helper who work part-time—they sometimes help with the teen classes. They recently 

hired three more peer helpers, as they have abundant funding for breast-feeding services right 

now. 

Funding. Staff time is funded from WIC breast-feeding promotion funds. The coordinator 

also obtained a grant from the MOD, and small grants from other local hospital foundations. 

These grants ranged from $500 to a few thousand dollars. They also take advantage of some free 

materials from manufacturers and donated space at the church where the WIC classes are held. 

The MOD funding helped pay for incentives for the girls and for the food at the classes. As 

part of the grant, they asked the WIC agency to include MOD material on folic acid in the 

informational packets offered to the girls, which the agency was glad to do. The coordinator also 

tries to offer a snack high in folic acid for the class. 

When we spoke with the breast-feeding coordinator in May, the MOD funding was about to 

run out, but the WIC agency director had added funds to the WIC budget for the incentives the 

grant had paid for. The agency received permission from the state agency to pay for these 

incentives, because the program is seen as successful. 

ASSESSMENT AND LESSONS LEARNED 

Program Strengths. There is little direct evidence concerning program outcomes for the 

teen classes, but the Toledo-Lucas County breast-feeding program overall shows signs of 

success. The breast-feeding coordinator reported that since she started at the agency six years 

ago, breast-feeding initiation rates have increased from around 20 percent to 39 percent. 

Unfortunately, they do not track breast-feeding rates separately for teens. 

The coordinator reports the teens react pretty positively. Some of the mothers of the teens 

say, “I wish you had been around when I had my kids.” She bonds even more with the girls in 

the school programs, as she sees them repeatedly during their pregnancy. These girls gave a 

luncheon for her and other speakers who came in to talk to them at the end of the school year. 

Most of these girls, she says, breast-feed at least for a short while, often until they return to 

school. 

Key Challenges. It is an ongoing challenge for the WIC program to find ways to persuade 

pregnant teenagers to breast-feed. The special class for pregnant teens seems to be a step in the 

right direction. The classes offered through the schools and related work to build support for 

breast-feeding in the schools are even stronger steps. The breast-feeding coordinator felt it was 

more useful to reach the young women repeatedly with the message of breast-feeding than to 

provide the information only once. Nonetheless, even the single class seems a useful way to 

open more young women to the idea of breast-feeding, particularly if the hospital lactation 

consultants and WIC staff can then follow up at the time of the birth. 
101

Lessons Learned. The classes described above were developed and operate at minimal cost 

and it seems like they could easily be replicated, particularly by staff experienced in working 

with teenagers. The key idea is to try to reach teenagers about breast-feeding in terms that relate 

to their interests and concerns.

CONTACT INFORMATION 

Gloria Shortridge, RN, IBCLC 

WIC Breast-feeding Coordinator 

Toledo-Lucas County Health Department 

635 N. Erie St., Room 268 

Toledo, OH 43624 

Phone: 419-213-2124 

Fax: 419-213-4624 

103

III. ENHANCING NUTRITION EDUCATION 

WIC has always provided nutrition education and counseling to clients, often in the form of 

one-on-one counseling and lecture-style classes. In recent years, WIC programs across the 

country have taken steps to reinvigorate and update their approaches to nutrition education. 

Moreover, as described in Chapter I, FNS has encouraged these efforts through its RQNS grant 

program and revised Nutrition Services Standards. Programs in three of our five key areas of 

interest—obesity prevention, preventive health care, and staff training—are all examples of 

strategies to strengthen and broaden the nutrition education and counseling provided through 

WIC. 

In looking at these and other programs that offer enhanced nutrition education, we discerned 

some common themes: 

• New Methods for Working with Clients. Staff are learning to use approaches such as 

facilitated group discussions and motivational interviewing to help clients change 

their behavior. We highlight a training program in Michigan focused on facilitated 

group discussion but also note that these techniques have been incorporated to some 

extent into the Oklahoma and Pennsylvania obesity prevention initiatives. 

• Updated Education Content. Programs are working to include nutrition messages 

related to today’s main nutrition-related health concerns, in a positive framework of 

healthy eating and lifestyle choices. Relevant programs include those related to 

obesity prevention and healthy lifestyles for young children (including physical 

activity), preventive dental care, and screening for alcohol problems for prenatal 

participants. We describe three initiatives related to obesity prevention (in 

Oklahoma, Florida, and Pennsylvania), one related to dental health (in Alabama), and 

one related to alcohol screening (in Los Angeles). 

• Broader Target Audience. WIC nutrition education has traditionally focused on 

mothers, but initiatives are increasingly targeted to young children and the family as a 

whole. For example, both the Oklahoma and Alabama initiatives include activities 

for children, such as puppet shows and reading children’s books related to the theme 

of the initiative. Another way in which WIC agencies seek to reach a broader 

audience is to find better ways to serve non-English speakers, such as the Wisconsin 

training program (discussed below) that trains bilingual support staff to provide 

nutrition education. 

• More Staff Training. Many of the programs discussed in Sections A and B (and in 

Chapter II) involve special training. In Section C, we highlight three very different 

programs that all have state agencies providing special training to local agency staff: 

one focused on methods, one focused on content, and one focused on improving 

services for non-English speakers. 
104

A. OBESITY PREVENTION INTERVENTIONS 

Overweight and obesity among children have been growing over time; in particular, obesity 

(defined as a BMI greater than the 95th percentile on standard growth charts) among children 6 

to 11 has tripled from 5 to 15 percent since the late 1970s (National Center for Health Statistics 

2003). Policymakers are increasingly concerned with the issue, because of the negative health 

consequences of obesity. WIC is a natural setting in which to implement preventive strategies, 

as poor eating habits may begin to develop during the preschool years. Parents tend to think that 

a child being overweight (as measured by growth charts) is not a concern at preschool age 

(Baughcum et al. 2000; Jain et al. 2001). Parents are more receptive to programs that focus on 

healthy eating behaviors and physical activity. To fulfill the program’s preventive mission, 

materials need to target all families, not just those with overweight children. 

In this section, we describe two comprehensive obesity prevention programs and one with a 

very focused message: 

• The Oklahoma Get Fit With WIC program includes lesson plans for parents and 

children, incentive items, activities for children, staff training, and modifications to 

the food package, which were developed using special WIC funding. 

• The Pennsylvania Obesity Prevention Modules are steps in a similar direction, but 

without special funding. Pennsylvania state WIC staff developed lesson plans for 

encouraging healthy eating and materials for training staff to use the plans, but they 

have left it to local nutrition education coordinators to conduct the training. 

• Florida’s Mooove to Lowfat or Fat Free Milk Campaign focused on a specific 

message that is very salient to WIC—use low-fat or fat-free milk for children age 2 or 

above. It is interesting in part because this campaign was a joint effort of a number of 

state programs. The campaign included waiting room displays, flip charts, and props 

to use during nutrition education contacts, interactive activities such as taste tests, and 

(on a voluntary and pilot basis) modified food coupons. 

At the same time as this study was in progress, the FIT WIC study tested a range of 

approaches to obesity prevention among children in five states. An implementation report from 

this study is now available (U.S. Department of Agriculture 2003), but it was not available at the 

time our programs were selected. 
105

GET FIT WITH WIC1

OKLAHOMA 

OVERVIEW 

Location: Statewide 

Start Date: November 2001 

Target Population: WIC infants and children, and by extension, their parents and caregivers 

Purpose: To provide a unified nutrition education message for children, primarily regarding 

overweight and obesity prevention, that focuses on (1) reducing consumption of sweet drinks; 

(2) consuming less than six ounces of fruit juice a day; (3) using low-fat or nonfat milk for 

children older than age 2; (4) increasing consumption of water, fruits, and vegetables; 

(5) increasing daily physical activity; and (6) encouraging breast-feeding as the preferred method 

of feeding infants. 

Services: Get Fit With WIC (GFWW) uses a multifaceted approach, including group nutrition 

education classes for adults and children ages 1 to 5, individual counseling in clinics with a small 

caseload, staff training, and revision of the WIC food package. 

Funding: $501,210 from operational adjustment funds. 

Why Program Was Chosen: Nutrition education in Oklahoma’s WIC program addresses 

healthy eating, but it also emphasizes physical activity and how the two are related to overweight 

and obesity prevention. This is a focused, statewide campaign that is integrated into everything 

that WIC does while giving local staff flexibility in nutrition education delivery. In addition, 

nutrition education is directed, in part, to 1- to 5-year-olds through the Kids Club. 

Key Challenges: Nutrition educators are not always comfortable with the new approaches and 

sometimes lack time to prepare or conduct the new lessons. Adequate space for activities and for 

storing intervention tools can also be a challenge. In addition, it is hard to both encourage 

flexibility and ensure quality in a statewide program. 

 1

 Telephone interview, April 9, 2003; site visit, September 22-23, 2003. 
106

 

BACKGROUND 

State Characteristics. Oklahoma has a population of about 3.5 million, based on an 

estimate for 2001. In 2000, about eight percent of the population was American Indian or 

Alaskan Native, higher than the U.S. average. That same year, about eight percent of the 

population was African American and six percent Hispanic, both lower than the nation as a 

whole. The number of people living below poverty is higher in Oklahoma than the U.S. 

average—approximately 15 percent versus 12 percent, respectively. 

WIC Program Background. The Oklahoma State Department of Health (OSDH) oversees 

142 WIC clinics in 77 counties, serving about 90,000 clients per month, on average, for all 

categories of participants. There are approximately 50 nutritionists on staff at the local level. 

The Oklahoma WIC program has Program Consultants for each of the eight service areas. These 

are state-level nutritionists who function as liaisons between the local agencies and the state 

office in Oklahoma City to transfer information and policy change.

Program History and Objectives. Obesity is widespread in America, and the evidence 

clearly shows that trying to prevent obesity early in the life cycle is more productive than trying 

to treat the condition later. GFWW has responded to the need for prevention through a 

multifaceted program designed to promote healthy food choices, lifetime activity, and parental 

involvement in all nutrition education efforts. The initial planning for the campaign began in 

2000. At that time, the Oklahoma State WIC program was identifying ways to revitalize 

nutrition education. Until that point, WIC nutrition education had varied considerably from local 

agency to local agency. State and local staff members admit that, before GFWW, nutrition 

educators in WIC lacked direction and focus. Staff members and clients often found nutrition 

education boring. In turn, staff members were not very energized and motivated. Clients 

attended classes because they had no other choice, not because they enjoyed being there. The 

lesson plans available from the state for local educators were also limited in number and not very 

innovative or creative. 

The GFWW platform provided an opportunity to change how WIC conducted nutrition 

education. It enabled local agencies to focus on physical activity and obesity prevention, two 

topics that had not received much previous attention. It was clear from the beginning, however, 

that the initiative needed to address obesity without targeting the obese. In addition, the state 

saw it as important for the campaign to promote “healthy weight” terminology consistently 

among local agencies rather than calling a child fat, overweight, or obese or making negative 

statements about obesity. 

The challenge during the planning phase was developing a unified nutrition message for the 

state. However, getting input from the Nutrition Education Focus Group (NEFG) and 

coordinating progress at the state level facilitated this process.2

 According to the Director of 

Nutrition, Education, and Training Division, the main goal of GFWW is to standardize the 

state’s nutrition education messages to focus on six behaviors intended to reduce childhood 

2

 The NEFG is a group of local agency nutrition education staff who meet quarterly to 

provide feedback to state staff. 
107

obesity rates. WIC nutrition educators learn to emphasize the following objectives for young 

children: (1) reducing consumption of sweet drinks; (2) consuming less than six ounces of fruit 

juice a day (per the American Academy of Pediatrics’ recommendation); (3) using low-fat or 

nonfat milk for children older than age 2; (4) increasing consumption of water, fruits, and 

vegetables; (5) increasing daily physical activity; and (6) encouraging breast-feeding as the 

preferred method of feeding infants (since some research suggests a connection between breastfeeding and reducing childhood obesity). 

Target Population. GFWW is aimed at WIC children of all ages, even infants, and 

consequently, the parents and caregivers of these children. While program officials hope that 

families will be inspired to eat better and exercise more, they primarily hope that children will 

adopt good habits that will continue throughout their lives. Importantly, the messages of the 

initiative are for all WIC children, not just those who are overweight or obese, or who have 

overweight or obese parents. Some nutrition education classes target caregivers. Kids Club is a 

nutrition education class for children 1 to 5 years old. All clients have been introduced to the 

themes of the GFWW initiative to some degree. 

PROFILE OF INNOVATIVE PROGRAM 

Services Provided. GFWW is the overriding theme of Oklahoma’s WIC program; it is not 

considered a separate program. However, lesson plans and activities are classified as GFWW if 

they fall under any of the six objectives. Although WIC staff members all work on the same 

nutrition messages, local agencies implement these messages differently. The state provides the 

focus and parameters for the initiative. Because of demographic and cultural differences at the 

local level, however, the initiative must be flexible to meet the needs of a diverse clientele and 

special needs of a particular geographical location. The initiative focuses on “fun” so that 

participants will want to attend a nutrition education class and staff members will enjoy their 

work. 

The state has a list of state-approved lesson plans that can be used in nutrition education 

efforts (see Table). Each clinic has a manual containing these lesson plans. Local staff members 

review the list of lesson plans to determine what will work best in their clinic. In addition, local 

staff members find that certain activities or lessons are better received than others among their 

clients, so they tailor the lesson plans to meet their clients’ needs. Established lesson plan topics 

include increasing fruit and vegetable consumption, increasing whole grain consumption, 

increasing physical activity, using nonfat or low-fat milk for children 2 years of age or older, 

increasing water consumption, using the food guide pyramid, and reducing the fat content of 

foods. Local staff members may develop their own lesson plans or use ones from other states, 

but their Program Consultant must first approve these plans. Sometimes staff members will 

inform the state of the need for a lesson plan on a particular topic. Typically, the state Education 

and Training Coordinator will develop a draft of such a lesson plan and make revisions based on 

feedback from the NEFG. 

The components of the lesson plans can vary. All the lesson plans include objectives, an 

activity, discussion questions, and lists of intervention tools and resources. Often, the lesson 
108 

STATE-APPROVED LESSON PLANS 

(AS OF MAY 2003) 

Coordinating 

Children’s Book Lesson Plan Target Audience 

2003 

Get Fit with WIC Children 

I Want My Banana I Want My Banana Children 

Milk and Cheese Are Sure To Please Children 

Have Fun with WIC Foods Children 

2001 

Pecos Pyramid and the Food Group Gang 

Billy the Bread Children 

Soda Pop Sam Says . . . Not Every Day! Children 

Pecos Pyramid Children 

Charlie Cheese and Judge Roy Bean Round Up 

Protein 

Children 

Bronco Broccoli and Citrus Sue Fly to Mars Children 

2000 

Quick Meals from Your Pantry All 

Let’s Do Lunch All 

Eat Your Vegetables All 

Foods at the Tip All 

What’s for Supper Don’t Be a Square: Planning Meals the Pyramid 

Way 

All 

Packed with Protein All 

1999 

Maintain or Improve Your Health All 

Where is Your Milk Mustache? Children 

Babies Need Calcium, Too! Infants 

Cheerio’s Play 

Book 

Move for the Fun of It Infants/Children 

Safe and Healthy Eating All 

Folate: An Ingredient in the Recipe for Wellness All 

Holiday Low-Fat Leftovers All 

1998 

What’s for Supper Don’t Be a Square: Planning Meals the Pyramid 

Way 

All 

Quick Meals from Your Pantry All 

Fruits and Vegetables for Babies Infants 

How to Pack 5 A Day for Children Children 

Begin with Breakfast All 

Feeding the Right Way Infants 
LESSON PLANS (continued) 

109

Coordinating 

Children’s Book Lesson Plan Target Audience 

Elmo’s World - 

Food

Smart Snacking for Kids Children 

Holiday Survival Tips All 

1997 

Infant Anemia Infants 

Meat for Kids Children 

Milk: Strong Bones and Teeth Infants 

Calcium: Feed Your Bones Children 

Fruits for Fun Children 

Starting Fruits Infants 

Veggies for Babies Infants 

I Want My Banana Picky Eaters Children 

Food Safety and You All 

Breast-Feeding Classes 

The Joy of Breast-Feeding Breast-feeding/ 

prenatal women 

The Case for Breast-Feeding Breast-feeding/ 

prenatal women 

Special Classes 

Teens: Eating for Two 

(Nutrition During Pregnancy: <18 years) 

Prenatal teens 

Pregnancy Weight Gain: Too Much or Too 

Little? (Weight Gain During Pregnancy) 

Prenatal women 

Help Your Child Grow Healthy 

(Underweight/Overweight Children) 

Children 

Iron Deficiency All 

No Milk or Cheese, Please (Lactose Intolerance) All 

A Healthy Weigh to Live (Weight Management) All women 
110

plans incorporate games and the Food Group Gang puppets.3 Some lessons plans have a literacy 

component, which extends the learning to the home (see box). Households are often given the 

book that is read and discussed during a nutrition education class. The nutrition education 

classes rotate topics, so households often eventually receive several different books. 

Nutritionists will often read a book to the children as a means of modeling to caregivers. Some 

caregivers may not be able to read very well or at all. Sometimes, after hearing the story, they 

can “read” to their children by telling the story from memory or making up their own story. 

As mentioned before, physical activity had not been a focus of nutrition education efforts in 

the past in Oklahoma. Now, all the nutrition education protocols used at certification 

BOOKS FOR REFERENCE, CLASSES, AND INTERVENTION TOOLS 

Books for reference for nutritionists: 

Baby Play & Learn by Penny Warner, Meadowbrook Press © 1999 

Preschool Play & Learn, by Penny Warner, Meadowbrook Press © 2000 

Books that are read as part of a nutrition education lesson: 

I Eat Fruit! by Hannah Tofts and Rupert Horrox, Zero to Ten © 2001 

I Eat Vegetables! by Hannah Tofts and Rupert Horrox, Zero to Ten © 2001 

Oliver’s Fruit Salad by Vivian French and Alison Bartlett, Orchard Books © 1998

Oliver’s Milkshake by Vivian French and Alison Bartlett, Orchard Books © 2001 

Oliver’s Vegetables by Vivian French and Alison Bartlett, Orchard Books © 1995 

Books that are read and distributed to households as part of a nutrition education lesson: 

The Cheerios Play Book by Lee Wade, LITTLE SIMON © 1998

Food (Elmo’s World) by John E. Barrett and Mary Beth Nelson, Random House © 2000 

I Want My Banana (English and Spanish), by Mary Risk, Lone Morton, and Alex de Wolf, 

Barron’s Educational Series © 1998 

Snacktivities! by MaryAnn F. Kohl and Jean Potter, Robins Lane Press © 2001

Vegetable Friends by Tony Lawlor, Bruce Kociemba, and Barry Duncan, Gazelle Inc. © 1999 

What’s For Supper (English and Spanish), by Lone Morton, Mary Risk, and Carol Thompson, 

Barron’s Educational Series © 1998 

Books that will be read and distributed to households as part of a nutrition education 

lesson in 2004: 

Feast for 10 by Cathryn Falwell, Houghton Mifflin Co. © 1993

I Will Never NOT Ever Eat a Tomato by Lauren Child, Candlewick Press © 2000 

LUNCH! by Denise Fleming, Henry Holt & Company, Inc. © 1998

 3

 The Food Group Gang is a set of characters developed by the Oklahoma WIC Program. 

Characters include Pecos Pyramid, Judge Roy Bean, Charlie Cheese, Citrus Sue, Billy the Bread, 

Bronco Broccoli, and Soda Pop Sam. 
111

appointments include an emphasis on daily physical activity for all WIC categories. Brochures 

will be available in 2004 that address the importance of physical activity for infants and children. 

In time, questions related to physical activity will be incorporated into the certification computer 

program to better establish measurable trends and evaluate progress toward increasing activity 

goals. In addition, the lesson plans that focus on physical activity make it clear that physical 

activity is not just about organized sports or membership in a fitness club, but also about ageappropriate play. Nutrition educators often use the “It’s Toddler Time” (by Carol Hammett and 

Elaine Bueffel, KIMBO®) cassette tape with its fun songs and accompanying activities to get 

children moving during a class. The state also provided nutrition educators with reference books 

on age-appropriate play, and they can photocopy pages to give to clients as appropriate. 

To get people back into the kitchen, the state WIC office is currently working on a series of 

“Cooking with WIC” live distance education broadcasts. These broadcasts use 

videoconferencing technology and will provide food demonstrations using WIC foods. The 

overall purpose of “Cooking with WIC” is to present nutrition education concepts using 

methods, such as field trips and cooking demonstrations, that are not feasible in a clinic setting. 

Specific objectives include improving how WIC supplemental foods are used; improving skills 

in food purchasing, meal planning, and preparation of nutritious meals and snacks; including 

children in food purchasing, meal planning, and food preparation activities; and improving 

dietary behaviors. Based on client feedback, five topics have been selected: Snacktivities, 

Quick & Easy Meals, Nature’s Original Fast Foods—Fruits & Veggies, Breakfast for Everyone, 

and Making Fast Food Fit. The format of “Cooking with WIC” will involve a live introduction 

assisted by the receiving site’s nutrition educator in a facilitated discussion. Key points will be 

introduced live, followed by a previously recorded food preparation segment that details 

purchasing information and shopping tips when applicable. A videotape with the live broadcast 

and food preparation segments will then be distributed to the clinics with a lesson plan for future 

use. The packet will include talking points, discussion questions, recipes, and other handouts. 

For the first lesson, each family will receive the “Snacktivities” book, whether viewing the 

partially live or taped broadcast. Subsequent nutrition intervention tools include a magnetic 

shopping list, chop chop cutting board, cereal bowls, and food guide pyramid magnet. 

Intervention tools are essential for the GFWW campaign. The nutrition education lesson 

plans designate which intervention tools should be distributed during the class. Intervention 

tools include GFWW beach balls, Frisbees, sippy cups, chop chop boards, infant spoons, 

magnets with the Food Group Gang characters, and books. The WIC staff members also have 

GFWW mouse pads, nametags, and lanyards. Before October 2003, intervention tools were 

distributed through an annual drop shipment based on caseload. It was often difficult for local 

staff members to find room to store the large volume of materials and to plan well enough in 

advance so that they would not run out of materials. Some local staff members would need to 

exchange intervention tools with other clinics. For example, one clinic might have had more 

success with the Frisbees than with the beach balls, but the reverse might have been true in 

another clinic. In such a situation, the Program Consultant would facilitate the exchange of tools 

between the clinics so that both had what they needed instead of being oversupplied with unused 

materials. Now, the state will allow local WIC clinics to order intervention tools through the 

state by a minigrant process. In this way, local agencies get what they need for their clientele. 
112

Many clinics also have learning tables, which offer WIC children a constructive diversion 

while they are waiting for their appointments. Tables are painted with fruits and vegetables, and 

have toys attached that address healthy eating. The tables have activity stations that are bolted to 

the table and have attached pieces so that the activities and pieces do not get lost or stolen. The 

stations involve counting, spatial arrangements, or working an item through a maze. 

To reinforce the GFWW messages, the WIC food package has been modified to meet the 

American Academy of Pediatrics juice recommendation of no more than four to six ounces of 

fruit juice a day. This modification also included adding vegetable juice to the WIC food 

package. Although participants can choose any type of milk, the WIC staff members encourage 

nonfat or low-fat milk for children older than age 2. In addition, clients who have a high body 

mass index do not receive both cheese and peanut butter in the same month. 

KIDS GET FIT WITH WIC 

Kids Get Fit With WIC (KGFWW) is an annual event that typically takes place during 

National Nutrition Month in March. This initiative has taken the place of Team Nutrition 

efforts.4

 State WIC office staff, including nutritionists and support staff, conduct this event 

targeting Head Start children, families, and their teachers. The two- to three-day event goes to a 

different region each year and puts on two to three health fairs a day. All the regions have been 

visited. In 2003, more than 300 Head Start children, their caregivers, and their teachers attended 

the event. During KGFWW events, Head Start children visit five different stations featuring 

(1) the Tooth Fairy, a dental health game; (2) the Wheel of Food, a game that helps children 

identify members of different food groups; (3) a puppet show featuring Citrus Sue and Bronco 

Broccoli, discussing good sources of vitamins A and C and the benefits of physical activity; (4) a 

Food Tasting Table, where children are encouraged to taste fruits and vegetables; and (5) the 

Pyramid Hat Table, where children choose cutouts of their favorite foods and glue them to a 

construction paper hat. The children also participate in a group version of the “The Hokey 

Pokey” to demonstrate how much fun moving to music can be. In addition, the state staff 

members dress up in adult-sized costumes of Pecos Pyramid and the Food Group Gang. The 

activity features Pecos Pyramid, Judge Roy Bean, Charlie Cheese, Citrus Sue, Billy the Bread, 

Bronco Broccoli, and Soda Pop Sam in a skit about variety and moderation in food choices. 

Each of these characters is represented as a hand-sized puppet in all of the local clinics and 

incorporated into nutrition education and Kids Club classes to complement the lesson plans and 

books. 

 4

 Team Nutrition is a USDA program that provides training and technical assistance in 

promoting healthy eating to programs such as Head Start that participate in the Child and Adult 

Care Food Program. 
113

 

Coordination and Collaboration. In some counties, the Expanded Food and Nutrition 

Education Program (EFNEP)5

 conducts general nutrition education classes in the clinics using 

GFWW lesson plans. Oklahoma State University’s EFNEP program is working with the state 

WIC office on the “Cooking with WIC” videoconference telecast. GFWW was presented at the 

2003 Oklahoma Public Health Association conference, and there are plans to present the 

campaign at the Oklahoma Dietetic Association conference in 2004. Other agencies identified as 

stakeholders include the National WIC Association, OSDH, Head Start, Turning Point,6

 and the 

various state-level task forces that Program Consultants participate in. 

Publicity and Outreach Efforts. Messages for GFWW are primarily intended to be 

introduced during nutrition education classes, but local agencies can incorporate them into the 

WIC certification process, bulletin boards, and waiting rooms. Some sites introduce elements of 

the initiative to their clients during certification, because there is such a small caseload that there 

are never enough incoming clients at one time to have a group nutrition education class. In these 

sites, nutrition education is more individualized. In addition, the intervention tools are also a 

means of advertising. Clients see what nutrition education class participants receive and are told 

by WIC staff members that they can only receive the intervention tools if they come to class. In 

addition, the OSDH WIC Approved Food Card has a GFWW message on the back panel with 

Pecos Pyramid, as well as the six objectives of the initiative. 

ORGANIZATION AND MANAGEMENT 

Staff and Organizational Structure. The Director of Nutrition, Education, and Training 

Division and the Education and Training Coordinator assume responsibility for the annual 

Nutrition Educators Seminar and for conveying the statewide GFWW nutrition messages to WIC 

staff. The Education and Training Coordinator disseminates lesson plans and intervention tools 

to the local WIC agencies, facilitates the quarterly NEFG meetings, and addresses questions and 

concerns that come from the local staff. The role of the Director of Nutrition, Education, and 

Training Division is administrative; she is responsible for the operational adjustment funds. 

Program Consultants, as well as the NEFG members, channel questions and input about nutrition 

education between the state and local staff. The State WIC Director sees himself as a 

cheerleader for the campaign. He participates in nutrition education trainings, often providing 

opening remarks to show top management support of local nutrition education efforts. His 

5

 EFNEP is a U.S. Department of Agriculture (USDA) program that helps those with limited 

resources acquire the knowledge, skills, attitudes, and changed behavior necessary for 

nutritionally sound diets. Implemented at the local level, EFNEP delivers services through group 

classes, one-on-one teaching, mailings, and mass media. EFNEP often collaborates with local 

food stamp and WIC programs to enhance community nutrition education efforts. 

6

 Turning Point is a national initiative of the W.K. Kellogg and Robert Wood Johnson 

Foundations to transform and strengthen public health infrastructures. Turning Point starts at the 

local level to generate community support and participation in public health goal setting and 

action. In Oklahoma, Cherokee, Tulsa, and Texas counties were awarded Turning Point grants. 
114

responsibilities are similar to those in the planning phases of the initiative—providing support 

and resources so that the initiative can move forward. 

Non-nutritionists can teach general nutrition education classes if there is no nutritionist 

available or if the nutritionist has designated a non-nutritionist to teach. The staff person 

teaching a class must be either a nurse or Certified WIC Nutrition Technician (CWNT). 

The NEFG is made up of 13 WIC nutritionists, nurses, and other staff members representing 

county health departments and independent clinics across the state. The mission of the NEFG is 

to “serve as an advisory and sounding board in the development and implementation of nutrition 

education and training initiatives to enhance and promote quality service provided to the WIC 

participant.” The first NEFG meeting took place at the first Nutrition Educators Seminar in 

February 2002. The NEFG holds quarterly meetings at the state agency office in Oklahoma 

City. Program Consultants were charged with identifying staff members from their region to 

serve on the NEFG. 

Participation in the NEFG does not affect members’ responsibilities in the clinics. NEFG 

members know of the meeting schedule far enough in advance so that they can plan accordingly. 

The meetings are typically from 10 A.M. to 2 P.M. on Fridays, a day when staff members have set 

aside time for office work. The meetings are productive, and NEFG members do not usually 

leave with tasks to accomplish afterward, unless they volunteer to do so. Typically, the 

Education and Training Coordinator takes on the follow-up tasks and write-up responsibilities. 

Training and Quality Assurance. The state held its first WIC Nutrition Educators Seminar 

in February 2002, and the second one in February 2003. These annual seminars in Oklahoma 

City began, in part, as a memorial to Laura K. Savage, the Nutrition Education Coordinator who 

was killed in a car accident while on a site visit at a local agency. During these two-day 

sessions, state WIC officials bring local staff members together and communicate Oklahoma’s 

nutrition education goals for the upcoming year. WIC nutrition educators attend the seminars, 

including WIC nutritionists, nurses, and CWNTs. While attendance is not mandatory, a majority 

of agencies send at least one staff member, and approximately 150 participants attend the 

seminars each year. In 2004, clerks will also be invited to the seminar. 

The Nutrition Educators Seminar includes a poster session so that local staff members can 

share best practices in nutrition education. The winner of this poster session, receiving the Laura 

K. Savage Creativity Award in Nutrition Education, then competes in the poster session at the 

National WIC Association meeting. The NEFG assists the state staff in identifying training 

needs and potential topics that should be addressed. Moreover, the seminar provides an 

opportunity to introduce and demonstrate new lesson plans. Motivational speakers and 

presentations to increase general knowledge are also included. The trainers for the event include 

outside experts, county nutritionists, Program Consultants, and state-level program officials. 

The first Nutrition Educators Seminar in 2002 included teaching WIC nutritionists and other 

relevant staff members about the GFWW campaign’s goals, intervention methods and tools, and 
115

 

the stages of change model.7 The guest speaker discussed childhood obesity. In 2003, a child 

development instructor and author of Baby Play & Learn and Toddler Play & Learn discussed 

the stages of infant and toddler development. Staff learned how they and parents or caregivers 

could incorporate books, play, and physical activities into on-site nutritional counseling and in 

the home.

The strengths of the Nutrition Educators Seminar include the opportunity to bring all staff 

members together, which can lead to greater consistency across the state. The seminar brings in 

quality speakers that are nationally recognized rather than just relying on state WIC staff. The 

training energizes and motivates staff members to try new things and share ideas, and it provides 

the opportunity to network with peers across the state. The training also tries to address staff 

member attitudes, morale, and customer service. Local staff members point out that the 

demonstrations, time for questions, networking, poster sessions, and the high quality of speakers 

are valuable. They also appreciate the State WIC Director’s opening remarks that show top 

administration support. 

There are several challenges in attracting staff members to this training event. It is difficult 

to close the WIC clinics for such a long time; staff members need significant advance notice so 

that they can plan accordingly. Some county administrators may not send staff members because 

of fears of losing too much clinic time. Travel can be a challenge for staff members who do not 

live near Oklahoma City, and the time commitment can be a challenge for participants with 

children. 

In addition to the Nutrition Educators Seminar, the CWNTs receive training and program 

updates through video teleconferences, memorandums, and the CWNT Online Training 

Program.8

 A supervising nutritionist trains CWNTs using the online training curriculum. 

CWNTs also observe other CWNTs and nutritionists facilitating nutrition education classes. The 

nutritionist in the local agency and/or the Program Consultant will then observe and provide 

feedback to CWNTs until they are ready to teach on their own.

To assure the quality of the many GFWW activities, the state WIC office asks a nutritionist 

from each WIC site to complete a Nutrition Education Plan for the upcoming year. Program 

7

 The stages of change model is based on the premise that behavior, and consequently 

behavior change, is a dynamic process unfolding over time in five predictable stages: 

(1) precontemplation, (2) contemplation, (3) preparation, (4) action, and (5) maintenance. 

Precontemplation represents the stage where an individual has no interest in making changes 

within the next 6 months. Contemplation is when the individual is thinking about making 

changes within the next 6 months. The preparation stage is when the individual plans on making 

changes in the immediate future (1 month) and may have had some behavior change in the past 

year. In the action stage, the individual has made a specific overt change within the past 6 

months and is becoming more consistent with it. In maintenance, the individual has maintained 

a new behavior for more than 6 months and is working to prevent relapse. 

8

 The CWNT Online Training Program is an online training tool for CWNTs that allows 

staff members to train at their own pace without having to leave the clinic. 
116

Consultants review the Nutrition Education Plan. It details a tentative schedule of classes, lesson 

plans that are going to be used, the staff members who will be facilitating the classes, 

certification codes, and how the clerks will know how to schedule participants. The staff 

members can use lesson plans distributed at the Nutrition Educators Seminars or developed in 

previous years and approved by the state. Any lesson plans that are included in the Nutrition 

Education Plan that were developed by a local staff member or another state must be approved 

by the Program Consultant before being implemented. 

In addition, the eight Program Consultants monitor activities in their regions by observing 

nutrition education classes. These observations are a required part of the bi-annual clinic review. 

The state staff also communicates the initiative’s parameters during the Nutrition Educators 

Seminar. Distance education offerings include a videoconference on a quarterly basis called 

“What’s Up With WIC” that communicates policy changes and other items of interest and that 

helps keep everyone on the same page. Furthermore, local WIC nutritionists stay abreast of what 

is going on in the classes facilitated by CWNTs since the CWNTs are under their licensure. It is 

possible that CWNTs stray from the lesson plan, but it is unclear as to how often this occurs 

because the CWNTs are not monitored regularly. However, when it is clear that someone is 

being inaccurate or straying from the lesson, nutritionists make sure the individual gets back on 

track. 

Record Keeping and Data Systems. There has been no change or addition to the record 

keeping or data systems as a result of GFWW. However, program officials intend to add 

questions about physical activity to the certification process soon.

Funding. Nutrition ranked number eight in fiscal years (FYs) 2003 and 2004 for the OSDH 

Budget Request Priorities. Nutrition was not ranked in the top 10 in FY 2000, 2001, or 2002, 

indicating the increased emphasis on nutrition in the state. Funding for GFWW comes from the 

yearly operational adjustment dollars. The initiative was allocated one percent of the total WIC 

budget ($50,121,046), or $501,210 in FY 2003. Nutrition Services and Administration (NSA) 

funds are used for state staff time spent on GFWW. For lesson plans involving food, local staff 

members use their own money to purchase the food or ask a local grocery store for a donation. 

ASSESSMENT AND LESSONS LEARNED 

Program Strengths. Overall, GFWW has been a well-received campaign among clients 

and staff members. According to the Director of Nutrition, Education, and Training Division, 

GFWW’s greatest success is the fact that the initiative tries to make nutrition education fun. 

Much of the success stems from the clinics having ownership of their own nutrition education 

efforts. The variation and flexibility at the local level allows staff members to meet the specific 

needs of clients. The intervention tools allow learning to continue at home and encourage 

participants to return. In addition, the Kids Club nutrition education classes provide services 

directly to the children. The state and local staff have identified secondary outcomes of the 

campaign, including getting families more physically active and eating healthier diets, and 

helping families work with children early in their development to promote lifestyle changes. The 

initiative provides an affordable and doable means of achieving these outcomes in the WIC 

population. 
117

 

From a quantitative analysis standpoint, the program officials need to reconsider how to 

evaluate their efforts. In the planning stage, they decided to measure nutrition educator 

knowledge and skill. Therefore, at the Nutrition Educators Seminar in 2002, a survey was 

distributed to staff members as a means of evaluating GFWW and other nutrition education 

efforts. The survey first asked about participant satisfaction with the training. The survey then 

inquired about the usefulness of the presented topics and asked clients if they were already 

applying the information presented in the topics prior to the training. The topics the survey 

covered were WIC clients’ readiness to change, putting stages of change models into practice, 

connecting with WIC clients, adult learning, getting WIC clients to participate, and making 

nutrition education fun. The survey responses were intended to be matched in a post-survey, but 

there was no need to conduct a post-survey since the responses indicated that there was no room 

for improvement. Staff rated the topics as useful and claimed to be regularly applying the 

information. Currently, they are considering using body mass index as a means of measuring 

program impact. 

The participation and “re-show” rates for classes have increased. Based on informal 

feedback, clients have been receptive and positive about WIC’s nutrition education efforts. 

However, because GFWW is so integrated into the WIC culture, clients do not necessarily see a 

distinction between WIC and GFWW. Clients appreciate the intervention tools and books and 

comment that it is worthwhile to come to the classes just for them. Caregivers often leave 

classes with an idea that they want to try, and children enjoy coming to the health department 

because it is seen as a fun place rather than a place to receive shots. The Kids Club is very well 

received; however, some caregivers are hesitant or resistant to the physical activity classes 

because they believe this is WIC’s way of saying their child is “fat” or “heavy.” 

GFWW has made the nutrition classes more fun and enjoyable for staff members. Program 

Consultants see that staff members are more excited, satisfied, and motivated in their work, in 

part because they have more resources to work with. The FISH! Philosophy9

 of promoting a 

more supportive and energized place to work “fits into everything that [we are] doing with 

GFWW.” In addition, many staff members have reevaluated their own lifestyles and initiated 

health behavior changes so that they “walk the talk.” Finally, the NEFG members, who feel 

empowered and valued by the state, bring the local perspective to the campaign and help local 

staff members buy in to the initiative, both of which have a tremendous impact. 

Key Challenges. At the clinic level, it can be a challenge for nutrition educators to do 

nutrition education in a way that is different from what they are used to or comfortable with. 

Some nutrition educators are more comfortable one-on-one than in a class setting. Others 

struggle in teaching a wide age range of children or in being flexible enough to handle the 

unexpected. The time needed for class preparation to coordinate the intervention tools and 

9

 While not an integral part of the GFWW initiative, state officials introduced the FISH! 

