Abt Associates Inc. Executive Summary i

Executive Summary

The WIC Nutrition Education Assessment Study was conducted by Abt Associates Inc. of

Cambridge, Massachusetts, under contract with the Food and Nutrition Service (FNS) of the

United States Department of Agriculture (USDA). The study was designed by FNS to fill several

important gaps in information about the nutrition education component of the WIC Program. It was

not designed to be a "best practices" study, nor was it meant to provide a nationally representative

picture of nutrition education in the WIC Program. Rather, the study was exploratory in nature and

examined processes and outcomes in six local WIC agencies that serve different populations and

use a variety of different approaches to providing nutrition education. Findings from the study are

intended to provide a focus for future research in this area.

The study is unique in that it used a longitudinal design, i.e., repeated measures from the same group

of WIC participants over a period of time. In addition, the study employed a mixed-method

approach to data collection that allowed for collection of comparable data from different sources. 

This feature provides broad coverage of important issues from different perspectives.

Six local WIC agencies participated in the study which focused on pregnant and postpartum WIC

participants. A separate report describes the nutrition-related knowledge, attitudes, and behaviors

of study subjects at the time they enrolled in WIC (Fox, M.K., et al., 1998). This report describes

the nutrition education services offered in study sites, participants' receipt of and satisfaction with

these services, and changes in participants' knowledge, attitudes, and behaviors between the time of

prenatal WIC certification and four-to-six-months postpartum.

Overview of the Study

The study had four key research objectives:

• To assess pregnant women's nutrition-related knowledge, attitudes, and

self-reported behaviors at the time of WIC enrollment.

• To describe the processes used by local agencies in delivering WIC

nutrition education to pregnant and postpartum women and the type and

amount of nutrition education actually received by these participants.

• To assess participants' satisfaction with WIC nutrition education services,

materials, and staff.

• To the extent possible, to assess the impact of WIC nutrition education on

participants' knowledge, attitudes, and behaviors.
Abt Associates Inc. Executive Summary ii

The impact study encompassed in the study's fourth objective was exploratory in nature. Because

program policies precluded establishment of a true control group, i.e., a group of WIC participants

to whom WIC nutrition education services were not offered, a quasi-experimental design was used.

Although the design does not permit a definitive assessment of the impact of WIC nutrition

education, nor yield results that are generalizable to the WIC population nationwide, the study does

provide useful insights about the potential magnitude and direction of changes in participants’

knowledge, attitudes, and behaviors over time. Moreover, because the demographic

characteristics of the study sample were quite similar to those of pregnant WIC participants

nationwide, study findings have broad relevance for the WIC Program. 

Participating Local Agencies

Six local agencies, located in three different States (two agencies per State), participated in the

study. Sites were purposefully selected to include a variety of approaches to the delivery of WIC

nutrition education, as well variability in community type (urban versus rural) and ethnic and cultural

backgrounds of WIC participants.

Sample Recruitment

Newly enrolling pregnant women were recruited into the study just prior to WIC certification. A

newly enrolling pregnant woman, while just being certified for her current pregnancy, may have

participated in WIC during previous pregnancies and/or as caretaker of an infant or child WIC

participant. To ensure that baseline information was collected before women received any nutrition

education for their current pregnancy, recruitment and baseline interviews were completed before

women met with any WIC staff. 

Data Collection 

Sample members were interviewed three times. The baseline survey was completed at the time of

prenatal WIC certification. The first follow-up survey (prenatal survey) was completed at 32-36

weeks gestation and the second (postpartum survey) was completed four to six months

postpartum. Identical measures of nutrition knowledge, attitudes, and behavior were included in all

three surveys. Follow-up surveys also included questions about experiences and satisfaction with

WIC nutrition education. 

In addition, data were abstracted from WIC records to ascertain the number and type of nutrition

education contacts provided to study respondents during prenatal and postpartum certification

periods. Finally, to supplement background information provided by local agency directors and

obtain a “real world” picture of WIC nutrition education, a limited number of nutrition education

contacts were observed in each site.
Abt Associates Inc. Executive Summary iii

Key Findings

Characteristics of Nutrition Education Offered in Study Sites

• Methods used to deliver nutrition education varied considerably across sites, including

use of individualized counseling for all nutrition education contacts and use of a

newsletter (distributed by voucher clerks) for follow-up contacts with low-risk women.

