GAO

United States General Accounting Office

Report to Congressional Committees

February 2001 FOOD ASSISTANCE 

Performance 

Measures for 

Assessing Three

WIC Services

GAO-01-339

Page 1 GAO-01-339 Measures for Three WIC Services

United States General Accounting Office

Washington, D.C. 20548 Letr

February 28, 2001

The Honorable Richard G. Lugar

Chairman

The Honorable Tom Harkin

Ranking Member

Committee on Agriculture, Nutrition, and Forestry

United States Senate

The Honorable John A. Boehner

Chairman

The Honorable George Miller 

Ranking Minority Member

Committee on Education and the Workforce

House of Representatives

The Special Supplemental Nutrition Program for Women, Infants and 

Children (WIC) is a federally funded $4.1 billion-a-year nutrition assistance 

program administered by the U.S. Department of Agriculture’s Food and 

Nutrition Service (FNS). During fiscal year 2000, this program provided $3 

billion for supplemental foods and $1.1 billion for nutrition services and 

administration to assist lower-income pregnant, breastfeeding, and 

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

risk. FNS provided annual cash grants to support program operations at 88 

state-level agencies.1

 These 88 agencies administered the program through 

more than 1,800 local WIC agencies. 

To help the Congress better understand the costs of delivering nutrition 

services and administering WIC, the William F. Goodling Child Nutrition 

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

aspects of WIC nutrition services and administration. This report, the third 

in a series responding to this request, examines the performance measures 

that FNS uses to assess the nutrition education, breastfeeding promotion 

1

State agencies are located in the 50 states, the District of Columbia, American Samoa, the 

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

organizations. These agencies typically are public or private nonprofit health or human 

services agencies; they can be an Indian Health Service Unit, a tribe, or an intertribal 

council.
Page 2 GAO-01-339 Measures for Three WIC Services

and support, and health referral services provided to WIC program 

participants.2

We based our evaluation on the performance measurement framework 

contained in the Government Performance and Results Act of 1993 (Results 

Act), which, among other things, encourages agencies to measure program 

performance by determining the extent to which intended program 

outcomes have been achieved. Program outcomes are the results of 

delivering a program’s products and services, while program outputs are 

the products and services delivered. An example of the distinction between 

the two concepts can be seen in the case of a job-training program. In such 

a program, an output could be the number or percentage of program 

participants who completed the training. A program outcome, on the other 

hand, could be the number or percentage of program participants 

employed 1 year after the training. Outcome measures on which objective 

data can be collected at reasonable cost can be difficult to develop, 

particularly for programs that are intended to influence the behavior of 

individuals. While emphasizing the use of outcome measures, the Results 

Act recognized that the output measures traditionally used by agencies for 

measuring performance remain critical to program management. 

Consistent with the Results Act’s approach to performance measurement, 

this report discusses FNS’ use of both outcome and output performance 

measures. Specifically, it provides information on how FNS measures (1) 

the outcomes of three services provided by the WIC program—nutrition 

education, breastfeeding promotion and support, and health referral 

services; and (2) program outputs for these three service areas.

Results in Brief FNS has an outcome-based measure for one of the three nutrition 

services—breastfeeding promotion and support. However, the measure, 

breastfeeding initiation rate, examines only one of several important 

aspects of the service’s possible impact on WIC participants. Other key 

aspects, for which FNS has not established outcome measures, include the 

length of time that WIC mothers breastfeed their infants and 

breastfeeding’s contribution to an infant’s overall nutritional needs. Several 

2

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

Services and Administrative Costs (GAO/RCED-00-66, Mar. 6, 2000). The second report was 

Food Assistance: Activities and Use of Nonprogram Resources at Six WIC Agencies 

(GAO/RCED-00-202, Sept. 29, 2000). 
Page 3 GAO-01-339 Measures for Three WIC Services

obstacles have hindered FNS’ efforts to develop and implement outcomebased measures for nutrition education and health referral services for the 

WIC program. These include difficulties in identifying measures that would 

allow the agency to appropriately link a particular service’s activity to a 

desired outcome and resource constraints affecting FNS’ ability to collect 

data needed to implement a proposed measure. 