Philosophy at the WIC Nutrition Educators Seminar. The goal is to improve customer service 

for clients by improving the work environment for staff. Seminar organizers screened the FISH! 

video, a nationally known tool that demonstrates the importance of having fun at work and how 

this can improve the services that the organization provides. 
118

materials with a particular lesson plan can be more extensive than the time needed to simply 

“show up” with handouts. The Nutrition Educators Seminar tries to address these barriers by 

providing breakout sessions where staff members can share their concerns and ideas. In 

addition, some clinics have indoor and outdoor space limitations, making classroom activities, 

outdoor play, and intervention tool storage difficult. Space limitations are exacerbated as the 

class show and “re-show” rates increase as clients have more fun with nutrition education. This 

increase in participation is desirable, but overcrowding requires staff members to quickly adapt 

to last-minute space limitations. 

OSDH provides the resources and support necessary for GFWW to be in the clinics. Getting 

support from these internal financial advisers and leaders is a challenge because they are not 

responsible for the success of the initiative, but will be responsible for the failure if they do not 

permit the program to move forward with adequate resources. Along similar lines, 

communication between state staff and local nutrition educators can also be a challenge. More 

specifically, the state tries to make it clear that the intervention tools should only be distributed 

as part of a nutrition education class, but some local staff members do not follow these 

instructions consistently, thinking of the tools as “freebies” or “incentives” rather than tools that 

are incorporated into a lesson to enhance learning. Appropriate intervention tool distribution is 

addressed at the Nutrition Educators Seminar and through internal memorandums. 

The Nutrition Education Plans and Program Consultant site visits provide some quality 

assurance over nutrition education, but because efforts are not monitored regularly, there are 

concerns about local staff members having so much freedom that they lack consistency. Because 

the state has no intention of “policing” GFWW efforts, quality assurance is difficult. The 

Program Consultants are not direct supervisors of local staff, so they can only make suggestions. 

Variation and flexibility at the local level also add to the challenge of coordinating a statewide 

training that will meet everyone’s needs. Along similar lines, it is a challenge to develop lesson 

plans and select intervention tools that will be widely accepted and used appropriately. 

Lessons Learned. Program officials believe they are doing something that works. They are 

using a client-centered, simple, back-to-the-basics approach. Other agencies can successfully 

implement GFWW with this in mind, even if they do not replicate all of the elements. It is 

critical to present nutrition education in an enjoyable, as well as informative, way so that WIC 

participants will want to come to the classes. The program officials also suggest collaborating 

with sister agencies, such as child nutrition and food stamps, to promote physical activity and 

healthy eating so that clients are receiving a consistent message. Finding a means to measure 

success is important as well, possibly by bringing in a statistician during the planning phase. The 

Director of Nutrition, Education, and Training Division suggests an evaluation strategy that 

documents nutrition education success as well as body mass index. 

The initial kickoff must include everyone so that there is a clear understanding of the 

initiative’s goals. Moreover, local staff members need clear, repeated communication regarding 

the appropriate distribution of intervention tools. To prevent misuse, it is helpful to hold training 

on new intervention tools and lesson plans before they are used. During this time, it is important 

to have staff members model lesson plans so that those in attendance can learn by example. It is 

also essential to conduct a needs assessment to identify client needs and interests, as well as the 

needs of the local staff. An NEFG is an excellent way to collect ideas from the local level and 

weave them into a statewide nutrition plan. Ideas can be shared with other parts of the state, yet 
119

local agencies are encouraged to be creative and identify or design lesson plans that work for 

their specific clients. 

At the clinics, local staff members need, and want, to make purchasing decisions for their 

intervention tools because they know what works and does not work with their clients. Program 

officials in Oklahoma recognize this and no longer recommend having an annual drop shipment 

of materials. The local staff members would like to see even more intervention tools so they 

have a greater assortment and variety available for distribution. Finally, local staff members 

suggest designing lesson plans for one-person delivery that last no longer than 20 minutes. 

CONTACT INFORMATION 

Traci Lundy, MS, RD/LD 

Director of Nutrition, Education, and Training Division 

Oklahoma State Department of Health 

WIC Services 

Shepherd Mall 

2520 Villa Prom Street 

Oklahoma City, OK 73107-2419 

Phone: 405-271-4676 x50034 

Fax: 405-271-5763 

E-mail: TraciL@health.state.ok.us 

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OBESITY PREVENTION MODULES10

PENNSYLVANIA 

OVERVIEW 

Location: Pennsylvania 

Start Date: The modules were developed in 1999–2000, and made available to local Nutrition 

Education Coordinators in June 2000, with the understanding they would train their staff over a 

two-year period. 

Target Population: First-level: WIC staff who do nutrition education—Second level: Parents 

of low-risk children age 2 or older 

Purpose: Provide staff with nutrition education materials and methods targeted at behavior 

changes that will prevent or reduce childhood obesity. 

Services: Materials include guidance for local Nutrition Education Coordinators in how to train 

staff to work with parents, lesson plans, and handouts to review with parents for each topic. 

Funding: Regular WIC nutrition services funding. 

Why Program Was Chosen: This program is an example of a comprehensive, yet realistic, 

obesity prevention initiative, and several other states have already adapted its materials. 

Key Challenges: Local staff sometimes feel it is difficult to cover the modules in the limited 

time they have with clients. It has also been challenging for some staff to understand that the 

modules are preventive materials that target all parents, not just parents of those already 

overweight. State agency staff regretted that funds were not available for centralized training. 

BACKGROUND 

State WIC Program Background. Pennsylvania’s WIC program has 25 local agencies 

serving 67 counties. Throughout the state, there are 348 active Competent Professional 

Authorities (CPAs), including nutritionists and other health professionals and trained 

paraprofessionals, who can evaluate the nutritional risk status of WIC clients. The state’s 

caseload has generally been between 230,000 and 240,000. 

 10 Telephone interview, April 9, 2003. 
122

Although Pennsylvania has several large metropolitan areas, much of the state is rural, and 

WIC clients in rural areas often find transportation to be their major barrier to receiving services. 

State staff note that people in the rural areas tend to feel decisions about their personal lives are 

private matters, so are sometimes not receptive to discussion of issues such as breast-feeding. 

State WIC staff also perceive support from the medical community as lacking in some cases, 

particularly for addressing child obesity, but hope that will change as the issue receives more 

national attention. 

Program History and Objectives. In 1999, nutrition educators at the state WIC agency 

recognized the need to do something about the childhood obesity problem. They believed that 

WIC’s role would be more beneficial if it had a preventive focus rather than a focus on 

interventions after weight problems had started. They also saw the need to give people more 

concrete suggestions on how to make changes in their behavior. Obesity prevention was a statelevel initiative because state staff realized that local nutrition educators did not have time to 

develop obesity prevention materials on their own.

The state Nutrition Education Coordinator at that time developed most of the materials with 

input from other state-level WIC Public Health Nutrition Consultants and local agency Nutrition 

Education Coordinators. The current Chief of Nutrition Services wrote the final two modules 

after she started working at the state agency in November 2000. The Nutrition Education 

Coordinator had previously developed nutrition education modules on other subjects for local 

agencies, and she drew on this experience. 

The state Nutrition Education Coordinator started by devising a set of survey questions for 

parents, then developed the modules around them (one module for each question). She used the 

basic format of previous modules, but the obesity prevention modules were more detailed. She 

also developed one or more handouts to be given to the parents for each module, as well as 

materials on how to train local staff to use the modules. 

In June 2000, the Nutrition Education Coordinators at each local agency were given the 

modules and told that, over the next two years, they were responsible for training their local 

agency’s staff on how to use them. 

Target Population. The modules target parents of WIC children age 2 or older. However, 

they are not to be used if the child has other, more pressing risks that need to be discussed during 

nutrition education contacts. Because the modules are meant to be preventive, they are intended 

for use with all children, not just those who are already overweight or at risk of becoming 

overweight. The training materials include a discussion of how to adapt the modules if the child 

is already overweight or at risk of becoming so. 

PROFILE OF INNOVATIVE PROGRAM 

Content of Modules. Pennsylvania WIC developed seven Obesity Prevention Modules (see 

box) and a document entitled “Preventing Childhood Obesity—Introduction,” which provides a 

general overview of the obesity issue and training materials for staff on how to discuss their 

child’s growth with parents of overweight children. 
123

Materials for each module include a curriculum for training local WIC staff (for local 

Nutrition Education Coordinators to use); a “Staff Reference Sheet,” which provides staff with 

background information on the topic discussed in the module; the module itself—a nutrition 

education lesson plan to discuss with parents; and one or more handouts to give the parents. 

Each module is built around a question on the Nutrition Education Plan Survey, which the parent 

is asked as a way to start the discussion. The eight-question survey was kept in the child’s chart 

as a way to document use of the modules, but now is documented online in the state WIC data 

system. The specific questions are not asked all at once—each question is asked in preparation 

for the relevant lesson plan. 

The training materials encourage staff to ask open-ended questions, provide interactive 

counseling, and give clients ideas about how to change their behavior. Training for local staff 

involves reviewing the nutritional basis for each recommendation (also covered in the “Staff 

Reference Sheet”), reviewing the module and handouts, and observing and practicing roleplaying presentation of the material—both as the nutritionist and the participant. 

For example, training for the module on “Eating More Fruits and Vegetables” first involves 

review of the food guide pyramid and the reasons for eating at least five fruits and vegetables per 

day. Each staff member is asked to complete a food frequency questionnaire on their own diet 

and to discuss barriers they face in reaching the goal of five a day. Next, the module and 

handouts are reviewed and the group discusses issues such as what to do if they think the 

participant is not answering the questions honestly. The trainer then asks a member of the 

audience to role-play the participant and she presents the module to them. Afterward, the 

Module Number Topic Handouts 

1 Increasing Physical Activity/Reducing 

TV Viewing 

Get Them Moving! 

Children and TV 

Easy Ways to Get Active 

2 Teaching Children Positive Attitudes 

About Food 

Teaching Your Child to Enjoy

Mealtime! 

3 Choosing Healthy Snacks Snacks for Kids 

4 Limiting Juice Intake Hey Mom, I’m Thirsty 

5 Choosing Fast Foods Wisely Happy Meal, Healthy Child? 

Fast Food Restaurant Guide 

6 Increasing Fruits and Vegetables Hey Mom, Give Me Five! 

Color Your Plate to Health 

7 Reducing Fat Intake The Facts on Fat 

Fats in Foods 

Cut Out Fats to Cut Back Calories 

Changing Recipes to Reduce Fats 
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audience is asked to evaluate what was effective about the contact and what was less effective. 

Finally, the group divides up and does more role-playing, taking turns being the nutritionist and 

the participant. When conducting local training, the training curriculum is sometimes copied and 

given to WIC staff, but sometimes the Nutrition Education Coordinator hands out only the staff 

reference sheets. 

Each module involves asking parents open-ended questions, then following up with relevant 

information. Followup may involve changing parents’ ideas where not correct or addressing 

barriers to change that they identify. Each module ends with the question, “Which ideas will you 

try?” The participant’s response is noted in the chart for future followup. 

Each module is accompanied by handouts. For example, the module on fruits and 

vegetables has two handouts: “Hey Mom, Give Me Five!” addresses barriers to eating more 

fruits and vegetables with concrete suggestions. “Color Your Plate to Health!” presents the idea 

of eating fruits and vegetables from a variety of color groups to achieve good nutrition. Parent 

handouts are available in English and Spanish. 

Training in, and Implementation of, the Modules. As noted, local Nutrition Education 

Coordinators were expected to use the modules and accompanying materials to train their staff. 

The trainers had a lot of flexibility in how they did the training. Usually, they held in-service 

trainings or did the module training during a staff meeting. Training for one module took about 

1.5 to 2 hours. The state agency recommended that all staff be trained on the modules, because 

sometimes clients talk to clerical staff or someone other than the staff responsible for nutrition 

education. However, it is the professional and paraprofessional nutrition education staff who use 

the modules with clients.

This flexibility resulted in some initial confusion in how to schedule the training and the use 

of the different modules. Some agencies decided to train their staff on one module at a time in 

staff meetings. Staff used the module they had just learned for the next three months, then were 

trained to use another module and used it for three months, and so on. Other agencies chose to 

train staff on two or three modules at a time, while others were not successful even in starting the 

training process. Thus, initial implementation was uneven. At the end of the two-year period, 

some agencies were adept at using the modules, while others were not, and there was a lot of 

variability in the ways that the materials were being used. 

Related Staff Training. There was no statewide training on implementation of the 

modules. However, Pennsylvania WIC has held several related trainings in the past few years as 

part of its effort to (1) shift the focus of nutrition education contacts from information 

dissemination to behavior change, and (2) target obesity and overweight prevention. 

In 2001, Pennsylvania WIC held a statewide Nutrition Services meeting for WIC staff. The 

meeting focused on training staff in overweight and obesity issues, including the prevalence of 

overweight, and on the importance of physical activity. The meeting’s keynote speaker was 

Bettylou Sherry of the Centers for Disease Control and Prevention (CDC). She used data from 

the Pediatric Nutrition Surveillance System, which is largely collected by WIC clinics, to 

describe the increasing problem of obesity nationally and in Pennsylvania. Additional sessions 

were offered on anticipatory guidance materials, social marketing, and studies related to early 
125

childhood eating habits and feeding practices. Approximately one-third to one-half of WIC 

professional staff attended the conference.

In 2002, the Chief of Nutrition Services held regional in-services with local agencies and 

introduced the ideas of anticipatory guidance, facilitated group discussion, and motivational 

interviewing, to help staff figure out how they could make these techniques work for them. She 

discussed with staff their lack of time with clients and how they could use at least some of the 

techniques even when time is limited. Given that they can only spend a short time with clients, 

she discussed with staff how to determine the appropriate times to bring up the topic of weight 

and use the modules. 

Refinements to Implementation of the Modules in 2003. For fiscal year (FY) 2003, the 

state set as a goal that local agency staff provide to the state a protocol to ensure the continued 

use of and continued training on the modules. The protocol was to be part of the annual nutrition 

education plans submitted by each agency. The state Nutrition Education Coordinator is 

currently evaluating the nutrition education plans submitted this year, so state staff cannot yet 

assess how this has worked out. The state agency will either approve the plans or ask for 

revisions. 

In addition, state WIC staff developed new materials for local agencies related to the 

modules. First, they provided quizzes that can be used to assess staff’s competency in each of 

the modules. A quiz might ask, for example, what a WIC staff member would do to approach a 

parent with an overweight child. The focus of the quizzes is less on knowing the facts presented 

in the module than on staff’s competency in handling situations with clients. The state agency 

also developed a checklist to help assess whether a contact with a client is effective or not. This 

tool is sometimes used during performance reviews to ask staff whether they are using specific 

techniques when they meet with clients. For example, the checklist includes introducing oneself 

to the client and making eye contact. 

Coordination with Other Agencies. Pennsylvania WIC partners with other health and 

advocacy organizations around obesity and overweight education and prevention, although not 

the modules specifically. However, as word about the modules has spread, other organizations 

in Pennsylvania involved in nutrition education have asked state WIC staff to give presentations 

on the modules. Cooperative Extension asked the former Chief of Nutrition Services to speak 

about the modules, and the current Chief of Nutrition Services recently spoke about them at a 

Maternal and Child Health Advisory Panel meeting. The former Nutrition Education 

Coordinator also provided the modules to the Maternal and Child Health Consultants who work 

out of Pennsylvania’s State Health Centers. 

In addition, the modules are available on the WIC Works Website, and several other states 

are adapting them for their use (see more discussion below). 

ORGANIZATION AND MANAGEMENT 

Staff and Organizational Structure. In Pennsylvania, the Nutrition Services Section, 

which supervises WIC, is made up of the Chief and four Public Health Nutrition Consultants. 

One of these consultants now functions as the State Breast-Feeding Coordinator, one is 
126

designated as the State Nutrition Education Coordinator, and the others have other areas of 

expertise. The Nutrition Education Coordinator and the Nutrition Services Chief are the primary 

staff members who worked on developing the modules, and the Nutrition Services Chief is the 

main person monitoring implementation of the modules and providing technical assistance to 

local agencies as needed. 

In addition, the local agency Nutrition Education Coordinators have contributed to this 

process. In particular, several local agency Nutrition Education Coordinators participate as 

members of the Nutrition Education Committee, which holds monthly conference calls to 

strategize statewide initiatives. 

Record Keeping and Quality Control. Nutrition educators document use of the modules 

in clients’ charts, using either the survey or the Nutrition Education Plan form that was used 

before the implementation of the modules. Nutrition education contacts typically occur every 

three months. If a child stays in WIC, each child’s caregiver should be exposed to all of the 

modules eventually. 

Responsibility for quality control is primarily at the local level. The checklists and quizzes 

for the local agencies should help with this process. At the same time, as in other states, the four 

consultants conduct annual program reviews. Each fiscal year, 13 local agencies are reviewed, 

and the 2 largest agencies have clinics reviewed each year. An integral part of the reviews is to 

observe nutrition education delivery in the clinics, including the implementation of the Obesity 

Prevention Modules.

Funding. This initiative did not receive any special funding; it was paid for out of WIC 

Nutrition Services and Administration funds. 

ASSESSMENT AND LESSONS LEARNED 

Program Strengths. The Obesity Prevention Modules address an area previously not 

targeted by WIC with a set of clear messages for parents of children age 2 and older, and specific 

suggestions for behavior change in response to each message. At the same time, they present the 

message in a client-centered discussion format. 

Although implementation has been challenging, the state Chief of Nutrition Services feels 

that the local agencies have gone further than she originally expected in adopting the modules 

and using them consistently. Overall, staff have reacted favorably to the new approach, as they 

feel that the modules make it easier for them to target what they want to talk about with WIC clients. 

After some initial resistance, they seem to find a more behavior-focused approach rewarding. 

As noted above, the modules have been posted on the WIC Works Web site, and the state 

WIC agency has received positive feedback. Several other states are adapting the materials for 

their use. Hawaii, for example, will be using the modules to train staff at their statewide conference, 

and then will implement the modules in nutrition education contacts. Florida took the lessons of the 

modules, turned them into flip charts, and added some graphics. The state now uses them in its 

clinics. 
127

Key Challenges. A major challenge for staff in implementing the modules is the limited 

time they have to spend with clients—10 to 15 minutes at most. The state staff tried to be 

sensitive to this in developing the modules and working with local staff on implementation. 

Another challenge has been getting local staff to understand this is a preventive program for 

all children, not an intervention for those who are overweight. Staff turnover is also a concern in 

Pennsylvania, as staff may leave by the time they are trained in all the modules and comfortable 

using them, and then the agency needs to start over. Although it would be helpful for all staff to 

have the same understanding of the goals of the program, this has been a challenge because 

Pennsylvania WIC did not have the resources to do regional training sessions. 

State staff hear that client reactions to the new approach have been mixed. Some clients fear 

that WIC staff are going to “get on their case” about their child being overweight. However, 

some clients feel that the information in the modules is more useful than nutrition education they 

received from WIC in the past. Although staff are specifically trained in how to deal tactfully 

with parents of overweight children, some parents will still be concerned about what they 

perceive as criticism. 

Finally, Pennsylvania WIC introduced a new data system in 2002. This distracted staff 

attention from implementation of the modules for some time. 

Lessons Learned. This approach is promising in adopting a small number of very specific 

messages, offering interventions that can be completed in short amounts of time, and helping 

staff develop skills for more interactive counseling. 

In retrospect, state staff wish they had had the resources to do regional staff trainings. 

Another option could have been to do a centralized “train the trainer” session for the Nutrition 

Education Coordinators. In addition, the state agency could have avoided some initial confusion 

by providing more guidance about scheduling the introduction of the modules, but it wanted to 

be flexible, as local agencies face very different constraints. 

CONTACT INFORMATION 

Shirley Sword, MS, RD, LDN 

Chief, Nutrition Services Section 

PA Dept. of Health – WIC Division 

P.O. Box 90 

Room 604, Health & Welfare Building 

Harrisburg, PA 17108-0090 

Phone: 717-783-1289 

Fax: 717-705-0462 

E-mail: ssword@state.pa.us 

To obtain materials:

http://www.nal.usda.gov/wicworks/Sharing_Center/statedev_PAmodules.html 

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MOOOVE TO LOWFAT OR FAT FREE MILK CAMPAIGN11

FLORIDA 

OVERVIEW 

Location: Statewide 

Start Date: March 2002 

Target Population: All adults and children over 2 years old in Florida. 

Purpose: The statewide nutrition education initiative aimed to help reduce the incidence of 

overweight and obesity in Florida by encouraging all adults and children over 2 years old to 

drink lowfat (1 percent) or fat free (skim) milk. 

Services: Specialized educational and outreach strategies that convey the benefits of lowfat and 

fat free milk 

Funding: The campaign used Nutrition Services and Administration (NSA) dollars; total WIC 

expenses were about $12,000, exclusive of staff time and other in-kind contributions. 

Why Program Was Chosen: The Mooove to Lowfat or Fat Free Milk Campaign was the first 

Florida-wide nutrition education initiative that encompassed multiple state agencies. It is a 

broad-based social marketing campaign that uses creative approaches delivered through a wide 

range of organizations. Other WIC agencies have mounted similar campaigns, but the extent of 

coordination with other agencies in Florida may be unique. Furthermore, for those WIC 

agencies not familiar with the campaign, the materials could easily be adopted at little cost. 

Moreover, it is an example of an obesity prevention intervention with a focused behavior change 

message that is very salient in the context of the WIC food package. 

Key Challenges: The WIC Bureau was unable to gain active support from local grocery stores 

in promoting the campaign’s message, despite approval from store executives. Moreover, 

program staff were surprised by the myths that WIC participants believed about milk and its 

nutritional content. 

 11 Telephone interview, April 8, 2003. 
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BACKGROUND 

State Characteristics. Florida is the fourth-most-populous state in the country, with 

15,982,378 residents. Of those, 65.4 percent are white but not of Hispanic or Latino origin, 

16.8 percent are Hispanic or Latino, and 14.6 percent are African American. Almost a quarter of 

the population over 5 years of age speak a language other than English at home. In 2002, 

13.0 percent of the state lived below the federal poverty line (American Community Survey 

2002). According to the U.S. Department of Agriculture (USDA), 19.6 percent of all Florida 

children under 18 are overweight, which is 3.5 percentage points higher than the national average 

for children (Community Nutrition Research Group 2003). 

WIC Program Background. At present, 42 WIC agencies serve 67 counties statewide. 

The average number of participants per month for fiscal year 2003 was more than 350,000. 

The Mooove Campaign was the first of three interagency nutrition education initiatives. For 

the second year’s campaign, the Bureau of WIC and Nutrition Services, in collaboration with 

two other bureaus of the Department of Health (Child Nutrition Programs and Chronic Disease 

Prevention), launched a statewide nutrition education campaign in March 2003. The theme for 

2003 is 3 + 2 = 5 A Day the Florida Way! The 2004 theme will be Healthful Nutrition (with an 

emphasis on healthy snacks) and Physical Activity.

Program History and Objectives. The Mooove to Lowfat or Fat Free Milk Campaign 

(Mooove Campaign) began as a WIC initiative, was then adopted by another Department of 

Health group (the Bureau of Child Nutrition Programs), and gradually expanded into a state 

interagency effort. Many of its materials and lesson plans were adapted from the “1% or Less 

Campaign,” launched by the Center for Science in the Public Interest (CSPI) in 1996. The 

Mooove Campaign encourages Florida adults and children over 2 years old to drink lowfat or fat 

free milk to help reduce the incidence of overweight and obesity. According to data from the 

Behavioral Risk Factor Surveillance System (BFRSS) [www.doh.state.fl.us/family/obesity], 

nearly 1 in 5 Florida residents were obese in 2002, whereas only 1 in 10 were obese in 1986. 

State health officials hope that this initiative will influence people to drink less-fattening milk, 

and thus help decrease the incidence of obesity. 

In 2001, the Bureau of WIC and Nutrition Services of the Florida Department of Health 

received state funds for a limited marketing effort to promote good nutrition. WIC and Nutrition 

staff decided to focus on drinking healthier milk and so enlisted the Department of Health’s fulltime graphic artist to design educational materials to promote this message. She created a cow 

cartoon figure that became the “mascot,” or logo, for the campaign and designed a colorful and 

informative display. The Bureau used the funds to put together two displays that were lent to 

local WIC agencies that chose to promote the lowfat or fat free milk message. Each display 

contained a banner, as well as instructions for conducting milk taste tests, an instructional flip 

chart, and promotional stickers. In addition, cow print tablecloths and aprons were included with 

each display. At this stage, the Mooove Campaign operated on a very small scale. The two 

displays were offered to all local WIC agencies to borrow, and seven local WIC agencies used 

one for three months at a time. The Bureau received positive feedback about the display and its 

accompanying materials. Moreover, the Bureau of Child Nutrition Programs used the cow logo 

to design its own materials to launch a Mooove Campaign in all its affiliated day care centers.
131

 

The next step toward the statewide Mooove Campaign came from the Florida Interagency 

Food and Nutrition Committee (FIFNC), a nutrition task force founded more than 20 years ago, 

which has as its purpose to coordinate efforts to provide effective nutrition, food security, and 

food safety programs and services to Floridians. FIFNC members are representatives from a 

variety of state agencies whose missions and goals are related to providing effective food and 

nutrition services.12 Over the years, this committee has provided a valuable mechanism for 

coordination, advocacy, and outreach activities for food and nutrition services in Florida. 

The FIFNC concluded that the cow mascot/logo would be an effective marketing tool to use 

for promotional materials for an interagency campaign, and decided to launch the statewide 

nutrition education initiative—Mooove to Lowfat or Fat Free Milk—in March 2002 (March is 

National Nutrition Month).

Target Population. The statewide initiative targeted all adults and children 2 years of age 

and older. Although the Mooove Campaign began with a set of publicity materials that were 

originally developed for the WIC program, these materials were soon adapted to meet the needs 

of the other targeted groups. For example, the Department of Education marketed lowfat and fat 

free milk in all public schools—kindergarten through 12th grade—with a specially designed 

stand-alone “skating cow” display, which was placed near the milk section of school cafeterias 

throughout Florida. The Department of Elder Affairs ensured that its senior centers, congregate 

meal sites, adult day care centers, and area aging agencies were supplied with the colorful poster 

designed for the campaign. 

PROFILE OF INNOVATIVE PROGRAM 

Services Provided in WIC. The FIFNC developed nutrition education materials and 

activities that local WIC staff could offer in clinics to raise awareness about the benefits of 

lowfat and fat free milk. Generally, services promoting the Mooove messages and activities took 

place in WIC waiting rooms and nutrition education classes. The campaign was designed to last 

one year, and activities could be spread out over the year so that the nutritional messages would 

be continuously reinforced in fun, educational ways. 

All WIC sites (along with other agencies and organizations affiliated with the FIFNC) were 

provided with the campaign kit, which contains a press release, lesson plans for all ages, taste 

test instructions, consumer handouts, an article to be used in professional newsletters, and 

evaluation forms. The most popular item developed for the campaign was the poster, which was 

12 FIFNC agencies that participated in the Mooove Campaign were the Florida Department 

of Education; the Florida Department of Elders Affairs; the Florida Department of Health; the 

Florida Department of Children and Families; the University of Florida Institute of Food and 

Agricultural Sciences Extension Programs; the U.S. Food and Drug Administration (Florida 

District, Southeast Region); and the Suwannee River Area Health Education Center. The only 

FIFNC agency that did not participate was the Florida Dairy Council, which could not endorse 

the initiative since its policy is not to promote one type of milk over another. 
132

 

available in both English and Spanish. In addition, the state WIC office developed additional 

materials, which included a Mooove display, bulletin boards, buttons, grocery store placards, 

“envelopes” to hold WIC checks, and tent cards. In summer 2002, a tabletop display with test 

tubes depicting the fat amounts in each type of milk was distributed to all WIC nutritionists to 

use with clients. 

The WIC Bureau also developed newsletters in English and Spanish and suggested activities 

that clinics could offer. WIC clinics used a variety of these activities, and they were popular 

with both staff and clients. For example, WIC staff mimicked the milk mustaches from the Got 

Milk?TM ad campaign, took photographs of everyone, and displayed them in the waiting room 

during the first few months of the initiative. Other activities in WIC clinics included children’s 

art contests, recipe contests, door prize contests, and the setting up of displays demonstrating the 

importance of calcium.13 Clinics also provided taste tests to staff and clients, which were very 

successful in changing attitudes and opinions about lowfat and fat free milk.14

The degree to which local agencies implemented the Mooove Campaign varied from agency 

to agency. The WIC public health nutrition consultant noted that one county health department 

WIC coordinator “went all out,” incorporating the activities described above as well as making 

cow print aprons for the entire staff, painting cow prints on tennis shoes, and wearing cow 

earrings. The coordinator conducted ongoing milk taste tests with clients, and also developed a 

teaching tool display of milk container lids showing the lid colors that are used on lowfat and fat 

free containers in every grocery store in the county. 

Participation. While the Mooove Campaign was a statewide initiative, state WIC officials 

did not mandate that all agencies participate. Rather, local staff could incorporate as much or as 

little of the materials into their routine services as they chose. However, the WIC health 

educator estimated that 90 percent of the 42 local agencies conducted some outreach and 

nutrition education related to healthier milk choices. 

Since the Mooove Campaign targeted multiple audiences, the FIFNC could not determine 

the number of Floridians that the nutrition messages reached. For example, a WIC client’s clinic 

may have elected not to use any of the materials, but her child might have attended a day care 

center that focused on promoting lowfat or fat free milk and had a strong parent education 

component that encouraged healthy drinking practices at home. As this example illustrates, it is 

possible that WIC clients were exposed to the promotional materials from multiple sources. 

13 Staff place chicken bones in glass jars full of vinegar and in separate jars containing 

water. The bones in vinegar lose calcium in the form of calcium crystals, which causes them to 

weaken and bend or break easily. After a few weeks, WIC staff dry the bones and show clients 

that the ones in vinegar became brittle. This activity is borrowed from the National Dairy 

Council. 

14 The milk taste test is an interactive hands-on experiment that compares whole, reduced-fat 

(2 percent), lowfat, and fat free milk. Clients are blindfolded and then taste the four different 

types of milk from small cups, trying to guess which type of milk is in each cup. 
133

Coordination and Collaboration. The Mooove Campaign is very collaborative in nature. 

For example, the state WIC public health nutrition consultant conferred with a staff member 

from CSPI about adapting its “1% or Less” materials for WIC’s Mooove Campaign, and the 

request was approved.

Members of the FIFNC developed the campaign kit. Each agency contributed to the kit in 

ways that focused on its own clients, but also developed components that could be used by other 

FIFNC agencies and other programs as well. For example, a professor from the University of 

Florida developed activities for elderly people and wrote an article that could be submitted to 

professional newsletters. WIC nutrition consultants developed materials specific to the WIC 

clinics, but at the same time worked with the Department of Health’s graphic artist to create the 

cow mascot that was used to identify the entire campaign. They also assisted with the 

development of the Mooove Website. 

Publicity and Outreach Efforts. WIC clinics used a number of promotional materials to 

convey the message to drink lowfat or fat free milk. Clients were given newsletters that 

(1) explain the health benefits of drinking lowfat and fat free milk, and (2) present nutritional 

labels for the four types of milk. In addition, materials presented in nutrition education classes or 

waiting rooms (see the box on materials) informed clients about the Mooove Campaign and 

educated them about healthier milk. State officials also used marketing and educational 

materials at special nutrition awareness events and conferences to promote the campaign. Press 

releases and an article for professional publications helped disseminate information to the entire 

community. The Mooove Website makes many of these materials available to other interested 

agencies. A Mooove display was exhibited at the Food and Nutrition Service (FNS)/USDA 

Nutrition meeting in Washington, DC, in February 2003 and won a participant award. 

Educational and outreach materials are available free on the Florida Department of Health’s 

Website [www.doh.state.fl.us/family/mooove/milk.html], including: 

Sample newsletter to parents 

Sample press release 

Literature review about the benefits of lowfat and fat free milk 

Article for a professional newsletter 

Lesson plans and activity sheets for preschoolers 

WIC clinic activities 

Milk taste test instructions 

WIC nutrition education newsletter 

Cow graphics 

Mooove Campaign posters in English and Spanish 

Handouts for health fairs and other community events 

Milk-related Websites 
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ORGANIZATION AND MANAGEMENT 

Staff and Organizational Structure. While the Mooove Campaign fell under the umbrella 

of the FIFNC and its members jointly developed certain materials, each participating agency 

assumed responsibility for tailoring the initiative to its programs and clients. While there was no 

formal training for the Mooove Campaign, the state public health nutrition consultant organized 

a conference call with all local WIC agencies to inform them about the initiative and to discuss 

how to implement various activities in their clinics. Local WIC staff did not have to assume any 

responsibility for producing materials, unless they chose to do something extra for their clients. 

State officials encouraged local WIC staff to be creative and tailor the campaign to their clients. 

Funding. The cost of the educational and outreach materials comprised the majority of 

expenses associated with the Mooove Campaign. The state-level staff time spent on the 

initiative was considered an in-kind contribution. A graphic artist from the Florida Department 

of Health designed the cow mascot and publicity items, and the FIFNC developed the lesson 

plans and other materials. In addition, the state public health nutrition consultant and a volunteer 

produced the test tube displays, administrative and support staff were trained to make cow 

buttons during “down time,” and a secretary assembled the campaign kits.

WIC’s portion of the Mooove Campaign was funded with NSA dollars. Aside from the inkind contributions of WIC staff for materials development, the state WIC office spent about 

$12,000, primarily for the printing costs of the Mooove promotional materials. Total costs to 

WIC and FIFNC were about $21,000, which once again does not include in-kind contributions 

from the FIFNC members. State officials consider the Mooove Campaign to be very costeffective. Assuming that the initiative’s message reached all WIC clients throughout Florida to 

some degree, costs were pennies per client.

ASSESSMENT AND LESSONS LEARNED 

Evaluation and Outcomes. The desired outcomes for the Mooove Campaign were that 

more Floridians will begin to choose lowfat or fat free milk instead of reduced fat or whole milk. 

The WIC Bureau wanted to see as many WIC participants as possible engage in healthier 

behavior by changing their milk-drinking habits. 

Initially, state officials did not conduct an evaluation that could examine WIC outcomes in 

isolation. However, the Mooove Website offered an on-line survey that collected information 

from FIFNC staff members on Mooove activities that they conducted in their local agencies, 

feedback and suggestions for future nutrition-related campaigns, and results of taste tests. In 

addition, clients completed a short survey in which they were asked questions about their milkdrinking habits. 

Implementation Successes. The state health educator remarked that the campaign has been 

successful because “everyone—WIC staff and clients—loves the cow.” (In fact, the cow mascot 

appeals to all clients, regardless of their age, who are served by FIFNC agencies.) She noted that 

many activities were visual and hands-on, reinforcing nutrition education in an original and 

innovative way. These strategies, including use of the chicken bones in vinegar, milk taste tests, 

and test tubes comparing the different fat content of milk types, effectively conveyed the core 
135

message to clients. Local WIC staff reported that the test tubes with various fat contents and the 

taste tests were powerful, as was a display that read: “Do you know that these 2 donuts have the 

same artery-clogging fat content as one glass of whole milk?” “Do you know that 3 pieces of 

bacon have the same artery-clogging fat content as one glass of whole milk?” State officials 

observed that these comparisons were a “real eye-opener” for WIC staff and clients. 

Local agency staff very much appreciated the fact that state-level FIFNC members 

developed the entire Mooove campaign kit (including lesson plans, taste test instructions, 

buttons, and press releases) and clearly explained how to implement the initiative. The materials 

“were all there for them, ready to go.” Informal feedback revealed that the prepared materials 

allowed some agencies to do even more than they would have if they had been asked to develop 

the materials themselves. Another key component for success was administering the taste test to 

LOWFAT OR FAT FREE MILK VOUCHERS: A PILOT 

As a supplement to the statewide nutrition education initiative, the Florida WIC program 

decided in September 2002 to pilot test WIC checks that specified only lowfat or fat free milk 

could be purchased. The Martin County WIC Project was chosen as the pilot county due to its 

high obesity rates. Specific project goals included (1) reinforcing the Mooove message, 

(2) determining if retail grocery stores had issues with lowfat milk-only checks, (3) determining 

the number of clients who chose to continue with the lowfat milk-only checks, (4) determining 

the acceptability of the checks among clients, (5) determining the number of clients who chose to 

continue with the lowfat milk-only checks, and (6) monitoring the body mass index (BMI) of the 

pilot children. The clients in Martin County were given the choice of the new lowfat milk-only 

checks after they were counseled by the nutritionist. Participation by clients was voluntary. At 

any point, the WIC client could return to reduced-fat or whole milk, and some did. Ten percent 

of clients accepted the specialized checks; they received promotional items as incentives, 

including pens, book marks, literature, and stickers. 

The pilot continued until March 2003. Results of the pilot study showed that 80 percent of 

families who participated will continue to choose the lowfat-milk-only checks, 97 percent 

encountered no problems using the checks in grocery stores, and 93 reported that stores were 

adequately stocked with lowfat or fat free milk. Preliminary results of monitoring the BMIs of 

the pilot children indicated that 38 percent had lower BMIs six months after receiving the 

lowfatmilk-only checks, 31 percent had no change in their BMIs, and 31 percent had BMIs that 

increased between 1 and 2 percentage points.15

 15 In June 2003, the lowfat-milk-only check option was made available statewide. As of 

August 2003, more than 2,500 low-fat-milk-only food packages had been assigned. In addition, 

a state WIC office report has been developed that tracks the number of WIC children over 

2 years old who are overweight or at risk being so, by county. Figures are collected quarterly. 
136

local WIC staff before administering it to the clients. State officials knew that agencies would 

promote the Mooove Campaign more effectively if WIC staff believed in the initiative. 

Key Challenges. A few operational challenges emerged during the planning phase of the 

Mooove Campaign. First, the WIC Bureau did not succeed in its efforts to solicit help from the 

grocery stores in promoting the campaign’s message. State officials obtained permission from 

all the major grocery chains in Florida to place on their dairy cases a cow placard promoting 

lowfat or fat free milk. They also sent letters to WIC vendors asking that they display Mooove 

Campaign placards in their stores for one month. Unfortunately—despite permission from food 

executives—most stores did not display the placards. While some managers were enthusiastic 

and posted the placards, the WIC Bureau did not achieve the statewide presence it anticipated in 

grocery stores. Ideally, state officials would have tracked milk sales by store to see whether 

sales of lowfat and fat free milk increased because of the placards. It was impossible, however, 

to obtain price scan reports, since grocery stores are reluctant to divulge proprietary data. 

In addition, staff in local agencies were surprised by some nutritional myths that they heard 

expressed by clients. During the first six months, WIC nutritionists repeatedly heard clients say 

that reduced-fat milk is the same as lowfat milk. To combat this myth, WIC staff produced tent 

cards that could be easily displayed on a clerk’s window or counselor’s desk that read, “2% milk 

is NOT lowfat.” Staff were also surprised that some clients thought they could not use regular 

WIC checks for milk to buy lowfat or fat free milk. This misconception led the state WIC office 

to add to WIC checks, under “Health Tips,” the following statement, “For those over the age of 

2, choose lowfat or fat free milk—same great taste, just less fat and calories.” The health tips on 

the checks reinforced the message of the Mooove Campaign and reminded clients that they can 

use WIC checks to buy lowfat or fat free milk. 