• Four of the six study sites experienced problems with participant no-shows for followup contacts. The problem was quite significant in two sites, so much so that local

agency directors ultimately implemented procedures specifically designed to ensure that

participants receive a second prenatal contact.

• A majority of sample members were certified for postpartum participation. Most

certified during the six-week transition period allowed after the birth of the baby. The

proportion of women who did not recertify in one site was notably higher than the other

sites. This may be because women were required to attend separate certification

appointments for themselves and their infants. The five other sites used joint

appointments that allowed both certifications to be completed at the same time.

• The quality of staff/participant interactions was generally quite high. WIC nutrition

educators did an excellent job of addressing participants' questions or concerns in a

supportive manner; providing opportunity for questions; offering specific and

appropriate ideas on how to implement recommended behaviors (e.g., ways to increase

milk consumption other than drinking milk as a beverage); maintaining nonjudgmental

attitudes; and providing positive feedback on current dietary intake (i.e., highlighting

positive aspects of participants’ current behaviors before discussing needed

improvements).

• At the same time, staff in five of the six sites frequently did not assess participants'

understanding of the information being communicated or attempt to determine whether

there were barriers that might affect a participant's ability to adopt a recommended

behavior. Staff in four of the six sites often did not ask about participants' willingness to

make a recommended behavior change. And, in three sites, WIC staff tended to

assign, rather than negotiate, goals for behavior change. Use of group contacts

(classes) did not preclude these desirable interactions, nor did use of individual contacts

ensure them.

• With one exception, the physical environment in which nutrition education was delivered

was appropriate and comfortable. 
Abt Associates Inc. Executive Summary iv

• The topics covered in WIC nutrition education contacts were generally consistent with

expectations. Most of the concepts included in the nutrition knowledge measure

developed for this study received widespread or moderate coverage. Certification

contacts tended to cover a broad array of topics, with an emphasis on content of the

WIC food package and, for prenatal certifications, recommended eating practices

during pregnancy. Follow-up contacts tended to focus on a single or more limited

number of concepts. In follow-up prenatal contacts, the most frequent topic was

recommended weight gain during pregnancy. 

• Referrals to health and social services were relatively rare. Because referrals are

supposed to be tailored to the individual needs of a participant, the absence of a referral

does not necessarily imply that a needed referral was missed. The data suggest that the

number and type of referrals offered in local WIC agencies is more reflective of the

context or local environment in which programs operate, i.e., the extent to which

participants are already hooked into needed programs and services before entry into

WIC, than of the quality of nutrition education offered to program participants.

Participants’ Receipt of Nutrition Education Contacts

• According to data from WIC administrative records, a majority of respondents (80-

97% across all study sites) had the opportunity to receive two nutrition education

contacts between prenatal certification and the birth of their babies. The extent to which

this goal was achieved varied across sites, and the pattern observed was entirely

consistent with findings from on-site observations of nutrition education contacts. The

percentage of women in each site who received two contacts during the prenatal period

ranged from a high of 92 percent to a low of 24 percent.

• The two sites that were most successful in providing two prenatal contacts used trimonthly voucher issuance which, in theory, decreases the number of contact

opportunities. No-show rates for follow-up nutrition education contacts were

substantially lower in these two sites, as reported by local agency directors and

documented during on-site observations.

• Although virtually all study subjects had the opportunity to receive two nutrition

education contacts between postpartum certification and the time WIC record abstract

data were collected (approximately six months postpartum), a large proportion received

only one contact (the certification contact). The maximum percentage for receipt of two

nutrition education contacts was 59 percent. The minimum was five percent.

• Respondent self-reports regarding information and advice received from WIC staff

were largely consistent with findings from on-site observations. In general, topics that
Abt Associates Inc. Executive Summary v

received widespread coverage in the on-site observations were reported frequently and

topics that received less coverage were reported less frequently.

• Respondents reported few referrals from WIC staff. This finding is consistent with the

on-site observations. Because most study sites did not record information about

referrals in WIC records, it was not possible to cross-check participant self-reports

with administrative data.

• The following types of women were significantly less likely to receive a second prenatal

contact: women who had previously been pregnant but not enrolled in WIC; women

who enrolled in their third trimester; and women who smoked. The following types of

women were significantly more likely to receive a second prenatal contact: previous

WIC participants; women with higher overall nutrition knowledge scores at baseline;

women who reported regular use of prenatal vitamins; and women who were planning

to breastfeed for at least six months at the time of WIC enrollment.