FNS employs a large number of program output measures to gauge 

performance of the three WIC services. Generally, these measures are used 

to examine the types and quantities of services that state and local agencies 

provide and whether the agencies are in compliance with grant expenditure 

and other program requirements. FNS has been hindered in measuring 

program compliance because of weaknesses in the management evaluation 

process used to collect data on these measures. Among other problems, 

inconsistencies in procedures used to conduct the evaluations have 

resulted in problems in interpreting evaluation results as well as in 

comparing and analyzing results across evaluations. FNS is considering 

recommendations its special task force made in a January 2001 report to 

strengthen its processes for management evaluations. 

While we believe that the weaknesses in FNS management evaluations 

should be addressed expeditiously, we are not making specific 

recommendations at this time because FNS is actively considering 

corrective actions. However, we will continue to monitor the agency’s 

actions on these matters and, if warranted, make recommendations in the 

future. In commenting on a draft of this report, FNS officials generally 

agreed with the information presented, but cautioned that the report 

discussed performance measures only as they pertained to three nutrition 

service components of the WIC program and not the program in its entirety. 

They believed that when viewed from this broader context, the program 

has resulted in a number of desirable health outcomes.

Background As part of its administration of the WIC program, FNS makes grants to the 

88 state agencies that in turn provide program benefits—supplemental 

foods and a variety of nutrition services—to participants through more 

than 1,800 local WIC agencies. The state agencies develop guidelines 

intended to ensure that local agencies effectively deliver WIC benefits to 

eligible participants, and monitor local agencies’ compliance with these 

guidelines. Local agencies serve participants directly or through one or 

more service delivery sites or clinics located within their service areas. 

Staff at local WIC agencies and clinics approve applicants for participation; 
Page 4 GAO-01-339 Measures for Three WIC Services

provide food benefits, typically in the form of vouchers that can be 

exchanged for WIC-approved supplemental foods at specified grocers; 

provide nutrition education; and make health referrals to eligible 

individuals. 

For fiscal year 2000, grants for this program totaled $4.1 billion—$3 billion 

for supplemental foods and $1.1 billion for nutrition services and program 

administration costs. Grants for nutrition services and administration 

(NSA) are typically used to support activities in four broad categories: 

participant services, including health care referrals; nutrition education; 

breastfeeding promotion and support; and program administration, such as 

planning and budgeting. This report focuses on three specific services—

nutrition education, breastfeeding promotion and support, and health 

referrals. Table 1 describes some of the specific activities that local WIC 

agencies provide as part of these services.

Table 1: Three Nutrition Services by Activities 

FNS Has an OutcomeBased Measure for One 

of Its Three Nutrition 

Services

FNS established the breastfeeding initiation rate as an outcome-based 

measure for the WIC program’s breastfeeding promotion and support 

activities, but has no outcome measures for its nutrition education or 

Type of service Description

Nutrition education • Providing individual and/or group nutrition education sessions. 

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

translating materials to facilitate nutrition education of non-English-speaking participants. 

• Providing or receiving training regarding nutrition education promotion, and evaluating and monitoring 

nutrition education.

• Providing information on the benefits of the supplemental foods provided by WIC and how to exchange WIC 

food vouchers for food products at WIC-approved grocers.

Breastfeeding promotion 

and support 

• Providing individual counseling sessions at WIC clinics or in hospitals and by telephone to promote and 

support breastfeeding, and maintaining a clinic environment that encourages breastfeeding. 

• Consulting with medical providers regarding breastfeeding issues.

• Providing or receiving training regarding breastfeeding promotion and monitoring and evaluating 

breastfeeding promotion activities.

Health referrals • Providing each participant with information on available health care providers.