Lessons Learned. Overall, the WIC Bureau has been very pleased with the Mooove 

Campaign. It promoted a targeted nutritional message: choose lowfat or fat free milk to support 

better health. This simple, clear theme was appealing because various organizations and 

agencies could easily endorse the mission. The state health educator also stressed that the 

campaign has begun to dispel some milk myths held by WIC clients, such as considering 

reduced-fat milk to be the same as lowfat. Further, the cost was quite small. However, data are 

not really available to track the effects of the program. 

Yet despite the campaign’s good reception, state officials wish they had done several things 

differently. First, they would have reconvened the local agencies after the initial conference call 

to monitor how the campaign was being implemented at the local level. Such a debriefing would 

have enabled WIC staff to share ideas and discuss concerns or challenges. 

Second, program planners would have approached outreach differently for clients who are 

lactose-intolerant. As the campaign got under way, WIC staff began to hear staff and clients in 

this subgroup say that they did not have to be concerned about the different types of milk since 

they were lactose-intolerant. Unfortunately, the campaign did not address the fact that lactosereduced milk is also produced in lowfat and fat free forms that could have been promoted just as 

easily as regular milk. If the Mooove Campaign is reintroduced, this matter will be addressed. 
137

Finally, the nutrition consultant and health educator would have preferred that the Mooove 

Campaign be a multiyear effort. Even so, although the campaign officially ended in February 

2003, most local WIC agencies continue to display posters and tent cards. In addition, WIC 

clients are still reminded of the milk initiative in a special “health tips” section on their WIC 

checks. According to the state public health nutrition consultant, many agencies still use the test 

tube displays as teaching tools, conduct taste tests, and “actively promote lowfat or fat free 

milk.” Furthermore, the WIC Bureau and the FIFNC plan to reemphasize the milk campaign 

during the third statewide nutrition education initiative (scheduled to begin in March 2004), 

which will highlight the benefits of physical activity and healthy snacks. State officials hope that 

agencies will continue to use the Mooove materials, and that they will reintroduce the cow 

mascot with future outreach efforts to promote healthy nutrition. Other partners, such as schools 

and day care centers, also continue to use campaign materials. 

CONTACT INFORMATION 

Kathy Reeves, MS, RD, LD, Public Health Nutrition Consultant 

Mary Ann Patterson, Health Educator 

Florida Department of Health 

Bureau of WIC and Nutrition Services 

Bin A#16 (HSFW) 

4052 Bald Cypress Way 

Tallahassee, FL 32399-1726 

Phone: 850-245-4202 

E-mail: Kathy_Reeves@doh.state.fl.us 

 MaryAnn_Patterson@doh.state.fl.us 

To obtain materials:

http://www.doh.state.fl.us/family/mooove/milk.html 

139

B. PREVENTIVE HEALTH INTERVENTIONS 

Adding preventive health interventions or other services to WIC’s menu of services has long 

been controversial, particularly as such mandates have sometimes come without additional 

funding, which places added strain on the often limited time that WIC staff can spend with 

clients. In this section, we focus on initiatives that are at the margins of WIC’s responsibility 

and seem appropriate to characterize as “WIC Plus.” Furthermore, these initiatives received 

outside funding and were developed in part outside the WIC program. However, both initiatives 

offer promising strategies for supplementing WIC and seem worthy of further study (as long as 

the services have appropriate funding): 

• Alabama’s program to prevent early childhood caries among WIC children 

(particularly those age 2 or younger) builds naturally on the connection between 

infant and toddler feeding practices and early tooth decay. A range of materials have 

been designed to be useful with minimal staff time. This team effort is an interesting 

example of collaboration, as WIC worked with the Department of Health’s Oral 

Health Branch and several university researchers.

• At clinics run by Public Health Foundation Enterprises Management Solutions in the 

Los Angeles area, a demonstration tested both a new method of screening prenatal 

WIC clients for alcohol use and a brief intervention to use with those who reported 

drinking alcohol during their pregnancy. Screening and referrals for alcohol abuse 

are part of WIC’s mandate, but intervention arguably is not. This initiative offers a 

way to reach prenatal clients more effectively, with little or no increase in staff time. 

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WIC NUTRITION EDUCATION MODEL FOR THE 

PREVENTION OF EARLY CHILDHOOD CARIES16,17

ALABAMA 

OVERVIEW 

Location: Statewide 

Start Date: October 2002 

Target Population: The initiative targets pregnant and postpartum women, infants, and children 

up to age 5 years enrolled in WIC. 

Purpose: To promote good dental practices for WIC families, using a culturally sensitive, lowliteracy nutrition education model, and ideally to reduce the rate of early childhood caries (ECC) 

in Alabama, which before the initiative was 6 percent above the national rate (27 versus 

21 percent). 

Services: Educational tools, including video, flip chart, tip cards, and posters, are used in group 

classes or one-on-one sessions. Staff distribute a referral list of dentists who charge fees on a 

sliding scale and/or accept Medicaid participants. Additional services that fall under the twoyear state nutrition education plan include adult and pediatric toothbrushes, toothpaste, and 

dental floss, along with other incentive items like coloring books, crayons, and stickers that 

promote good oral health. 

Funding: Funding from a U.S. Department of Agriculture (USDA) infrastructure grant18 and 

the Alabama Department of Public Health’s WIC Division and Oral Health Branch totaled 

$160,330. This does not include in-kind personnel and travel expenses. 

Why Program Was Chosen: Through a collaborative partnership with the Oral Health Branch, 

the University of Alabama at Birmingham (UAB) School of Dentistry, and the UAB School of 

Public Health, the WIC Division incorporated dental health education, an area in which WIC 

does not traditionally engage, into routine services. 

Key Challenges: Logistical problems prevented a planned staff training video from being 

produced and delayed completion of a video for clients. Local staff wished they had received 

more training. In addition, lack of dentists who accept Medicaid or offer sliding fees and also 

serve young children made referrals difficult. 

 16 Caries is the medical term for tooth decay, which includes baby-bottle tooth decay. 

17 Telephone interview, April 14, 2003; site visit, June 25-26, 2003. 

18 Infrastructure grants are from a pool of funds allocated by the Secretary of Agriculture to 

improve WIC infrastructure and for selected other purposes. 
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BACKGROUND 

State Characteristics. In 2000, the population of Alabama was 4,447,100. Whites 

(71.1 percent) and African Americans (26.0 percent) make up the bulk of state residents. About 

16 percent of Alabama’s population lived in poverty in 1999, and the median household income 

was $34,135. 

WIC Program Background. The state WIC program is divided into 11 public health areas. 

All counties have WIC sites within the county health departments, though a few local private 

agencies also operate WIC clinics. In May 2003, 26,566 women, 28,057 infants, and 54,156 

children were enrolled in WIC, and participation rates were 87.5 percent, 90.1 percent, and 

88.2 percent, respectively. Of those enrolled, 52.1 percent were white, and 39.4 percent were 

African American.19

Before the WIC Nutrition Education Model for the Prevention of Early Childhood Caries 

initiative, WIC had engaged in limited dental health education. For the most part, nutritionists 

talked with clients about the importance of weaning the baby and preventing ECC. To this end, 

they typically passed out tear-off sheets on caries, pictures of babies suffering from caries, and a 

weaning pamphlet during one-on-one nutrition education sessions or group classes, as well as 

referred families to dentists who used a sliding fee scale. Staff targeted dental health education 

to parents with children who were 9 to 12 months old. 

Program History and Objectives. The development of the ECC initiative stemmed from 

the collaborative efforts of two departments at UAB and the WIC Division and Oral Health 

Branch under the health department’s Bureau of Family Health Services. All four stakeholder 

groups—the WIC Division, the Oral Health Branch, the School of Dentistry, and the School of 

Public Health—appreciate the detrimental effects that poor dental health can have on young 

children. Dental caries is the single most common chronic childhood disease (Crall et al. 2000). 

Severe pain can limit a child’s ability to eat and talk, and can interfere with later success in 

school. According to the National Governors’ Association, more than 51 million school hours 

are lost each year to dental-related illness (Krause 2002). Partners in the ECC project aim to 

reduce the caries rate among the WIC population through education and prevention activities. 

In 2000, the southeastern regional Food and Nutrition Service (FNS) office began notifying 

state-level officials about “a new push in WIC to provide dental education with an emphasis on 

the nutritional aspects of good dental care.” Around the same time, the Chair of the Department 

of Pediatric Dentistry at UAB, who also serves as a consultant to the state health department, 

expressed an interest in developing, through the health department, a program focusing on the 

prevention of ECC. He has a history of serving the dental needs of low-income populations and 

19 Participation data are not stratified according to Hispanic origin or Spanish speakers. 

However, local program staff report that the number of Spanish speakers in certain areas is 

growing. For example, the nutrition area coordinator for public health area 5 (northeastern 

Alabama) estimated that 40 percent of WIC clients are Hispanic, and the coordinator for public 

health area 2 (north-northeastern Alabama) noted that one-third of statewide Hispanic 

caseloads—about 10,000 total—are in her service region. 
143

 

is interested in learning about new ways to improve dental care among children. At that time, 

the chair of the department knew little about the specific components of the WIC program. 

Before the initiative, the Oral Health Branch partnered with the dental school to conduct a 

needs assessment of the WIC population in Alabama in 1999. Dentists examined a small sample 

of 136 WIC children ages 18 to 48 months from several clinics. The exams revealed a pediatric 

dental caries rate of 26.7 percent, about 6 percentage points higher than the national average. 

With evidence that there was a problem with dental caries among WIC children in Alabama, 

stakeholders needed to determine the best course of action. At the time, the state had a very 

small Oral Health Branch and did not have a full-time dental director. Because its staff was 

small, the branch was somewhat limited in how much it could contribute to any project. Because 

WIC staff have experience in working with young children and in nutrition education, and 

because diet has a significant impact on dental health, it was a perfect opportunity to form a 

partnership between the Oral Health Branch and WIC, along with people at the university. 

State officials then invited behavioral scientists to incorporate behavior modification into a 

dental education model. An epidemiologist from the UAB School of Public Health designed 

focus groups and surveys for WIC staff and parents to gather information that would be used to 

guide the development of the education materials. State and area WIC staff, along with dental 

staff, helped shape the focus group and survey questions, and suggested clinics to visit 

statewide.20 These surveys enabled program planners to learn more about staff and client 

awareness, knowledge, behaviors, and interest levels in dental-nutrition education. They were 

especially interested to find out whether WIC staff thought that dental health education could fit 

easily into routine nutrition education activities, which they did. Regarding topics for the parent 

focus groups, two School of Public Health researchers were interested in learning about whom 

clients identify as credible sources of information, optimal methods of receiving information (for 

example, brochures versus videos), barriers to dental care and social services in general, the 

knowledge gaps for good oral health, and current dental care practices. They collected input 

from clients at nine ethnically and geographically diverse clinics and through a survey of 

20 WIC coordinators. 

During the focus groups, several misconceptions emerged that confirmed for program 

planners that the WIC population needed better dental health education. For example, a large 

portion of parents were unfamiliar with ECC and how often they needed to brush their children’s 

teeth. Many did not know that milk and formula contain sugar that bacteria use to cause tooth 

decay and that children should start to see the dentist after they turn 1 year old; they had assumed 

that they could wait until the children were 4 or 5. Parents were very interested in learning more 

about appropriate practices to prevent ECC. 

With this information, university representatives developed—in consultation with state 

health department, WIC, dental, and graphic design staff—several teaching tools, including a 

20 Because state officials wanted to develop a culturally sensitive model, various ethnic 

groups from the WIC population participated in focus groups, including African American, 

Native American, Hispanic, and Vietnamese program participants. 
144

 

video, flip charts, tip cards, and posters. Because they wanted to minimize staff burden, they 

abandoned the notion of time-intensive counseling and opted instead for an easy-to-read flip 

chart that WIC staff could use with participants, posters for the clinics, a dental referral sheet, 

and other intervention materials that clients could review at home. 

After the USDA infrastructure grant was approved, the state WIC office presented the ECC 

project to the Nutrition Area Coordinators, who are responsible for selecting the statewide 

nutrition education plan every two years. For the coordinators, it was a timely project, since 

WIC staff knew that caries was a pervasive problem, particularly since adequate dental care is 

often not available in rural parts of the state. Moreover, they had been familiar with the 

program’s development since (1) the assistant state dental director, at the 1999 WIC Nutrition 

Education Workshop, presented an overview of what caries is, how it develops, and how it can 

be prevented; (2) WIC staff completed the surveys that influenced the grant application at this 

workshop; and (3) UAB representatives presented their findings from the participant focus 

groups to nutritionists and nurses at the 2001 Annual WIC Training Conference in September 

2001. The coordinators approved ECC prevention as the focus of the two-year plan from 

October 2002 through September 2004. 

Target Population. The ECC initiative is intended to reach pregnant and postpartum 

women, infants, and children who are enrolled in WIC. For the statewide 2002–2004 nutrition 

education plan, however, Nutrition Area Coordinators chose to focus specifically on WIC clients 

from infancy through 2 years of age, when good oral health practices are established and when 

infants and toddlers are at the highest risk for developing ECC. Although the initiative formally 

targets ages 0 to 2, state officials encourage clinics to provide ECC education to prenatal women 

and all children in the program, including three-, four-, and five-year-olds. The extent to which 

staff actively deliver services to older children varies from clinic to clinic.21

In designing the ECC model, program planners recognized the importance of developing a 

pedagogical model that was ethnically and culturally appropriate to the WIC population. For 

example, some focus group participants revealed that African Americans often view a maternal 

figure as a credible source of information and guidance. Therefore, program planners used an 

older African American woman as the narrator for the video. Other actors in the video and in 

models for the flip charts represented a range of ethnic groups so that the educational tools 

reflected the WIC clients to whom they are targeted. All materials have been produced in 

English and Spanish. 

PROFILE OF INNOVATIVE PROGRAM 

Services Provided. Because the teaching preferences and learning environments vary 

among different sites, state officials wanted to grant local agencies the flexibility to select which 

supplies and activities to implement. Therefore, the characteristics of service delivery for the 

ECC initiative vary from site to site. Under its second objective, the statewide nutrition 

21 A group of nutrition area coordinators believed that many clinics give the incentive items, 

such as toothbrushes and stickers, to older siblings. 
145

 

education plan states that “dental health education materials may include the following: 

toothbrushes and toothpaste, dental floss, a large model of a mouth with toothbrush, pamphlets, 

flip chart, video, and posters.” The flip chart explains (1) the importance of baby teeth, (2) the 

seriousness of ECC in dental health, (3) the causes of tooth decay, (4) the ways proper oral care 

can prevent caries, (5) some important feeding tips, and (6) the importance of regular dental 

visits starting at age 1.22

The video shows the proper way to clean an infant’s mouth and the way to brush and floss a 

child’s teeth, covers general nutrition education information, and recommends how often 

children should see a dentist. The Oral Health Branch also purchased and distributed largetoothed puppets that staff could incorporate into education classes to make them fun and 

appealing for young children. Dental screenings are not a part of this initiative, though for years 

some clinics have had dentists come on site to do screenings. WIC staff do, however, provide a 

dental referral sheet of local low-cost dental services. One side contains information on how to 

find Medicaid dentists and provides toll-free numbers, and the other contains a list of low-cost, 

non-Medicaid community health centers that are federally funded. The following paragraphs 

illustrate the range of services between two local agencies. 

A clinic in Jefferson County provides one-on-one dental education sessions with clients 

every six months on any weekday. Staff switched to individual sessions as opposed to group 

classes several years ago because (1) clients are more comfortable discussing confidential issues 

in private, (2) clients are no longer pulled out of classes for a scheduled appointment, and 

(3) there is adequate staff to deliver individualized contacts. Specific ECC services shift 

according to the sequential contact (for example, first versus second visit) and age of the child. 

During the primary contact, one nutritionist may talk about bottle use and weaning, and the 

importance of scheduling the first dental appointment when the child turns one. If a mother is 

reluctant to decrease or eliminate bottle use, she shows them a color postcard or “tip card” that 

depicts a mouthful of caries, a potential result of poor oral health. During the next appointment, 

the nutritionist distributes adult and pediatric toothbrushes, toothpaste, the tip card (see box), and 

the video to keep and watch at home, and also discusses proper brushing techniques.23 She 

might ask the parent about how much sugar, juice, and milk the child is consuming, and talk to 

her about ECC. After asking whether the client is on Medicaid, she can refer the parent to 

several dentists who accept Medicaid participants or to the dental clinic in the health 

department.24 At the third session, clients receive dental floss, crayons, and coloring sheets 

22 Audiotapes and compact discs are available for Hispanic clients who do not speak English 

and cannot read Spanish, so that they can follow along in the Spanish flip chart without having to 

rely on a translator. Tapes and discs contain the spoken version of the Spanish flip chart. 

23 For clients who do not have a videocassette recorder, equipment is available at all WIC 

sites throughout the state. 

24 On the first floor of the Central Medical Center, there is a dental clinic that takes patients 

on a walk-in basis. To qualify, patients must live in the county. This clinic is an invaluable 

resource, because WIC nutritionists can immediately send clients downstairs for a dental 

appointment. 
146

TIP CARD 

1. Baby teeth are important. 

2. Mom’s teeth are important. 

3. Clean teeth and gums every day. 

4. Only formula, water, or breast milk in bottle. 

5. No bottle or breast when sleeping. 

6. Give juice in a cup only. 

7. Trade bottle for cup by the first birthday. 

8. Give healthy snacks. 

9. Baby’s checkups start at age 1. 

10. See white spots? See the dentist. 

that focus on flossing. (Staff downloaded these sheets, which are aimed at two- to three-yearolds, from the Internet.) 

In contrast, a clinic in Calhoun County prefers to deliver most (75 percent) dental education 

contacts through group classes. All group nutrition classes take place at 8:30 A.M. and again at 

1 P.M. on Mondays, Tuesdays, Thursdays, and Fridays, and dental classes are scheduled four 

times a month. Classes last about 15 minutes and are divided roughly into three age groups. The 

4- to 5-month-old class might focus on stressing the importance of cleaning gums every day with 

a washcloth and water. For the 10-month-old class, nutritionists discuss weaning, offer tips for 

preventing caries, and distribute a list of local dentists who accept Medicaid clients. During a 

typical class for those with children 1 to 5 years old, the format is primarily lecture-based but 

also elicits feedback and personal experiences from clients. Topics for the session, entitled 

“Something to Smile About,” included examination of a picture of dental caries, the causes of 

caries, baby bottle tooth decay and the consequences of long-term bottle use, plaque and unlikely 

sources of sugar, a step-by-step progression of tooth decay and early warning signs, and 

serious—albeit rare—medical effects of poor oral health.25 The nutritionist then discussed the 

10 important steps that families should take to prevent ECC (see box), and demonstrated 

appropriate brushing techniques and the adequate amount of toothpaste. At the end of the class, 

clients received a bag (one bag per child or prenatal client) that contained (1) a pediatric 

toothbrush, (2) toothpaste, (3) mint floss, (4) crayons, (5) an ABCs of Good Oral Health coloring 

book, (6) a colored postcard of severe childhood caries on one side and a list of important tips on 

the other, (7) a two-sided Oral Health Fact Sheet developed by the Department of Public Health, 

(8) an information sheet on the Medicaid dental program that lists 20 reduced-fee dental clinics 

throughout the state, (9) a referral list of dentists, and (10) a Medicaid information booklet. 

 25 This is a PowerPoint version of the flip chart. It is available for the few clinics equipped 

to use it. 
147

 

Prenatal mothers sometimes have their own class; sometimes they join one of the other 

classes. If clients miss a scheduled class, their charts are forwarded to the service rooms,26 and 

they can be seen for a one-on-one session at any point during the day when they come to the 

clinic. All service rooms contain bilingual dental flip charts nutritionists can refer to. Staff 

occasionally show the video in the waiting room, where it is rotated with other nutrition videos. 

Participation. All 115 WIC sites throughout Alabama must incorporate some elements of 

the ECC model into their two-year nutrition education plan. The average monthly caseload for 

fiscal year 2003 was 119,463 total participants. In looking at the targeted population as defined 

by the Nutrition Area Coordinators as part of the statewide plan, WIC estimates that 100,000 

children aged 0 to 2 will be served over the two years. As described above, specific services 

vary across the state. Beyond September 2004, the English and Spanish education materials and 

the dental referral sheet that were developed as part of the ECC initiative will continue to be used 

routinely in providing education about ECC for pregnant women, infants, and children up to age 

5 who are enrolled in WIC.

Coordination and Collaboration. The ECC project has been a collaborative effort of the 

Alabama Department of Public Health (WIC Division and Oral Health Branch), the UAB School 

of Dentistry, and the Department of Health Behavior within the UAB School of Public Health. 

Drawing upon each other’s strengths, and with substantive input from clients and local staff, 

these stakeholders worked together to develop a nutrition education model for the prevention of 

ECC in order to promote and cultivate proper oral health practices among WIC families. 

One interesting partnership that emerged after the ECC prevention initiative began is 

between the WIC program and Head Start. Over the past few years, there has been more of an 

emphasis at the state level on WIC clinics collaborating with other agencies in providing 

nutrition education. One nutrition area coordinator teaches a class about ECC prevention at local 

Head Start centers. The class counts as a secondary nutrition education contact for those 

children enrolled in the WIC program and is a way to encourage good dental health among other 

families with limited resources. Parents sign a form on the day of the class granting permission 

for their children to attend; this documentation also allows WIC to count the class as a secondary 

nutrition education contact for children participating in WIC.27 Since it would be difficult in 

terms of scheduling for local nutritionists to travel off site to Head Start centers, the coordinator 

assumed responsibility for teaching the classes. The Oral Health Branch covers the cost of 

distributing dental supplies and other incentives in the Head Start centers. 

The first class took place in May 2003 at a Head Start center in Cleburne County, a rural 

area that contains only one part-time dentist. On that same visit, the nutrition area coordinator 

also showed the video to a group of parents representing about 25 families. It soon became clear 

26 This WIC clinic has multiple service rooms (which resemble exam rooms at medical 

clinics), and staff rotate from room to room. 

27 The nutrition area coordinator estimated that 32 percent of children in these classes are 

also enrolled in the WIC program. 
148

that raising awareness about healthy dental practices was an important mission for WIC in 

working with Head Start. 

The central educational tool in the Head Start classrooms is an alligator puppet with large 

teeth and a foot-long toothbrush. The coordinator talks to the class about brushing regularly and 

eating healthy snacks, and each child gets a chance to practice brushing the alligator’s teeth 

while the coordinator coaches their technique as needed. Children receive new pediatric 

toothbrushes, toothpaste, stickers, and a yellow chart (6 by 8 inches) entitled “Have you brushed 

your teeth today?” with spaces for each day of week that children can check off for four weeks. 

As of July 2003, the nutrition area coordinator had conducted only three classes at two 

centers and a local nutritionist had conducted a class at a center in Randolph County; they served 

a total of about 65 children. However, the collaboration is relatively new. The area coordinator 

taught two more classes at a Head Start center in September and described her efforts at the 

statewide Annual WIC Training Conference that same month. Moreover, the coordinator, a 

nutritionist, and a WIC clerk visited this Head Start center twice to certify a total of 11 children 

for WIC. It is unclear, however, how many other public health areas in Alabama will begin 

partnering with Head Start. Service delivery will have to be done on a case-by-case basis, 

depending upon available staff time and client caseloads. 

Publicity and Outreach Efforts. As a part of the statewide nutrition education plan, each

local WIC site is required to conduct at least one outreach activity related to ECC prevention 

over the two-year period. Outreach activities vary from site to site. Clinics prepare a bulletin 

board; write articles for local newspapers or other publications; create a display for the clinic’s 

lobby; host a poster session for a community health fair where staff talk about the WIC program, 

good oral health practices, and affordable dental services; meet with local dentists to raise 

awareness about the ECC initiative and promote access to dental care for WIC clients, or some 

combination.

ORGANIZATION AND MANAGEMENT 

Staff and Organizational Structure. During the program planning phase, the Chair of the 

Department of Pediatric Dentistry spent 20 percent of his time participating in a needs 

assessment and writing the grant proposal. Representatives from the School of Public Health 

conducted focus groups and administered surveys that shaped the development of the flip chart, 

the video and accompanying script, and other educational materials. They modified the content 

with feedback from other partners involved in the development of the project. UAB 

representatives will likely be involved in a future evaluation of the ECC project. 

In most cases, nutritionists and nurses conduct group dental classes and individual ECC 

sessions for WIC clients. Local staff also assume responsibility for outreach activities 

surrounding the education initiative. The 11 nutrition area coordinators ensure that the nutrition 

education plan is implemented in their agencies and send progress reports into the state office 

every six months. The state WIC nutrition coordinator and the assistant state dental director are 

responsible for disseminating dental supplies, flip charts, posters and videos to local agencies; tip 
149

 

cards are ordered directly from the warehouse. The state officials also serve in an overall 

support role for local agencies, and will be involved in any evaluation.

Training. Training for the two-year nutrition education plan was not as extensive as state 

officials had originally planned. They intended to introduce the educational tools in a training 

video and even designed a script to accompany it. However, delays in production of the dental 

video for clients and a backlogged work schedule for the health department’s video 

communications division forced program planners to devise an alternative training format. 

As a result, the WIC state nutrition education coordinator and assistant state dental director 

drafted and distributed a memorandum with attachments to nutrition area coordinators, county 

WIC coordinators, and private local agencies, which covered all information contained in the flip 

chart. The attachments explained all the materials and supplies that local agencies would 

receive, and expanded on the information in the flip chart to give WIC service providers 

additional details about ECC and its prevention. State officials relied on the nutrition area 

coordinators to train their respective WIC county coordinators, who then trained their clinic 

staffs on the ECC model and on how to use ECC education materials. Most local in-service 

sessions lasted no more than an hour and generally took place during the regularly scheduled 

monthly clinic meetings. Nutritionists and nurses could use the attachments as a “quick 

refresher” for easy reference. (The nutrition area coordinators and clinic WIC coordinators 

oriented local WIC staff to the Nutrition Education Plan in October 2002.) 

Funding. Expenses for the ECC initiative were covered through a combination of funds 

from a USDA infrastructure grant ($37,038), the WIC Division ($52,889), and the Oral Health 

Branch ($70,413). Most of the funding from the state oral health program went toward 

toothbrushes and toothpaste. Salaries and travel costs for the WIC state nutrition education 

coordinator, the assistant state dental director, and the pediatric dentist from the dental school,28

as well as other miscellaneous personnel costs, were considered in-kind. A subcontract with 

representatives from the School of Public Health was paid for by a portion of the USDA 

infrastructure dollars.

ASSESSMENT AND LESSONS LEARNED 

Evaluation and Outcomes. The primary objective of the ECC initiative is a reduction in 

the ECC rate among the WIC population, although the state plan did not specify a formal goal 

(such as a reduction of 5 percent after two years). Program officials intend to reexamine WIC 

children in the same age group as the initial 136 children examined during the planning phase to 

gauge the relative degree of oral health. The chair of the Department of Pediatric Dentistry 

noted that it will be important to calibrate the examiners and then compare the caries rate with 

the baseline rate of 26.7 percent. In addition, he recommends a follow-up survey of local WIC 

28 The chair of the Department of Pediatric Dentistry at UAB has served as a consultant for 

the Alabama Department of Public Health for several years; the contract stipulates that he spend 

one day a week on state grant tasks. The ECC project falls under the scope of this position. 
150

 

staff and would also like to visit a sample of clinics to interview staff and observe service 

delivery. 

To meet state tracking requirements for the two-year education plan, WIC staff in each 

clinic review a sample of participant records every six months to determine the number of 

participants in the targeted groups who received education on ECC, the number of children 

weaned by 15 months of age, and the number weaned between 16 and 24 months of age. The 

clinic WIC coordinator then reports this information, along with the clinic’s outreach activities 

over the previous six months, on a clinic progress report to the nutrition area coordinator. 

Finally, the nutrition area coordinators collect these reviews and prepare progress reports that are 

submitted to the state WIC office every six months. 

Implementation Successes. All stakeholders, including program planners, local WIC staff, 

and clients, perceive the ECC initiative as an effective and successful endeavor for several 

reasons. First, the initiative has brought the importance of good oral health to the forefront for 

the WIC population and those who serve them. Partnering with the UAB School of Dentistry 

and School of Public Health provided the opportunity to disseminate effective teaching tools and 

information to promote healthy dental practices. This has been especially important in rural 

areas where dentists—particularly those who accept Medicaid patients—are few and far 

between. As state officials observed, children cannot have healthy teeth without good oral 

hygiene and healthy eating habits, which is why focusing on dental health education was a 

logical partnership for WIC. Local nutritionists and nurses report that parents have been very 

interested in the ECC education and materials, particularly since many are unfamiliar with 

common causes of ECC (such as insufficient cleaning of infant gums). Some parents reported to 

staff that their pediatricians never discussed preventive practices for ECC, and many parents did 

not realize the importance of dental care before 2 to 3 years of age. 

The ECC initiative has also enabled WIC staff to provide clients with concrete tools that 

permit them to follow through and act upon the knowledge they receive at nutrition education 

contacts. Clients enjoy receiving free items like toothbrushes, toothpaste, and dental floss, and 

theoretically they have the materials and knowledge to start good dental care at home right away. 

Front-line staff say that “these little items really make a difference,” and children enjoy the 

puppets. Moreover, referral lists naming area dentists that provide free services to Medicaid 

participants or services on a sliding fee scale for those families who do not qualify for Medicaid 

have increased awareness that affordable dental care is available in certain communities.29

Finally, program designers purposefully created engaging educational materials that would 

appeal visually to clients. One WIC nutritionist noted that the colorful materials, such as the 

postcard depicting a severe case of childhood caries, help a lot in conveying what can happen to 

teeth without good-quality oral health care. Nutrition area coordinators reported that line staff 

like the fact that the nutrition education plan on the prevention of ECC is “more fun and 

interactive” than previous two-year plans and that they have many teaching materials at their 

29 As the challenges section describes, there is a shortage of dentists who accept Medicaid 

patients or offer inexpensive services throughout Alabama. 
151

 

disposal. Local agencies and nutrition area coordinators also seem to appreciate that it has not 

been difficult to incorporate ECC education into the daily routines in the clinics. Families are 

given copies of the video to watch at home, and information contained in the flip chart and 

accompanying audiotapes and compact discs is succinct and simple. The materials are available 

in English and Spanish, which is important since some clients have low literacy skills or are not 

fluent in English. 

Key Challenges. Limited training from the state and the lack of dentists who accept 

Medicaid participants or offer a sliding fee system and who also serve children under 2 or 

3 years old are two primary challenges that the ECC initiative has faced. Initially, state officials 

had planned to produce a training video, but logistical obstacles prevented this. Nutrition area 

coordinators and local staff who deliver services would have preferred more direction than the 

training memorandum. Although a training video was not available, some nutritionists would 

have welcomed such resources as (1) instructions for families that clearly outline proper 

brushing and flossing techniques, and (2) a satellite conference call convened by state officials to 

review training materials with regional coordinators. 

While not a challenge that program officials have any control over, several nutrition area 

coordinators and local staff commented on the lack of accessible, affordable dentists for the WIC 

population. Many families do not live near care providers who accept Medicaid or offer reduced 

fees for needy patients.30 (Program officials estimated that 50 percent of WIC clients do not 

even qualify for Medicaid in Alabama.) No dentists accept Medicaid enrollees in public health 

areas 2 and 5, and only one dentist does so in public health area 6. Most WIC participants in 

these regions must travel at least an hour (some as many as 100 miles one way) to find an 

appropriate dentist in Birmingham; pediatric dentists are even rarer. Because of transportation 

barriers, some families opt not to go to the dentist at all. Even if parents can gain access to an 

affordable provider, many dentists, even in large cities like Birmingham, refuse to serve children 

before they turn 3 years old and tell parents that it is not necessary. For many years, the 

Academy of Pediatric Dentistry recommended that children should first see a dentist upon 

turning 2, and in 2000 it reduced its recommendation to 1 year of age. However, given the 

protocols of many dental care practitioners, WIC program officials are concerned that parents 

have a difficult time finding a dentist who will take patients at 2 years old, let alone when infants 

turn 1. It is very frustrating for nutrition staff to convince parents of the importance of good 

dental care and of taking one-year-olds to the dentist, equip them with oral care supplies, and 

then learn that parents cannot find an affordable dentist or one who will accept infants and 

toddlers. 

During the planning phase, state officials encountered some problems with the production of 

the video. They collaborated with the Video Communications Division in the health department 

but could not—for financial reasons—hire professional actors to be in the video. Instead, they 

used WIC clients on a voluntary basis. It was challenging (1) to ensure that they had a 

representative sample of volunteers, (2) to work with volunteer “actors,” and (3) to handle 

30 State officials remarked that many dentists are not willing to forgo a portion of private 

practice time to serve low-income families, because income from appointments would decrease. 
152

logistics. For example, one picnic scene involved feeding 40 people, and some children did not 

cooperate in scenes at the dentist’s office. Overall, it took six months to produce the video, a 

delay they had not anticipated. It was challenging for state officials to juggle this with all their 

other responsibilities. Furthermore, officials encountered delays in getting the videos translated 

into Spanish, and local agencies did not receive the Spanish version until October 2003. 

Lessons Learned. Stakeholders agreed that the ECC prevention model could be replicated 

in other states. In fact, program planners intended to design a project that could be replicated, 

and program materials are available on the WIC Works Website. The initiative took some time 

to develop, so other states could benefit from their efforts. Nonetheless, other state WIC 

programs or local agencies could decide to supplement what has been accomplished in Alabama 

or to modify the tools to meet their own service population. For example, educational materials 

could be translated into a language besides Spanish. One nutrition area coordinator observed 

that special methods may be needed for delivering dental education on Indian reservations. 

In addition, collaboration between different kinds of partners—in this case the WIC 

program, the Oral Health Branch, the School of Dentistry, and the School of Public Health—is 

critical when a program seeks to expand into nontraditional WIC topics. Partners can benefit 

from each other’s expertise. In this case, a program that is, at its core, a supplemental food and 

nutrition education program chose to select ECC as a special initiative. The university was able 

to take the lead on collecting data, performing a needs assessment, and providing the knowledge 

about good dental care. Working with the health department’s state dental office and the dental 

school at UAB brought valuable information to WIC, which had very limited dental education 

services before the ECC began. 

Program planners also suggested that WIC programs in other states collaborate with any 

other stakeholders that have an interest in improving dental health, such as the Medicaid 

program. As an example of cross-program collaboration, the ECC project has demonstrated a 

promising partnership with local Head Start centers. The state WIC nutrition education 

coordinator noted that partnering with Head Start is an effective way to increase the number of 

secondary education contacts. 

CONTACT INFORMATION 

Gail Mask, WIC State Nutrition Education Coordinator 

Sherry Goode, Assistant State Dental Director 

Alabama Department of Public Health 

Suite 1300 

201 Monroe Street 

Montgomery, Alabama 36104 

Phone: 334-206-2922 (G. Mask) 

 334-206-2904 (S. Goode) 

E-mail: gmask@adph.state.al.us (G. Mask) 

 sgoode@adph.state.al.us (S. Goode) 

To obtain materials: www.nal.usda.gov/wicworks/Sharing_Center/statedev-oralhealth.html 
153

CEASE ALCOHOL RELATED EXPOSURE (CARE)31

LOS ANGELES AND ORANGE COUNTIES, CALIFORNIA 

OVERVIEW 

Location: Los Angeles and Orange counties, California 

Start Date: 2000 (research phase), 2003 (agency-wide rollout) 

Target Population: Prenatal WIC clients in Public Health Foundation Enterprises Management 

Solutions (PHFE) WIC centers in Los Angeles and Orange counties. 

Purpose: To improve the detection of prenatal alcohol use and to conduct a brief intervention 

for women who report current post-conception use. The ultimate goal is to improve birth 

outcomes by eliminating or reducing prenatal alcohol consumption. 

Services: A five-question self-administered alcohol-screening tool is administered to all 

prenatal women at PHFE WIC centers. For those who report current alcohol consumption, WIC 

staff use a 10-minute Health and Behavior Workbook to motivate behavior change. 

Funding: Almost $1 million in funding was awarded to the University of California, Los 

Angeles (UCLA) by the National Institute of Alcoholism and Alcohol Abuse (NIAAA) for a 

three-year research project, $282,000 of which went to WIC. The March of Dimes (MOD) gave 

$58,577 in 2003 for an agency-wide rollout. 

Why Program Was Chosen: This initiative is a straightforward and effective means of 

detecting and addressing prenatal alcohol use, and it addresses the WIC requirement to counsel 

pregnant women about drug and alcohol use. The model could easily be replicated in other 

agencies. Because few women meet the criteria for the brief intervention, the cost in additional 

staff time is modest. 

Key Challenges: Some staff resisted the additional responsibilities at first, particularly with the 

extra paperwork required by the research, but recognition of staff contributions helped. Staff felt 

they may not be reaching seriously addicted women, but the intervention is not really targeted to 

this group, as they need more intensive services. 

 31 Telephone interview, April 15, 2003. 
154

BACKGROUND 

Community Characteristics. Los Angeles (LA) County in California has a population of 

over 9.5 million people based on 2001 estimates. In 2000, 31 percent of the population was 

white, lower than the state average. In the same year, 45 percent of the population was Hispanic, 

12 percent Asian, and 10 percent black, all higher than the state average. Over half the 

population speaks a language other than English in the home. About 18 percent of the county 

population lives below the poverty level, compared to the state average of 14 percent. 

Orange County has a population of almost 2.9 million people based on 2001 estimates. In 

2000, 51 percent of the population was white, higher than the state average. In the same year, 

31 percent of the population was Hispanic, and 14 percent Asian. About 41 percent of the 

population speaks a language other than English in the home, which is comparable to the state 

average of 40 percent. About 10 percent of the county population lives below the poverty line. 

WIC Program Background. The PHFE-WIC program serves about 290,000 LA County 

WIC participants each month, and an additional 30,000 participants in Orange County. About 

11 percent of the PHFE-WIC participants in LA and Orange counties are prenatal women. At 

PHFE-WIC, only nutritionists, not paraprofessionals, see prenatal women. The PHFE-WIC 

program has 48 clinics in LA County and 7 in Orange County. 

Program History and Objectives. WIC is mandated to screen prenatal WIC clients for 

alcohol and drug use, and to provide annual training to staff members on these issues. The 

research on prenatal alcohol use indicates that as little as a few drinks a week can have serious 

implications for the child. In addition to decreased gestation, birth weight, length, and head 

circumference, there are also long-term effects like hyperactivity, response inhibition, poor 

coordination, poor habituation, depression, poor social judgment, and learning and memory 

problems. There is no known safe level of alcohol consumption during pregnancy; thus, WIC’s 

message is to avoid alcohol consumption while pregnant, as recommended by the Institute of 

Medicine (1996). If a pregnant woman drinks at high levels and is unable to quit, she should at 

least reduce consumption. WIC staff make it clear that this is a short-term restriction that lasts 

only for the duration of the pregnancy, unless the woman chooses to breast-feed. 