• These data suggest that the women most likely to return for follow-up prenatal nutrition

education contacts are those who already have higher levels of nutrition knowledge and,

to some extent, already exhibit desirable health behaviors. Conversely, women who are

theoretically most in need of services, e.g., those who enroll late in pregnancy and those

who smoke, are less likely to return for a second prenatal contact. 

Changes in Knowledge, Attitudes, and Behaviors Over Time

Nutrition Knowledge

• With the exception of one site that served a large population of recent immigrants,

participants entered WIC with reasonably high levels of nutrition knowledge. Overall

knowledge scores increased significantly in all sites between the baseline and prenatal

surveys. Gains persisted through the postpartum survey and, in most sites, actually

increased by a modest amount.

• The content areas that showed the greatest improvement were knowledge related to

breastfeeding and knowledge related to recommended infant feeding practices. Mean

scores for two other two content areas (general nutrition knowledge and healthy

practices during pregnancy) also improved, however, changes were less substantial and

did not always reach statistical significance. Overall, the pattern of change seen in these

data is consistent with the notion that WIC nutrition education is effective in

communicating key nutrition concepts to program participants. The two content areas

in which gains were most substantial (breastfeeding and recommended infant feeding

practices) were those in which women showed lower levels of baseline knowledge and
Abt Associates Inc. Executive Summary vi

which on-site observations and participant self-reports showed to be well covered in

WIC nutrition education contacts.

• In five of the six study sites, women who participated in WIC during a previous

pregnancy had significantly higher baseline knowledge scores than women with no prior

WIC experience. These differences were largely attributable to differences in scores

for breastfeeding knowledge (three sites) and knowledge about recommended infant

feeding practices (five sites) — the two content areas that showed the most substantial

gain in this study. This finding suggests that at least some of the gains in nutrition

knowledge described in the preceding section may be attributable to WIC nutrition

education.

Attitudes and Perceptions

• Five measures of nutrition-related attitudes and perceptions were included in the study. 

In general, changes over time, although statistically significant, were numerically small. 

The practical significance of these small changes is unclear. The general pattern

observed in the data was no change to a modest improvement in attitudes and

perceptions during the prenatal period followed by a decline during the postpartum

period. Postpartum scores generally approximated or were less than baseline scores.

• Infant feeding preference scores (a measure of a woman’s relative openness to

breastfeeding) improved in four of the six study sites between the baseline and prenatal

surveys. Nonetheless, the percentage of women who actually initiated breastfeeding

was not significantly different from the percentage who entered the WIC Program

already intending to breastfeed.

Nutrition-related Behaviors

• With one exception, use of prenatal vitamins and iron supplements increased

significantly between the baseline survey and the prenatal survey.

• Reported daily consumption of milk, 100% fruit juice, and WIC cereals increased

significantly in all six study sites between the baseline and prenatal surveys. Reported

consumption of cheese, as well as peanut butter and dried beans, peas, and lentils,

increased in four sites. Reported consumption of eggs increased in three sites. Only the

increased consumption of WIC cereals was maintained into the postpartum period. 

Differences in the composition of food packages provided to prenatal and postpartum

participants may contribute to differences in reported consumption of WIC foods.

• Most women followed recommended infant feeding guidelines during the earliest months

of life, however, some women offered their infants inappropriate fluids (primarily
Abt Associates Inc. Executive Summary vii

sweetened water) or solids (primarily infant cereal) before the age of two months. The

percentage of women who offered inappropriate fluids before two months of age

ranged from a low of five percent to a high of 27 percent. The percentage who offered

solid foods before two months ranged from three percent to 18 percent.

• The prevalence of undesirable infant feeding practices increased sharply for older

infants. More than 40 percent of women in each site offered their babies something

other than breastmilk, formula, or plain water before the age of 4 months. In several

sites, two-thirds to three-quarters of the respondents reported this behavior. Use of

solids (primarily infant cereal) before 4 months of age was also a common practice

(minimum of 39 percent and a maximum of 67 percent). In all but one site, roughly

one-third of the respondents offered their infants something that is considered

completely inappropriate for infants of any age (e.g., cows’ milk, fruit drinks, sodas, or

desserts) or not appropriate until at least 6 months of age (e.g., fruits or vegetables,

meats, or whole eggs). 