• Referring participants to a health practitioner, when appropriate, such as for immunizations, and to social 

services such as the Medicaid program.
Page 5 GAO-01-339 Measures for Three WIC Services

health referral services.3 While this single measure allows FNS to examine 

one aspect of the impact of its services on WIC clients, it does not measure 

ther important aspects of this service’s impact—such as the length of time 

that WIC mothers breastfeed their infants and the percentage of daily 

nutrition an infant obtains from breastfeeding. FNS has attempted to 

develop outcome-based measures for the WIC program’s nutrition 

education and health referral services but has not yet been successful in 

implementing these measures. FNS has identified a measure for nutrition 

education but has not implemented it because of resource constraints. For 

health referrals, FNS has been unable to identify a measure that, among 

other things, would permit it to appropriately link the service’s activities 

with a desired outcome. 

Breastfeeding Initiation 

Rate Measures Outcomes of 

Breastfeeding Promotion 

and Support Activities

FNS established the breastfeeding initiation rate as its outcome-based 

measure for breastfeeding promotion and support activities as part of its 

fiscal year 2000 performance plan.4

 The measure represents the percentage 

of WIC infants between 7 and 11 months of age who, at some time, have 

been breastfed. FNS first reported the results of this measure in May 2000 

as part of its 1998 WIC Participant and Program Characteristics Study 

(Characteristics Study), a biennial report on the characteristics of WIC 

participants and program activities. The overall rate of 42 percent for 1998 

will serve as a baseline against which FNS will gauge future years’ 

progress.5

 FNS has collected data for fiscal year 2000, which it is in the 

process of analyzing and expects to be available in the spring of 2002. 

Although FNS established an outcome measure for breastfeeding initiation, 

this measure does not assess the full range of potential impacts of 

breastfeeding promotion and support activities on WIC participants. The 

breastfeeding initiation rate includes only WIC infants who are breastfed at 

3

While FNS has no outcome measure specific to the WIC program’s nutrition education 

service, it has an outcome-focused diet quality measure to monitor progress in improving 

the diet quality for demographic groups generally eligible for participation in FNS’ 

programs. According to agency officials, data from this measure will be used in the future to 

target the Agency’s nutrition education efforts through programs such as WIC. 

4

Performance plans, developed pursuant to the requirements of the Results Act, assess 

progress toward the goals and objectives of an agency’s strategic plan. FNS’ performance 

plan reflects the agency’s priorities for the fiscal year covered by the plan. 

5

This percentage is based on data from 63 of 88 state agencies, which covered about 80 

percent of all WIC infants.
Page 6 GAO-01-339 Measures for Three WIC Services

some time. It does not address other aspects of breastfeeding, such as 

duration or the percentage of daily nutrition that an infant obtains through 

breastfeeding. FNS attempted to collect data on breastfeeding duration as 

part of its 1998 Characteristics Study. However, only 40 of the 88 state 

agencies were able to provide this information for at least 75 percent of 

WIC infants in their states. According to FNS, these state agencies were 

unable to provide the data because their automated information systems 

did not contain complete data on each participant. FNS anticipates the 

number of state agencies reporting sufficient data to increase as states 

become accustomed to reporting these data. FNS has not attempted to 

measure the percentage of daily nutrition an infant obtains through 

breastfeeding. While acknowledging the importance of this measure, FNS 

has not yet identified an appropriate means of implementing it. 

FNS’ Efforts to Implement 

Outcome-Based Measures 

for Nutrition Education and 

Health Referrals Have Been 

Unsuccessful

FNS established outcome-based measures for both the nutrition education 

and health referral services in its fiscal year 2000 performance plan. 

However, it was unable to implement these measures and did not include 

outcome-based measures for the two services in its 2001 performance plan.

FNS has identified an outcome measure for WIC nutrition education 

services, but has not implemented it primarily because of resource 

constraints. FNS intended to evaluate the impact of its nutrition education 

services by assessing the nutritional quality of meals consumed by a sample 

of WIC participants. FNS planned to implement this measure by extracting 

data from a national dietary survey of the U.S. population. This periodic 

survey, the Continuing Survey of Food Intakes of Individuals, includes WIC 

participants. However, FNS determined that the survey did not contain a 

large enough sample of WIC participants to establish national estimates. 