The California WIC program uses self-reports to assess alcohol use. Clients are asked, 

“When did you last drink alcohol?” Those reporting post-conception alcohol consumption are 

asked about drinking frequency and quantities, and whether they want to stop drinking. These 

responses are recorded in a central database, and women reporting post-conception alcohol use 

are given a special alcohol risk code in the database. About 5 percent of PHFE-WIC’s clients 

reported consuming alcohol post-conception in 1999 based on this sequence of questions, but 

other reports in the literature have prevalence rates of 10 percent, which suggests that WIC may 

not be detecting half the cases. Underreporting could be a result of client embarrassment or 

shame, particularly as alcohol use is communicated orally and directly to a WIC staff member. 

A more sensitive assessment tool would help in targeting interventions. 
155

 

Two investigators from the UCLA Fetal Alcohol Syndrome clinic, one of whom worked 

part-time at PHFE-WIC, wrote a grant to the NIAAA to develop, implement, and evaluate the 

CARE initiative.32 They were awarded the grant in September 1999. In general, CARE is 

intended to bridge research and practice, and to provide a stronger foundation for WIC to address 

prenatal substance abuse, particularly with alcohol. CARE includes a self-administered 

screening tool, an intervention tool called the Health and Behavior Workbook, and staff training 

on administering these tools and on prenatal alcohol use. The investigators developed the fivequestion self-administered screening tool that allows pregnant women to respond anonymously 

to questions about alcohol use. They also adapted the brief intervention model developed by 

NIAAA into a WIC Health and Behavior Workbook, a 10-minute intervention for those found to 

consume alcohol. The UCLA investigators collaborated with PHFE-WIC on a three-year 

research study of the screening tool and/or Health and Behavior Workbook comparing 12 CARE 

intervention sites (10 in LA County and 2 in Orange County) to 12 control sites that used verbal 

screening. Six of the CARE intervention sites used the screening tool with the intervention; the 

other six used only the screening tool. The research project began in May 2000. 

Because of the success of the research project, and thanks to funding from the MOD, CARE 

is being rolled out in all PHFE-WIC centers in LA and Orange counties. According to the 

investigators, measurable objectives of the project are as follows: (1) by August 31, 2003, 

90 percent of WIC staff that attend the Alcohol Prevention During Pregnancy training will be 

able to name 2 fetal effects of alcohol use during pregnancy and identify the proper alcohol 

screening protocol for pregnant WIC women; (2) by March 31, 2004, the detection rate of 

pregnant WIC women using alcohol during pregnancy will double (from 5 percent to 

10 percent); and (3) by March 31, 2004, at least 1,700 women will be individually counseled by 

WIC nutritionists (using the Health and Behavior Workbook) on the risk of alcohol use during 

pregnancy and their plan to manage their alcohol consumption.33

Target Population. Prenatal WIC clients in the PHFE-WIC program of LA and Orange 

counties are being targeted for the CARE screening tool and Health and Behavior Workbook. 

PROFILE OF INNOVATIVE PROGRAM 

Services Provided. CARE includes a self-administered alcohol screening tool for prenatal 

women and an intervention using the Health and Behavior Workbook for those reporting postconception alcohol consumption. CARE also includes staff training on administering these tools 

and on prenatal alcohol use. All CARE materials are available in English and Spanish. 

Every month during the research project, all prenatal WIC women at the 12 CARE centers 

received the screening tool from a paraprofessional and completed it privately in the waiting 

room before their appointment. In 2003, the screening tool was incorporated into the WIC 

32 Information about the research project comes from Whaley and O’Connor (2003). 

33 Excerpt from the original project proposal, updated in personal communication from 

Shannon Whaley, November 2003. 
156

prenatal questionnaire that clients complete once every trimester at the centers. The tool 

contains five questions. The first two ask about drinking habits before the woman knew she was 

pregnant. It has been found that women are more likely to be honest about current consumption 

if asked first about drinking habits before pregnancy. The third question asks about binge 

episodes of three or more drinks on one occasion. Some women are more likely to report a binge 

episode, because it is something that they can say happened only once. It is often more difficult 

to admit drinking habitually. The fourth and fifth questions inquire about the quantity and 

frequency of current use. Either the nutritionist or a paraprofessional scores the screening tool. 

A nutritionist sees all prenatal women and reviews the screening tool. For women who were 

drinking but stopped after they found out they were pregnant, nutritionists congratulate them for 

stopping and remind them of the reasons to stop during pregnancy. Nutritionists review the 

Health and Behavior Workbook with those who are still drinking. 

The 11-page Health and Behavior Workbook takes about 10 minutes to review with a client. 

It provides facts about the problems an infant can have due to alcohol exposure in utero, and 

reminds the client that she can have a healthier baby if she stops drinking while pregnant. There 

is also information on risky circumstances that can lead women to drink (she is depressed, bored, 

or angry, smoking, or attending a celebration), and the means of coping with these situations (for 

example, taking a walk, talking to a friend, reading a magazine, grabbing a snack). The 

workbook also defines a standard drink (12 ounces of beer, 5 ounces of table wine, 1.5 ounces of 

hard liquor). Toward the end of the workbook, the woman sets a goal for the next month—either 

to stop drinking alcoholic beverages or to cut back by a specific amount. About 98 percent of 

clients say they will stop. For those who choose to cut back, the workbook provides strategies to 

reduce consumption (such as measuring drinks, watering down drinks, sipping drinks, eating 

food with a drink). At the end of the intervention, the client is given the workbook for review 

later. The nutritionist has a form to document reactions and the goal that was set. Clients also 

receive MOD’s “Alcohol Use & Pregnancy” brochures and fact sheets. 

The screening tool is administered again in the next trimester, and if the woman is still 

drinking, the Health and Behavior Workbook is readministered. However, 95 percent of women 

report that they have stopped drinking by the second time they complete the tool. 

As standard WIC protocol prior to CARE, if a woman is drinking three or more drinks three 

or more times a week, she completes a referral questionnaire inquiring further about drinking 

habits (including drinking first thing in the morning, drinking while driving). If there are more 

than three positive responses, the woman is to be referred to a physician or inpatient treatment. 

However, even without answering the referral questionnaire, clients consuming that much are 

referred elsewhere. Nutritionists use a book of substance abuse resources in the community to 

make referrals. 

Participation. PHFE-WIC conducted the research project in 12 intervention and 12 control 

sites in LA and Orange counties in 2000–2002. Sites were randomly assigned to intervention or 

control status. The 12 control sites did not use the screening tool or the Health and Behavior 

Workbook. With MOD funding, PHFE-WIC expanded the program to include all 55 LA and 

Orange County PHFE WIC clinics in 2003. These 55 clinics serve 35,000 prenatal women a 

month and have 600 staff. 
157

Coordination and Collaboration. PHFE-WIC and UCLA collaborated on the research 

project. 

ORGANIZATION AND MANAGEMENT 

Staff and Organizational Structure. The research project investigators are both from 

UCLA’s Fetal Alcohol Syndrome clinic, and one works part-time for PHFE-WIC. A Research 

Assistant, who also works part-time for PHFE-WIC, was funded by the NIAAA and MOD grants 

for her time on CARE. PHFE-WIC staff members implement the screening tool and/or the 

Health and Behavior Workbook. 

Training and Quality Assurance. In the research project, the investigators and research 

assistant developed and conducted the training. In general, WIC staff members were trained so 

that they understood the study purpose, protocols, and consent forms. Paraprofessionals were 

trained to score the screening. Nutritionists are the only WIC staff who provide counseling and 

administer the Health and Behavior Workbook to prenatal clients. They participated in ongoing 

training three or four times a year at PHFE-WIC’s central office. The same 25 to 30 WIC 

nutritionists attended all the two- to three-hour meetings. The initial training addressed the 

problem of Fetal Alcohol Syndrome, information about the research project, WIC staff’s role in 

the project, using the training manual, tracking clients, and using the research protocols. 

Subsequent trainings addressed the status of the project and participant questions or concerns. 

As agency-wide rollout began, the information specific to the research study was removed 

from the training manual. The manual details the use of the screening tool and the Health and 

Behavior Workbook. All 175 nutritionists received training in early August 2003 in a two-hour 

session that focused on three aspects of the rollout: (1) screening, (2) intervening, and 

(3) documenting. Nutritionists who missed the August training were trained in October 2003. 

Nutritionists then trained their staff to help with the screening. No further full-staff trainings are 

planned; instead, the 13 managers who oversee the 55 sites assess the project regularly.

Record-Keeping and Data Systems. A nutritionist rating form is sent in for each 

workbook completed. This form allows program officials to track the number of interventions 

and record information such as intervention duration, how much women are drinking, and client 

reactions to the intervention. Since the screening tool is incorporated into the WIC prenatal 

nutrition questionnaire that is distributed each trimester, it is kept on file. 

Funding. NIAAA funding was close to $1 million for the research project. Of that amount, 

$282,000 went to WIC, who served as UCLA’s subcontractor, and the other portion went to 

UCLA for designing the research and analyzing the data. PHFE-WIC received $58,577 in MOD 

funding to expand the intervention, not the research, to all PHFE-WIC sites in 2003. The grant 

paid for the Health and Behavior Workbook reproduction, integration of the screening tool into 

the WIC prenatal form, MOD “Alcohol Use & Pregnancy” brochures and fact sheets, and 

investigators’ labor. During the research phase, the NIAAA grant paid for the 10 minutes of 

staff time for every intervention. With the expansion, WIC is assuming that cost, because the 

number of women per center per month who need the intervention is fairly small. The 
158

investigators have submitted additional grant proposals to NIAAA for evaluation of the 

expansion and longitudinal followup. 

ASSESSMENT AND LESSONS LEARNED 

Program Strengths. An important strength of the program is that it was rigorously 

evaluated and outcomes were positive. In the research study, UCLA targeted a sample of 

300 women in the intervention sites to follow during their pregnancy. Half were in the six 

clinics that provided the screening tool and the Health and Behavior Workbook, and half were in 

the six that provided the screening tool and strong verbal messages to avoid alcohol during 

pregnancy. In both groups, most women stopped drinking. However, only 23 percent of the 

women who were administered the workbook continued to drink, compared to 50 percent in the 

group that received the standard verbal warning. Further, as of the third trimester visit, most 

women in the intervention group had maintained their abstinence, whereas most women who 

received only the standard verbal message had not. Thus, any message helped, but the Health 

and Behavior Workbook seems to have had a greater impact both immediately and throughout 

pregnancy. 

Screening outcomes were also compared between the 12 intervention sites and the 

12 control sites. Investigators concluded that the self-administered screening tool increased the 

reporting of prenatal alcohol use, which is an essential first step in reducing or eliminating it. 

Specifically, in 1999, before the CARE initiative, about 5 percent of all pregnant women in 

PHFE-WIC were reporting alcohol use based on the verbal standard of care. With the new 

screening method, the rate was closer to 15 percent in the 12 intervention sites, compared to 

about 5 percent at the 12 control sites. If the investigators receive additional NIAAA funding, 

they will be able to follow up with the sample members when the children are 3 or 3.5 years old 

and to evaluate long-term alcohol use. 

Key Challenges. The investigators suspect that CARE may be missing mothers who are 

seriously addicted. The project was a research study that involved consent forms, which those 

with severe problems may not have signed. In general, the Health and Behavior Workbook is 

not going to work well with addicted women, who need intensive assistance. Unfortunately, 

there are not many community resources for treating alcohol abuse in pregnant women. 

It is important for agencies that might implement such an initiative to determine a strategy 

for motivating staff to support the effort. Often, special projects entail more work for staff. 

Even though such projects are consistent with “core” WIC services, they can increase the staff 

workload. This project did not mandate that WIC staff work extra hours, but it did require that 

they counsel pregnant women more thoroughly about alcohol use. They also needed to keep 

track of paperwork that was specifically for the evaluation. Therefore, incentives such as clinic 

pizza parties and movie tickets for nutritionists who intervened with the most women were 

effective and appreciated. Also, program-wide recognition of the 12 sites involved in the 

research project was well received. 

Lessons Learned. Program officials believe that this low-cost, straightforward initiative 

can be replicated in other agencies, particularly at the state level or in large agencies. All that is 
159

necessary to implement the initiative is to incorporate the screening tool into prenatal forms, 

make the Health and Behavior Workbook available, and train staff to use these tools, which takes 

just a few hours. 

CONTACT INFORMATION 

Shannon Whaley, PhD 

WIC Child Development Specialist 

Public Health Foundation Enterprises Management Solutions – WIC Program 

12781 Schabarum Avenue 

Irwindale, CA 91706 

Phone: 626-856-6650 x309 

Fax: 626-851-0231

E-mail: Shannon@phfewic.org 

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C. STAFF TRAINING: IMPROVING METHODS, NUTRITION KNOWLEDGE, AND 

CULTURAL SENSITIVITY 

States are increasingly trying to improve the quality of nutrition services by providing 

specialized training to local staff. Although many states have annual conferences and all provide 

regular updates on policy changes, some states have developed additional training sessions, often 

lasting a day or more, on specific topics. The types of training initiatives they have developed 

are quite diverse, as illustrated below. In some instances, states have used “train-the-trainer” or 

videoconferencing approaches to reduce the costs of training. Sometimes training materials are 

adapted from other programs or developed by an outside consultant, while other projects develop 

these resources internally. Nutrition education committees on which state and local staff work 

together were important arenas for developing and/or testing new curricula in several of the state 

initiatives described here. 

Many of the state initiatives already discussed include extensive training, such as the Texas 

Peer Counselor train-the-trainer sessions and the Nutrition Educators Conference in Oklahoma. 

This section discusses three state efforts in which training is the major activity. First, we discuss 

a “train-the-trainer” program on facilitated group discussion in Michigan, a method for achieving 

behavior change that was not previously used in the state. Other states have also emphasized 

facilitated group discussion in their staff training. However, the Michigan program stands out 

because it may be the only one with a train-the-trainer approach. Its materials are also very 

readable, and could easily be adopted by others.34 Second, we discuss a content-focused 

California program to provide training, reference materials, and technical assistance to WIC 

registered dieticians so that they can keep up with changes in available infant formulas and other 

pediatric nutrition issues. Finally, we present a Wisconsin program that trains bilingual support 

staff to provide nutrition education and sometimes certification for non-English-speaking clients, 

with the goal of getting key nutrition messages to clients more effectively by reducing language 

barriers. 

34 Initiatives in other states that have used facilitated group discussion include the FIT WIC 

programs. A manual on facilitated group discussion developed by researchers at Pennsylvania 

State University is available on the FIT WIC Website: www.nal.usda.gov/wicworks/Sharing_ 

Center/statedev_FIT.html. 

163

LEARN TOGETHER APPROACH: MICHIGAN35

OVERVIEW 

Location: Michigan, statewide 

Start Date: Planning began in 2000; two rounds of training were held in 2001, with a third 

round in 2003. 

Target Population: Training program for WIC staff, for use with adult WIC clients or parents 

of WIC infants and children. 

Purpose: To provide WIC staff with tools needed to conduct nutrition education sessions for 

adults through facilitated group discussions, which are seen as more likely to be successful in 

reaching adult learners and producing behavior changes. 

Services: A “train-the-trainer” curriculum in nutrition education through facilitated group 

discussion was developed, and local WIC leaders were trained. Nutrition education modules 

have been developed at the local level, using a format taught in the training. The training 

curriculum and sample nutrition education modules are available on the Web. 

Funding: The curriculum development and training were funded largely by the state WIC 

program and through registration fees paid by local WIC agencies. The train-the-trainer format 

was used to keep costs low. 

Why Program Was Chosen: The use of a train-the-trainer approach for teaching about 

facilitated group discussion is innovative. In addition, the training materials and lesson plans are 

well written and widely applicable. 

Key Challenges: After the first session, staff needed to shorten the training to enable more staff 

to attend. Because of limited travel funding, they also needed to offer it in various locations.

 35 Telephone interview, May 14, 2003. 
164

BACKGROUND 

State WIC Program Background. Michigan is in the U.S. Department of Agriculture 

(USDA) Midwestern region. Its 2001 population was just under 10 million. Michigan had fewer 

Hispanics (3.3 percent) and a lower 1999 poverty rate (10.4 percent) than the nation as a whole 

(12.5 percent Hispanic and 12.4 percent in poverty), but it is similar to the nation in median 

income (from Census QuickFacts). The Michigan WIC program served 215,989 people a month 

in fiscal year (FY) 2002, which made it the ninth-largest program in the nation (see 

[www.fns.usda.gov/pd/wifypart.htm]). There are 50 local WIC agencies, including some tribal 

agencies; most are county or district (multi-county) health departments, but some are health care 

providers or community-based organizations. The local WIC agencies range greatly in size; the 

Detroit area is home to the largest program (operated by the Detroit City Health Department—

serving nearly 70,000 a year) and several other sizable programs. However, some specialized 

medical centers and rural health departments have very small programs (see 

www.mdch.state.mi.us/wicenroll/state_ag.asp). 

Program History and Objectives. The idea for the program arose in 2000, when the state 

was making plans for revitalizing nutrition services. The use of facilitated group discussion was 

the approach they decided to pursue. Based on what state staff saw during management 

evaluations of local agencies, they felt that nutrition education in Michigan was fairly stale—

most of it was in a lecture format, which was not really suited to the needs of the adult learner. 

Two state agency staff had attended a conference where Susanne Gregory gave a presentation. 

The state WIC agency decided to hire her to develop a training curriculum and conduct the initial 

training. Susanne Gregory is an expert in facilitated group discussion who had provided training 

for WIC staff in several states. However, she had not used a “train the trainer” approach before 

she worked on the Learn Together Approach with Michigan staff. 

Target Population. The training is intended for WIC staff who provide nutrition education 

or for their supervisors. They in turn are expected to train any of their staff who provide 

nutrition education but could not attend the state-sponsored training. WIC participants are the 

ultimate target population, as the goal is to improve nutrition education for adult WIC 

participants and parents of child participants. As discussed further below, the training was also 

designed to be used in training Michigan State University Cooperative Extension (MSU-E) staff 

who provide nutrition education to low-income families. 

PROFILE OF INNOVATIVE PROGRAM 

Development of Training and Materials. In fall 2000, state staff worked with Suzanne 

Gregory to develop a proposal for the program, including a contract with Suzanne to develop the 

training materials and conduct the initial training. They then submitted the proposal to 

management at the Department of Community Health. One reason it was approved was that this 

type of training is less expensive than having the state train all staff who provide nutrition 

education. The cost for the contract was only about $6,000. (Most likely, the low cost partly 

reflects the fact that Ms. Gregory had materials from elsewhere to build upon.) Ms. Gregory 

drafted the training materials, and the state staff reviewed drafts and provided comments. The 

materials were completed in the spring of 2001. 
165

Trainings Held. The first training, in June 2001, was led by Suzanne Gregory. It was held 

in Lansing, the state capital, near the center of the state. The session was limited to WIC and 

MSU-E staff. Attendees had to fill out an application describing their experience as nutrition 

educators. Local WIC staff also needed a signed statement from their WIC Coordinator saying 

she would support the attendee in implementing the Learn Together Approach. In addition to 

local WIC staff, several state-level WIC staff (including those who would run future training) 

attended the initial training. About five MSU-E staff attended. 

A second round of training sessions, taught by state WIC staff, was held in October 2001, in 

four different regions of the state, in an effort to reach more WIC agencies. Michigan WIC 

opened the training to staff who worked in programs other than WIC and MSU-E (see more 

below). They no longer required the WIC Coordinator to sign off on the applications. 

A third training was held in Lansing in April 2003. The major goal was to reach WIC staff 

who had joined WIC since the earlier training. 

The initial training lasted two days, but the training was then cut to one day. Training 

sessions were limited to 24 persons, so that all could participate fully. Over 100 WIC staff have 

been trained across all the sessions.

Training Curriculum and Sample Nutrition Education Modules. The Learn Together 

Approach is a train-the-trainer model of training in facilitated group discussion. Training was 

very hands-on. After presenting the idea of facilitated group discussion, the trainers led a sample 

discussion to model the approach (with some of the trainees playing the role of clients). 

Next, trainees developed a nutrition education module for a facilitated group discussion (at 

the two-day training; they used existing modules at the one-day training). They were trained to 

use a template for developing a nutrition education discussion module around a specific topic, 

such as introducing new foods to picky eaters. A key idea was that, in a particular discussion, 

the leader should leave people with three ideas they could apply in their daily lives, and no more. 

The discussion should start with an icebreaker to get everyone talking. The leader should have 

prepared three or four open-ended questions for discussion on the topics to be covered. The 

module also should include a question to use at the end, asking all participants to sum up what 

they have learned or what new behavior they are going to try. In addition to training staff on 

developing these modules, the training also covered techniques for correcting incorrect 

information and moving the discussion along. 

Trainees then split into groups of about five. One led the discussion, one observed and 

evaluated the leader, and the rest acted the part of participants. These “practice sessions” were 

repeated several times, so each trainee could experience all three roles. (Staff reported the 

“clients” were often hard on the discussion leaders—probably more than real WIC clients would 

be.) 

Last, the training moved to how to set up a session to train others at their local agencies in 

facilitated group discussion; this covered the materials needed and key steps; the training manual 

provides step-by-step instructions on what to do. The one-day version of the training covered 

this in less detail than the two-day version. 
166

 

All trainees received a comprehensive training manual and sample forms and materials to 

use in training local staff and in planning facilitated group discussions. The Michigan WIC 

program has also posted these materials on the WIC Works Website. Responsibility for 

developing nutrition education modules was left to the local WIC agencies, but after the first 

training, the state staff gathered some of the best ones to post on the Web and use in later training 

sessions. 

Nutrition education modules came from various sources. Some were adapted from materials 

that previously had been presented in a lecture format. In 2002, Michigan WIC sponsored a 

statewide training on the feeding relationship ideas of Ellyn Satter.36 State staff incorporated 

some of her infant-feeding ideas into sample modules used in the 2003 Learn Together Approach 

training. Another module, on picky eaters, uses as a “hook” asking WIC clients to try dried 

seaweed—a strange food to most of them (and they are not told in advance what it is). Clients 

then use this experience to consider how their children might feel when asked to try new foods 

and to share strategies that are successful. 

Training Logistics. The first training was conducted by Suzanne Gregory, and the later 

training was conducted by the three WIC agency staff (two nutritionists and a psychologist) who 

had worked most closely with her on developing the materials. All three participated in the first 

regional training, and then two led the later training. It is important to have at least two people 

so that it is possible to split into smaller groups. 

Trainers collected evaluations at each training and made changes in response—one key 

change was cutting the training from two days to one day, because it was difficult for WIC staff 

to get away for two days. In addition, it was difficult for local agencies to pay for overnight 

accommodations. Local agencies paid a registration fee for their staff to attend the training (see 

discussion of funding). 

Collaboration with Other Agencies. The state WIC agency works often with MSU-E on 

nutrition education training. MSU-E was included in this initiative from the start and sent some 

of their staff to each training. MSU-E contributed one-third of the funding for the first training. 

When the four regional training sessions were conducted in fall 2001, the state WIC office 

did outreach to local health departments, Head Start, and Indian Tribal Organization (ITO) WIC 

agencies in the state. WIC and MSU-E staff had priority for the training slots, but staff from 

some of these other agencies participated in the training. 

Publicity for the Training. The Michigan Department of Community Health regularly 

contracts with the Michigan Public Health Institute, and used them for this project to create the 

flyers, send out mailings, and handle conference arrangements for each training, including 

36 Ellyn Satter is a nutritionist known for providing advice on developing positive feeding 

relationships between parents and their infants and toddlers. Her books include, Child of Mine: 

Feeding with Love and Good Sense (2000). 
167

 

lodging (for the first training), registration, and setup of the meeting rooms. The training was 

also publicized through the Nursing Forum, which is part of the state Department of Community 

Health; members of this group publish a newsletter that is sent to their colleagues. The state’s 

WIC Nutrition Education Working Group, on which state and local WIC staff are represented, 

helped to get the word out. MSU-E sent information about the training to their staff. 

One important way to attract participation in the training was to obtain continuing education 

credits. State WIC staff found this to be challenging for the first training, because the process 

most frequently used was to submit through the Michigan Nurses Association (MNA), which 

requires significant lead time. They obtained continuing education credits through one of the 

other categories of allowable credits by the Michigan Board of Nursing for the first training. 

They received the credits through MNA for subsequent training.

ORGANIZATION AND MANAGEMENT 

Staff and Organizational Structure. As noted, state WIC staff worked with an outside 

consultant to develop the training, and with another consultant to handle outreach and logistics. 

Four staff members at the state agency were initially involved with the project, and three worked 

on the regional training sessions. Two of the four conducted the 2003 training; the others have 

left the agency. 

Record Keeping and Quality Control. One issue is how well the state WIC agency can 

follow up to learn whether the training is indeed being implemented at the local level. One 

important change that they made was to add to their management information system a code for 

“facilitated group discussion” as a type of nutrition education contact. The state staff can track the 

code in the computer to find out whether an agency is using facilitated group discussion either alone 

or in combination with some lecture-style nutrition education. However, this would require creating 

an “ad hoc” report, which so far has not been done. 

In December 2001, they conducted a survey to follow up on the training, and found that 

28 of 50 agencies were using facilitated group discussion, at least to some extent. Local agencies 

also report on nutrition education in their annual “Nutrition Services Plan.” State staff monitor 

the plan’s implementation during management evaluations, which include observations of 

nutrition education in the agency. In agencies’ Nutrition Education Plans for FY 2003, 

54 percent (27 of 50 agencies) indicated they were using facilitated group discussion. In 

addition, 64 percent (32 of 50 agencies) indicated they were using a combination of lectures and 

facilitated group discussion.37 Further, the WIC Nutrition Education Workgroup meets every 

two months—it includes state and local staff from all over the state—and members report on 

what is happening at the local level. The state agency tends to use them as a “focus group.” 

The state agency has not systematically tracked whether participants have trained others in 

their local agencies in the Learn Together Approach, and has not had the resources to collect this 

37 Multiple responses were allowed concerning modes of nutrition education—it is not clear 

how much these two categories overlapped. 
168

information. It would be interesting to know if the train-the-trainer aspect of the training proved 

useful. 

Funding. The training was funded from state WIC Nutrition Services and Administration 

(NSA) funds and registration fees. In addition, MSU-E contributed funding for the first training. 

The major costs included the cost of Susanne Gregory’s contract, the cost of the contract with the 

Michigan Public Health Institute, the cost of the time of the four state agency staff involved, and 

costs for printing of materials. There was also a cost for applying for continuing education units. 

The state WIC agency also paid for some of the travel and lodging for the trainings, but these 

costs were covered mostly by local agencies (and were not much of an issue except for the June 

2001 training, the only two-day training). The registration fee was $25, which paid for the 

materials; it was covered by the local agencies for most local WIC staff, and by MSU-E for their 

staff. Overall, the costs for developing the materials and conducting the five trainings were less 

than $20,000 (not counting the labor costs for state agency staff). 

The state WIC agency viewed the costs as very reasonable when compared to the cost of 

having a central training for all state WIC staff who do nutrition education. Of course, state 

costs do not include costs incurred by local agencies to send their staff to the state-sponsored 

trainings or to do local training, but those would probably not be too large. 

ASSESSMENT AND LESSONS LEARNED 

Program Strengths. The Learn Together Approach seems a useful method for teaching 

how to lead facilitated group discussions at reasonable cost. In training evaluations, participants 

responded positively. The state staff observed that trainees seemed very excited and motivated. 

Some staff were uncomfortable with the approach at first, because they felt they should be conveying 

more information, or because they feared losing control of the group or having people leave with 

erroneous ideas. During the training, they tried to show trainees multiple approaches to 

acknowledging client contributions but still correcting any incorrect beliefs. 

Our state contact felt the major strengths of this training are that it helps people to realize 

that: 

• Nutrition education can be fun 

• Lectures are not a good approach to adult learning 

• Clients have varied experiences and can learn best when they can relate the content to 

their own experiences 

She felt the approach was “freeing” for many. They were relieved to hear it is enough to 

share a few good ideas and have clients make a commitment to a specific behavior change. 

Another strength of this training is the materials available on the Web are comprehensive 

and easy to read, so that they could be readily applied elsewhere. 
169

Key Challenges. In implementing the Learn Together trainings, one challenge staff faced 

was making the training accessible to local staff, by choosing the appropriate locations and 

length of training. Some other areas in which the program might be strengthened include 

monitoring the extent to which trainees conduct local training (to determine whether the trainthe-trainer focus is indeed useful), and developing methods for sharing training modules 

developed at the local level with other local agencies. 

Lessons Learned. The Learn Together Approach to training the trainers in facilitated group 

discussion seems widely useful, particularly in large states or other areas where funding 

constraints make it infeasible to train all local WIC nutrition educators. The materials could be 

adapted by other agencies with few or no changes. 

Michigan staff recommended to other states that would be interested in such a program that 

they work with a professional experienced in the field, so they can see the approach modeled by 

someone with experience. It is also important to realize that the approach is not suited to all 

topics. In particular, it is not appropriate for anything with a “psychomotor” component, such as 

teaching nursing mothers how the baby should latch on to the breast. However, many of the 

skills involved can also be used in one-on-one counseling—for example, asking open-ended 

questions and affirming the client’s experience. 

The WIC programs in many states are moving to increased use of facilitated group 

discussion techniques for nutrition education. It would be useful to conduct further research to 

determine whether these approaches are more likely to produce increased knowledge and 

behavioral change than traditional lecture-based classes. 

CONTACT INFORMATION: 

Mary VandenBosch, Nurse Consultant 

MI Dept. of Community Health, WIC Division 

2150 Apollo Drive 

Lansing, MI 48906 

Phone: 517-335-9694 

E-mail: VandeBoschM@michigan.gov 

To obtain materials: www.nal.usda.gov/wicworks/Sharing_Center/statedev_MI.html 

171

WIC RD: ADJUNCT TO PEDIATRIC HEALTH CARE 

PEDIATRIC NUTRITION TRAINING AND SUPPORT FOR WIC RDs38

CALIFORNIA 

OVERVIEW 

Location: Statewide 

Start Date: 2001 

Target Population: WIC Registered Dietitians (RDs), and by extension, WIC nutrition 

assistants, other program staff members, and the clients they serve. 

Purpose: To provide formula and pediatric nutrition training and technical assistance to WIC 

RDs and other health professionals. In turn, clients are given accurate information on infant 

feeding, as a means to decrease symptoms of infant formula intolerance and allay parental 

anxiety.

Services: Intensive formula and pediatric nutrition training, Formula Guidebook (professional 

educational material), and technical assistance over the telephone regarding complex pediatric 

nutrition matters. 

Funding: State Nutrition Services and Administration (NSA) funding covers program costs, but 

savings from the program in reduced use of non-contract formulas outweigh the costs. 

Why Program Was Chosen: Although WIC promotes breast-feeding, there is a state staff 

position dedicated to providing training and support to local staff on infant formula and pediatric 

nutrition issues. State officials recognize that although breast-feeding is best, most WIC mothers 

choose formula, so staff must be able to determine which type of formula to give. 

Key Challenges: Keeping the manual and training up-to-date is demanding, because of frequent 

changes in the formulas available and in knowledge about pediatric nutrition. Another challenge 

is finding the resources and staff time to regularly train new staff and retrain other staff. 

 38 Telephone interviews, May 1 and May 6, 2003. 
172

BACKGROUND 

State Characteristics. California is the most populous state, with 34 million residents. In 

2000, about 47 percent of the population was white, 32 percent Hispanic, 11 percent Asian, and 

7 percent African American. Almost 40 percent speak a language other than English in the 

home. California’s poverty rate is higher than the U.S. average, 14.2 percent versus 

12.4 percent. 

WIC Program Background. California has the largest state WIC program in the country, 

with 81 local agencies serving 1.3 million participants at 660 local clinics. About 10 percent of 

participants are pregnant women, 7 percent breast-feeding women, 6 percent postpartum nonbreast-feeding women, 23 percent infants, and 54 percent children. The WIC caseload is 

diverse: 73 percent of participants are Latino, 12 percent white, 7 percent African American, and 

6 percent Asian. California WIC is proud that diverse WIC staff members interact effectively 

with and assist the WIC population. Staff provide effective communication and understand 

different cultures, thereby serving as a “gateway” to other preventive health programs and health 

care. 

Program History and Objectives. The emphasis of WIC, the American Academy of 

Pediatrics, and the medical community has been on promoting breast-feeding. The reality is that 

many WIC mothers use formula or combination feedings (both formula and breast milk). 

Specifically, in September 2003, only 10.6 percent of California’s 293,014 WIC infants were 

exclusively breast-fed. Many mothers initiate breast-feeding in the first one to two weeks after 

birth, but by two to three months of age, more than 90 percent of California infants are on 

formula, either exclusively or in combination with breast-feeding. The short breast-feeding 

durations are due, in part, to the availability of formula in hospitals, advertising and promotion 

by formula companies, and the ease of using formula for women returning to work or school. 

In addition, the Integrated Statewide Information System (ISIS) provides data indicating that 

the WIC population is becoming more complex in its ethnic, cultural, social, and health care 

needs. California WIC has seen an increase in pediatric morbidity and rates of medical 

conditions that require special formula or special feeding practices. At the same time, formula 

choices are becoming more complex. Issues with formula include reformulation, changes in can 

size, allergies and other medical conditions, types (cow, soy), nutritional quality, and new 

additives. When changes in these areas occurred before 2001, it took several months to 

communicate the changes to the 660 WIC clinics throughout the state. 

State WIC officials recognized that local WIC agencies struggled in addressing infant 

formula and feeding, especially since no specific resources were available from the state. 

Officials also recognized that WIC would benefit from a cost standpoint if more formula-fed 

infants consumed a contract formula. Therefore, WIC staff members needed the skills, 

knowledge, and resources to counsel caregivers on formula use and recommend the appropriate 

formula for an infant. A Pediatric Nutrition Specialist with neonatal intensive care unit (NICU) 

experience was selected to address these issues, update the state WIC policy on formula, and 

provide training and technical support to local agencies and clinics. 

It is difficult for practitioners to know how to treat all cases and stay abreast of current 

information. Therefore, the Pediatric Nutrition Specialist applied an RD training and support 
173

model used at the University of Washington at Seattle, where a Maternal and Child Health grant 

funded one-week training sessions for nutritionists working in pediatric environments. After this 

training, ongoing support was provided through a closed listserv where nutritionists could post 

questions about cases and policy issues. The university provided answers and references that 

nutritionists could use to gain additional information and expand their pediatric practice. 

Target Population. The primary target population for the training and technical assistance 

is WIC RDs. Other WIC staff members, hospital RDs, and other medical providers are 

sometimes involved. In turn, these practitioners have the knowledge, skills, and resources to 

improve service delivery to an increasingly complex WIC population. 

PROFILE OF INNOVATIVE PROGRAM 

Services Provided. The Pediatric Nutrition Specialist conducts staff training on infant 

formulas and pediatric nutrition, provides technical assistance to local staff on formulas and 

pediatric nutrition, and updates the Formula Guidebook. (All clinics have the Formula 

Guidebook, which contains information from the American Academy of Pediatrics as well as 

nutrition information on various formulas.) If this book cannot assist the local staff members, 

they call the state WIC branch for technical assistance from the Pediatric Nutrition Specialist or 

another RD. 

At the request of a local clinic or agency, the Pediatric Nutrition Specialist travels to the 

local clinic or agency to conduct formula training for WIC RDs, hospital RDs, or other 

professionals with a four-year degree in nutrition. Other pediatric medical providers are often 

invited, as are some WIC Nutrition Assistants and CPAs. Local agency RDs have also taken on 

the direct trainer role for their respective agencies. This requires less travel time for the Pediatric 

Nutrition Specialist, who provides technical assistance to the local trainer. In particular, the 

Pediatric Nutrition Specialist reviews trainer educational materials, examines formula and 

pediatric nutrition training presentation materials, and discusses education and treatment 

strategies related to difficult cases that are used for case studies. 

The five- to six-hour formula training, developed by the Pediatric Nutrition Specialist, 

includes the following topics: WIC’s goals and desired outcomes, public health principles, tools 

available to RDs, formula choices, the nutritional value of formula, pre-term babies and their 

nutritional needs, feeding issues and problems (such as reflux or constipation), cow- versus soybased formulas, contract versus non-contract formulas, allergies and hypoallergenic formulas, 

the Formula Guidebook, the California WIC formula policy, health plans that will or will not 

cover formula, how to work with health care providers, WIC screening forms, and case studies 

for a group activity. Once an RD or agency director is trained, they are to pass the knowledge 

along to other staff in their organization. The training is not mandatory, but it is one of the few 

RD support systems that California WIC has to offer. 

California WIC plans to extend RD education through teleconferencing, which can easily be 

accessed by local agencies. The teleconferences will discuss and review complicated case 

studies, a natural extension of the technical assistance already provided by telephone. 
174

Participation. About 90 percent of local agencies have staff that have participated in the 

formula training.

Coordination and Collaboration. When the Pediatric Nutrition Specialist goes to local 

agencies or clinics to conduct trainings, she invites pediatric medical providers and RDs from 

area hospitals to attend. In this way, participants can learn about other services and resources in 

the community and identify opportunities for collaboration. 

Publicity and Outreach Efforts. A letter is distributed to local agencies and clinics about 

formula changes and information. The availability of formula trainings is announced at the 

annual WIC conference and during site audits, and is listed in WIC’s training manual. 

ORGANIZATION AND MANAGEMENT 

Staff and Organizational Structure. The Pediatric Nutrition Specialist, the primary 

contact for the initiative, conducts the training and oversees technical assistance. Another 

specialist works with her directly. Three other RDs in the state WIC branch provide technical 

assistance to local agencies that call with questions or concerns. These three spend about 

25 percent of their time on infant-feeding questions related to formula. 

Record Keeping and Data Systems. California WIC devised two communication forms, to 

be completed by WIC RDs, to share WIC nutrition screening results with medical providers 

prescribing formula for medical conditions. Both the “Infant Screening and Medical 

Justification Form for Formulas for Medical Conditions” and the “Child Screening and Medical 

Justification Form for Formulas for Medical Conditions” include information on a client’s 

feeding history, feeding practices or behaviors, medical history, and screening results, as well as 

the WIC RD’s recommendation. The form is either given to the parent or caregiver to share with 

the medical provider or faxed directly to the medical provider. The medical provider completes 

the bottom portion, which describes the medical diagnosis, formula recommendation, 

recommended duration of formula, and feeding instructions. The back contains an abbreviated 

version of WIC policy regarding contract formula and formula for medical conditions. 

Funding. The main costs for this initiative are the Pediatric Nutrition Specialist’s salary, 

telephone calls, travel (about two trips a month), and the development, reproduction, and 

distribution costs associated with the Formula Guidebook. These expenses are covered in the 

general WIC budget. 