Other Behaviors

• Many women who smoked cigarettes prior to pregnancy reportedly quit after becoming

aware of their pregnancy and before enrolling in WIC. Nonetheless, in all but one site 

(where very few women smoked even before pregnancy), 20 to 41 percent of women

reported using cigarettes at the time of the baseline survey. At the time of the prenatal

survey, the prevalence of cigarette use was significantly lower in two of these five sites. 

• A majority of women who stopped smoking before or after WIC certification resumed

the habit by the time of the postpartum survey. In all six sites, the percentage of women

using cigarettes at the time of the postpartum survey was significantly greater than at

baseline. Although cigarette use had not returned to pre-pregnancy levels, there was a

definite trend in this direction.

• Most women who used alcohol prior to pregnancy reportedly discontinued this practice

prior to WIC certification. With one exception, fewer than ten percent of women

reported use of alcohol at the time of the baseline interview. Over the course of

prenatal WIC participation, use of alcohol decreased further (and significantly) in two

sites. In the other four sites, the value of the estimates shifted somewhat, sometimes up

and sometimes down, but the differences were not statistically significant.

By the time of the postpartum survey, many women had resumed use of alcohol. In all

six sites, the percentage of respondents who reported use of alcohol during the

postpartum period was significantly greater than at baseline but still substantially lower

than prior to pregnancy.
Abt Associates Inc. Executive Summary viii

• More than 70 percent of respondents in each site entered WIC already following the

recommendation that over-the-counter medications should be taken only with physician

approval. Nonetheless, adherence to the recommendation increased significantly in all

sites between the baseline and prenatal surveys, reaching levels of 82 to 97 percent.

Participants’ Satisfaction with WIC Nutrition Education

• Virtually all respondents reported receiving written nutrition education materials. At the

time of the prenatal survey, three-quarters or more of the respondents in each site

reported reading all or most of the materials provided. Another ten to 23 percent of

respondents reported reading some of the written materials. Two percent or less of the

respondents indicated that they did not read any of the materials. The overall pattern of

responses was similar for the postpartum survey data.

• Women who reported reading at least some of the written materials provided by WIC

were asked to rate the relative usefulness of the materials. More than half of the

prenatal survey respondents in each site rated the written materials as either extremely

useful or useful. With one exception, roughly a third of the respondents in each site

found written materials to be only somewhat useful and a small percentage (2-3%)

judged the materials to be not very useful or useless. Again, the overall pattern of

responses was similar for the postpartum survey data. 

• More than 60 percent of prenatal survey respondents who attended a nutrition

education class rated the class(es) as either very interesting or interesting. Postpartum

assessments were somewhat more positive in two sites and somewhat more negative in

three sites.

• With one exception (the site with a large population of recent immigrants), five percent

or less of the respondents reported that they had questions or concerns that had not

been addressed by WIC staff. In the site with the large immigrant population, the

percentage of women who reported an unmet information need at the time of the

prenatal survey (12%) was more than twice that of any other site. By the time of the

postpartum survey, the prevalence of this problem had dropped considerably and was

comparable to other study sites. This pattern suggests that language and/or cultural

barriers may have complicated, but did not impede, communication of nutrition

education messages in this site.

• Participants were asked directly whether they learned anything from WIC ("Did you

learn anything that you did not know before you visited the WIC Program?"). In most

sites, less than half of the prenatal survey sample responded affirmatively. Results for

the postpartum survey were similar. 
Abt Associates Inc. Executive Summary ix

• Respondents who reported learning something from WIC were asked to identify what

was learned. Responses were consistent with findings regarding topics covered in WIC

nutrition education. The topic areas in which most respondents reported knowledge

gain were recommended eating practices during pregnancy and breastfeeding.

• Respondents' self-reports about knowledge gain also corresponded well with changes

in both nutrition knowledge scores and infant feeding preference scores. Although

knowledge scores increased significantly over time for both self-described learners and

non-learners, respondents who said they learned something from WIC (self-described

learners) gained significantly more knowledge than respondents who said they did not

learn anything from WIC (self-described non-learners). Mean overall knowledge

scores for self-described learners increased 6.8 percentage points between baseline and

prenatal surveys, compared to 4.5 percentage points for self-described non-learners. 

Likewise, between the baseline and postpartum surveys, overall knowledge scores

increased 8.8 points for self-described learners compared to 6.3 percentage points for

self-described non-learners. A similar pattern was noted for the infant feeding

preference score.