FNS lacked the resources needed to develop another sample with a large 

enough number of WIC participants to establish national estimates. FNS 

officials said that the agency is exploring ways to overcome the sample size 

problem for future implementation of this measure. 

In addition, FNS has not established a measure for WIC health referral 

activities that appropriately links the service’s activities with a desired 

outcome. Initially, FNS intended to use the percentage of WIC child 

participants who were immunized as the outcome measure for its health 

referral services. To implement this measure, FNS planned to use data 

gathered by the federal Centers for Disease Control and Prevention (CDC) 

from its National Immunization Survey. In its 1999 Survey, the CDC began 

reporting immunization data for children participating or not participating 
Page 7 GAO-01-339 Measures for Three WIC Services

in WIC. However, with its 2001 performance plan, FNS discontinued this 

measure. Agency officials gave two reasons for this decision. First, they 

noted that FNS is not responsible for ensuring that children participating in 

WIC are actually immunized, but rather those children needing 

immunizations are referred to doctors as appropriate. Second, they pointed 

out that immunization data provided by CDC on WIC participants did not 

permit FNS to measure the extent to which WIC health referrals actually 

contributed to the immunization of WIC child participants. 

FNS officials noted that the problems they faced in finding a measure that 

appropriately linked WIC health referral activities to a desired outcome are 

not unique to the health referral services. They pointed out that it is 

difficult to measure the impact of any of the individual services WIC offers 

because, among other things, other variables also influence the behavior 

these services are intended to promote. For example, there are several 

other state and local programs that, like WIC, are aimed at improving 

health through nutrition education. Separating the effects of these efforts 

from those of the WIC program is difficult at best. 

FNS Relies on a Variety 

of Output Measures to 

Monitor Program 

Performance 

FNS employs a large number of program output measures to gauge 

performance of the WIC nutritional services it offers. Generally, these 

measures are used to examine the types and quantities of services the state 

agencies provide and whether the agencies are in compliance with grant 

expenditure and other program requirements. (A detailed list of output 

measures can be found in app. I.) To monitor these measures, FNS depends 

in large part on data provided by state and local agencies through routine 

financial reports, its biennial Characteristics Study, and FNS’ management 

evaluations of state and local agency operations. Of these monitoring 

methods, FNS relies heavily on its management evaluations to measure 

state and local WIC agency compliance with program requirements. 

However, weaknesses in the procedures for conducting evaluations of WIC 

agencies reduce its value as a performance oversight tool. FNS recently 

completed an examination of its practices for conducting management 

evaluations for all FNS programs, including WIC, and made several 

recommendations for improvements. 

FNS uses several financial reports submitted by state agencies to measure 

the extent to which state and local agencies meet expenditure 

requirements. The principal measure is whether states are adhering to a 

legislatively established requirement for spending on nutrition education 

activities and breastfeeding promotion and support activities. Combined 
Page 8 GAO-01-339 Measures for Three WIC Services

spending for these two activities must equal at least one-sixth of the NSA 

expenditures plus a target amount for breastfeeding promotion and 

support established by FNS at the beginning of each fiscal year. The 

Addendum to the WIC Program Annual Closeout Report, prepared by each 

state, serves as the primary source of data on the state’s compliance with 

this expenditure requirement. For fiscal year 1999, the most recent year for 

which complete data were available, FNS reported that two states and four 

Indian tribal organizations did not meet this minimum spending 

requirement. In addition, the WIC Program Annual Closeout Report each 

state prepares provides data on the final status of the state’s grant and costs 

for the report year. 

To measure the nature and amount of program services WIC agencies 

provide, FNS primarily uses data obtained from state and local agencies 

and reported in FNS’ Characteristics Study.6

 As noted earlier, the 

Characteristics Study provides information on a variety of program 

activities. Table 2 lists some of the key program activities in the three areas 

of service included in the Characteristics Study as well as information on 

the percentage of local WIC agencies offering the activity. 