ASSESSMENT AND LESSONS LEARNED 

Program Strengths. The state is meeting the training needs of RDs through intensive 

training in formula and pediatric nutrition. The attitude before was that RDs are professionals 

who should take responsibility for reviewing the latest research and gaining knowledge on their 

own, but the training evaluations revealed that RDs need and want ongoing training. With 

increased knowledge, support, and resources, RDs have more confidence. In turn, these RDs are 

providing better customer service for mothers who choose to use formula. These mothers, as 

well as fathers, partners, and other caregivers, are getting assistance early in the feeding process 
175

so they can successfully feed their infant, avoid future eating disorders or problems, and parent 

positively and effectively. 

Furthermore, California’s rate of non-contract formula use has decreased. In January 2002, 

4.7 percent of formula used in California WIC was non-contract. In October 2003, that figure 

was down to 1.7 percent. This reduction in non-contract formula use may be, in part, due to the 

program. RDs and local agencies have more support, and thus may be more convincing with 

participants in recommending contract formula. According to the Pediatric Nutrition Specialist, 

“the savings obtained from inappropriate formula choices far outweigh the costs for technical 

assistance.” Specifically, California WIC estimates $250,000 in monthly savings as a result of 

decreased use of non-contract formula. (This change cannot be attributed definitively to the 

training and the Formula Guidebook, but they seem likely to have played a part.) 

Key Challenges. The project is evolving, as evidenced by the interest of local agencies in 

doing their own training, with technical support. The challenge is keeping up with future needs 

using an efficient educational format. In addition, budget constraints that limit staffing and time 

pose a challenge for program officials, as does the high local staff turnover, which results in an 

ongoing need for training. 

Lessons Learned. The Pediatric Nutrition Specialist believes that if California, with the 

largest and one of the most complex WIC programs in the country, can put this kind of support 

system into place, other states can as well. California’s program started out as a single staff 

position and has expanded to include a few additional staff giving support to the RDs in the state. 

Smaller state agencies may not be able to afford this level of staff, but may perhaps form 

consortia with other states (particularly if they join together on infant formula contracts). The 

apparent cost savings achieved in California suggests that such training is cost-effective. 

Other states may not be able to implement this type of training, but they can take other steps 

to help their RDs keep up to date. Related strategies would be to encourage RDs to stay abreast 

of current information, whether through state or national trainings, classes, listservs, or other 

media. WIC branches could identify ways of sending RDs to national training for practitioners 

interested in pediatric nutrition, and give RDs time for professional development activities. 

CONTACT INFORMATION 

Michele van Eyken, MPH, RD 

Acting Chief of Nutrition Programs 

or 

Judy Sundquist, MPH, RD 

Pediatric Nutrition Specialist 

California WIC Branch 

3901 Lennane Dr. 

Sacramento, CA 95834 

Phone: 916-928-8615 

Fax: 916-928-0612

E-mail: mvaneyke@dhs.ca.gov 

 jsundqui@dhs.ca.gov 

177

BILINGUAL TRAINING PROGRAM39

WISCONSIN 

OVERVIEW 

Location: Statewide 

Start Date: 2001 

Target Population: Bilingual Hmong and Hispanic WIC staff and, by extension, the Hmong 

and Hispanic WIC clients they serve. 

Purpose: To provide more effective and culturally appropriate nutrition services to nonEnglish-speaking Hmong and Hispanic WIC clients. 

Services: Bilingual Hmong and Hispanic WIC staff receive training to become bilingual 

translators, certifiers, or educators for at-risk Hmong and Hispanic clients, and bilingual 

translators for high-risk Hmong and Hispanic clients. 

Funding: In fiscal year (FY) 2003, the program received $43,000 in funding: $39,000 from the 

State WIC Program and $4,000 from the Wausau Health Foundation. 

Why Program Was Chosen: This program is innovative in that it trains bilingual staff 

members, or “bilinguals,” to provide nutrition education and certification services to WIC 

participants who are of the same culture yet do not speak English. The training curriculum and 

certification program can serve as a model for other programs trying to address the cultural needs 

of a diverse clientele. 

Key Challenges: Staff have worked hard to gain acceptance for the bilingual paraprofessionals, 

in the face of the attitude that only professionals should provide nutrition education. In some 

settings, the need for bilingual professionals who can train and monitor the paraprofessionals 

could be a challenge. 

 39 Telephone interview, April 17, 2003. 
178

BACKGROUND 

State Characteristics. Based on a 2001 estimate, the population of Wisconsin is more than 

5 million. About 9 percent live below poverty, compared to the national average of 12 percent. 

In 2000, about 87 percent of the population was white, 6 percent black, 4 percent Hispanic, and 

2 percent Asian. Most of the Asian community in Wisconsin is Hmong, with 0.63 percent of the 

state’s total population Hmong (University of Wisconsin Extension and Applied Population 

Laboratory 2002). Wisconsin’s Hmong population increased by 106 percent from 1990 to 2000. 

WIC Program Background. The Wisconsin WIC Program serves more than 108,000 

clients each month in 69 projects (the Wisconsin name for local WIC agencies) in 5 regions. 

About 24 percent of clients are infants, 52 percent children, 11 percent pregnant women, 

7 percent non-breast-feeding postpartum women, and 5 percent breast-feeding women. About 

4.5 percent of participants are Asian, and 18.5 percent are Hispanic. The Milwaukee/Southeast 

Region has about one-third of the state’s total caseload and has the largest Hispanic population 

of the five regions. The Northeast Region, particularly Brown County (Green Bay area) has 

many Hispanic clients as well, as does the Southern Region (Madison, Rock County, and 

Walworth County). The Hmong participants are concentrated in four of the five regions. 

The program provides basic WIC services, and the Farmers’ Market Nutrition Program is 

implemented in most counties. Most of the Competent Professional Authorities (CPAs) in 

Wisconsin are nutritionists and dietitians, but there are also some Dietetic Technicians (DTRs) 

and nurses. The trainees involved in the Bilingual Training Program are usually program 

support staff or health screeners, not professional or paraprofessional staff members. 

Program History and Objectives. State and local program officials recognized that 

bilingual nutrition education was necessary to meet the needs of the Hmong and Hispanic 

participants in the state. When a non-English-speaking client received nutrition education, a 

nutritionist and an interpreter were both needed, which was costly and not very effective. The 

nutritionist and the client could not communicate directly, and thus lost the personal interaction 

so critical in counseling. Several years ago, in a pilot project to promote breast-feeding among 

the Hmong population, WIC trained bilingual Hmong women who had breast-fed to become peer 

counselors. This program was very well received, and breast-feeding rates increased as mothers 

received support from women of the same culture. Therefore, state and local program officials 

decided that bilingual Hmong and Hispanic WIC staff, who were primarily in program support 

and health screener roles, would be trained to provide bilingual nutrition services. 

Two local WIC directors developed and started bilingual nutrition education training in 

2001. They worked closely with an advisory board of Central Office State WIC staff and 

Regional Nutritionists, which was responsible for providing insight into project development, 

curriculum design, planning, and implementation. The goal of the program is to provide quality 

and effective nutrition services that are culturally appropriate. Program officials believe that a 

client is more likely to make improvements in diet by working with someone of the same culture. 

Also, training bilingual staff could be more cost-effective than hiring interpreters to translate 

between English-speaking nutritionists and non-English-speaking participants. 

Target Population. Bilingual Hmong and Hispanic WIC staff can participate in the 

Bilingual Training Program. Most participants are WIC program support staff or health 
179

 

screeners. The Hmong and Hispanic clients that these bilinguals serve receive more effective 

and culturally appropriate nutrition services as a result of the training.

PROFILE OF INNOVATIVE PROGRAM 

Services Provided. The Bilingual Training Program is provided for bilingual Hmong and 

Hispanic staff in Wisconsin. Until 2003, participants were primarily program support staff and 

health screeners from WIC clinics, all of whom have a minimum of a high school education. To 

enroll in the training, local WIC projects submit a registration application form with the name(s) 

of employee(s) who are either Hmong or Hispanic and are interested in participating in the 

training. In 2003, as part of the Wausau Health Foundation grant, the training was expanded to 

include Hmong and Hispanic staff from local health departments, Head Start, Family Resource 

Centers, Community Action Agencies, and day care providers. 

A Hmong Registered Dietitian (RD) conducts the training for Hmong students, and a 

Hispanic RD trains the Hispanic students. Both trainers are, or have been, local WIC 

Nutritionists. The two trainings are held concurrently every 18 months. The training lasts 8 

days, and sessions are held in a central location so that all staff members can attend at once. In 

2001, the training was held in three 2-day sessions and two 1-day sessions. In 2002 and 2003, 

there were four 2-day sessions. The training usually takes place over a 4- to 6-month period. 

The Session 1/Translator training addresses basic nutrition, counseling and interviewing 

techniques, Hmong and Hispanic eating patterns, and confidentiality. The last three 2-day 

sessions are divided into nutrition education and WIC certification. After each session, 

participants have a take-home test and follow-up assignments to complete, and they must 

practice doing certifications and providing secondary nutrition education, with supervision from 

an RD at their local agency. 

After this work in the clinic, either the Hmong or the Hispanic trainer visits the local clinic 

to observe the trainee providing secondary nutrition education and/or WIC certifications, 

depending on how the local agency uses the trainee’s new expertise. If the trainer is satisfied 

with the trainee’s performance, the trainee receives a certificate of completion and is authorized 

to provide secondary nutrition education and/or to certify selected low-risk participants. The 

trainees must complete this certification process within 1 year, but it usually takes 9 months.40

Trainees can become translators, educators, and/or certifiers. A participant who attends the 

first two days of training, the translator section, can earn a functional translator certificate. A 

participant who attends the entire training, completes the assignments, and is approved by a 

40 Most trainees from non-WIC organizations complete assignments after the training as 

well. In these cases, the homework has been individualized. In some cases, the person works for 

a non-WIC agency, but the local WIC project may contract with that person for some translator 

or educator time. For these people, it is an essential part of the training to do the same 

homework as the WIC staff. A trainee who works for another program (such as Head Start) will 

use Head Start Program regulations and materials to complete the homework. 
180

trainer, can become a CPA with the knowledge and skills necessary for WIC certifications and 

nutrition education for low-risk Hmong and Hispanic infants, children, and women. A trainee 

has the option of taking the entire course, but only completing the assignments for the translator 

or educator role, not the certifier role. Along similar lines, a trainee who attends only the 

translator session and then the sessions on, for example, children and infants, can be tested on the 

children and infants sections and work with only those populations in the WIC clinics as a 

translator and nutrition educator, not as a CPA. Trainees who miss a training session can be 

tested on the completed sections and then finish the remaining section(s) when the course is 

offered again. 

Bilinguals are not qualified to certify high-risk clients, but are trained to identify such 

clients, who must be seen by an RD. For high-risk cases, they function as an interpreter. In 

addition, bilinguals can provide certification services only to Hmong or Hispanic clients, not to 

other groups of WIC participants. 

In some of the more rural local projects, the bilingual may be in the project only one or two 

days during the month, and the Hmong/Hispanic participants are scheduled for those days. In 

larger projects, the bilingual is usually a full-time employee. Most bilinguals were initially hired 

as program support staff or health screeners; thus, if they achieve CPA certification, they have 

two roles. On some days they function as a CPA, on others, in their initial role of program 

support staff or health screener. 

Participation. As of 2003, the program has trained 29 certifiers, 17 educators (14 from 

agencies other than WIC), and 24 translators. Twenty local agencies have sent staff to the 

training.

Coordination and Collaboration. In 2003, the Wausau Health Foundation provided 

funding for the program. For the program to receive this grant, the training had to be available to 

staff in organizations other than WIC. The curriculum was broadened to meet this need. 

Publicity and Outreach Efforts. The two trainers and the Regional Nutritionists, who 

were on the advisory committee, promote the training at the local and state level. WIC staff 

promote the program throughout the year and at statewide conferences. The initiative is also 

publicized in the “Monthly Update,” a newsletter for nurses, nutritionists, and other professionals 

in WIC, breast-feeding, and maternal and child health programs. In addition, flyers were 

distributed in 2003 to reach out to other organizations. 

ORGANIZATION AND MANAGEMENT 

Staff and Organizational Structure. The State Office and Nutrition Coordinator provide 

general oversight for the initiative, while the Program Coordinators plan, manage, and evaluate 

the program. The two trainers are responsible for the development and provision of the 

materials; both are RDs with extensive experience in staff training and educational activities. 

Training and Quality Assurance. Quality assurance is limited at this point, but it is under 

consideration by program officials. Charts are completed in English and reviewed by an on-site 

dietitian. If the staff member becomes a CPA, the project’s nutritionist oversees the member’s 
181

 

activities through chart audits and discussions with staff. At the annual state WIC meeting, 

previous graduates of the training program are invited to attend a two-hour workshop on issues 

in maternal and child nutrition to update their knowledge. 

Funding. For FY 2000 and FY 2001, the program received $128,000 in funding through a 

WIC Infrastructure Funds Grant. In addition, in FY 2001, about $40,000 was used from WIC 

Nutrition Services and Administration (NSA) funds. The FY 2000 and FY 2001 budget included 

the costs of planning, developing the curriculum and materials, providing training for those two 

years, trainee lodging and travel, and labor. In FY 2002, about $75,000 of state WIC funding 

was used for the program, including training and ongoing monitoring. In FY 2003, program 

officials received a grant from the Wausau Health Foundation for $4,000, as well as $39,000 

from the state WIC office to fund the program. In FY 2004, the state WIC office anticipates 

providing $20,000. Program officials are considering partnerships with other agencies to 

streamline the cost of training. 

ASSESSMENT AND LESSONS LEARNED 

Program Strengths. In 2001, the state agency conducted a program evaluation that had 

three components: (1) a written survey of 12 local WIC Directors who had sent bilingual 

paraprofessionals to the 2001 training, (2) a written survey of the 16 bilinguals that completed 

the 2001 training, and (3) telephone interviews conducted by the Hmong and Hispanic trainers of 

42 participants served and 37 participants not served by the bilinguals.41

Nine of the 11 local WIC Directors who responded are using their bilinguals as nutrition 

educators, with 6 of these 9 having their bilingual paraprofessionals functioning as both certifiers 

and nutrition educators. Most felt that the bilinguals had a better understanding of WIC after the 

training, and were better able to explain nutrition and health concepts. In addition, the WIC 

Directors noted that the bilinguals are more enthusiastic and satisfied with their work, and that 

other WIC staff members appear more confident in the bilinguals’ abilities. 

The 10 bilinguals that responded to the survey felt the training helped them develop new 

ways of explaining nutrition and health concepts. All but one enjoyed their jobs more, 

particularly the closer contact with WIC families. 

The telephone interviews of Hmong and Hispanic clients who worked with bilinguals 

indicated that they were more aware of why they were eligible for the program, more 

comfortable sharing health information, and more honest and open compared to similar clients 

who did not work with a bilingual. The bilingual certifiers and other WIC certifiers were 

comparable in listening to client concerns and in clients’ perceptions of certifiers’ knowledge. 

An important caveat is that program officials would like to study the program further. In 

particular, they would like to compare the costs of training the bilinguals to the costs of using 

41 The 2003 evaluation is complete, but the data were not available in time for inclusion in 

this report. 
182

interpreters. In addition, when program officials reviewed data for the Hmong clients who had 

met with the bilinguals, the duration of bottle-feeding appeared higher than among WIC clients 

who had met with non-Hmong staff. It is possible that Hmong women were more honest in 

reporting their behavior with bilinguals. Therefore, program officials plan further monitoring of 

the amount of time children remain on a bottle following nutrition education with a Hmong or 

non-Hmong staff member. 

Key Challenges. In the beginning, WIC RDs had reservations about bilinguals, who did not 

have professional training, providing nutrition education and certifying participants. 

Historically, RDs, nutritionists, and DTRs provide nutrition education in Wisconsin, and even 

nurses are not always well received by nutrition professionals. Helping local clinics see the 

value of having bilinguals deliver nutrition education was challenging but essential to the 

training’s success. The advisory board and the project directors that have used bilinguals helped 

ease these concerns and gain buy-in from the local RDs. 

Another challenge has been cultural differences. For example, among some immigrant 

families, it is not customary for women to travel alone to attend the training sessions and stay 

overnight. Some husbands were not supportive of this arrangement and wanted to accompany 

their spouses.

Lessons Learned. Program officials believe this initiative can be replicated. Their 

curriculum could be used with Hmong or Hispanic populations, or revised for different ethnic 

groups. Staff feel it is critical to find competent bilingual trainers who know the WIC Program 

and to form an advisory committee to help implement the project and gain buy-in at the local 

level. 

Overall, this training program is a creative approach to serving pockets of non-Englishspeaking clients from a particular group. It seems worthy of further study. As noted, the main 

concern is whether it is possible for nutritionists to monitor adequately the services bilinguals 

provide in another language. The use of English charts and frequent discussions of cases seem 

like promising approaches to solving the problem, however. 

CONTACT INFORMATION 

Patti Herrick, RD, MPA 

Chief Nutrition Section and Director of Wisconsin WIC 

Linda Lee, MS, MPH 

WIC Director and Nutrition Manager at Lacrosse County Health Department 

Kay Perkins, MS, RD 

WIC Director at Family Planning Health Services 

Division of Public Health 

1 W. Wilson Street, PO Box 2659 

Madison, WI 53701-2659

Phone: 608-266-3821 (Herrick), 608-785-9791 (Lee), 715-675-9858 (Perkins) 

Fax: 608-266-3125 

E-mail: herriph@dhfs.state.wi.us 
183

 

IV. INNOVATIONS IN SERVICE DELIVERY 

Innovative service delivery can include providing WIC services in nontraditional locations 

or using alternative modes of communication (such as by telephone versus in-person, or through 

videos instead of written materials). Several of the programs profiled in earlier chapters include 

interesting innovations in service delivery. For example, the Arkansas program involved a longdistance certification process, so mothers with infants in neonatal intensive care far from home 

could receive breast pumps promptly. The program in Washington and Greene Counties in 

Pennsylvania provided peer counseling by telephone only, while most programs have an inperson component. These programs and the programs discussed in this chapter all serve rural 

WIC clients and seek to address transportation barriers. Other service delivery innovations, such 

as videos, may address literacy or language barriers. 

This chapter discusses three programs that are innovative in that they include delivery of 

WIC services in two nontraditional settings: clients’ homes and workplaces. WIC clinics are 

traditionally located at public health departments, hospitals, health clinics, or in free-standing 

buildings; satellite clinics (open only occasionally) may be in locations such as schools, church 

basements, or community centers. But service delivery in the home or at work remains rare. 

Because of its high cost, home visiting usually implies not just services in a different 

location, but comprehensive and individualized services targeted at particularly high-risk clients. 

Because WIC funding does not cover comprehensive services, WIC services are rarely offered 

via home visits, unless they can “piggyback” on another program’s services. At the same time, 

because clients view WIC positively, home visiting programs find that delivering WIC food 

instruments makes home visits more welcome. In both examples of home-visiting programs 

discussed below, WIC was collaborating with Medicaid care coordination for high-risk pregnant 

women and infants. The home visits were funded largely under Medicaid. WIC services 

provided during home visits varied, as did the frequency of home visits, but visits included 

delivery of food instruments in both cases. 

For WIC services to be offered through home visits, WIC services must be coordinated with 

a home visiting program’s services. The programs in northwest Michigan and in Cullman 

County, Alabama—both located in local health departments—are good examples of coordinated 

services; they coordinate at the policy, administrative, and especially the clinical levels.1

 Such 

1

 The Coordination Strategies Handbook prepared for FNS by Health Systems Research 

distinguishes policy, administrative, and clinical coordination (U.S. Department of Agriculture 

2002). The handbook also distinguish three levels of closeness in how programs are related: 

(1) coordinated—at different locations and with different staff, but with some communication; 

(2) co-located—at the same or an adjacent location; and (3) integrated—under the same 

administrative management. The home-visiting programs described below are largely integrated, 

in that they ultimately are under the same division of the Health Department and at least some 

staff deliver services for both programs. However, records for WIC and the Medicaid care 
184

 

coordination can lead to more seamless service for clients (of which coordinated home visits are 

just one example) and cost savings for WIC. We thus describe the range of coordinated services 

delivered in these programs, not just the home-visiting component, in order to clarify the context 

for home visits. 

Workplace visits to provide WIC services are not widespread. However, as more WIC 

mothers enter the workforce under welfare reform, such programs may become more relevant. 

The program described here is on a rural Indian reservation with a small number of employers 

and significant transportation barriers for clients. In general, offering WIC services in clients’ 

workplaces seems most applicable in other rural areas or areas where individual firms hire many 

WIC clients. For a workplace program to operate, it is important that employers cooperate. 

Clients must also be willing to let coworkers know they receive WIC. Such programs are clearly 

not appropriate in all settings. For example, the program described below, which is operated by 

the Eastern Band of Cherokees WIC agency, serves clients who work in motels, clerical jobs, 

day care centers, schools, restaurants, and stores. However, those who work in sales or service 

jobs that involve direct public contact have more difficulty taking time off and may lack private 

space to meet with the WIC nutritionist. 

Overall, service delivery in homes or workplaces is an example of how WIC programs can 

become more flexible to meet diverse client needs. Coordination of WIC services with other 

programs can be an effective way to obtain both the resources and the administrative flexibility 

to use alternative service delivery mechanisms. 

(continued) 

coordination programs must be kept separate, and duplicative forms filled out at times, to meet 

state and federal requirements. 
185

COORDINATION OF WIC WITH MATERNAL AND INFANT SUPPORT SERVICES2

NORTHWEST MICHIGAN

OVERVIEW 

Location: Grand Traverse, Benzie, and Leelanau counties, Michigan. 

Start Date: 1990 in Grand Traverse, 1996 in Benzie-Leelanau (when their district health 

department was formed as the result of a separation from Grand Traverse County). 

Target Population: High-risk pregnant women, postpartum mothers, and infants who qualify 

for Medicaid. 

Purpose: To provide one-stop services to pregnant and postpartum mothers and infants, 

improve their access to services, and increase revenues for the health department. 

Services: WIC services are provided in conjunction with a Medicaid-funded program of 

intensive support services (Maternal and Infant Support Services [MSS/ISS]) for pregnant 

women and new mothers, involving monthly meetings with a nurse, dietitian, or social worker. 

Some of these meetings occur through home visits, allowing in-home WIC coupon delivery, 

nutrition education, and occasional recertifications. Other health department services, such as 

family planning and immunizations, are also closely integrated. MSS/ISS will also pay for 

public or private transportation, if needed. 

Funding: Medicaid covers much of the cost of the coordinated services through the MSS and 

ISS programs. 

Why Program Was Chosen: These programs include strong coordination of services, 

improved health care access in a rural area through the use of home visits, and good “leveraging” 

of funding. WIC is used as a “carrot” to draw clients into the MSS/ISS program, and WIC, in 

turn, benefits from the Medicaid funding, which provides a per-visit reimbursement for MSS and 

ISS. These practices likely contribute to higher participation rates, more efficient operations, 

stronger financial status for the health departments, and better services for the community. 

Key Challenges: Working out the logistics of integrated services—such as procedures for 

ensuring the security of food coupons on home visits—was an initial challenge. On an ongoing 

basis, the nurses providing both WIC and MSS/ISS services found that it was important to be 

clear with each other on division of administrative responsibilities and to communicate regularly 

with clerical staff about challenges they faced. 

 2

 Telephone interview, April 18, 2003; site visit, August 6-7, 2003. 
186

BACKGROUND 

Community Characteristics. This program operates in three Michigan health departments: 

Monroe County, Grand Traverse County (GT), and Benzie-Leelanau District (B-L). Other forms 

of coordination occur in other health departments in the state. We visited GT and B-L, which are 

both in the northwest “little finger” area of the Lower Peninsula of Michigan, and we will focus 

our discussion on these programs. This area comprises largely rural communities and small 

towns along Lake Michigan and Grand Traverse Bay; Traverse City is the largest city in the area, 

but none of these counties is considered metropolitan. Tourism and farming (especially cherries) 

are important industries. The population is over 95 percent white, with small pockets of Native 

Americans and Hispanics. Poverty rates are low, ranging from 5.4 percent in Leelanau to 

5.9 percent in GT to 7.0 percent in Benzie County, versus 10.5 percent for the state on average 

(1999 data from the 2000 Census). Benzie and Leelanau counties are low in population and 

more rural than Grand Traverse; their combined health department is one of the smallest in the 

state. 

Target Population. WIC and MSS/ISS coordination is targeted to low-income, high-risk 

pregnant and postpartum women and their infants. Medicaid (or other state or federally funded 

maternity care programs) must cover the pregnant woman or infant to be eligible for MSS/ISS 

services. Mothers or infants must also have one or more risk factors. For pregnant women, 

being a teenager or suffering from substance abuse, homelessness, or stress are among the risks 

that qualify them for MSS. As in WIC, the risk factors are sufficiently broad that essentially 

everyone who is income-eligible can qualify. Risk factors for ISS are somewhat more limited, 

but also include babies with eating/feeding problems, prematurity, or low birth weight. 

Staff reported that most clients are white and many stay home or work part-time (or irregular 

or evening hours) in low-wage service jobs. Some are seasonal workers in the tourist industry. 

In GT, many have some college education. B-L has a migrant camp with largely Spanishspeaking residents, which are served by a migrant health center that hosts a Health Department 

satellite WIC clinic once a week in the summer. Hispanics are about 5 percent of clients in GT 

and about 14 percent in B-L. Language barriers can be a problem in serving them, as there are 

no Spanish-speaking staff members in B-L and few in GT. The migrant health center supplies a 

translator, and in the B-L offices they use a telephone service or a local volunteer if the client 

does not bring someone to translate. The GT health department sees fewer Native Americans 

clients than in the past, as a local casino has given them higher incomes. However, B-L has seen 

Native Americans increase from 5 to 8 percent of the caseload since 1997. 

Lack of housing and lack of good jobs are the major challenges for clients in the area. 

Housing can be very expensive, because the demand for summer homes drives prices up, and 

homelessness is a concern. Many jobs are seasonal or have irregular hours, and there are few 

opportunities for advancement. GT staff did not see access to health care as a major problem in 

the area; there is a large regional hospital, services from the health department, and an adequate 

supply of doctors who take Medicaid. In B-L, staff were more concerned about access, as they 

find that local providers accept only limited numbers of Medicaid clients. Distance to health 

care providers and jobs with no health care benefits are also concerns for many members of the 

community. 
WIC Program—Grand Traverse. The GT WIC program served about 1,800 clients in 

March 2003, including about 200 pregnant women.3

 The main clinic in Traverse City is open

5 days a week, and there are two satellite clinics—one in Kingsley open once a month, and one 

in Interlochen open one day every other month. At the main clinic, they schedule one day a 

week to be the nutrition education and coupon pick-up day for clients who are in the middle of 

their certification period. On that day, there are “parent sharing sessions” each hour from 8 A.M. 

to 6 P.M. On the same day, MSS/ISS nurses do intakes for pregnant women into MSS and WIC;

this is described further below. The other four days of the week are largely for certifications and 

recertifications (for those other than pregnant women). The GT clinic has extended clinic hours 

on some days, staying open until 6 P.M. instead of 4 P.M., and will serve walk-in visitors

whenever possible. 

In GT, there are 15 nurses and 1 nutritionist who provide WIC services; 10 of the nurses and 

the nutritionist also provide MSS/ISS services.4

 The nurses rotate their hours between WIC and 

the other health department programs. In general, the nurses see clients on two clinic days a 

week in the various programs (WIC, MSS/ISS, Immunizations, Reproductive Health). Other 

days are used for paperwork, meetings, or home visits. Some of the nurses work part-time. 

WIC Program—Benzie-Leelanau. The B-L WIC program served about 700 clients in 

March 2003, including about 70 pregnant women. There is a weekly clinic in each county at the 

health department offices—one is in Lake Leelanau and the other in Benzonia—one in 

Thompsonville, which is open once a month, and the migrant clinic, which is open once a week 

during the summer months (June to October). 

At Lake Leelanau, staff run a WIC clinic for a full or half day each week (depending on 

demand), and they provide the immunizations at the same time, so families are able to get all 

services in one trip. The caseload is too small to run nutrition education classes in Leelanau, so

nutrition education contacts are often one on one. Each pregnant client sees the nutritionist at 

least once—this counts as an MSS visit if they are enrolled in MSS. The nurses assess weight 

gain (and growth for infants) at each visit. The regular WIC appointments, when not combined 

with MSS, are set up at the rate of 20 per day. The appointments, depending on the type, are for 

15 to 30 minutes with each client. If a mother has several children on WIC, she receives several 

consecutive appointments. The scheduling is similar in Benzonia. 

There are five nurses and four clerical staff at B-L—two nurses and two clerical staff in 

Lake Leelanau, and three nurses and two clerical staff in Benzonia. Staff at each site may travel

to the other site to fill in, or for meetings or special events. The Director of Personal Health is a 

nurse, but she does not carry a caseload. 

187

 3

 Participation figures reflect food coupons issued. They are based on participation reports 

for March 2003 provided by the state WIC agency. 

4

 GT also had a part-time nutrition educator who conducted classes, but she was about to be 

laid off.
188

Program History. The integration of WIC and MSS/ISS services developed gradually at 

GT. The MSS program began in 1988, and ISS was added in 1993. A new supervisor for both 

WIC and MSS joined the agency in 1990, and she worked to integrate the services. First, they 

cross-trained all the nurses in both WIC and MSS (and later ISS) and began doing combined 

intakes. The second stage of integration, several years later, was when they began delivering 

WIC coupons as part of MSS/ISS home visits, along with WIC nutrition education contacts. The 

major challenge was figuring out a system for issuing the coupons in advance of the visits and 

ensuring their security. In the last three years, as a third step, the GT WIC nutritionist has taken 

on a bigger role in the MSS/ISS programs. She now meets with every pregnant woman in MSS 

on one of the clinic visits, and manages some ISS cases. 

The B-L District Health Department opened in 1996 with all new staff. They integrated 

services from the beginning, in part because of necessity, since the staff was so small. B-L took 

the concept of integrated services and the approach to scheduling from the Northwest Michigan 

health agency in Charlevoix, as they shared their administrator in the early years of the B-L 

health department. 

PROFILE OF INNOVATIVE PROGRAM 

The MSS/ISS Program. The Maternal and Infant Support Services programs are case 

management programs for high-risk pregnant women, new mothers, and infants. Funded 

through Medicaid, the programs are intended to prevent infant mortality and promote healthy 

development. The MSS/ISS program is statewide, but services are provided in much of the state 

through Medicaid managed-care plans, and are not generally integrated with WIC services. In 

Northwest Michigan, they have generally not had Medicaid managed care that provides 

MSS/ISS, so the health departments provide these services. 

MSS involves up to nine visits during pregnancy and the immediate postpartum period, 

generally on a monthly basis. The first visit is an in-depth assessment/screening with a nurse. 

After the assessment, the full MSS team (all nurses who provide MSS services, the nutritionist, 

and the social worker) meets to develop a plan of care for the client. The second visit in Grand 

Traverse is a combined visit to the nutritionist and the social worker. This “RD/MSW” day 

occurs about once a month. The nutritionist goes over a nutrition plan with each client, and the 

social worker can help them address any housing, transportation, or family issues. In B-L, 

clients are also scheduled with the Registered Dietitian (RD) and the social worker (Master’s in 

Social Work or MSW) early in pregnancy, and further visits are scheduled as needed after the 

plan of care is reviewed by all members of the MSS team. The nurse who conducted the intake 

generally makes the remaining visits after the assessment, but there are exceptions. For example, 

some mothers may need to see the nutritionist again due to a special need. At least two of these 

visits are supposed to be home visits, if possible, including the one immediately after the birth, 

which may include enrolling the newborn on WIC. In some cases, the nurses make more than 

two home visits, with the major reason being transportation problems that make it difficult for 

the woman to come in. Other situations in which home visits occur more than twice include 

pregnant women who are on bed rest, mothers with child care problems, and, sometimes, women 

who did not come to their scheduled appointment at the office—staff try to avoid losing them. 
189

ISS is delivered entirely through home visits. Medicaid funds 10 visits for most cases, but 

can fund 9 more if the baby has a medical problem, and up to 37 if there are drug or alcohol 

problems in the family. In general, the same nurse who saw the family during the pregnancy 

also follows them after the birth. Staff usually visit once a month, but sometimes, for older 

children, they visit every other month. In GT, the nutritionist handles some ISS cases instead of 

a nurse, particularly if there is a growth or feeding issue, such as tube feeding, failure to thrive, 

chromosomal problems, or children older than 1 year who are on formula for a special health 

care need. 

Each MSS/ISS staff member, whether nutritionist, social worker, or nurse, is a support 

person and is not providing primary care. The nurse does crisis intervention, parenting 

education, and health and nutrition education, and provides the mother with moral support and 

connections to other resources, as needed. The staff follow up by telephone frequently. For 

example, telephone calls are made to schedule appointments, follow up with no-shows, check in 

with the client’s doctor, or make referrals to other agencies, such as the Family Independence 

Agency (FIA), which is Michigan’s Temporary Assistance for Needy Families (TANF) program. 

How WIC Services Are Integrated with MSS/ISS. WIC and MSS/ISS intakes are 

integrated. In GT, when a pregnant woman calls to sign up for WIC, she is scheduled for a 

combined intake appointment, which lasts about an hour. In that initial appointment, she first 

meets with the prenatal outreach and advocacy staff member (a skilled clerical position), who 

screens her for Medicaid (and enrolls her, if needed), whether she has a prenatal care provider, 

and income-eligibility for WIC. After this, she sees a nurse to screen her for MSS and WIC 

nutritional risks. The overall goal is to offer pregnant women the full range of services. These 

appointments are available one day each week. 

Intake is also coordinated in B-L. When a pregnant woman calls to sign up for WIC, she is 

generally placed on the schedule for a combined WIC/MSS intake. If a woman comes in for a 

pregnancy test, and it is positive, the staff also try to schedule a WIC/MSS intake for her. Joint 

scheduling does not always work in B-L, however, because of timing. The MSS clinic is held on 

only three days a month, but WIC rules require that a pregnant woman be seen within 

10 calendar days after her initial call. Sometimes, initial visits can be coordinated with clerical 

and MSS staff on a nonclinic day. 

When clients come in for the intake appointment, the nurses do not emphasize that WIC and 

MSS are separate programs, but instead describe how they are going to receive WIC coupons 

and also periodically see a nurse who will check on how they are doing and answer any 

questions they may have about their pregnancy. Many clients refer to the nurse as their “WIC 

nurse,” even though she is providing primarily MSS services. 

Over time, as noted above, clients see the same nurse for WIC and MSS/ISS services. In 

particular, MSS/ISS clients can arrange to pick up their WIC coupons during an MSS office 

visit, or to have them delivered by the nurse during a home visit. When nurses bring WIC 

coupons, it makes home visits welcome, and is particularly convenient for clients who lack 

transportation. Many of the parenting education contacts during these visits (and the weight 

checks) can also be counted as WIC nutrition education contacts. For example, most ISS visits 

involve discussions of breast-feeding issues or age-appropriate infant feeding. However, WIC 
recertification usually requires an office visit. The nurses will try to do recertifications in the 

home if the mother has particular difficulty getting to the office, but the test for iron levels 

requires equipment that is not easily transported. The recertification that is easiest to do in the 

home is the “midcheck” for infants around 6 months of age, as no blood test is required at that 

point for most babies. 

Another way in which services are integrated is that the nutritionist has a key role in both 

programs; in GT, as noted above, she carries an ISS caseload. In addition, the breast-feeding

support component of the two programs is integrated. The WIC Coordinators in GT and B-L 

both have special certification in lactation (one is an Internationally Board Certified Lactation

Consultant [IBCLC] and one is a Certified Lactation Educator). Because of this certification, the 

WIC Coordinators can provide home visits to new mothers to address lactation issues or provide 

lactation consultations in the office. These visits are charged to MSS. However, it is WIC that 

provides training in breast-feeding for the nurses and provides breast pumps to give or lend to 

new mothers. (The Healthy Futures program, described further below, also helps promote 

breast-feeding.) 

Participants Served by Joint Services. In Grand Traverse, about 50 percent of pregnant 

WIC clients are in MSS; most who are not in MSS are those with private insurance. The MSS 

program serves about 120 women a month. In Benzie-Leelanau, about 80 percent of pregnant 

WIC clients are in MSS; the MSS caseload is about 55 women a month. In some cases, women 

who have been in MSS previously or have had previous children may opt out of the services. 

Not all MSS clients continue in ISS. In Grand Traverse, about 75 percent of families 

continue from MSS to ISS; the caseload is about 90 infants each month. In Benzie-Leelanau, 

staff estimated about 80 percent continue, which would be a caseload of about 44. The most

common reasons for not participating in ISS include returning to work and losing Medicaid 

coverage. In addition, some experienced mothers do not feel they need the services. 

Coordination with Additional Programs. There are many ways in which these health 

departments coordinate services for pregnant and postpartum women and infants, in addition to

the coordination between WIC and MSS/ISS. Since spring 1998, both GT and B-L have

participated in a program called Healthy Futures—the program covers any birth at Munson 

Hospital, the only hospital in the area for giving birth. Federal Maternal and Child Health block 

grant money funds this program. Every mother, while in the hospital, is offered a home visit 

from a nurse within the first weeks postpartum. The nurses from the health department do these 

visits, although the hospital maintains a central registry for the program. The nurse does an 

assessment for WIC, Medicaid, and ISS and makes referrals to these programs as appropriate.

The nurse will also follow up by phone. Healthy Futures visits reach 75 percent of first-time 

mothers, which helps increase awareness of and participation in WIC and ISS. Healthy Futures 

is an important mode of outreach to those who do not know they qualify. It may also have 

helped increase WIC breast-feeding rates in these counties, as it provides a personal visit to 

mothers right after the birth that includes breast-feeding assistance, if needed. 

Other services that are coordinated with WIC and MSS/ISS include Medicaid enrollment, 

reproductive health services, and immunizations. During the WIC/MSS intake visit for pregnant 

women, if they are not already enrolled in Medicaid, they are screened for Medicaid eligibility. 

190
If eligible, they can complete the first steps in the enrollment process without having to visit the 

FIA office. This enrollment process is especially helpful for women in B-L, who would 

otherwise have to travel 20 to 30 miles to Traverse City. The health department nurses can also 

offer reproductive health services during ISS visits or arrange for clinic appointments, as both 

health departments are Title X providers. In addition, they make immunizations available at the 

same time children are coming in for WIC appointments, and monitor immunization status 

during ISS visits. Finally, they provide referrals to a range of other programs, including FIA. 

Publicity and Outreach Efforts. The health departments each have a brochure on

MSS/ISS services that is distributed to various agencies to give to their clients. They also do 

outreach to physicians in the area about both WIC and MSS/ISS. In GT, WIC and MSS/ISS 

staff work with Planned Parenthood, the Pregnancy Resource Center (a Christian group), FIA, 

and the Women’s Center. In turn, all these groups refer pregnant women to the combined 

WIC/MSS program. In B-L, health department staff send brochures on WIC and MSS every six 

months to local day care providers, Head Start centers, and family practice physicians. They put 

up WIC posters in local grocery stores and other community locations, and check on them every 

six months. Both GT and B-L also distribute information at health fairs and community events. 