• These data indicate that both learners and non-learners increased their nutrition

knowledge over the course of the study. The fact that participants who reported

learning something from WIC showed significantly greater gains in knowledge than

participants who said they did not learn anything from WIC suggests that, for these

participants, at least some of the knowledge gain realized over time is attributable to

WIC nutrition education.

• Respondents were asked to identify up to three things they liked about the WIC

Program and up to three things they disliked. WIC supplemental foods ranked as the

leading positive program attribute in all six sites in both prenatal and postpartum

surveys. This was the only program characteristic that was consistently included in the

top three positive aspects of the WIC Program.

• The next most frequently cited positive feature, included among the top three in four of

the six sites, was that the WIC Program/WIC staff care(s) about participants. An

argument can easily be made that the nutrition education component of the program

plays a role in generating this perception. Other program characteristics that vied for

third place on the top-three list for all sites combined included "learn about healthy

eating," "talking to the nutritionist," and "talking with other WIC staff." All three of

these features are clearly related to the nutrition education component of the WIC

Program.
Abt Associates Inc. Executive Summary x

• Respondents in most sites found it more difficult to identify unfavorable aspects of the

WIC Program than favorable aspects. With one exception, more than two-thirds of the

prenatal respondents and more than half of the postpartum respondents were unable to

identify anything they did not like about WIC.

• Respondents were asked to provide specific suggestions for improving WIC nutrition

education, however, relatively few respondents were able to offer specific suggestions. 

In the prenatal survey, suggestions were offered by four to 15 percent of respondents. 

The range for the postpartum survey was three to 19 percent. Among respondents who

did offer suggestions, recommendations most often related to improving the content

and/or delivery of nutrition education. Specific recommendations included increasing

the amount of individualized contact and increasing participants’ awareness of, or

opportunities for, nutrition education. 

• Responses to a battery of items designed to assess program satisfaction indicate that,

overall, the vast majority of respondents in all six study sites were quite satisfied with

WIC nutrition education. In five of the six sites, more than 90 percent of prenatal and

postpartum respondents found WIC staff to be helpful as well as warm and friendly;

believed that WIC staff respected them as individuals; found explanations offered by

WIC staff to be readily understandable; had their questions answered; felt satisfied

when they left the WIC clinic; and found the information offered to be helpful. 

Likewise, more than 90 percent of respondents in five of six sites, did not feel confused

when they left the WIC clinic. 

• Although the overall picture of participant satisfaction was highly positive, respondents

did identify some areas of dissatisfaction. Five to 37 percent of respondents reported a

concern about the waiting time at WIC clinics (agreed or strongly agreed with the

statement “The staff made me wait too long”). The percentage of respondents who said

they had to wait too long increased between the prenatal survey and the postpartum

survey in five of the six study sites.

• Another area of dissatisfaction was the fact that some of the information and guidance

provided by WIC staff conflicted with information provided by physicians (agreed or

strongly agreed with the statement “Some of the advice I received contradicted what my

doctor told me”). At the time of the prenatal survey, the percentage of respondents

reporting such conflicts, ranged from 15 to 24 percent. Contradictory advice most

often involved advice related to weight gain during pregnancy; the need for iron

supplements (i.e., whether or not a respondent was anemic); and breastfeeding. 

• The prevalence of contradictory advice from physicians increased in the postpartum

survey (range from 24% to 47%). Conflicts during the postpartum period most often
Abt Associates Inc. Executive Summary xi

involved breastfeeding — with WIC staff encouraging breastfeeding and local

physicians either downplaying or actually discouraging breastfeeding.

• Analyses that explored relationships between overall satisfaction (a composite

measure), individual measures of satisfaction, and participants' experiences with WIC

nutrition education revealed that characteristics of women’s nutrition education

experiences may influence their overall level of satisfaction with the WIC Program. The

following types of self-reported experiences were associated with significantly higher

levels of overall satisfaction: strongly agreed that counselors helped in decision about

how to feed the baby; strongly disagreed that WIC staff made them wait too long;

strongly disagreed that advice given by WIC staff was contradictory to advice given by

physician; thought written nutrition education materials were useful or very useful; and

did not have any outstanding issues/questions to discuss with a nutritionist. In addition,

two factors—not having been referred to health or social services and not learning

anything new from WIC—were associated with slightly lower levels of overall

satisfaction.