Table 2: Selected Program Activities Used by Local Agencies 

6

FNS also utilizes special reports to measure the nature and amount of program services 

provided to participants. For example, FNS uses such reports to evaluate the success of 

state adoption of FNS’ national breastfeeding promotion campaign, Loving Support.

Program activitya

Percentage of local

agenciesb

Nutrition education

Nutrition education sessions for pregnant participants provided 

during 

 Certification

 Food benefit issuance

 Dedicated nutrition education sessions

 Other health care appointments

96.8

65.8

44.7

20.2

Nutrition education offered in a language other than English

 Spanish

 French

 Vietnamese

 Laotian

 Various Native American languages

 Hmong 

50.0

 5.7

 5.3

 4.6

 3.9

 3.8
Page 9 GAO-01-339 Measures for Three WIC Services

a

A total of 460 local WIC agencies responded to the survey. Responses were weighted to reflect the 

universe of 2,203 local agencies, the estimated universe of 8,932 service delivery sites, and the 

universe of 8,042,758 enrollees.

b

Figures may not sum to 100 percent because respondents could provide multiple responses.

c

Responses for these services are by percentage of WIC service delivery sites providing the service.

According to FNS officials, survey data from local agencies, of the sort seen 

in table 2, may no longer be collected for the Characteristics Study for 2002 

and beyond because research funds are unavailable for that purpose. These 

officials explained that the Agriculture, Rural Development, Food and Drug 

Administration, and Related Agencies Appropriations Act of 1998 (P.L. 105-

86) effectively transferred primary responsibility for research on food 

assistance and nutrition programs from FNS to the Department’s Economic 

Research Service, which has not subsequently funded the collection of the 

local WIC agency data. FNS officials believe that these data are important 

Nutrition education topics especially for pregnant women

 Importance of folic acid

 Using WIC foods for a healthy diet

 Strategies to prevent or manage overweight

81.0

82.9

47.6

Methods or materials always used in providing nutrition education

Counseling/discussion

Food models

Videos, films, slides

Testing participant’s knowledge

90.7

25.5

 7.4

 4.1

Average length of group nutrition education sessions for non highrisk participants, in minutes

Less than 10

10-19

20-29

30-39

40-49

50 and longer

18.1

28.8

21.2

 5.1

 2.1

 3.1

Breastfeeding promotion and support

Group education sessions devoted solely to breastfeeding

Breastfeeding support groups 

Provision of breast pumps 

Individual counseling 

Home/hospital visit 

Peer counseling 

97.4

80.7

43.6

31.4

30.9

16.7

Health referralsc

Type of referral or service provided

 Well-baby care and immunizations, referral for all participants 

 Well-baby care and immunizations, referral as needed

 Immunizations only, referral for all participants

 Immunizations only, referral as needed

22.6

60.6

10.6

48.1

(Continued From Previous Page)

Program activitya

Percentage of local

agenciesb
Page 10 GAO-01-339 Measures for Three WIC Services

for monitoring the nature and level of services being delivered by local 

agencies. To address this and other research concerns, FNS has attempted 

to regain direct responsibility over research funding for food assistance 

and nutrition programs.

To measure overall compliance with program requirements, including 

those related to nutrition education, breastfeeding promotion and support, 

and referral services, FNS regional offices conduct management 

evaluations at each of the 88 state WIC agencies and at a sample of local 

agencies. In general, each of the state agencies and selected local agencies 

are reviewed every 3 years. According to FNS, management evaluations are 

the primary means of measuring state and local WIC agency compliance 

with program requirements. As part of the management evaluations, staff in 

FNS’ regional offices conduct interviews, review planning documents, 

observe interactions, and examine participants’ files. Listed below are 

some of the types of nutrition education, breastfeeding promotion and 

support, and health referral service program requirements that can be 

assessed during management evaluations: 

• Nutrition education

• State agency WIC plan includes nutrition education goals and action 

strategies,

• Local agencies offer each participant a minimum of two nutrition 

education contacts during each 6-month certification period and 

documents the provision of service or the participant’s refusal or 

inability to participate,

• State agency has developed or identified nutrition education 

resources and materials for use by local agencies, and

• Nutrition education material provided is easily understood by 

participants.