In all these counties, health department staff also work extensively in coalitions with other 

social service agencies, and they reported that these contacts are often very important in getting 

the word out about their programs. 

ORGANIZATION AND MANAGEMENT 

Staff and Organizational Structure. Both programs visited were in small health 

departments, with one supervisor, the Director of Personal Health Services, in charge of WIC, 

MSS/ISS, and several other programs. The Director in B-L works part-time and shares some

supervisory duties with the MSS/ISS Coordinator, who is based at the other clinic. Both 

supervisors are very committed to integrated services. 

In each office, one senior nurse serves as the WIC Coordinator and another as the MSS/ISS 

Coordinator. The Coordinators generate reports for the state, coordinate training and quality 

control in the rules of the specific program, and serve as the primary resource for staff with 

questions about program rules. They also provide line services. The WIC Coordinators at both 

sites have special training in breast-feeding support. The WIC Coordinator in GT is an IBCLC, 

and the WIC Coordinator in B-L is a Certified Lactation Educator. In each case, the health

department funded the coursework and training for their credential. 

Other nurses in these health departments have their own areas of specialty, such as

reproductive health or HIV counseling, but, in general, “everyone does everything.” In 

particular, most nurses provide both WIC and MSS/ISS services. The clerical staff is also crosstrained in all clerical aspects of each program. 

Coordination of Paperwork and Record Keeping. The WIC and MSS/ISS programs have 

separate policy and procedures manuals and separate paperwork in separate program charts, but

staff try to make services seamless from the client perspective. Most of the records are in hard

191
192

 

copy, although some information from the intake interview is entered into the statewide WIC 

automated system. A major reason that the records must be kept separately is that MSS/ISS is 

covered by HIPAA, the law that protects the confidentiality of health information, whereas WIC 

is not. Thus, MSS information cannot go in the WIC file. In GT, they simply note in the WIC 

file if there was a visit under MSS and the general reason for the visit. In B-L, a copy of the 

WIC health history is kept in the MSS or ISS chart. In the WIC charts, a notation is made that 

the client is enrolled in MSS or ISS. In both offices, nurses try to mesh the WIC and MSS 

Health Histories during the initial interview so they do not have to ask the same things twice—

but they must fill out both forms. In B-L, the MSS chart also includes a visit log that tracks all 

visits and calls, including calls to physicians and FIA and any other community resources to 

which the client was referred. One challenge is for nurses to remember to check both charts 

when a visit is for both programs. 

Staff Training and Quality Assurance. The WIC Coordinators go to state-sponsored WIC 

trainings and report back what they have learned. Others attend if funding is available, 

particularly if the training is nearby. The WIC Coordinators spoke favorably about the statelevel training in facilitated group discussion and in the infant/child feeding approaches of Ellyn 

Satter.5

In each office, there is a monthly, all-day meeting of all staff (including clerical staff), which 

includes updates on each program and training in any new procedures or policies. In B-L, chart 

reviews are also conducted to make sure staff are following procedures consistently. The WIC 

Coordinator and MSS Coordinator review charts for their programs. 

Funding. Staff must charge their time to WIC and MSS/ISS separately. GT did a study of 

how much time during an intake appointment was spent on WIC and found it was about 

15 minutes. So, initially, they charged 15 minutes to WIC and the remaining time, about 

45 minutes, to MSS. Later, they started charging the entire visit to MSS, as they realized that the 

process of enrolling the client in WIC fell under the definition of MSS screening. Overall, the 

program leads to savings for WIC; the only increased cost is for coordinating issuance of food 

coupons with home visits, which is now routine. 

MSS/ISS funding has been secure. In fact, rates were increased a few years ago. The major 

change has been as Medicaid has moved into managed care, managed care organizations need to 

approve MSS visits for their clients. There is only one Medicaid managed care provider in GT 

and none in B-L, however, so clients still have the option of seeing fee-for-service providers 

(including the health department).6

5

 See the profile of the Learn Together Approach training in Chapter III. 

6

 Clients must always have at least two options for care. 
193

ASSESSMENT AND LESSONS LEARNED 

Program Strengths. Most state Medicaid programs now have case management programs 

for high-risk pregnant women and infants. However, many have not integrated these services 

with WIC. The programs in GT and BL are strong examples of program integration in terms of 

management, staff, and client services, although the programs remain administratively separate. 

It is difficult to assess the role of the integration of services in outcomes for these programs, 

as many other factors may be at work. Nonetheless, program staff believe that they are serving 

more eligible women in WIC and MSS/ISS than they would if the programs were not 

coordinated, and achieving better outcomes (such as higher breast-feeding rates). Although by 

no means conclusive, some data suggest that these counties may serve a greater percentage of the 

target population than elsewhere. In particular, the percentage of infants on WIC and Medicaid 

is about equal to the state average in GT and higher than the state average in B-L (based on data 

from the Michigan WIC Website), although the poverty rate in both areas is lower than the state 

average. Both health departments certify new mothers as breast-feeding at about twice the rate 

as the state as a whole. However, this probably reflects a local environment sympathetic to 

breast-feeding and the effects of the Healthy Futures program as well as the effects of the 

integrated services. Furthermore, staff reported that providing WIC coupons during MSS/ISS 

home visits or MSS office appointments reduced the proportion of “no-shows” for the MSS/ISS 

appointments. 

Another important outcome from the point of view of program staff is the ability to draw on 

federal funds more effectively to support the combined services, as Medicaid reimburses for 

MSS/ISS services on a fee-per-visit basis, while WIC nutrition services funds are related only to 

the number of clients. This is particularly important in a tight budget environment. 

The programs have not done studies of client satisfaction, and even if they had, there is no 

way to compare clients’ views to what they would have been in a less integrated program. 

However, staff uniformly reported positive feedback from clients moving to the area from other 

parts of the state, in terms of access to services. 

Nurses in both offices reported that their ability to deliver a wide range of services makes 

their jobs much more satisfying, for several reasons. First, they can try to help clients receive 

whatever services they need, as they are trained in all the health department programs and well 

linked to other community services. Second, they can follow up with MSS/ISS clients over time, 

so they become familiar with their situations. Finally, several reported that they find their job’s 

variety keeps it challenging and rewarding. 

Key Challenges. As discussed earlier, the major operational challenges were developing 

systems for ensuring the security of food coupons delivered to clients during home visits and 

arranging clinic schedules to provide joint services effectively. Keeping up with the paperwork 

for both programs can also be a challenge. 

Because the nurses work on multiple programs, they learned that it is important to be clear 

about the division of administrative responsibilities for each program, such as ordering supplies, 

or these tasks can fall through the cracks. In addition, it is important to be sensitive to the needs 
of clerical staff, who may have more difficulty juggling their tasks than the nurses realize. For 

example, clerical staff had to learn to handle the demands of generating WIC food coupons both 

for WIC appointments and for MSS appointments. The nurses reported that the monthly staff 

meetings were useful forums for working out these issues. 

Lessons Learned. Medicaid-funded programs to provide case management to high-risk 

pregnant women and infants are natural partners with WIC, as they target the same populations

and share the major goals of improving birth outcomes and the health of mothers and children. 

Program staff in the three northwest Michigan counties identified several factors that they felt 

contributed to successful service integration in their programs: 

• The WIC and MSS/ISS programs were operated by the same agency and had one 

manager with responsibility for both programs. 

• Each agency’s management and staff were committed to a client-centered 

approach—they wanted to provide clients with the services needed in a seamless 

fashion, and keep the paperwork for the separate programs in the background.

• Staff and management worked together to make the logistics work, particularly in the 

areas of scheduling appointments and tracking WIC food coupons that were to be 

delivered during home visits. It is important not to overwhelm nurses and clerical 

staff with their varied responsibilities. In turn, staff need to be organized and able to 

juggle.

• WIC is a useful way to draw clients into an intensive case management program. It

is also important to offer the services to clients positively, and as a package. 

Most staff also felt that service integration was most appropriate in small agencies, where 

staffs are small and caseloads tend to be smaller as well. One noted that paraprofessionals 

sometimes handle scheduling and assessments in larger WIC agencies, which implies that 

procedures cannot be as flexible. However, one manager argued that some integration is 

possible in larger agencies, as long as services are co-located. She had worked in a larger WIC 

agency, and said that her former agency was now working on integrating WIC and MSS/ISS 

services to some extent.

CONTACT INFORMATION 

Terri Riemenschneider 

Local Agency Consultant, NPE Section 

MDCH/WIC

P.O. Box 30195 

Lansing, MI 48909 

Phone: 517-335-9562 

E-mail: riemenschneidert@michigan.gov 

194
195

Deb Deering, RN, BSN, IBCLC 

WIC Coordinator 

Grand Traverse County Health Department 

2325 Garfield Road N., Suite A 

Traverse City, MI 49686 

Phone: 231-922-2724 

E-mail: ddeering@co.grand-traverse.mi.us 

Debbie Aldridge, RN, CLE 

WIC Coordinator 

Benzie-Leelanau District Health Department 

7401 E. Duck Lake Rd., Suite 100 

Lake Leelanau, MI 49653 

Phone: 231-256-0209 

E-mail: daldridge@bldhd.org 

197

STEPS AHEAD/WIC COORDINATION7

CULLMAN COUNTY, ALABAMA 

OVERVIEW

Location: Cullman County, Alabama. 

Start Date: Steps Ahead began about 10 years ago; collaboration with WIC in Cullman County 

occurred gradually—current staff were not able to say exactly when the process started.

Target Population: Low-income pregnant and postpartum women eligible for both Medicaid 

and WIC. 

Purpose: The purpose of the Steps Ahead program is to ensure that every pregnant woman has 

access to medical care, with the goal of lowering Alabama’s infant mortality rate and improving 

overall maternal and infant health. The program collaborates with WIC as one way to reach 

these goals. 

Services: In Cullman County, the Steps Ahead program is coordinated closely with WIC, as 

both programs are run out of the county health department. Staff coordinate initial appointments 

for WIC and Steps Ahead and do cross-referrals. In addition, Steps Ahead funds a home visit for 

high-risk women immediately after the birth. Among other services, the nurse who conducts 

these home visits is able to do WIC certifications or recertifications and to issue WIC food 

coupons to the new mother. 

Funding: The Cullman County Health Department is a subcontractor to Alabama Maternity, 

Inc., which operates the Steps Ahead Program. Services are billed to WIC or Steps Ahead as 

appropriate, including time spent on home visits. Staff are all state employees. 

Why Program Was Chosen: The program is an example of coordinated case management 

between WIC and Medicaid for pregnant and postpartum women, which sometimes results in 

delivery of WIC services via home visits. It also operates in a rural setting, where transportation 

to appointments can be a barrier. Specifically, appointments are coordinated, so women can 

receive needed services at the same time. Follow-up with no-shows is also coordinated. To 

augment the “one-stop services” further, families can also enroll in Medicaid at the Health 

Department. 

Key Challenges: About 10 percent of clients typically do not show up for their appointments or 

make an effort to reschedule, in part due to significant transportation barriers. 

 7

 Telephone interview, April 11, 2003. 
198

 

BACKGROUND 

Community Characteristics. Cullman County is a rural county in northern Alabama with 

a population of about 78,000 in 2001. It is largely agricultural but also has some manufacturing 

firms. The county is located halfway between Huntsville and Birmingham, about 45 miles from 

each. It has few minority residents (5 percent), unlike the state as a whole (30 percent). 

Although median income is slightly lower than that of Alabama overall, the percentage of 

residents in poverty is also lower (13 percent versus 16 percent for the state), based on Census 

data for 1999. 

Target Population. Pregnant and postpartum women who participate in both Steps Ahead 

and WIC receive coordinated services. Pregnant women who are on Medicaid and wish 

Medicaid to cover their maternity care and delivery are required to have their care coordinated 

through the Steps Ahead program, with coverage continuing for about 60 days after the birth 

(until the end of the month containing the 60th day). When pregnant women call in for a WIC 

appointment or an initial Steps Ahead appointment, they are scheduled for a joint intake for both 

programs, unless they have other medical coverage. 

WIC Program Background. In March 2003, the monthly WIC caseload in Cullman 

County included 350 prenatal women, 217 postpartum women, 122 breast-feeding women, 

31 exclusively breast-feeding women (no formula), and 672 infants. The county health 

department serves as the WIC agency and site of the only WIC clinic in the county. Three staff 

members work primarily on WIC—the WIC nutritionist, the WIC Coordinator (who is a nurse), 

and a WIC clerk. However, all nurses at the health department are trained to do WIC 

certifications, and all clerks are trained to issue vouchers. 

Program History and Objectives. Collaboration between WIC and Steps Ahead care 

coordination happened naturally in Cullman County because both programs were located in the 

health department and run by health department staff. In many areas in Alabama, WIC and the 

Medicaid maternity care coordinator are in separate locations, which makes it much harder to 

coordinate services. There are other communities in which the health department handles both 

functions, but they are not coordinated as in Cullman. 

PROFILE OF INNOVATIVE PROGRAM 

The Steps Ahead Program. In 1988, Alabama began the Alabama Medicaid Maternity 

Care Program (AMMCP), which established locally coordinated systems of care so that women 

on Medicaid would receive maternity services in environments that emphasize quality, access, 

and cost-effectiveness.8

 The purpose of the program is to ensure that every pregnant woman has 

8

 Until 1999, the AMMCP operated on a waiver system that had to be renewed every two 

years and relied on primary contractors for implementation. Primary contractors established and 

monitored delivery care systems, frequently subcontracting out to service providers. Primary 

contractors included hospitals, federally qualified health care centers, county health departments, 

and nonprofit organizations. However, in 1999, the state elected to convert the waiver program 

to a state plan option. This changed the waiver program to an operational program, which 
199

 

access to medical care, with the goal of lowering Alabama’s infant mortality rate and improving 

overall maternal and infant health. The AMMCP is organized into 14 maternity care districts. 

Cullman County is in District 5, which consists of nine counties. Services are provided by 

Alabama Maternity, Inc., and the program is known locally as Steps Ahead. 

Steps Ahead provides maternity care to women who choose to use Medicaid to pay for their 

maternity costs. Benefits include covered costs of maternity care, delivery, and hospital care. In 

Cullman County, there are two hospitals that provide primary care services for Steps Ahead 

clients. The care coordinator and registered nurse, who are health department employees, 

provide care coordination and health education services under a subcontract with the Steps 

Ahead program. During their pregnancy, women must see the care coordinator three times. 

Doctors will not see Medicaid patients for prenatal care unless they have a referral slip from the 

care coordinator. 

First, the care coordinator (also considered to be a social worker or case manager) completes 

a social assessment on a new program participant. Assessments are conducted at the health 

department, which also houses the local WIC agency. In fact, the staff focused on the two 

programs have adjoining offices. 

During the assessment, the care coordinator attempts to get a sense of “what is going on in 

the person’s life” so that she can determine if a home visit would be appropriate. Typically, a 

Medicaid client must be categorized as “high risk” to qualify for a home visit.9

 For example, 

women who qualify include those who are HIV positive, have a history of drug or alcohol abuse, 

suffer from a mental condition, have experienced domestic violence and/or child abuse, are late 

entrants for prenatal care, are expecting twins, or are under 20 years old and have two or more 

children.10 However, the care coordinator can use discretion if she thinks that a client warrants a 

home visit. For example, lack of transportation to a health care facility is a serious barrier for 

this rural county; there is only one private transportation company in the county, which is funded 

through a federal grant program. Medicaid participants can get travel vouchers to use the 

company’s vans free of charge. 

Frequently, the care coordinator knows from the start whether someone would qualify for a 

home visit (for example, a pregnant teen who already has a child or a woman who will deliver 

(continued) 

alleviated the need to renew the waiver every two years. This change led to a shift in program 

rules and the use of a different system of contractors. 

9

 Before 1999, home visits were required for all women—the visits were automatically a 

part of service delivery. After 1999, Medicaid revised their guidelines and developed criteria for 

home visits. However, officials included an “other” category that granted the care coordinator 

some discretion in requesting a home visit. 

10 Low birth weight is a common trigger for a home visit. However, the care coordinator 

remarked that the “home environment” (for example, domestic abuse, drug abuse) is a more 

common reason for a home visit than a medical condition. 
200

twins), but sometimes certain factors do not emerge until the second or third pregnancy 

appointment (for example, domestic abuse). Once the care coordinator determines that a client is 

at high risk, an appointment for a home visit is scheduled that will take place 10 to 20 days after 

delivery. The registered nurse conducts the visit, which involves a range of services. An 

average visit lasts 1 to 11⁄2 hours, and some last as long as 2 hours. 

During the home visit, the nurse measures the infant’s weight, height, and blood pressure, 

and asks a series of questions to make sure that the mother’s health—as well as the baby’s—is 

good overall. Most time is spent on this health assessment. If there is a medical concern, the 

nurse notifies the doctor from the home (or from the Health Department if there is not a phone) 

and makes an appointment. Otherwise, the doctor follows up with the patient directly. In 

addition to general health assessments, the nurse can provide selected WIC services (see next 

section below), make referrals to a variety of social services, discuss nutrition education, conduct 

family planning counseling, and counsel on breast-feeding. (Mothers have already decided 

whether they want to breast-feed or not, so she also can address issues such as latch-on 

problems.) Further, the nurse completes a questionnaire to evaluate the state of the home 

environment, which covers topics such as safety, income sources, presence of the father, and 

child care resources. The care coordinator collects these questionnaires and keeps them in the 

clients’ files. 

Program participants qualify for care coordination only for about 60 days after giving birth. 

Therefore, mothers must see the care coordinator for a postpartum appointment four to eight 

weeks after the home visit. During this “postpartum encounter,” the care coordinator verifies 

that the clients have kept their appointments with the pediatrician and obstetrician/gynecologist 

and are following up with their birth control method. The care coordinators also refers mothers 

back to the pediatrician if they are having trouble with breast-feeding, are dissatisfied with their 

formula, or are having any health problems.

How WIC Services Are Integrated with Steps Ahead. Co-location offers an opportunity 

to coordinate services more easily than in other maternity care districts throughout Alabama. 

The two programs have coordinated intake procedures. Therefore, new clients coming into WIC 

for the first time see a nutritionist for WIC certification and then see the Medicaid care 

coordinator, who can refer clients to hospitals, conduct social assessments, and make doctor’s 

appointments. Similarly, clients who come to see the care coordinator but are not on WIC have a 

WIC appointment set up as well. WIC and Steps Ahead have designated Wednesdays and 

Fridays as “New WIC Maternity Days.” Staff from both programs can do referrals on any day of 

the week, but these two days have been ‘tagged’ so that staff can anticipate clients coming in for 

multiple services. 

WIC and Steps Ahead also try to coordinate other appointments. Consolidated service 

delivery is especially helpful for participants who have trouble accessing transportation. Thus, a 

WIC client who comes in to pick up a food voucher can also have one of the three pre-delivery 

appointments with the care coordinator. A Medicaid caseworker is also on site to enroll eligible 

women and children in Medicaid. Staff work together to ensure that clients who qualify are 

enrolled in Medicaid and WIC and that they are receiving prenatal care. Staff from both 

programs verify when a particular client had her last WIC appointment (or maternity care 

appointment). According to the care coordinator, if a client has missed one type of appointment, 
201

 

chances are high that she has missed another. To prevent this, the coordinator and WIC 

nutritionist can make appointments for the other program (they share the same computer system). 

They also work together to track down clients. For example, if a client missed an appointment 

with the care coordinator, the coordinator flags her WIC card with a colored tab so that, if she 

comes into the WIC office, WIC staff know to notify the care coordinator that the client is in the 

building and should come to arrange an appointment. (A similar system is used by WIC staff.) 

Finally, the nurse who conducts the Steps Ahead home visits is trained to provide some WIC 

services during the visits. She can do certifications and recertifications. Most women that she 

visits have enrolled in the WIC program prenatally; only 2 to 3 percent of her caseload are new 

WIC certifications. The nurse does, however, process many recertification cases (that is, when a 

woman must be recertified in the transition between prenatal and postpartum, and the infant as 

well).11 She also can certify the infant. The nurse can also issue food vouchers to mothers and 

informs them that free breast pumps and breast pads are available at the WIC agency.12

Participation. The care coordinator for the Steps Ahead program has, at any given point, a 

caseload of between 250 and 300, but these figures do not include those who are due for “last 

appointments” postpartum. There are about 12 new WIC/Steps Ahead clients each week, and 

she refers 3 out of the 12 for a home visit. Overall, she estimates that about 95 percent of Steps 

Ahead patients receive WIC. 

ORGANIZATION AND MANAGEMENT 

Staff and Organizational Structure. The current maternity care coordinator, a licensed 

social worker, is the primary contact for the Steps Ahead Program.13 If doctors or hospital staff 

have questions or concerns, she is available for consultation. She also conducts the social 

assessments and all required appointments, principal and postpartum. The registered nurse 

assumes responsibility for conducting the home visits. The WIC coordinator ensures that the 

nurse receives any policy changes in the WIC program. The care coordinator works full-time on 

the Steps Ahead program. The registered nurse works partly on the Steps Ahead and partly on 

other health department programs, but home visits for Steps Ahead are her priority.

Funding. The Steps Ahead program is funded entirely with Medicaid dollars. The Health 

Department bills Steps Ahead (and they bill Medicaid) using a flat rate of $200 for three 

appointments with the care coordinator throughout the pregnancy and a postpartum session, and 

$60 for each home visit. They can also bill Medicaid if a client moves out of the district or has a 

miscarriage before completing all the visits. The amount of the fee depends on the number of 

11 Blood work may be completed at a later visit. 

12 WIC mothers of high-risk infants can borrow electric pumps, and manual pumps are 

distributed to keep. 

13 To be a care coordinator for the AMMCP, a person must either be a licensed social 

worker or a registered nurse. 
202

appointments with the care coordinator. If a client does not show up, the Health Department can 

bill for the visit if there have been three unsuccessful attempts to contact the client. The WIC 

program is charged for the part of the home visit involving WIC. 

ASSESSMENT AND LESSONS LEARNED 

Program Strengths. Program officials listed several program successes. First, clients often 

do not know about many of the resources that are available to them before meeting with the care 

coordinator. For example, many postpartum mothers do not know about child care subsidies. 

The care coordinator’s role in making referrals for a wide range of services is “a huge benefit.” 

The WIC coordinator thinks that the collaboration between Medicaid, Steps Ahead, and WIC 

helps ensure that clients enrolled in only one program, but qualifying for both, have access to all 

services. In her opinion, it is a “win-win situation for getting women on WIC, Medicaid, and 

prenatal care.” The registered nurse thinks that an important element of Steps Ahead home visits 

is early intervention, particularly detecting a problem before it develops into a more serious 

medical condition. 

Moreover, exit surveys that clients fill out after their postpartum appointment are forwarded 

to the main office, and these results have been overwhelmingly positive. 

Key Challenges. The biggest challenge cited by program staff was patient compliance—

having women come in for all scheduled appointments. About 10 percent of clients miss their 

appointments and do not make an effort to reschedule. Staff spend a lot of time trying to track 

them down, although coordination with WIC helps. Transportation is the main reason that 

clients have difficulties meeting their scheduled appointment. As long as clients keep their 

appointments, program staff have the necessary resources to meet their maternity care needs. 

They also see the coordination between WIC and Steps Ahead as proceeding smoothly. 

Lessons Learned. Staff felt that co-location has been a key factor to successful 

coordination between WIC and the AMMCP, especially in Alabama’s system of using private 

contractors to provide care coordination. They believe Cullman County is the only county in 

Alabama that integrates WIC with Medicaid maternity care coordination. In this case, the 

programs are operated through the same agency, and their proximity (and some cross-training of 

staff) allowed them to develop methods and strategies for working together to serve clients 

better. Having adequate staff and a strong commitment to the collaboration by staff of both 

programs was also important. 

Both Steps Ahead and the program in Michigan suggest that, when institutionally 

appropriate, including WIC services as part of home visits for high-risk mothers on Medicaid 

makes the visits more welcome to the mothers. In addition, coordination of assessments and 

follow-up visits increases participation in needed services and reduces burden on high-risk 

families. 
203

CONTACT INFORMATION 

Stacey Methvin 

Maternity Care Coordinator 

Steps Ahead Medicaid Maternity Program 

Cullman County Health Department 

601 Logan Avenue, SW 

Cullman, AL 35056-1678 

Phone: 256-734-1030 

Fax: 256-737-9646

E-mail: smethvin@adph.state.al.us 

205

WIC SERVICES IN WORKPLACES14

EASTERN BAND OF CHEROKEE INDIANS, NORTH CAROLINA 

OVERVIEW 

Location: Eastern Band of Cherokee Indians reservation in North Carolina. 

Start Date: Before 1991. 

Target Population: WIC participants who are members of the Eastern Band of Cherokee 

Indians and work on the reservation. 

Purpose: To improve access to WIC by bringing services to clients’ places of employment. 

Services: Receipt of food vouchers, assistance with completing WIC applications, follow-up 

nutrition contacts, and referrals. 

Funding: No additional funding for this initiative. 

Why Program Was Chosen: WIC staff provide certain services to clients at their places of 

employment, improving access in a rural area. WIC staff make arrangements with employers to 

offer services during employee breaks or lunch hours. This idea may be of interest to other 

agencies in rural areas or areas with large employers who employ many WIC clients. 

Key Challenges: Initially, clients often did not show up for appointments. Staff lost valuable 

time that they could have spent with other clients, and they had to reprint pre-dated food 

vouchers that were not claimed. Telephone reminders have reduced this problem. 

 14 Telephone interview, April 15, 2003. 
206

 

BACKGROUND 

Community Characteristics. The Eastern Band of Cherokee Indians (EBCI) covers 

88.5 square miles in five rural counties in western North Carolina; the largest tribal land holdings 

are in Jackson and Swain Counties. The population of the EBCI is 13,033, of whom 7,476 live 

on tribal lands. Tourism is a primary industry in the region, since the reservation borders the 

Great Smokey Mountains National Park. The WIC manager estimated that Indian craft stores 

and motels make up 80 percent of businesses on tribal lands, although they do not employ the 

most residents. The Tribe, Tribal Enterprises,15 and the casino hotel are the largest employers 

and provide year-round employment—with 930, 500, and 1,800 workers, respectively. 

WIC Program Background. The EBCI WIC program—staffed by a manager, a full-time 

nutritionist, a part-time nutritionist, a fiscal grants coordinator/administrator, and two clerical 

workers—had an average monthly caseload of 562 women, infants, and children in fiscal year 

2002 (about 100 cases per staff member, although the project manager and grants 

coordinator/administrator do not provide direct services unless filling in for an absent 

employee).16 In August 2003, there were 124 women enrolled in the WIC program. The WIC 

agency, which serves the entire EBCI, operates from 7:30 A.M. to 5 P.M. and is co-located in the 

Indian hospital, which is centrally situated on the reservation. This convenient location enables 

clients to attend WIC and maternity care appointments on the same day. WIC staff attempt to 

accommodate clients’ schedules by offering a walk-in clinic on Mondays, which offers the same 

services as during regular business hours. A satellite clinic operates on a monthly basis, but staff 

there only schedule appointments and process paperwork for clients.

Staff can also make referrals to the hospital’s health care clinic. If during an appointment 

the WIC nutritionist detects that the mother is not getting appropriate health care for her child—

particularly during the first year after birth—she makes a well-child appointment at the hospital. 

The nutritionist can also encourage expectant mothers to schedule their initial prenatal 

appointment at the health care clinic. 

Program History and Objectives. Program officials instituted service delivery in work 

sites to make it more convenient for WIC clients to receive services, which were available only 

during typical business hours. At that time, the region faced high unemployment rates and 

offered few employment opportunities. The primary employers, a craft factory and a textile 

plant, were fairly strict about allowing their employees to leave in the middle of a shift for a WIC 

appointment. Because workers received minimum wage and could not afford to take unpaid 

leave during the regular work day, many of them—about half—opted to skip WIC appointments. 

WIC program staff decided to negotiate with the owners of the two factories and a small 

casino to create an agreement that would help deter employees from forfeiting needed services. 

As a result, staff could visit the work sites on Wednesday mornings and meet with clients in the 

15 Tribal Enterprises includes the hospital, schools, and the Boys Club. 

16 Caseload is from [www.fns.usda.gov/pd/wifypart.htm], accessed September 24, 2003. 
207

break rooms. Initially, the only service that WIC offered at employment sites was delivering 

food vouchers to participants. 

Target Population. Members of the EBCI who participate in WIC are eligible to receive 

WIC services in their places of employment if their work sites are located on the reservation. 

The service delivery area includes Cherokee, Graham, Haywood, Jackson, and Swain Counties 

in North Carolina. About 45 percent of EBCI WIC mothers work, either full- or part-time. 

Although the WIC manager has received requests for workplace services from EBCI members 

who work in the small towns that border the reservation, they do not qualify, because they fall 

outside the EBCI’s jurisdiction. 

PROFILE OF INNOVATIVE PROGRAM 

Services Provided. A WIC nutritionist and clerk deliver selected services in places of 

employment. While initially WIC distributed food vouchers for only one or two months at a 

time, the program expanded services in the mid-1990s. Clients now can obtain three months of 

food vouchers and receive assistance in filling out a WIC application. The nutritionist can refer 

clients to the diabetes clinic, the dental clinic, the food stamp program, the Food Distribution 

Program on Indian Reservations, Head Start, Medicaid, or the Children’s Health Insurance 

Program, as appropriate. While she cannot make well-child appointments on site, she 

encourages clients to call her at the main office to remind her to schedule an appointment for 

them. In addition, the nutritionist can conduct follow-up nutrition education contacts with lowrisk clients. (These second contacts can include information for children, although children are 

not present at the work sites.) Examples of low-risk topics include weaning, healthy snacks, 

folic acid, solid foods, dental care, 5-A-Day, and physical exercise. However, certifications, 

recertifications, and prenatal nutrition education sessions must still take place at the WIC agency. 

The WIC nutritionist and clerk make rounds to various work sites each Wednesday from 

9:30 A.M. to 12 noon. Staff do not follow a formal schedule (such as serving the tribal 

administrative offices on the first Wednesday of each month), but instead schedule clients for the 

next available and most appropriate date. They also track which clients need food vouchers. 

This allows WIC staff the flexibility to meet the needs of clients based on their demand for 

services. Individual sessions generally last 10 to 15 minutes. On any given Wednesday, staff 

visit one to six workplaces.

Because pre-dated food vouchers are printed ahead of time, clients must make appointments 

in advance through the main office or a satellite office. The nutritionist can answer quick 

questions from those who are not on the schedule, but otherwise she directs clients to make an 

appointment or attend the walk-in clinic on Mondays. Because appointments are frequently 

made several months in advance, the clerk mails reminder notices in advance and telephones the 

client the day of the scheduled appointment to remind them of the session and verify that they 

still work for that employer, and that they are not absent. If the client is not available, then the 

food vouchers are not printed and the appointment is cancelled or postponed. 

WIC has expanded the number of workplaces where it delivers services throughout the 

1990s. The textile plant shut down, but employment opportunities in the region have grown over 
208

 

the past several years, including jobs in the tribal government and in small craft stores that cater 

to tourists.17 Employers in the service delivery network include five day care facilities, two 

restaurants, Cherokee Elementary School, Cherokee High School, several motels, an office 

supply store, an arts and crafts co-op, seven tribal offices (the health and medical, housekeeping, 

finance, legal, construction, and extension services divisions, along with the visitor’s center), 

Cablevision, the Bureau of Indian Affairs, the Department of Housing and Urban Development, 

and a new tribal office complex that houses multiple programs, a library, and a wellness center. 

Participation. The proportion of WIC clients who take advantage of service delivery in 

places of employment is small as compared to overall enrollment. From January 1 to September 

10, 2003, WIC staff visited 43 work sites and provided services to 102 WIC participants. Thus, 

they served about 13 clients a month (and/or their children), out of a caseload of 562. 

Coordination and Collaboration. For this initiative to succeed, employers must be willing 

to allow WIC staff to visit their places of employment to deliver services. The WIC manager 

reported that most employers are quite flexible with their employees’ work schedules to 

accommodate short appointments during regular business hours and permit employees to meet 

with WIC staff on site. Workers at a local factory can arrange to meet the nutritionist and clerk 

in the break room, and tribal government workers can meet with staff at their desks most of the 

time. If a client interacts frequently with the public (for example, as a sales clerk in a craft store) 

and is busy when the nutritionist arrives, the nutritionist can either wait for a lull in business or 

arrange to return to the store later that day. At the local Head Start program, the lead teacher and 

teacher’s assistant take turns meeting with WIC staff outside the classroom. 

Publicity and Outreach Efforts. Because the EBCI reservation covers a small geographic 

area, residents learn about the WIC program and its service delivery in work sites entirely 

through word of mouth. The WIC manager noted that available social services are “known 

entities” in the community, especially since many families have lived on the reservation for 

generations. Other organizations will refer clients to the WIC program if they are not 

participating, but there is no formal referral or marketing process for the work site service 

delivery option.

ORGANIZATION AND MANAGEMENT 

Staff and Organizational Structure. A full-time nutritionist and one of the clerical 

workers conduct the service visits to the work sites. The WIC manager, who has a bachelor of 

science degree in nutrition and dietetics, can fill in for the nutritionist if needed. The nutritionist 

17 A larger casino replaced the small one in 1998 and ceased on-site WIC service delivery. 

The management is quite strict and would not permit employees to alter their break schedules to 

accommodate WIC appointments. However, the WIC manager does not think that a substantial 

number of casino employees miss critical services, since many of them earn high enough wages 

to make them ineligible for WIC. Furthermore, many casino employees work evening hours, 

which makes it possible for them to come to WIC in the daytime. 
209

handles the low-risk nutrition contacts, makes referrals, and assists with completing WIC 

applications, while the clerk oversees the distribution of food vouchers. 

Funding. No additional funding is required to implement the service delivery at local 

businesses on the reservation. Rather, staff adjust their labor efforts to alternative locations as 

opposed to delivering services solely at the traditional clinic sites. The WIC manager predicted 

that the work site initiative will continue indefinitely as long as there is a demand for the service. 

ASSESSMENT AND LESSONS LEARNED 

Program Strengths. According to the WIC manager, the biggest success of the initiative is 

that scheduling sessions in work sites greatly eases burden for clients. They no longer must take 

time off from work—often unpaid—to complete routine WIC visits, such as submitting program 

applications, collecting food vouchers, and receiving second nutrition education contacts and 

referrals. 

While the WIC manager has not administered a formal survey to collect feedback, informal 

comments suggest that clients appreciate the option of service delivery in places of employment 

and would like to see the alternative system continue.

WIC staff think that the initiative is running smoothly. The only thing that the manager 

would change if her staff had adequate time and resources would be to assist clients who live and 

work in small towns that border the reservation and have requested WIC services at their work 

sites. Most—but not all—of these people are EBCI members, but they work outside the 

reservation and thus do not qualify. This anecdotal evidence suggests that residents in other rural 

areas might welcome the opportunity to receive certain WIC services at work.

Key Challenges. The WIC nutritionist and clerk encounter very few ongoing challenges in 

meeting clients at their places of employment. With the exception of the large casino that 

opened in 1998, business owners and supervisors have welcomed the on-site services. Initially, 

staff frequently wasted valuable time by arriving at a site only to discover that the employee was 

sick or on vacation, or had resigned. Further, it became necessary to reprint pre-dated food 

vouchers, which the clerk needed to generate in advance of the appointment. As a solution, in 

2001, they began to call a day or two in advance to confirm the appointment. Now a clerk calls 

the morning of the scheduled appointment before printing the food vouchers or visiting the work 

site. 

Lessons Learned. This WIC initiative is potentially replicable, though the extent to which 

it could be replicated in other regions would depend upon how receptive employers and clients 

were, the population’s size and geographic parameters, and caseload levels. 

If a client does not work in an environment conducive to a flexible break schedule—such as 

an administrative office with minimal public interaction—then WIC staff would need to 

negotiate with the supervisor to arrange a time period to conduct appointments. Clients would 

also need to be willing to receive services at work, where their privacy could be compromised (at 

least in that their employer and coworkers would know they participate in WIC). 
210

Moreover, implementing a comprehensive service delivery system in work sites could be 

easier in rural areas as opposed to urban centers in some situations, but not in others. In 

metropolitan areas, a larger volume of clients would require that WIC staff be selective and 

concentrate on a core group of employers, which may eliminate some clients from this service, 

depending on where they work. At the same time, not as much travel time would be needed in 

urban centers, whereas great distances in rural regions could limit the number of work sites 

visited. The EBCI WIC manager also noted that a sizable portion of clients may work second 

and third shifts. Determining where clients are employed, and whether they work during regular 

business hours, would help program officials plan services. 

CONTACT INFORMATION 

Teresa Bryant, WIC Manager 

Eastern Band of Cherokee Indians WIC Program 

P.O. Box 1145 

Cherokee, NC 28719 

Phone: 828-497-7297 

E-mail: terebrya@nc-cherokee.com 
211 

V. CONCLUSIONS 

This report has described 20 promising WIC initiatives in 12 states, which are in five of the 

seven FNS regions. The programs vary considerably in the services delivered, target 

populations, and staffing, as well as in the scale of operations of the state or local WIC agencies 

that developed them. In this chapter, we consider what we can learn from these programs. In 

particular, we focus on the following questions: 

• What are the sources of innovative ideas? How do these ideas become reality? 

• What do these programs suggest about the implementation of similar programs? 

What contrasts among the programs may deserve further study? 

• What types of funding do innovative programs use? How do programs with outside 

funding or special WIC funding differ from those funded using only WIC Nutrition 

Services and Administration (NSA) funds? 

• To what extent is there evidence that the initiatives are well implemented or result in 

positive outcomes? If evidence is not available, why not? Would it be feasible to 

design an evaluation to test the effect of some of these initiatives? 

• Can these programs be replicated? What types of adaptations would be needed? 

We emphasize that we have not conducted a formal evaluation of these programs—for the 

most part, we cannot assess their impacts. (We discuss the available evidence concerning 

impacts below.) What we can say is that the programs have useful goals, are being implemented 

largely as planned, and are well received by staff and clients. Their approaches seem carefully 

thought out, and other WIC agencies may find their materials useful. Thus, some may be worthy 

of replication and more rigorous study of their impacts on key outcomes such as breast-feeding 

rates, children’s body mass index (BMI), and the extent to which families adopt healthy eating 

practices (for example, using lowfat or fat free milk for children age 2 and older or consuming at 

least five servings of fruits and vegetables per day). 

A. SOURCES OF INNOVATION 

Most of the programs we studied were conceived and developed by the state or local WIC 

staff who administer them, yet other stakeholders often made important contributions to program 

planning. In many of the state initiatives, state staff obtained ideas and feedback on plans from 

the local level. In local initiatives, agency leaders innovated in varied circumstances, but two 

seemed most common: (1) to take advantage of outside funding sources to expand services, or 

(2) to stretch scarce resources farther. Programs with outside funding were sometimes 

developed, at least in part, outside of WIC, or reshaped to meet the funders’ needs. 

State staff developed new initiatives in response to needs they formally or informally 

identified. They also gathered information on related programs at professional conferences and 
212 

 

from other state WIC or public health agencies. For example, Michigan staff decided to conduct 

training in facilitated group discussion based on their perception that nutrition education was 

“stale” in the state, as well as a presentation on the topic that they heard at a National WIC 

Association meeting. The California pediatric nutrition training was modeled after a university 

training program for nutritionists and dietitians working in pediatric environments. Regardless 

of the source of inspiration, it often took one or a small group of dedicated, enthusiastic staff to 

make the new initiative happen. 

Many of the state-level initiatives profiled in this report involved collaborative efforts 

between central-office state staff and local or regional staff to decide on new approaches and 

develop new materials. In particular, three states—Michigan, Oklahoma, and Pennsylvania—

mentioned relying on nutrition education committees, which consisted of both local and state 

nutrition education staff, to develop or review materials for the new initiative.1

 For example, 

Oklahoma WIC used its Nutrition Education Focus Group (made up of local staff with state staff 

facilitating) to build support for and review materials for the Get Fit With WIC initiative through 

quarterly meetings. In Pennsylvania, several local agency nutrition education coordinators are 

part of a nutrition education committee and have a monthly conference call with the state 

coordinator to provide feedback on nutrition education initiatives, including the Obesity 

Prevention Modules. Another approach to obtaining local feedback is to involve state employees 

responsible for particular regions (who are in close touch with local agencies in their region) to 

provide feedback on the initiative. Managers reported this approach was helpful in the 

Wisconsin bilingual training program, the Alabama initiative to prevent early childhood caries, 

and the Oklahoma Get Fit With WIC initiative. 

At the local agency level, leaders developed innovative programs in response to local 

service needs, the local funding environment, and their relationships with other stakeholders. 

For example, the three California county breast-feeding initiatives (in Alameda/Contra Costa, 

Riverside, and Sacramento counties) used outside funding sources to build on services already 

available. Staff at these large agencies had the time and skills to develop detailed funding 

proposals. In contrast, one manager creatively working with limited resources implemented the 

volunteer peer counseling program at Community Action Southwest in Pennsylvania. 

Coordination of service delivery between WIC and home visiting programs for Medicaid highrisk mothers in several northwest Michigan counties was a product of tight funding, an 

institutional structure in which both programs fell under the same management, and staff who 

worked together to make services more seamless for their clients. 

Furthermore, outside partners involved in funding programs—particularly the programs we 

would consider “WIC Plus”—often contributed to the program’s design. In two cases, the 

original idea was developed to some extent outside of WIC: (1) the Alabama dental program 

(initiated by and funded in part by the State Oral Health Branch); and (2) the Los Angeles area 

CARE program (funded by NIAAA and initiated by UCLA staff, one of whom also works at 

PHFE-WIC). In other instances, the WIC staff modified the original purpose or design of the 

1

 Other states may have such committees, but the states noted are those that mentioned a 

committee’s role in providing feedback on, and building support for, the initiatives. 
213 

initiative in response to the requirements of outside funders. For example, both the Berkeley and 

Riverside breast-feeding programs agreed to serve all mothers in a certain area or served by a 

certain hospital as a condition of their funding. Programs with March of Dimes funding agreed 

to provide some of the March of Dimes’ materials. These were changes the program officials 

were willing to make. 

B. IMPLEMENTATION LESSONS 

These 20 initiatives suggest preliminary lessons for those interested in implementing similar 

programs. They also suggest some implementation issues that may be worthy of more research 

and experimentation. 

1. Lessons from Breast-Feeding Programs 

We first discuss lessons from the implementation of breast-feeding peer counseling 

programs, since Congress has recently providing funding that targets such initiatives. We then 

discuss lessons from other breast-feeding programs and some issues for future research. 

a. Lessons from Peer Counseling Programs 

In designing a peer counseling program, it is important to develop a job description, a 

recruitment and retention strategy, guidelines for supervision and documentation, and good 

relations between the WIC staff and peer counselors. More specifically, as peer counseling 

programs are now eligible to receive special funding, it is important to define what exactly can 

be considered a peer counseling program, as great variety currently exists in the hours, 

compensation, training, and duties of peer counselors. The basic qualifications for peer 

counselors—enthusiastic current or former WIC participants with breast-feeding experience—

are well established, but there may also be variation in additional requirements for the job. 

Several officials who operate peer counseling programs (particularly those that are volunteer 

or part-time) report that it is becoming more challenging to recruit and retain peer counselors 

because welfare reform has led more WIC mothers to enter the workforce on a full-time basis. 

Possible strategies for addressing this challenge are (1) to design a full-time peer counselor 

position with adequate pay and benefits, or (2) to allow peer counselors to work by telephone 

during evening hours, so that mothers could work another job and also be peer counselors for a 

few hours a week. Recently, USDA has expressed interest in supporting fathers of breast-fed 

infants. The Texas peer dads program, however, has had difficulty finding peer fathers who can 

be at the clinics because most work full-time. This situation could become increasingly common 

among women. 

However, many peer counselors, even those who worked as volunteers, found they gained 

valuable skills in this position that allowed them to move on to full-time or better-paying jobs. 

Given this experience, another strategy would be to develop a career ladder from the peer 

counselor position to a permanent job with WIC or a related agency. After a career ladder is 

established, an agency might expect that peer counselors would work only a year or two, but that 
214 

the training investment would remain useful as they move on to another position. This career 

ladder could also be used as a recruitment tool for the peer counseling program. 

Peer counselors need adequate supervision, clear protocols, and sufficient literacy skills to 

maintain WIC clients’ records. In general, supervisory staff members report that the few peer 

counselors who did not work out had difficulty keeping up with paperwork or would “wing it” 

when they did not know something, instead of seeking assistance from the supervising lactation 

consultant or other WIC professionals. Although the programs profiled do not have formal 

educational requirements for peer counselors, the extensive training programs could be serving 

as a literacy screen. Some programs reported one-third to one-half of prospective counselors did 

not complete the training. 

Peer counselors may be more effective and satisfied if regular WIC staff (such as nurses, 

nutritionists, and clerks) understand the peer counselors’ roles and value their work. For 

example, some managers reported their staff questioned whether peer counselors who sat and 

nursed their babies in the WIC waiting room were really working, not realizing that modeling 

breast-feeding and talking to other WIC mothers is their job. 

b. Other Lessons from Breast-Feeding Programs 

Most of the promising breast-feeding programs we studied (whether they use peer 

counselors or not) emphasize three services, above and beyond the prenatal classes and 

counseling that most clinics provide: 

1. Contacting the mother in-person or by phone within the first two weeks after birth 

(often, while in the hospital). 

2. Making help available within 24 hours when a problem arises. Ideally, help is 

available by telephone 24 hours a day and in person during office hours for more 

severe problems. However, some programs have only in-person help available, 

some have only telephone help available, and some cannot return calls received in 

the evenings or on weekends until the next business morning. 

3. Providing follow-up calls to breast-feeding mothers at regular intervals after the 

birth, rather than waiting for them to call in—many mothers are too overwhelmed to 

call themselves. 

In addition to services in these three areas, outreach to community health providers is a 

desirable part of a WIC breast-feeding program, so that women receive a pro-breast-feeding 

message wherever they receive services. It also is a mechanism for changing the image of WIC 

among health providers from “WIC is where to get formula” to “WIC makes breast-feeding 

easy” (the slogan of the Miami-Dade breast-feeding program). Transforming how stakeholders 

perceive the program may, in turn, improve referrals to WIC. However, as the discussion of the 

Miami-Dade program shows, such outreach is hard to do with current WIC NSA funding, even 

in large agencies—those programs most successful in doing outreach have non-WIC funding. 
215 

c. Questions for Future Research 

The breast-feeding initiatives described in this report raise important questions: 

• How effective is telephone support alone versus providing breast-feeding support 

both in person and by telephone? Telephone support has obvious cost advantages, 

and it is certainly better than no support, yet the physical nature of breast-feeding 

suggests that in-person support may be very important in some situations. 

• What are the most appropriate tasks for peer counselors? One possible approach to 

examining this is to compare programs that use peer counselors in different ways. 

States such as Texas with large, varied peer counseling programs may provide a 

natural laboratory for studying this issue, as they may allow researchers to find 

similar areas with different roles for peer counselors. 

• Should peer counselors be regular employees, temporary employees, contractors, or 

volunteers? Regular employees would be easier to recruit and retain, and it may be 

easier to create a career ladder for them, but they are the most expensive. Temporary 

employees or contractors may have more flexibility to work the number of hours they 

feel comfortable, if peer counseling is a second job, and are less expensive, as they 

generally do not receive benefits. Volunteer status is useful if the program is funding 

constrained. Volunteering is also an option if potential peer counselors do not want 

to work because of concern about losing welfare benefits or cannot work because of 

immigration status. However, regular staff may see temporary workers or volunteers 

as a threat. Similarly, combining paid and volunteer peer counselors may create 

tension, as occurred in the Miami-Dade program. 

2. Lessons from Nutrition Education Programs 

Substantial consensus exists that traditional WIC nutrition education needed improvement in 

both style and substance. The initiatives reviewed in this report focused on (1) improving 

methods for conveying information; (2) broadening the audience for nutrition education to 

include children and non-English speakers; and/or (3) updating the content of nutrition education 

to reflect changes in nutrition knowledge, new concerns about obesity, and changes in foods 

available, particularly infant formulas. We first discuss lessons from implementation of new 

nutrition education approaches, followed by lessons regarding staff training and possible areas 

for future research. 

a. Lessons Regarding Nutrition Education Approaches 

Several programs have implemented interactive approaches to nutrition education, which 

seem promising because they are more fun both for staff and clients and may motivate clients to 

show up for their nutrition education sessions more often. In addition, these approaches seek to 

be more effective in encouraging behavior change. Changing from a lecture-style format to 

facilitated group discussions, for example, allows clients to share and affirm their experiences, 

while staff address misconceptions, introduce a few key messages, and ask participants to 
216 

commit to a change in behavior. In Michigan, the Learn Together training taught local WIC staff 

how to use and train others in the facilitated discussion approach. Instead of providing specific 

curricula for discussions, state-level staff encouraged local agencies to develop their own 

discussion plans using a specific template. Staff in Oklahoma and Pennsylvania also received 

training in this method, along with new curricula. 

The Get Fit With WIC initiative in Oklahoma, the project to prevent early childhood caries 

in Alabama, and the Florida Mooove campaign also included interactive materials and 

incentives. More specifically, the waiting room often had displays that could be examined and 

manipulated. For example, Florida used test tubes to indicate the amount of fat in different types 

of milk, and Oklahoma’s WIC waiting rooms included learning tables for children. Incentive 

items linked to the programs’ messages were common, especially in Oklahoma (beach balls, 

magnets, stickers) and Alabama (toothbrushes and toothpaste). These items add fun to learning 

and can help clients remember key messages. 

Several initiatives involved WIC children in nutrition education activities, which also makes 

nutrition education more fun and engaging for staff and parents or caregivers. In both the 

Alabama and Oklahoma initiatives, puppet shows were used to convey key messages. Although 

it is not clear how much the children retained, these activities are also important in modeling 

positive behaviors for parents. For example, some activities involved reading a children’s book 

about food with a group then giving each child a copy of the book to take home—this fosters 

literacy at home, while reinforcing healthy eating habits. In Oklahoma, children were also 

involved in play and movement activities, which helped show and reinforce to parents that active 

play is the most age-appropriate physical activity for preschoolers. 

Another promising development in Alabama and Oklahoma is collaboration with local Head 

Start programs. WIC staff present nutrition-related puppet shows or activities to children 

attending Head Start programs in some areas of the state. By working with children attending 

Head Start, many of whom participate in WIC, staff may reach more WIC children. WIC staff 

also can model the presentation of positive nutrition messages to Head Start staff. 

b. Lessons Regarding Staff Training 

Direct training in content is useful, as the science is changing rapidly in many areas of 

nutrition, including obesity prevention, the understanding of the benefits of breast-feeding, and 

the available types and new formulations of formula. Traditionally, professionals were expected 

to keep up with the current literature more or less on their own, but many of the reviewed 

initiatives included content-focused staff training. Examples include the formula training for 

WIC nutritionists and dietitians in California and the statewide conferences for WIC staff 

emphasizing obesity prevention in Oklahoma and Pennsylvania. (Although the Pennsylvania 

conference was not specifically on the Obesity Prevention Modules, it presented a lot of 

information about childhood obesity and its implications as a foundation for the implementation 

of this initiative.) 

Staff training may also be needed to implement new approaches effectively. In 

Pennsylvania, state agency staff regretted that they had not done in-person training in the Obesity 
217 

Prevention Modules because of resource constraints. Training was left to local nutrition 

education coordinators. The state staff reported that some local agencies had implemented the 

modules much more than others. 

To successfully introduce new training curricula or new client materials and curricula for a 

state initiative, state WIC agencies need to follow up at the local level to make sure the new 

approach, curricula, and materials are being used (and used appropriately) and to provide 

additional assistance to those who need it. Nutrition education committees can help, as they 

provide regular feedback to the state agency. State staff also observe nutrition education during 

regular program reviews and review nutrition education plans that local agencies have 

developed. 

Another way to monitor implementation is to adapt data systems to track the types of 

nutrition education contacts made. For example, when they developed the Learn Together 

training, Michigan WIC staff also arranged for a code for facilitated group discussion to be 

added to the state data system. A further step that might be useful would be to develop a 

standard report that assessed use of this method versus other nutrition education methods. 

c. Questions for Future Research 

The nutrition education initiatives profiled here suggest the following questions for future 

research: 

• Are the new approaches to presenting nutrition education to clients more effective 

than a lecture-style class in changing knowledge, attitudes, and behavior? As 

discussed further below, rigorous evaluation of these questions is much more feasible 

than for other types of WIC practices. 

• Is formal staff training to present new content or techniques a useful investment? 

Is it effective to reduce the cost by using train-the-trainer sessions or 

videoconferences? Or would it be better to use (only) other types of resources—such 

as Web sites, listservs, or hotlines—to give WIC staff the information they need? 

• Does participation in nutrition education increase when more interactive methods 

are used? Such an outcome would imply that more clients are at least hearing key 

messages. 

3. Lessons from Service Delivery Programs 

The innovations in service delivery examined in this report have the goal of improving 

access to WIC for those with barriers of time or distance, such as working parents and those in 

rural areas or other situations where transportation is not readily available. 

Two of the programs reviewed—those in Cullman, Alabama, and northwest Michigan—

incorporate WIC services into Medicaid-funded home visits as part of a broader, coordinated 

effort between WIC and Medicaid-funded care coordination for high-risk pregnant women and 
218 

 

infants. This collaboration seems to work well, in part because both programs are operated by 

the same agency and are co-located. However, this may not be feasible in places where two 

different agencies operate the programs, as has become more likely under Medicaid managed 

care. It would be interesting to learn whether there are examples of successful coordination 

between WIC and Medicaid managed care providers and, if so, whether such partnerships 

include home visits. 

Workplace delivery of WIC services is not an option in all circumstances, but the program 

of the Eastern Band of Cherokee Indians suggests it may be worth considering, as more WIC 

participants are working full-time. In particular, it may be applicable in rural areas with few 

employers or other places where large concentrations of WIC participants work for a single 

employer. Privacy and logistics, such as having a private space to meet, can be challenges. 

However, WIC clinics have been established successfully in schools, which are the “workplaces” 

of teenage mothers—these programs may be useful models. Furthermore, employers should 

have some interest in cooperating, since a visit to a WIC nutritionist at work during a break can 

be much less time-consuming than taking off from work to go to an off-site WIC clinic. 

C. FUNDING SOURCES 

The interventions and training programs described in this report have a variety of funding 

sources, but they fall into three major categories (Table V.1): 

1. WIC Plus—interventions with substantial outside funding (and often including 

services that go beyond WIC). The programs that provide home visits in cooperation 

with Medicaid care coordination are counted in this group, as the home visits are 

largely paid for by Medicaid funds. 

2. Interventions with special WIC funding from the state, regional office, or central 

USDA. For example, some of the programs received large grants from WIC 

operational adjustment or infrastructure funds from USDA, others from their state 

agency. 

- Operational Adjustment Funds—the FNS regional offices allocate operational 

adjustment funds.2

 The Oklahoma and Texas programs each received large 

grants. The expansion of PITS in Hawaii, a fairly small-scale program, 

received a modest grant. 

2

 FNS regional offices retain 10 percent of NSA funds allocated to the state agencies in their 

region to use for regional priorities; these are called “operational adjustment” funds. Some of 

these funds may be awarded to states through a competitive proposal process. 
219 

 

- Infrastructure Funds—Modest grants supported the planning and startup of the 

Wisconsin Bilingual Training program and were among several funding 

sources for the Alabama Prevention of Early Childhood Caries initiative.3

- State-allocated Funds—Riverside County received a “best practices grant” 

from the California State WIC agency for its “Lunch and Learn” program, 

above and beyond standard NSA funding. 

3. Interventions with little or no special funding 

It may be difficult for other WIC agencies to replicate programs with substantial outside or 

special WIC funding, if such resources are not available. In some cases, however, the wellfunded initiatives have developed materials that other WIC agencies can adopt at much lower 

cost. In addition, other agencies may find specific elements of these initiatives’ services 

applicable to their needs, even if they cannot afford to implement all the services. 

Among the initiatives profiled, those that rely only on WIC NSA funds are generally more 

modest. Some are inexpensive, because they can be incorporated into existing local staff’s 

activities, such as the Toledo-Lucas County breast-feeding class for teens, and the Arkansas and 

Hawaii breast pump programs. Some programs, such as the volunteer peer counseling program 

in southwest Pennsylvania, are developed specifically because funding is tight. In contrast, in 

large state or local agencies, the scale of the WIC program overall may make it possible to 

implement more expensive WIC initiatives with NSA funds—such as the California pediatric 

nutrition training for RDs (which involves several dedicated staff positions) or the Miami-Dade 

County breast-feeding support program. Furthermore, in many states (particularly large ones), 

some state staff members have program development among their regular responsibilities, so that 

tasks such as development of training materials are not seen as an extra cost. 

In addition to funding constraints, staff time constraints are significant barriers for some 

nutrition education programs, as systems are set up so that WIC appointments are brief. Thus, 

adopting new nutrition education programs can require changes in WIC infrastructure (such as 

state performance standards or scheduling software). 

D. OPTIONS FOR EVALUATION 

This section summarizes what is known about the effects of the initiatives profiled in this 

report, as well as considerations for designing future evaluations of these or similar programs. 

3

 Under current law, the Secretary of Agriculture is awarded a pool of WIC funds to allocate 

for various purposes, including strengthening of WIC infrastructure. 
220 

TABLE V.1 

FUNDING SOURCES FOR WIC INITIATIVES 

Special WIC Funding 

Program Name State

Outside 

Funding 

Operational 

Adjustment Infrastructure State 

Steps Ahead/WIC Coordination—Cullman 

County AL 9

WIC Nutrition Education Model for Prevention 

of Early Childhood Caries AL 9 9

Breast Pumps for Mothers of Premature or 

Seriously Ill Infants AR 

Cease Alcohol Related Exposure (CARE) CA 9Expanded Breast-Feeding Peer Counselor 

Program CA 9

Loving Support Breast-Feeding Helpline—

Riverside County CA 9 

Lactation Consultant Services—Sacramento 

County CA 9

WIC RD: Adjunct to Pediatric Health Care CA Breast-Feeding Promotion and Support 

Program—Miami-Dade County FL 

Mooove to Lowfat or Fat Free Milk Campaign FL Pumps in the Schools (PITS) HI 9Coordination of WIC with Maternal and Infant 

Support Services MI 9

The Learn Together Approach MI 
TABLE V.1 (continued) 

221 

Special WIC Funding 

Program Name State

Outside 

Funding 

Operational 

Adjustment Infrastructure State 

WIC Services in the Workplace—Eastern Band 

of Cherokee Indians NC 

Infant Feeding Classes for Pregnant Teens OH Get Fit With WIC OK 9Obesity Prevention Modules PA Telephone Peer Counseling by Volunteers PA Breast-Feeding Peer Counselor Program TX 9Bilingual Training Program WI 9Note: All programs were funded in part by WIC NSA funds. NSA = Nutrition Services and Administration. 
222 

 

1. Current Evidence Concerning Outcomes 

Among the 20 programs examined, there was a rigorous impact evaluation in only one—the 

CARE program to screen for alcohol consumption among pregnant WIC mothers. In general, 

evidence of program impacts on nutritional and health outcomes is somewhat weak. 

a. Evaluation Approaches 

In most instances, the program was judged to be effective based on comparison of desired 

outcomes before and after the intervention occurred (particularly when the outcomes were 

measures that the programs already collected), with little or no controls for other factors that may 

be responsible for observed trends. For example, staff for many of the breast-feeding initiatives 

reported that breast-feeding rates had increased among their clients since the intervention started. 

However, breast-feeding rates have been increasing nationally, so it is possible that other factors 

are associated with the increases noted, besides the WIC initiative (Abbott Laboratories 2003).4

In other initiatives, the outcomes are sufficiently narrow that it seems unlikely factors other 

than the intervention are responsible for the trends. For example, it seems plausible that the 

formula training in California is at least partly responsible for the reduction in use of noncontract 

formulas that occurred. Similarly, initiatives to train staff in a new approach to nutrition 

education often judge their success simply by whether the new approach is in fact used 

consistently, which seems a valid measure as far as it goes (but does not address the ultimate 

outcomes of nutrition education). 

In a few instances, agencies compared outcomes in clinics with and without the intervention 

available, but without controlling for (or only partly controlling for) other differences between 

the two sets of clinics. 

More surprisingly, many of the programs studied had not tried to assess outcomes or 

impacts, at least so far—some mentioned plans to do so in the future. In these initiatives, they 

often judged the success of the initiative by the enthusiasm of staff and clients, which are 

probably necessary but not sufficient conditions for impacts. In all fairness, however, some of 

the interventions are sufficiently inexpensive and small (and have sufficient face validity) that a 

formal evaluation may not make sense. Examples include the teen breast-feeding classes in 

Toledo and the breast pump program in Arkansas. Table V.2 shows the extent of evaluation in 

each of the 20 programs. Most programs had not conducted formal evaluations with written 

reports; instead, the categories in Table V.2 characterize the types of information staff used to 

demonstrate that their program was successful. 

4

 On the other hand, the work of WIC and other agencies on breast-feeding promotion may 

be at least partly responsible for the national trend. 
223 

TABLE V.2 

EVALUATION APPROACHES USED 

Program Name State

Experimental

Design 

Comparison

Group 

Design 

Pre/Post 

Trend 

Comparison 

Clien

St

Satisf

Steps Ahead/WIC Coordination—Cullman County AL 9WIC Nutrition Education Model for Prevention of 

Early Childhood Caries AL 

Breast Pumps for Mothers of Premature or 

Seriously Ill Infants AR 9 9

Cease Alcohol Related Exposure (CARE) CA 9Expanded Breast-Feeding Peer Counselor Program CA 9 Loving Support Breast-Feeding Helpline—

Riverside County CA 9 

Lactation Consultant Services—Sacramento 

County CA 9 

WIC RD: Adjunct to Pediatric Health Care CA 9Breast-Feeding Promotion and Support Program—

Miami-Dade County FL 9

Mooove to Lowfat or Fat Free Milk Campaign FL 9Pumps in the Schools (PITS) HI Coordination of WIC with Maternal and Infant 

Support Services MI 

The Learn Together Approach MI 9WIC Services in the Workplace—Eastern Band of 

Cherokee Indians NC 
TABLE V.2 (continued) 

224 

Program Name State

Experimental

Design 

Comparison

Group 

Design 

Pre/Post 

Trend 

Comparison 

Clien

St

Satisf

Infant Feeding Classes for Pregnant Teens OH Get Fit With WIC OK 9 Obesity Prevention Modules PA Telephone Peer Counseling by Volunteers PA 9 Breast-Feeding Peer Counselor Program TX 9Bilingual Training Program WI 9 Note: “Evaluation” here means any assessment of program success, not necessarily a formal study. aFormal survey conducted. bPlans are tentative. 
225 

b. Key Findings 

What findings concerning outcomes emerge from the evaluations that were conducted? 

• The CARE evaluation gives strong evidence for the usefulness of a self-administered 

alcohol screening tool (instead of interview questions) in detecting pregnant women 

consuming alcohol (Whaley and O’Connor 2003). The researchers also found that 

administering the Brief Intervention protocol for those who were consuming alcohol 

reduced the proportion who reported alcohol consumption at their next visit, when 

compared to a short admonition not to drink during pregnancy. In this evaluation, 

12 clinics were randomly selected for the intervention groups, then matched to 

12 clinics not selected based on similar characteristics. The 12 intervention clinics 

were then randomly assigned to one of two groups: (1) 6 that offered the screening 

tool only, and (2) 6 that used both the screening tool and the Brief Intervention. 

• Most of the breast-feeding promotion and support programs are in agencies in which 

breast-feeding rates among WIC mothers have increased since the program started. 

For example, breast-feeding rates at age 5 to 6 months increased from 30.4 to 

34.3 percent in Sacramento County over the period June 2002 to February 2003; 

exclusive breast-feeding rates increased from 10 to 11 percent to 15 percent in 

Riverside over the period from 1999 to 2003. In addition, the Texas peer counselor 

coordinator reported that all agencies in Texas that had peer counseling programs had 

seen breast-feeding rates increase. Although it is not possible to rule out other 

factors, it seems plausible that the WIC breast-feeding programs are at least partly 

responsible. 

• In the peer counseling program in Washington and Greene counties in Pennsylvania, 

the WIC director observed that the duration of breast-feeding increased in clinics with 

peer counselors but not in the clinics without peer counselors. However, she did not 

attempt to control for other factors—in particular, the clinics without peer counselors 

tended to be in more remote areas. 

• The start of formula training for WIC dietitians in California was associated with 

decreased use of special formulas, as was the Arkansas program that provides breast 

pumps to mothers with premature or seriously ill infants. Again, the programs seem 

likely to be responsible, as they are targeted to providing alternatives to these 

formulas, but it is not possible to rule out other factors. 

What is generally known about the other interventions is that staff and clients have 

responded positively; in some state initiatives, the state agency staff also monitors the extent to 

which new materials or approaches are used. 

2. Data Needs 

WIC local agency staff often lack the resources and skills to evaluate their programs. In 

addition, their data systems are not easily set up to track outcomes, other than those they must 

report to the state and federal governments. Although we did not systematically examine the 
226 

data systems in the initiatives profiled, in general we observed some key limitations in data 

available: 

• Electronic data systems do not always have the types of process measures needed to 

examine the effects of nutrition education initiatives; for example, they may not track 

the specific lessons covered or if the contact was a facilitated discussion or a more 

formal class. Such tracking systems are important in evaluating the effects of specific 

methods. 

• WIC agencies still rely extensively on hard-copy records. 

• Even when the data are available, staff may not have the skills or time needed to 

produce reports. 

FNS is working with state agencies on developing models for improved automated systems 

in WIC, so data and reports needed to manage and evaluate program services will become more 

readily available (U.S. Department of Agriculture 2003b). 

3. Design Issues 

Designing evaluations to assess the effects of the initiatives described in this report could be 

challenging. Some interventions affect the entire agency or community, so that it is not possible 

to randomly assign some clients to services without the intervention and others to receive the 

new services. Other initiatives can be evaluated more easily. For policymakers who might be 

interested in funding additional evaluations of some of the types of programs described here, this 

section considers the options for evaluating the various types of initiatives, and, in particular, the 

circumstances under which random assignment would be feasible. 

Implementation Studies. As a preliminary step, more rigorous implementation studies 

could be of interest. In particular, it is important to judge a program not only by examining its 

goals and design, but also by monitoring staff use of new services or methods and the quality of 

implementation of the planners’ vision. Programs that are not implemented successfully are 

unlikely to have the desired effects. An implementation study of peer counseling programs 

could involve, for example, observing or reviewing records of peer counseling sessions to assess 

whether appropriate protocols were followed. A study of a new nutrition education method 

could examine how well staff use the method, client attendance at sessions, and satisfaction 

among clients who attend. 

Experimental Evaluation. In a large clinic, it might be feasible to assign individuals 

randomly to receive nutrition education under one of two different approaches (for example, 

lecture versus facilitated group discussion), provided the frequency of contacts and the 

information covered were the same for both groups. This approach is ethical in that both ways of 

providing the service are plausibly effective, so it is not clear that clients are receiving more or 

better services under one intervention. However, it may be unduly burdensome to expect staff in 

a clinic to be prepared to offer two different approaches. 
227 

Another option, if the WIC agency operates many clinics, is to randomly assign clinics to 

different interventions, as was done in the CARE study. Such a design is most appealing in large 

agencies in which the populations the clinics serve are relatively similar. If such an evaluation 

were conducted at the state level, it might be useful to select matched pairs of clinics from a wide 

range of agencies, then randomly assign one clinic in each pair to the new approach and the other 

to the existing approach. However, a state-level evaluation would require substantial resources. 

For initiatives that affect the entire atmosphere of the WIC clinics and the community in 

which they are located (such as Florida’s Mooove campaign and the Riverside Loving Support 

program), the only possible random assignment evaluation would be to randomly assign matched 

local agencies (and their communities) to the new initiative or the existing approach. Such an 

approach is both expensive and difficult to implement. Matching of communities is likely to be 

imperfect, and obtaining cooperation with a demonstration at the community level will not 

always be feasible. Furthermore, because WIC is a decentralized program, “the existing 

approach” is likely to differ substantially from place to place. 

Nonexperimental Evaluations. It may be more feasible to evaluate WIC initiatives using 

comparison groups or pre/post evaluations, building on the comparisons used to assess outcomes 

in many of the initiatives studied. The large amount of variation in services provided in local 

WIC agencies may facilitate comparisons between service approaches. Few of the programs 

studied, however, had attempted to control for other factors that might explain observed trends 

(or differences between the program group and a comparison group). By collecting data on the 

characteristics of the clients, clinics, or agencies being compared, comparison group evaluations 

can be strengthened. Such data make it possible to control, at least in part, for how differences 

other than the initiative being tested affect the outcomes of interest. Similarly, before/after 

comparisons can be strengthened by controlling for other factors that change over time. To 

collect control variables may require augmenting WIC automated systems or conducting surveys. 

At the same time, even when carefully designed, these designs are weaker than an experimental 

design. Other factors than the initiative may still be influencing the outcome, but may not be 

available as control variables. Nonetheless, such approaches are less expensive, and they may 

provide evidence of impacts, particularly if the differences in outcomes are large. 

E. REPLICATING AND ADAPTING WIC INITIATIVES: ISSUES AND 

CHALLENGES 

All the initiatives described in this report involve models for providing services that could 

be applied more widely. This section describes the issues that USDA or state agencies would 

need to consider before replicating any of these initiatives, either on a pilot basis or on a wider 

scale. These issues are: 

• Is the program affordable with existing WIC resources? If not, are there options for 

obtaining additional funding? Does the program require an up-front investment with 

few costs afterward, or does it require long-term funding? 

• For what types of WIC agencies is the initiative appropriate? For example, is the 

program of most interest to urban or rural agencies? 
228 

• Are materials for replicating the program readily available? Do they include 

materials for training staff? How much adaptation would be required for state or 

local circumstances? 

• Will these initiatives need to be modified in light of current and future WIC 

challenges, such as increased ethnic diversity, larger proportions of WIC mothers 

working, changes in the health care environment, and state funding shortfalls? 

1. Program Cost 

The first question to address in deciding whether to replicate an initiative is how much it 

will cost. A number of factors affect the cost of replicating these initiatives. For example, the 

availability of materials that have already been tested can reduce the cost for future adopters. In 

contrast, programs that are costly on an ongoing basis may be more difficult to adopt than 

programs that require an up-front investment in training but do not substantially affect costs of 

ongoing operations. 

A related issue is whether adequate funding is available. More costly programs may be 

worthy of further testing if they are expected to result in long-term savings or if other 

organizations—such as universities, foundations, nonprofit organizations, or other government 

agencies—may be interested in funding the program. 

2. Appropriate Setting 

WIC is a highly decentralized program, and few initiatives will be appropriate in all types of 

WIC agencies and clinics. In this study, differences in the needs and abilities of rural versus 

urban agencies (particularly large urban agencies) stood out. 

Small, rural agencies have more potential for integrating WIC and other services and tend to 

provide more personalized services. Services can be integrated more readily because it is often 

true that “everyone does everything,” or, if they have questions about another program, they 

simply need to walk down the hall to get an answer or resolve a problem. As discussed in 

Chapter IV, even in these settings, service integration requires planning and commitment. 

Another strength of rural agencies may be more personalized services, in part because 

“everybody knows everyone,” and in part because caseloads may be smaller. Furthermore, staff 

members may stay with WIC longer, as WIC positions compare more favorably with other local 

professional opportunities in rural areas than in urban ones. A stable staff can get to know 

families over time. 

However, rural agencies often face challenges that urban agencies do not. They may have 

more difficulty meeting specialized needs, such as bilingual professional staff (who can be 

difficult to recruit even in urban areas). The Wisconsin initiative was designed to address this 

type of situation. The northwest Michigan WIC agencies reported that lack of Spanish-speaking 

staff was a concern at times. In addition, they may have more difficulty sending staff for 

specialized training because of both distance and the lack of back-up staff to keep services 

functioning. Finally, although lack of transportation is a barrier for many WIC families in both 
229 

urban and rural areas, the problem tends to be more acute in rural areas, as they have little or no 

public transportation. 

In contrast, large urban agencies may have more ability to train staff and increase efficiency 

through specialization, but they almost inevitably are less personal and more bureaucratic, which 

makes collaborations with other programs more difficult. Caseloads may also be higher and staff 

turnover more frequent. Creating initiatives, such as peer counseling programs, in which clients 

receive one-on-one attention outside of their regular WIC appointments, may be more critical in 

these agencies. 

3. Ease of Adoption 

Initiatives based on written materials are easiest to adopt. Many of the initiatives in this 

report have made materials available on the Internet, and we provide the Web sites here for those 

who are interested. Others could do so, or could provide hard copies. In some instances, 

materials could be used with little change (for example, the Florida Mooove campaign materials 

or the Get Fit With WIC materials), while, in others, materials need to be adapted to local 

conditions (for example, the California Formula Guidebook, which other states would need to 

tailor to the specifications of their formula rebate contracts and their regulations). 

Even if materials are available, it is easiest to adopt those that are relatively self-explanatory, 

rather than those for which staff need extensive training. For example, the Florida Mooove 

campaign would be much easier to adopt than the Learn Together Approach, which requires two 

days of training. 

Initiatives that are not based on written materials pose other challenges for replication. Staff 

adopting the program may need to make site visits to the original program, attend training 

sponsored by the original program, or arrange for staff from that program to come and train the 

staff newly adopting the initiative. Examples include the collaborations between WIC and 

Medicaid managed care and the services provided by the Riverside breast-feeding 

representatives. For these types of initiatives, the up-front investment in setting up the program 

may be larger. 

4. Challenges for the Future 

In considering the feasibility of new initiatives, it is important to take into account the 

following challenges for WIC in the next several years: 

• Cultural Diversity. The WIC population is becoming more diverse ethnically and 

linguistically. In particular, Hispanics have grown steadily as a proportion of the 

WIC population and, in 2002, were 38 percent of participants, a larger group than 

non-Hispanic whites (U.S. Department of Agriculture 2003c). California WIC 

agencies may be the most advanced in addressing this challenge. In the Riverside 

county WIC agency, a large proportion of staff is bilingual, and all written materials 

are available in both English and Spanish. Berkeley WIC has hired peer counselors 
230 

who speak a wide range of languages, but Sacramento WIC is still trying to expand 

the availability of Spanish-speaking staff with lactation training. The Wisconsin 

bilingual training initiative is an attempt to serve pockets of Hmong and Spanish 

speakers better. 

• Mothers Working. With welfare reform and the strong economy of the late 1990s, 

more WIC mothers were working. This trend may have slowed, but it is unlikely to 

reverse. One implication is that peer counseling programs that rely on volunteer or 

part-time help are less feasible now than they were 10 years ago. Another implication 

is that WIC needs to develop approaches to improve access for working parents, such 

as extended hours, more telephone contacts, or workplace WIC visits. 

• Changes in the Health Care System. Coordination between WIC and health care 

providers is often critical to the WIC initiatives profiled. For example, WIC peer 

counselors coordinate with hospital maternity staff to provide counseling in hospitals, 

and WIC staff coordinate with Medicaid home visiting programs to provide food 

instruments during home visits. However, experiences during the past few years 

suggest that such coordination becomes more difficult as Medicaid managed care 

providers serve more WIC clients. Furthermore, the privacy rules used to implement 

the Health Insurance Portability and Accountability Act (HIPAA), which took effect 

in April 2003, make coordination more difficult. In northwest Michigan, WIC and 

health records need to be kept separately, even though this involves duplication of 

effort. HIPAA may also make it more difficult for WIC peer counselors to obtain 

access to hospital maternity wards. 

• State and Federal Budget Crises. State and federal budget crises may lead to 

cutbacks in WIC funding and staff, which make implementation of new approaches 

more difficult. Several of the programs profiled were facing layoffs or the possibility 

of other cutbacks. In talking with a range of WIC staff, our impression is that funding 

constraints are more of an issue in some places than others. Furthermore, special 

funding sources such as those provided through California’s Proposition 10 are not 

available everywhere. One way to address this is to emphasize that “WIC Plus” 

initiatives are optional and not expected of WIC programs everywhere. At the same 

time, some of the initiatives discussed in this report have low costs and may even 

save WIC money. 
231

REFERENCES 

Arora S., C. McJunkin, J. Wehrer, and P. Kuhn. “Major Factors Influencing Breast-feeding 

Rates: Mother’s Perception of Father’s Attitude and Milk Supply.” Pediatrics, vol. 106, 

no. 5, 2000, p. E67. 

Besharov, Douglas J., and Peter Germanis. Rethinking WIC: An Evaluation of the Women, 

Infants, and Children Program. Washington, DC: AEI Press, 2001. 

Baughcum, Amy E., Leigh A. Chamberlin, Cindy M. Deeks, Scott W. Powers, and Robert C. 

Whitaker. “Maternal Perceptions of Overweight Preschool Children.” Pediatrics, vol. 106, 

no. 6, December 2000, pp. 1380-1386. 

California Food Policy Advocates. Alameda County: A Profile of Poverty, Hunger, & Food 

Assistance. CFPA, June 2003. Available at [www.cfpa.net]. 

Children Now. California Report Card 2001: Factors for School Success. 

[www.childrennow.org/california/rc-2001/reportcard.pdf], November 2002. 

Cole, Nancy, David Hoaglin, and John Kirlin. “National Survey of WIC Participants.” 