• Breastfeeding promotion and support

• State and local agencies have a designated breastfeeding promotion 

and support coordinator who provides technical assistance to local 

agencies,

• State agencies have developed standards for local agencies for use in 

providing breastfeeding promotion and support, and

• Local agency staff has received training on promotion and 

management of breastfeeding promotion and support.

• Health referrals

• Local agency staff refers participants, as appropriate, to private or 

public health care services.
Page 11 GAO-01-339 Measures for Three WIC Services

FNS has not made full use of management evaluations to measure program 

performance and provide needed oversight. In large part this is due to 

inconsistencies in the procedures used to conduct the evaluations, which 

have caused problems in interpreting evaluation results as well as in 

comparing and analyzing results across evaluations. FNS recently 

examined its practices for conducting management evaluations for all FNS 

programs, including WIC. Results of this review were highlighted in a 

January 2001 report to the Administrator. The report noted that (1) 

management evaluations at state and local levels were not being conducted 

uniformly across FNS regional offices; (2) standard vocabulary did not 

exist for identification of certain concepts; (3) standard definitions were 

needed for such key terms as deficiency (a judgment that the agency being 

reviewed is not in compliance with program requirements and must take 

corrective action); (4) additional staff time needed to be allocated to 

testing and training prior to implementation; and (5) a learning, feedback, 

and modification period would be needed to support consistent data 

collection and the development of reporting methods. The task force 

recommended a number of actions aimed at obtaining more consistent 

information that, if implemented, could provide FNS with better data for 

identifying national trends, quantifying deficiencies, developing policies, 

and measuring mission effectiveness. Agency officials told us that a 

response from the Administrator is expected by April 2001. 

Agency Comments and 

Our Evaluation 

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

review and comment. We met with FNS officials, including the Director, 

Office of Analysis and Nutrition Evaluation; the Director, Supplemental 

Food Program Division; and officials in the Grants Management Division. 

These officials generally agreed with the information presented in this 

report. However, they cautioned that the report addressed performance 

measures as they pertained to three nutrition service components of the 

WIC program and not the program in its entirety, which includes 

supplemental foods and other aspects of nutrition services. FNS officials 

believed that research on the effects of the WIC program as a whole 

indicated that it has contributed to a number of desirable outcomes 

including improved diets and infant feeding practices, reduced incidence of 

anemia among children, reduced incidence of infant mortality and low 

birthweight infants, and reduced postpartum medical expenses. Also, these 

officials provided us with a number of technical comments that we 

incorporated into the report, as appropriate.
Page 12 GAO-01-339 Measures for Three WIC Services

Scope and 

Methodology

In developing information for this report, we spoke with and obtained data 

from officials at FNS’ headquarters in Alexandria, Virginia, and the seven 

FNS regional offices—Northeast in Boston, Massachusetts; Mid-Atlantic in 

Robbinsville, New Jersey; Southeast in Atlanta, Georgia; Midwest in 

Chicago, Illinois; Mountain Plains in Denver, Colorado; Southwest in 

Dallas, Texas; and, Western in San Francisco, California. We reviewed 

legislation, policies, procedures, and practices; reviewed reports issued by 

GAO and others related to WIC; and interviewed various officials 

responsible for administering the WIC program. We also reviewed FNS’ 

strategic and annual performance plans and other documents developed as 

part of implementing the Results Act. We conducted our work from 

September 2000 through January 2001 in accordance with generally 

accepted government auditing standards.

We are sending copies of this report to the appropriate congressional 

committees; interested members of the Congress; the Honorable Ann M. 

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

also make copies available to others upon request.

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

at (202) 512-7215. Key contributors to this report are listed in appendix II.

Robert E. Robertson

Director, Education, Workforce 

and Income Security
Page 13 GAO-01-339 Measures for Three WIC Services
Page 14 GAO-01-339 Measures for Three WIC Services

Appendix I

Output Measures for Monitoring Program Apendxies

Requirements and Activities for the Three 

Services ApendxiI

Performance measure Description of requirement or activity Source of data

Nutrition education

Amount of Nutrition Services and 

Administration (NSA) funds spent for 

nutrition education by state agency

Requirement that state agencies spend an 

amount not less than the sum of one-sixth the 

total amount of its NSA expenditures on nutrition 

education and breastfeeding promotion and 

support plus a breastfeeding promotion and 

support target amount established by FNS at the 

beginning of each fiscal year

Financial report

Extent to which participant actually 

receives nutrition education

Requirement that each participant will be provided 

with at least two nutrition education contacts 

during each 6-month certification period

Management evaluation review of 

participants’ files

Extent to which the nutrition education is 

in individual or group settings

Requirement that nutrition education contact will 

be provided to each participant in individual or 

group settings

Management evaluation observations of 

staff-participant interactions, and review 

of participants’ files and documents

Number of state agencies with a nutrition 

coordinator

Requirement that each state WIC agency will 

designate a nutrition coordinator responsible for 

nutrition education

Special reports to the agency and 

management evaluation review of 

documents

Number of state agencies that have 

developed nutrition goals and action plans

Requirement that state agency will include in its 

state plan a nutrition plan with education goals 

and action plans, including a description of 

education methods

Management evaluation review of state 

agency’s State Plan of Operations 

Extent to which nutrition education is free, 

easy for participant to understand, and 

bears a practical relationship to 

participant’s needs

Requirement that the participant will be provided 

with free nutrition education that is easily 

understood and bears a practical relationship to 

participant’s needs situation and cultural 

preferences

Management evaluation observations of 

staff-participant interactions, and review 

of participants’ files and documents 

Number of local agencies offering nutrition 

education in foreign languages

Requirement that, in order to meet the needs of 

non-English-speaking participants, WIC agencies 

offer nutrition education in languages other than 

English, such as Spanish, Laotian, and French

Management evaluation observations 

and review of documents; survey of local 

agencies through WIC Participant and 

Program Characteristics Study 

Extent to which nutrition education 

emphasizes the relationship between 

proper nutrition and good health

Requirement that state agency will provide 

nutrition education that emphasizes the 

relationship between proper nutrition and good 

health

Management evaluation observations of 

staff-participant interactions, and review 

of participants’ files and documents

Extent to which nutrition education 

reinforces positive changes in food habits 

that result in participant’s improved 

nutritional status 

Requirement that state agencies will assist 

nutritionally at-risk individuals in achieving positive 

changes in food habits, resulting in improved 

nutritional status and in prevention of nutritionrelated problems

Management evaluation observations of 

staff-participant interactions, and review 

of participants’ files and documents

Extent to which state agency provides the 

local agency with nutrition education 

resources and materials 

Requirement that each state agency will identify 

or develop nutrition education resources and 

educational materials for use in local agencies

Management evaluation review of state 

agency’s State Plan of Operations and 

other state documents; review of 

resources at local agency
Appendix I

Output Measures for Monitoring Program 

Requirements and Activities for the Three 

Services

Page 15 GAO-01-339 Measures for Three WIC Services

Number of visits made to FNS’ nutrition 

education Web site 

Measurement of local agency program activity to 

provide nutrition education strategies to WIC staff 

and increase staff nutrition education knowledge 

through FNS-implemented Web site, WIC Works

Special report 

Percent of WIC staff who are Registered 

Dieticians (or RD-eligible) or Registered 

Dietary Technicians

Measurement of FNS’ recruitment and retention 

efforts to increase the number of registered 

dieticians, which is critical to the delivery of quality 

nutrition services, including nutrition education

Special report (biennial survey by public 

health and nutrition program directors) 