Publication no. WIC-01-PCOM. Arlington, VA: U.S. Department of Agriculture, Food and 

Nutrition Service, 2001. 

Community Nutrition Research Group, Beltsville Agricultural Research Center. 

[www.barc.usda.gov/bhnrc/cnrg/cnmapfr.htm]. Accessed September 26, 2003. 

Crall, J., et al. “Disparities in Children’s Oral Health and Access to Dental Care.” Journal of the 

American Medical Association, vol. 284, no. 20, November 2000, pp. 2625-2631. 

Devaney, Barbara L., Linda Bilheimer, and Jennifer Schore. “Medicaid Costs and Birth 

Outcomes: The Effects of Prenatal WIC Participation and the Use of Prenatal Care.” 

Journal of Policy Analysis and Management, vol. 11, no. 4, 1992, pp. 573-592. 

Gordon, Anne R., and Lyle Nelson. Characteristics and Outcomes of WIC Participants and 

Nonparticipants: Analysis of the 1988 National Maternal and Infant Health Survey. 

Alexandria, VA: U.S. Department of Agriculture, Food and Nutrition Service, 1995. 

Gross, S.M., L.E. Caulfield, M.E. Bentley, Y. Bronner, L. Kessler, J. Jensen, and V.M. Paige. 

“Counseling and Motivational Videotapes Increase Duration of Breast-feeding in AfricanAmerican WIC Participants Who Initiate Breast-feeding.” Journal of the American Dietary 

Association, vol. 98, no. 2, 1999, pp. 143-148. 

Hale, Thomas. Medications & Mothers’ Milk: A Manual of Lactational Pharmacology. 

Pharmasoft Medical, March 2002. 

Institute of Medicine. Fetal Alcohol Syndrome: Diagnosis, Epidemiology, Prevention and 

Treatment. Washington, DC: National Academy Press, 1996. 
232

Jain, Anjali, Susan N. Sherman, Leigh A. Chamberlin, Yvette Carter, Scott W. Powers, and 

Robert C. Whitaker. “Why Don’t Low-Income Mothers Worry About Their Preschoolers 

Being Overweight?” Pediatrics, vol. 107, no. 5, May 2001, pp. 1138-1146. 

Krause, Brendan. “State Efforts to Improve Children’s Oral Health.” Issue Brief. NGA Center 

for Best Practices, Health Policy Studies Division, November 20, 2002. Available at 

[www.nga.org/cda/files/1102CHILDORALHEALTH.pdf]. 

Mohrbacher, Nancy, and Julie Stock. The Breastfeeding Answer Book. 3rd Revision. La Leche 

League International, 2003. 

National Center for Health Statistics. “Prevalence of Overweight Among Children and 

Adolescents: United States, 1999-2000.” Available at [www.cdc.gov/nchs/products/ 

pubs/pubd/hestats/overwght99.htm]. Accessed December 9, 2003. 

Peregrin, T. “Education, Peer Counseling, and Paternal Support: Three Ways to Encourage a 

Healthful Breastfeeding Schedule.” Journal of the American Dietetic Association, vol. 102, 

no. 7, July 2002, p. 943. 

Rose, Donald, Jean-Pierre Habicht, and Barbara L. Devaney. “Household Participation in the 

Food Stamp and WIC Programs Increases the Nutrient Intakes of Preschool Children.” 

Journal of Nutrition, vol. 128, no. 3, 1998, pp. 548-555. 

Rush, David, Jessica Leighton, Nancy L. Sloan, Jose M. Alvir, Daniel G. Horvitz, W. Burleight 

Seaver, Gail C. Garbowski, Sally S. Johnson, Richard A. Kulka, James W. Devore, Mimi 

Holt, Judith T. Lynch, Thomas G. Virag, M. Beebe Woodside, and David S. Shanklin. 

“Study of Infants and Children.” American Journal of Clinical Nutrition, vol. 48, no. 2, 

1988, pp. 484-511. 

Sacramento County Public Health Advisory Board. Saving Babies’ Lives: Community Health 

Plan. Sacramento, CA: Sacramento County Department of Health and Human Services, 

2001. 

Satter, Ellyn. Child of Mine: Feeding with Love and Good Sense. 3rd Edition. Boulder, CO: 

Bull Publishing, 2000. 

Shaw E., and J. Kaczorowski. “The Effect of a Peer-Counseling Program on Breastfeeding 

Initiation and Longevity in a Low-Income Rural Population.” Journal of Human Lactation, 

vol. 15, no.1, 1999, pp. 19-25. 

Sears, William, Gwen Gotsch, and Paul Froelich. Becoming a Father: How to Nurture & Enjoy 

Your Family. 2nd Edition. La Leche League International, 2003. 

University of Wisconsin Extension and Applied Population Laboratory. Wisconsin’s Hmong 

Population. Madison, WI: University of Wisconsin, November 2002. 

U.S. Census Bureau. County and City Data Book: 2000, A Statistical Abstract Supplement. 

Washington, DC: U.S. Census Bureau, 2002. 
233

U.S. Census Bureau. “State and County QuickFacts.” [http://quickfacts.census.gov]. Accessed 

fall 2003. 

U.S. Department of Agriculture, Food and Nutrition Service. Coordination Strategies 

Handbook: A Guide for WIC and Primary Care Professionals. Arlington, VA: USDA, 

FNS, 2000. Available at [www.fns.usda.gov/wic/resources/coordinationstrategies.htm]. 

U.S. Department of Agriculture, Food and Nutrition Service. “WIC Nutrition Services 

Standards.” Arlington, VA: USDA, FNS, October 2001. Available at 

[www.nal.usda.gov/wicworks/Topics/WICnutStand.pdf]. 

U.S. Department of Agriculture, Food and Nutrition Service. “Program Data: WIC Program.” 

[www.fns.usda.gov/pd/wichome.htm]. Accessed October 2003a. 

U.S. Department of Agriculture, Food and Nutrition Service. “State Information Systems.” 

[www.fns.usda.gov/wic/StateInformationSystems/menu.htm]. Accessed Dec. 19, 2003b. 

U.S. Department of Agriculture, Food and Nutrition Service. “WIC Participant and Program 

Characteristics: PC2002: Executive Summary.” Arlington, VA: USDA, FNS, 2003c. 

U.S. Department of Agriculture, Food and Nutrition Service. The Implementation Manual for 

the Fit WIC Childhood Overweight Prevention Project. [www.nal.usda.gov/wicworks/ 

Sharing_Center/statedev_FIT.html]. Accessed December 19, 2003. 

Whaley, S.E., and M.J. O’Connor. “Increasing the Report of Alcohol Use Among Low-Income 

Pregnant Women.” American Journal of Health Promotion, vol. 17, no. 6, 2003, pp. 369-

372. 
APPENDIX A 

PROCEDURES FOR SELECTING PROGRAMS 

AND COLLECTING DATA 

A.3

 

A. SELECTING PROGRAMS TO STUDY 

This appendix describes the steps used in selecting initiatives. 

1. Gathering Nominations 

First, in December 2002, we sent electronic letters to the directors of the seven FNS regional 

offices, to all 87 state and tribal WIC directors, and to representatives from the Food Research 

and Action Center and the National WIC Association seeking their nominations for appropriate 

programs for the study. We also contacted the California WIC Association and Public Health 

Foundation Enterprises Management Solutions in California for their input.1

 To encourage 

cooperation, officials from FNS headquarters notified the regional offices that MPR would be 

contacting them about the study and urged them to assist. 

The letters explained the purpose of the study, our definition of “innovative,” and the five 

types of programs in which we were particularly interested—breast-feeding promotion, obesity 

prevention, innovative service delivery, preventive health care, and staff training. (Appendix B 

contains the text of the letter.) We also invited program officials to bring other types of 

innovative programs to our attention. Thus, we allowed these officials considerable leeway in 

defining what they viewed as innovative within the five target areas. Programs were required at 

least to be partially funded with WIC dollars, but did not have to be solely funded by WIC. 

Because Special Project Grants and FIT WIC programs were already under study, we requested 

that officials omit any such programs from their list of nominations. 

To effectively use the information from regional offices, state and tribal WIC directors, and 

other experts to choose 20 to 25 programs for further study, we asked officials to include (1) a 

description of the service(s) and the target population, (2) the factors that make it a promising or 

innovative program, (3) the name of the local WIC agency or agencies, and (4) appropriate 

contact information. We followed up by e-mail with all states that did not respond within two 

weeks, then followed up with a random sample of about half the remaining programs by 

telephone.

Table A.1 presents the approximate number of programs nominated from the seven FNS 

regions (including the state WIC agencies in those regions) and the number of tribal programs 

nominated. We received nominations from 32 states and three Indian Tribal Organization (ITO) 

WIC agencies.2

 We received them directly from state WIC staff, submitted by states through the 

regional offices, or from regional office staff. Nine states and three ITOs told us or their regional 

office that they had no programs they wished to nominate. Twelve states and the remaining 

1

 The California WIC Association is a large, active local affiliate of the National WIC 

Association. Public Health Foundation Enterprises Management Solutions is the largest local 

WIC agency in the United States, covering the Los Angeles area, and is known for sponsoring 

innovative programs. It was the only local WIC agency contacted for nominations. 

2

 Throughout this report, we include the territories of American Samoa, Puerto Rico, Guam, 

and Virgin Islands as “states.” 
A.4

TABLE A.1 

GEOGRAPHIC RANGE OF NOMINATED PROGRAMS

FNS Administrative Regions Number of Programs 

Northeast: Connecticut, Maine, Massachusetts, New 

Hampshire, New York, Rhode Island, Vermont 3 

Mid-Atlantic: Delaware, District of Columbia, Maryland, 

New Jersey, Pennsylvania, Puerto Rico, Virginia, Virgin 

Islands, West Virginia 20 

Southeast: Alabama, Florida, Georgia, Kentucky, 

Mississippi, North Carolina, South Carolina, Tennessee 16 

Midwest: Illinois, Indiana, Michigan, Minnesota, Ohio, 

Wisconsin 36 

Southwest: Arkansas, Louisiana, New Mexico, Oklahoma, 

Texas 7 

Mountain Plains: Colorado, Iowa, Kansas, Missouri, 

Montana, Nebraska, North Dakota, South Dakota, Utah, 

Wyoming 6 

Western: Alaska, American Samoa, Arizona, California, 

Guam, Hawaii, Idaho, Nevada, Oregon, Washington 14 

Tribal Programs 5 

Total Programs Nominated 107 
A.5

 

ITOs did not respond. In a few cases, we contacted nominated programs by telephone to have 

brief conversations (15 to 30 minutes) to clarify some points and gather some information. We 

also called the contacts at several state agencies that had nominated many programs to obtain 

their impressions as to which of their programs were of the most national interest. We then 

reviewed lists of innovative programs on the WIC Works Website (compiled by the National 

WIC Association based on feedback from FNS regional offices). We selected a few programs 

from these lists (which added one state), after contacting the state agencies to ensure the program 

was still operating and was appropriate to include.3

 Because of resource and schedule 

constraints, we ended our efforts to obtain nominations in mid-February 2003. 

We reviewed about 107 nominations from WIC officials and/or selected from the WIC 

Works Website.4

 The number of nominations per state ranged from 1 to 18. The nominations 

are not necessarily representative, since many states did not respond, and states varied in how 

they interpreted our request. Some states interpreted “innovative” broadly, while others 

interpreted it so narrowly they responded they had nothing to suggest. Some clearly saw 

“innovative” as within the context of their state, while others had a more national perspective. 

2. Selecting Programs for Telephone Interviews 

After compiling nominations, the research team began the process of selecting 20 to 

25 programs to investigate further through telephone interviews with appropriate program 

contacts. One goal was to include programs that were geographically diverse and covered the 

range of services of interest—programs that promote breast-feeding, seek to reduce overweight 

and obesity, coordinate with preventive health care, or use alternative service delivery models or 

training approaches. We interpreted geographic diversity as programs from a range of states and 

regions, and from both urban and rural settings. A second goal was to include some programs 

that targeted high-risk groups. In addition, we sought to include programs that were beyond their 

start-up phase, so we asked for nominations of programs that had been operating for at least one 

year. We made a few exceptions to this rule for programs that seemed to have a lot to offer. 

Similarly, although we had planned to include only programs still in operation, we decided to 

include two that had ended or were about to end but that had a sufficient history of success to 

learn from. We dropped some nominations because they were for small interventions, not likely 

to make much difference in themselves, although many were good ideas. 

3

 See www.nal.usda.gov/wicworks/sharing_center/statedevrqns.html. 

4

 We say “about” 107 nominations because there was a certain amount of judgment involved 

in determining what to count. In general, if there was a mention of a program in an e-mail or list 

but no details about the program, we did not count it. When one regional office sent very 

detailed lists of activities in the region, we made judgments about which could be considered to 

be ongoing “programs” for the purposes of the study, and only counted those. In addition, we 

did not count an intrastate program to prevent fraud that involved several states and ITOs, 

because it seemed unrelated to the focus of this study and would artificially inflate the number of 

agencies with nominations considered. 
A.6

We received many nominations of breast-feeding programs (about half of the total) and 

relatively few in other areas. One reason for this is that WIC programs have had targeted 

funding for breast-feeding promotion since the late 1980s, so they have had substantial 

experience in developing these programs. More recently, WIC programs have received 

permission to use food funds to purchase breast pumps for breast-feeding clients, which has led 

to development of breast pump programs in many agencies. On the other hand, other nutrition 

services funds are limited, and USDA’s RQNS initiative is relatively new. Therefore, programs 

concerning other aspects of nutrition education, including obesity prevention, are not as well 

developed. The FIT WIC grants—the major USDA initiative concerning WIC and obesity 

prevention—are out of the scope of this study. Furthermore, WIC agencies are somewhat 

reluctant to discuss partnerships with other agencies related to other types of preventive health 

services, for fear they may be given “unfunded mandates”—new service requirements without 

additional funding to support them. 

To reflect the nominations received, breast-feeding support programs were about half of the 

programs selected, with the rest divided among the other categories of interest (and some 

programs falling into more than one category). However, all five categories were represented. 

Because of the abundance of breast-feeding programs, we could be more selective. We decided 

to focus on well-established, multifaceted programs, as well as on programs that have developed 

unique ways of reaching hard-to-reach populations, such as teenagers, rural mothers, or mothers 

of premature infants. We also included programs representing most of the major approaches to 

breast-feeding services that go above and beyond the core WIC requirements. In the other topic 

areas, we had few nominations to choose from. To obtain a range of interesting programs, we 

sometimes needed to bend our other requirements (for example, selecting a dental health 

program in operation for less than one year). We also sought out programs in the target areas 

other than breast-feeding on the WIC Works Web site; three of the final selections came from 

this source. 

In March 2003, MPR developed a list of potential programs for study that was somewhat 

larger than needed, then met with ERS and FNS staff members and obtained their feedback on 

which programs to drop and whether to add others. After several rounds of discussions, we came 

up with a list of 22 programs for telephone interviews. We selected more than 20 programs at 

this stage because we were concerned that some of the programs would not wish to be part of the 

study or would prove not to be good candidates when we spoke with them further. As it turned 

out, we completed interviews with all 22 programs, but decided to drop 2 programs because they 

were having implementation problems. 

B. DATA COLLECTION 

Because this study is an exploration of innovative practices in the WIC program, as opposed 

to a test of their effectiveness, we relied primarily on qualitative data. We used two main data 

sources for this study: telephone interviews and site visits. Gathering descriptive information 

and perspectives from various stakeholders was an effective way to answer our research 

questions. For example, interviewing program officials and line staff helped us identify key 

implementation successes and challenges, as well as lessons for future replication. This section 

describes the data collection procedures we followed for the study, including discussion guides 
A.7

for telephone interviews and site visits and procedures for conducting the telephone interviews 

and site visits. We did not analyze administrative data on any of the programs, nor did we 

interview clients. 

1. Telephone Interviews 

To obtain more detailed information on the design and operations of innovative WIC 

programs, we developed discussion protocols for conducting the telephone interviews. The 

protocols were organized according to topics related to the three main research questions. The 

topics included (1) program goals and development, (2) services provided, (3) organizational 

structure, (4) outreach, (5) clients’ perspectives, (6) funding, (7) implementation successes and 

challenges, (8) evaluation efforts, (9) lessons learned, and (10) likelihood for replication. The 

questions were tailored based on the type of program. For example, some specific questions 

asked of a local director operating a home visitation program would differ from those asked of a 

local breast-feeding coordinator overseeing a peer counseling program. Project members 

reviewed the protocols, tested them with several telephone interviews, discussed how effective 

they were in collecting the needed information, and made minor modifications. Table B.1 in 

Appendix B presents the protocol template that was used for the interviews. We adjusted, added, 

or eliminated questions for particular respondents, as appropriate. 

After the ERS project officer gave final approval of the 22 programs, we contacted the 

appropriate regional FNS offices by e-mail to let them know the programs that MPR would be 

contacting in their jurisdiction. Next, we arranged times for telephone interviews with the 

appropriate people from the 22 programs (see Table A.2). For state-level programs, we typically 

spoke with the state WIC director or a specialized official, such as a state nutrition education 

coordinator. For local programs, we spoke with individuals such as local agency directors and 

local breast-feeding coordinators. In a few cases, state officials were respondents for local 

programs that covered several local agencies. For one statewide program, we spoke with a state 

official and a breast-feeding coordinator from one of the local programs. Interviews lasted 

between 1 and 1.5 hours and were conducted by a single member of the research team. 

Sometimes, more than one official involved in the program participated in the interview. 

We began the conversation by explaining the purpose of the study, then proceeded through 

the protocol topics as described earlier. At the same time, many respondents provided 

information on a range of questions before they were asked, and we adjusted the flow of the 

discussion accordingly. In general, we covered most topics. At the end of the interviews, we 

asked respondents if they would welcome a site visit from MPR to examine their programs more 

in depth and if they would agree to have their contact information included in the final report. 

Everyone agreed to both requests. Table A.2 lists the selected programs and whether the 

officials with whom we spoke were at the state or local level, for the 20 programs that remained 

in the study. All interviews took place in April or May 2003. The interviewers prepared writeups of each interview, arranging the information from their interview notes into answers to the 

questions in the protocol. 
A.8 

TABLE A.2 

CHARACTERISTICS OF PROGRAMS CHOSEN FOR TELEPHONE INTERVIEWS 

Telephone Interview 

Respondent(s) 

Program Name State State-level Local-level Steps Ahead/WIC Coordination—Cullman County AL 9 ServiWIC Nutrition Education Model for Prevention of Early 

Childhood Caries AL 9 Preve

Breast Pumps for Mothers of Premature and Seriously Ill Infants AR 9 Breas

Cease Alcohol Related Exposure (CARE) CA 9 Preve

Expanded Breast-Feeding Peer Counselor Program CA 9 Breas

Loving Support Breast-Feeding Helpline—Riverside County CA 9 Breas

Lactation Consultant Services—Sacramento County CA 9 BreasWIC RD: Adjunct to Pediatric Health Care CA 9 Infan

Breast-Feeding Promotion and Support Program— 

Miami-Dade County FL 9 Breas

Mooove to Lowfat or Fat Free Milk Campaign FL 9 Obesi

Pumps in the Schools (PITS) HI 9 Breas

Coordination of WIC with Maternal and Infant Support Services MI 9 Servi

The Learn Together Approach MI 9 Train

WIC Services in the Workplace—Eastern Band of Cherokee Indians NC 9 Servi

Infant Feeding Classes for Pregnant Teens OH 9 Breas

Get Fit With WIC OK 9 Obesi

Obesity Prevention Modules PA 9 Obesi

Telephone Peer Counseling by Volunteers PA 9 Breas

Breast-Feeding Peer Counselor Program TX 9 9 Breas

Bilingual Training Program WI 9 Train
A.9

2. Site Visits 

The team reviewed the interview write-ups—along with written materials provided by 

several programs—to determine which WIC initiatives would be most appropriate for a site visit. 

We used several criteria to select the five programs. First, we sought to visit programs that 

represent a diversity of geographic regions, urbanicity, and types of interventions. For example, 

we did not want to include four breast-feeding programs and only one program of another type. 

We also decided not to visit more than one program in a state. Moreover, we decided to select 

initiatives that were ongoing, that were complex enough for us to substantially add to our 

knowledge by going on-site, and that had good potential for being replicable. We discussed our 

selections with ERS and FNS staff, and they approved our final five selections. 

In June 2003, we contacted the sites to notify them of their selection. All program staff were 

pleased and enthusiastic to have been chosen for on-site study. The lead site visitor collaborated 

with a key program contact—in each case, a person who participated in the telephone 

interview—to identify appropriate individuals to interview and program services to observe. The 

site visitor developed an agenda for the visit in collaboration with the key program contact. 

Table A.3 presents an example of an agenda.

In preparation for the site visits, we developed customized protocols for the five programs, 

which were based on the telephone interview protocol presented in Appendix B. Again, this was 

to ensure consistent data collection during the visit. Although the topics covered were similar to 

those discussed during the telephone calls, issues were covered in much greater detail and from a 

range of perspectives. Protocols included interview questions for specific program staff 

members, as well as an observation sheet on which to systematically record observations of 

program activities (see Appendix B for a sample observation sheet). Interview respondents 

varied according to the specific program, but included such individuals as (1) the local agency 

WIC director, (2) any key program managers (if different from the local agency WIC director 

and if different from telephone interview participants), (3) the local breast-feeding coordinator (if 

a breast-feeding program), (4) WIC nutritionists and/or nurses, (5) peer counselors, (6) other 

relevant staff in the WIC clinics who are involved in delivering innovative services, and (7) staff 

at associated health programs who interacted with WIC staff. We tried to speak with as many 

people as possible while on-site. 

One person took the lead on drafting the protocols for each program, then circulated the 

documents to other team members for comments, making adjustments as needed. As with the 

telephone interviews, we adjusted, added, or eliminated some questions for particular 

respondents once on-site, when that was appropriate. To improve the quality of the site visit 

data, we conducted two of the five site visits in teams of two, and we drafted our notes as soon as 

possible after returning from the visits. Thus, we could follow up quickly with the local program 

staff if there were gaps in the information gathered. Further, traveling in teams, when possible, 

allowed for firsthand accounts of program operations from two perspectives. Upon return, we 

reviewed each other’s notes to ensure data consistency. 
A.10 

TABLE A.3 

SAMPLE SCHEDULE FOR SITE VISIT 

WIC NUTRITION EDUCATION MODEL FOR THE PREVENTION 

OF EARLY CHILDHOOD CARIES 

BIRMINGHAM, ALABAMA, AND VICINITY 

JUNE 25-26, 2003

Time Activity 

Wednesday, June 25 

4:30-5:30 Interview with Professor and Chairman, Department of Pediatric 

Dentistry at the University of Alabama at Birmingham 

Thursday, June 26 

8:00-8:15 Arrive and meet staff at the Calhoun County Health Department 

8:15-8:30 Observe dental nutrition education class at Calhoun County Health 

Department 

8:30-9:15 Interview with WIC nutritionist who taught dental nutrition education 

class 

9:30-10:00 Arrive and meet staff at the Anniston Head Start Center; tour center 

10:00-10:15 Observe dental nutrition education class at the Head Start Center 

10:30-11:30 Interview with WIC nutrition area coordinator who taught Head Start 

class 

LUNCH 

12:30-1:30 Travel to the Jefferson County Department of Health, tour facilities 

1:45-2:00 Observe individual dental nutrition education contact at the Central 

Health Center 

2:00-2:45 Interview with WIC nutritionist who taught dental nutrition education 

class 

2:45-3:45 Group interview with four WIC nutrition area coordinators 

3:45-4:30 Interview with Assistant Professor, Department of Health Behavior at 

the University of Alabama at Birmingham 
A.11 

We conducted the five site visits from June through September 2003. Most visits were 

1.5 to 2 days long, although one visit was completed in one afternoon and the following 

morning. All visits involved interviews with program staff and community partners (if relevant) 

and observations of services and/or training activities. Table A.4 presents the five programs 

visited, the dates of the visits, and whether they were conducted by one or two team members. 

TABLE A.4 

CHARACTERISTICS OF WIC SITE VISITS

Program State Dates of Site Visit 

WIC Nutrition Education Model for the 

Prevention of Early Childhood Cariesa AL June 25-26, 2003 

Home Visiting for WIC Certification and 

Counselinga MI August 6-7, 2003 

Loving Support Breast-Feeding Helplineb CA August 12-13, 2003 

Statewide Peer Counseling Programb TX September 16-17, 2003 

Get Fit With WICa OK September 22-23, 2003 

a

One site visitor. 

b

Two site visitors. 

3. Final Review 

We asked all key contacts from the telephone interviews and site visits to examine the first 

draft of the profiles of their programs. After drafting the profiles, we sent electronic copies to 

our contacts and asked them to review the documents to determine if we recorded details about 

the program accurately and to provide any missing information needed to make the profile 

complete. All of our program contacts provided comments and corrections, if necessary.

APPENDIX B 

PROTOCOLS 
LETTER SENT TO STATE WIC DIRECTORS AND FNS REGIONAL OFFICES 

B.3

Hello! 

We at Mathematica Policy Research, a national research firm, are asking for your help. The USDA 

Economic Research Service (ERS) recently awarded us a contract to describe the range of innovative 

programs currently in place at WIC agencies. While research has shown that WIC is effective, there is 

not much information available about the promising and innovative practices that clinics are using. We 

would like your assistance in identifying promising programs in your jurisdiction. We will also be 

contacting [FNS regional offices/state WIC agencies], the National WIC Association, and other experts. 

What do we mean by an “innovative” program? We are trying to identify programs or practices that are 

different from what WIC usually does. Preferably, the program will be something that has been up and 

running for at least a year, and has shown evidence of its effectiveness. The program should also have 

potential for being replicated in other places. We are particularly interested in the following types of 

programs: (1) promotion of breast feeding and support of healthy infant feeding practices, for example, 

through programs such as peer counselors and lactation consultants; (2) prevention of overweight and 

obesity; (3) innovative service delivery approaches, such as home visits; (4) practices that increase wellchild health care and immunizations; and (5) special training programs for WIC staff. If there are other 

innovative programs that you would like to bring to our attention, please do so. We are interested in 

programs that are at least partially funded by WIC, but they do not have to be solely funded by WIC. 

Because they are already under study, please do not include information about any Special Project 

Grants or FIT WIC programs. 

Our plan is to use the information you provide us to select about 20 programs for further study, and 

5 among these for site visits. In order to do that, please provide us with the following information for 

each innovative program or practice that you wish to nominate: 

• a description of the service(s) and the target population 

• why you feel it is a promising or innovative program 

• the name of the local WIC agency or agencies, if applicable, and contact person information; 

if it is a state or regional program, also include the appropriate contact person information 

Kindly return your feedback to any of the names listed below by January 3. Feel free to e-mail, mail, or 

fax the information. Thank you in advance for your time. We know your time is very valuable and 

appreciate your attention to our request. If you would like to designate another person in your office to 

respond to our request and serve as liaison for this study, please feel free to do so. Otherwise we may be 

contacting you in early January to follow-up or request more information. If you have any questions, 

please do not hesitate to contact any of the staff for this study. 

Anne Gordon Tania Tasse Teresa Zavitsky 

Project Director Research Analyst Research Analyst 

P.O. Box 2393 P.O. Box 2393 600 Maryland Ave, SW, Ste. 550 

Princeton, NJ 08543-2393 Princeton, NJ 08543-2393 Washington, DC 20024 

Ph: (609) 275-2318 Ph: (609) 936-2715 Ph: (202) 264-3457 

Fax: (609) 799-0005 Fax: (609) 799-0005 Fax: (202) 863-1763 

With much enthusiasm, 

Anne Gordon, Tania Tasse, and Teresa Zavitsky 

B.5 

INNOVATIVE WIC PRACTICES 

TELEPHONE INTERVIEW PROTOCOL 

SPRING 2003 

INTRODUCTION 

Hello, my name is [INTERVIEWER] and I am calling from Mathematica Policy Research. We are 

conducting a study on innovative WIC practices for the Economic Research Service of the U.S. Department 

of Agriculture. This study will describe a range of WIC programs and collect information on current 

innovative practices and lessons learned to help policy makers and program staff think about ways to 

improve the WIC program. At this phase of our work, we are collecting detailed information on 

approximately 20 programs across the country for possible inclusion in our report; we will select 5 

programs from this group for more in-depth study. We received your name from *** with the ***, who 

thought that your program, [INITIATIVE], deserves to be studied further because it is innovative. When 

Mathematica invited nominations, we defined “innovative” as something that is different from what WIC 

usually does, and we were particularly interested in programs that include services in one of the following 

areas: (1) the promotion of breastfeeding, (2) prevention of overweight and obesity, (3) innovative service 

delivery approaches, such as home visits, and (4) coordination with preventative health care, such as dental 

health screening or lead screening. While we have a bit of information on[INITIATIVE], I would like to 

schedule a time to talk to you—or someone else from your agency if you think they would be more 

appropriate—to learn more about it. This conversation should take about an hour. Would you be interested 

in participating in this study for USDA, and if so, can we set up a time for me to call you back?

CONTACT INFORMATION 

Name and title: 

Program name: 

Address: 

Phone number: 

E-mail: 

Date of Interview: 

Interviewer: 
B.6 

WIC INITIATIVE 

A. Program Goals and Design of the WIC Initiative 

1. How long has [INITIATIVE] been operating? Is it intended to be a pilot for a specific period, or 

to continue indefinitely depending on funding sources? 

2. What prompted [INITIATIVE] to get started, and what are the main goals? What 

problems/issues is the program trying to address? Who were the main actors? 

3. How did the initiative develop...which stakeholders participated during the planning phase, and 

what steps were involved in designing the [INITIATIVE]? 

4. If this is a collaborative effort or part of a coalition, how did these relationships develop? What 

is the role of these community partners in [INITIATIVE]? 

5. Did any challenges emerge during the design phase of [INITIATIVE]? 

6. Do you know of other local initiatives in place to [choose one: improve coordination 

between the WIC agencies and health care agencies, or to deliver services through home 

visits/reduce obesity or improve dietary intake/improve breastfeeding rates]? 

B. Services Provided

1. Before [INITIATIVE] started, what did the overall service environment look like with regards to 

[choose one: improve coordination between the WIC agencies and health care agencies, or to 

deliver services through home visits/reduce obesity or improve dietary intake/improve 

breastfeeding rates]? What services were provided, and to whom? Were there any enhanced 

services in place, like lead screening? Essentially, get a sense of what services a WIC client 

would have had access to before the new initiative. 

2. What is the service area for [INITIATIVE]? (statewide, select counties/MSAs, one local WIC 

agency)? 

3. Who is eligible for the services and to whom is [INITIATIVE] targeted? Is it aimed at current 

WIC clients or the wider community? Does it target subgroups (e.g. Spanish-speaking families, 

teen parents)? Is it targeted at health professionals or other service providers? 

4. How many total clients (tailor for type of initiative...women—pregnant, breastfeeding/nonbreastfeeding postpartum women—and children) does [INITIATIVE] serve annually? Are the 

participation rates what you had expected? Is staff overwhelmed by the interest, or is it a struggle 

to get people to participate? 

5. Who is the ‘typical’ client? 

6. Describe the specific services provided by [INITIATIVE]. 
B.7 

7. Where do the services occur? How long are services designed to last, and how frequently do they 

take place (times per week or month)? What is the duration of each contact? Are services 

initiated by the program staff or by the client? If multiple services, may need to ask separately for 

different services.

8. What percentage of the targeted group participates, and how long to clients actually participate? 

If multiple services, may need to ask separately for different services.

For breastfeeding initiatives only: 

9. Before [INITIATIVE] started, what percentage of your WIC clients chose to breastfeed? What 

were the duration rates like? Did these rates vary by subgroup (for example, were teen parents 

less likely to breastfeed?) How did these rates compare to the state average? 

For coordination with health agencies and/or home visiting initiatives only: 

10.To what extent is [INITIATIVE] linked to other local social service agencies—are service efforts 

coordinated? What services do these groups provide? 

11.Does WIC provide services to health/medical center clients, and do health/medical centers 

provide services to WIC clients? How are these agencies linked to the WIC initiative? 

Through... 

 Co-location? 

 Referrals? 

 Shared staff? 

 Information sharing (e.g. clients’ records)? 

 Joint training? 

 Common nutritional protocol? 

 Coordinated screening? 

 Joint enrollment? 

 Cooperative follow-up with clients? 

For all initiatives: 

12.In your opinion, what sets [INITIATIVE] apart from what other states/counties are doing? 

C. Staff and Organizational Structure 

1. What is the management structure of [INITIATIVE]? Who are the key staff, and what are their 

roles and responsibilities? 

2. Are any staff employed by other agencies/partners? 

3. Are there specific qualifications required for staff who work on the initiative? Do they need to 

have specific degrees or certifications? 
B.8 

4. Were staff for the initiative considered to be ‘new hires,’ or had they already been working for the 

agency? 

5. Describe any training activities for {INITIATIVE]. 

 -- Who developed the training activities? 

 -- Who delivered the training? 

 -- How many and which types of staff participated? 

 -- When did the training occur? 

 -- How often is training repeated, if at all? 

 -- What are the strengths and weaknesses of this training? 

6. Are there formal written procedures (e.g. protocol manual) and training materials in place (so that 

other staff could easily come in and take over)?

7. Are volunteers involved in the initiative? If so, what is their role? Who supervises them, and 

have they received any special training? 

D. Outreach and Publicity Efforts 

1. How are clients informed about the initiative? 

2. How is the initiative publicized? 

-- Did staff develop brochures, posters, public service announcements, and/or newspaper 

articles? 

 

 -- What were the main messages? 

 -- How widely distributed were these publicity efforts? 

3. Are other community groups/local partners involved in outreach? Do other providers or agencies 

provide referrals to the initiative? If so, which ones, and how are referrals made? 

E. Client Reactions

1. How receptive were clients to [INITIATIVE]? 

2. What comments did they make about the services? What aspects of the program do WIC clients 

like the most? The least? What are you basing these impressions on—a survey, talking to staff, 

talking to clients? 
B.9 

3. Do you have any sense of how [INITIATIVE] affects the atmosphere in the clinic and clients’ 

behavior? 

F. Funding Levels/Budget 

1. What are the funding sources, including dollar amounts (WIC funding, and outside grants)? 

Confirm that it is not a Fit WIC program and has not received a Special Project Grant.

2. What are the general cost categories associated with [INITIATIVE] (labor, outreach materials, 

training materials, ‘incentives’ for clients, etc.)? How much staff time is spent on the initiative? 

3. Are the WIC dollars food funds, NSA funding, state matching funds for WIC, or some 

combination? 

4. If the program is funded with other grants, how did you get the grants and who was responsible 

for the grant application? 

5. Did any grants come from community partners? 

6. How stable is future funding for [INITIATIVE]? How long do you intend the initiative to 

continue? 

G. Challenges and Successes 

1. What have been the major challenges to implementing [INITIATIVE]? How were those 

challenges overcome (if at all)? 

2. What do you consider to be the biggest success(es) of [INITIATIVE] so far? What factor(s) led 

to that success? 

3. How would you assess the overall quality of the services provided and how well the program is 

being implemented? 

4. If you could make any change to [INITIATIVE], what would it be and why? 

H. Evaluation/Monitoring of Outcomes

1. What are the desired outcomes for [INITIATIVE]? 

2. Do you monitor the outcomes of the initiative (e.g. collecting data on increased use of health 

screenings, etc.)? How are the outcomes measured? 

3. What have been the results of [INITIATIVE]? If breastfeeding initiative, see alternate question 

below:
B.10 

For breastfeeding initiatives only: 

3b. What percentage of your WIC clients choose to breastfeed? 

 -- What are the duration rates like? 

 -- Have these figures changed significantly since the initiative started? 

-- Do these rates vary by subgroup (for example, are teen parents less likely to breastfeed?) 

4. Do not ask if we know this already. Has your agency conducted a formal evaluation of the 

program? If so, when was it conducted and by whom? Request a copy of the report.

5. If the evaluation is ongoing... What is the status of the evaluation? 

I. Replicability

1.

1. Do you think this model can be successfully replicated in other places? Do you think that the 

program could be used in a range of WIC settings? Why or why not? 

2. What advice would you give to an agency that wants to implement a similar WIC initiative?

BACKGROUND INFORMATION (if time) 

J. Community Context

1. Describe the area in general—locale, demographics, local economy, urban versus rural. 

K. Local WIC Program and Policies 

1. Describe the local WIC agency. What entity serves as the local agency (county health 

department, hospital, nonprofit)? If state-level initiative, see alternate question below:

For state-level initiatives only: 

1b. Describe the participating WIC agencies. What entities serve as the local agencies (county 

health departments, hospitals, nonprofits)? 

2. How many clinics are attached to this local agency(ies)? Where are the clinics located (e.g. 

hospital, nonprofit)? 

3. How big is the staff at each location? How many numbers served (breakdown of numbers served 

into pregnant women, breastfeeding women, non-breastfeeding postpartum women, children 

under 5). 
B.11 

4. Describe the certification process, including nutrition education provided, and how nutrition 

education contacts are usually provided post-certification. For breastfeeding programs: What 

about specifically for breastfeeding women? 

WRAP UP/NEXT STEPS

1. Is there anything that you would like to add about [INITIATIVE] or the WIC population in 

your community that we have not discussed? 

If we include this profile in the report, we would like to give an overall description—can we include your 

contact information in the report (or someone else who would be more appropriate?) 

Based on what you know about our study, do you think that this program would be a good candidate for 

a two-day site visit? The visit would take place sometime this summer by two members of the research 

team. We would like to interview stakeholders and participants, observe program services (e.g. a peer 

counseling session), tour a local WIC agency, and collect cost information. Information on topics that 

we covered today would be repeated during the site visit, but collected from a variety of perspectives, 

including the local WIC agency director, director of the innovative program (if different from local 

director), staff members in the WIC office, especially those delivering services, and finally the 

participants receiving services. 

B.13 

INNOVATIVE WIC PRACTICES 

XXX SITE VISIT 

AUGUST 2003 

OBSERVATION 

LOCATION:_______________________________________________ 

DATE, TIME:_______________________________________________

Location of observation (e.g. waiting room, classroom, WIC staff office, hospital, clinic) 

Description of participants 

 WIC/Hospital/Clinic clients (e.g. number, race, sex, approximate age) 

 Staff (e.g. number, title) 

Environment (e.g. distractions, cleanliness, comfort, engaging pictures/posters/bulletin boards) 

Is Loving Support Breastfeeding Program theme/logo evident? If so, how? (e.g. posters, staff 

lanyards) 

Description of activity taking place (e.g. class, counseling) 

Language (e.g. English, Spanish) 

Topic of activity 

Intervention tools utilized and/or incentives distributed (e.g. slide show, handouts, food) 
B.14 

If applicable, style of class (e.g. lecture, facilitated discussion, activity based, food demonstration, 

combination) 

If applicable, role of staff in activity 

If applicable, role of caregiver or other adult in activity 

If applicable, role of infant or child in activity 

If applicable, duration of activity