Breastfeeding promotion and support

Amount of nutrition services and 

administration funds spent on 

breastfeeding promotion and support 

Requirement that state agencies must spend a 

target amount of nutrition services and 

administration funds on breastfeeding promotion 

and support 

Financial report

Number of state agencies with a 

breastfeeding coordinator

Requirement that the state agency will designate 

a breastfeeding promotion and support 

coordinator to provide support and technical 

assistance to local agencies and to develop state 

agency activities

Special report; management evaluation 

of state agency’s State Plan of 

Operations and other documents

Number of local agencies that have a 

breastfeeding coordinator

Requirement that every local WIC agency will 

designate a breastfeeding coordinator responsible 

for providing promotion and assistance

Special report; management evaluation 

of local agency documents

Number of states that implement all or 

part of FNS’ National Breastfeeding 

Promotion Campaign

Measurement of the success of FNS’ campaign—

Loving Support—designed to promote 

breastfeeding in the WIC program

Special report

Extent to which state agency provides the 

local agency with breastfeeding education 

resources and materials 

Requirement that state agency will develop 

breastfeeding education resources and materials 

and provide technical assistance to local agencies 

Management evaluation review of state 

agency’s State Plan of Operations and 

other documents 

Number of state agencies that have 

developed standards for local agency use 

in providing breastfeeding support 

Requirement that the state agency develop 

standards for use by local agencies for 

breastfeeding support for prenatal and 

postpartum women 

Management evaluation review of state 

agency’s State Plan of Operations and 

other documents 

Number of local agencies offering 

education sessions devoted to 

breastfeeding

Measurement of program activity to encourage 

pregnant participants to begin and continue 

breastfeeding their infants

Survey of local agencies through WIC 

Participant and Program Characteristics 

Study

Number of local agencies that have staff 

that make home or hospital visits to 

mothers of newborns

Measurement of local agency activity to 

encourage and support breastfeeding by mothers 

of newborns through home or hospital visits

Survey of local agencies through WIC 

Participant and Program Characteristics 

Study

Number of local agencies offering peer 

counseling for breastfeeding

Measurement of local agency activity to 

encourage and support breastfeeding through 

peer support and discussion groups

Survey of local agencies through WIC 

Participant and Program Characteristics 

Study

Number of local agencies that have 

received training on promotion and 

management of breastfeeding promotion 

and support 

Requirement that the state WIC agency develop 

and provide to local agencies training on 

promotion and management of breastfeeding 

promotion and support

Management evaluation review of state 

agency’s State Plan of Operations and 

other documents

Performance measure Description of requirement or activity Source of data
Appendix I

Output Measures for Monitoring Program 

Requirements and Activities for the Three 

Services

Page 16 GAO-01-339 Measures for Three WIC Services

Health referrals

Number of participants provided with 

information on health care providers

Requirement that WIC staff provide each 

participant with information on available health 

care providers 

Management evaluation review of 

participant file data and other documents

Number of participants referred to a 

health practitioner when appropriate

Requirement that WIC staff refer participants to a 

health practitioner when appropriate, such as 

when a pregnant participant has not yet received 

prenatal care or a child participant has not 

received age-appropriate immunizations

Management evaluation review of 

participant file data and other documents

Number of WIC agencies with on-site 

pediatric care

Measurement of WIC agencies that are collocated 

with pediatric care facilities to assist in meeting, in 

part, the requirement that WIC staff help 

participants obtain and use preventive health care 

services and local agencies serve as a link 

between participants and health-care providers

Survey of local agencies through the 

WIC Participant and Program 

Characteristics Study; management 

evaluation of local agency operations

Number of WIC agencies offering wellbaby care and immunizationsMeasurement of WIC agencies that offer wellbaby care services to assist in meeting, in part, 

the requirement that WIC staff assist participants 

in obtaining and using preventive health-care 

services

Survey of local agencies through the 

WIC Participant and Program 

Characteristics Study; management 

evaluation of local agency operations

Performance measure Description of requirement or activity Source of data
Page 17 GAO-01-339 Measures for Three WIC Services

Appendix II

GAO Contact and Staff Acknowledgments ApendxiI

GAO Contact Robert E. Robertson, (202) 512-7215

Staff 

Acknowledgments

In addition to the contact named above, Abiud Amaro, Clifford Diehl, Judy 

Hoovler, Angela Miles, and Ron Wood made key contributions to this 

report.

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