Food Assistance: Research Provides Limited Information on the Effectiveness of Specific WIC Nutrition Services
Published: 2001-03-30T00:00:00

Fast Facts:

Highlights:
section_title: What GAO Found
paragraphs: Despite methodological limitations, demonstration studies provide program managers and policymakers with some useful information on the types of Special Supplemental Program for Women, Infants and Children (WIC) nutrition service interventions that can have positive results for participants. However, only one recent demonstration study provides any information on the costs associated with implementing various interventions. Given the limited resources available to provide WIC nutrition services, information on the costs to provide effective services could play a critical role in managers' decisions to implement the intervention and policymakers' decisions on funding the intervention.

section_title: Letter
paragraphs: The Special Supplemental Nutrition Program for Women, Infants and  Children (WIC) is a federally funded nutrition assistance program  administered by the U.S. Department of Agriculture’s (USDA) Food and  Nutrition Service (FNS). This program provides supplemental food and  nutrition services to lower-income pregnant, breastfeeding, and  postpartum women. The program also serves infants and children up to age  5 who are at nutritional risk. The WIC program serves a monthly average of  7.3 million individuals, including about 47 percent of all infants born in the  United States. In fiscal year 2000, the Congress appropriated $3.9 billion to  fund WIC, $2.8 billion of which was used to provide food benefits and $1.1  billion of which was used for nutrition services and program  administration. The nutrition services part of the program includes  nutrition education, breastfeeding promotion and support, and referrals to  health and social services.
A substantial body of research has examined the overall effectiveness of  the WIC program, but little is known about what research shows regarding  the effectiveness of specific WIC nutrition services. This report (1)  identifies the number and nature of recent studies that have examined the  effectiveness of three WIC services—nutrition education, breastfeeding  promotion and support, and referral services—and (2) summarizes what  the research shows about the effectiveness of these specific nutrition  services. This report is the fourth in a series providing information on  various aspects of WIC nutrition services as directed by the William F.  Goodling Child Nutrition Reauthorization Act of 1998 (P.L. 105-336).
To identify recent studies that examine the effectiveness of each WIC  nutrition service, we searched relevant databases, such as the National  Technical Information Service, Sociological Abstracts, and Wilson Social  Science Abstracts. We also consulted with USDA WIC program staff and  other program stakeholders including officials from the National  Association of WIC Directors. Initially, we identified more than 200  published WIC studies dealing with various aspects of the WIC program. In  order to focus on recent research, we eliminated from consideration  research published prior to 1995. We also eliminated any study that did not  specifically address the effects of at least one of the three WIC nutrition  services, whether nutrition education, breastfeeding promotion and  support, or referral services. We included research that falls in two general  categories: demonstration studies and impact studies. The demonstration  studies typically attempt to assess whether special interventions, such as  hospital visits to promote breastfeeding, more effectively achieve program  objectives than the usual WIC services. In contrast, impact studies attempt  to determine whether a WIC nutrition service, such as breastfeeding  promotion and support, improves WIC participants’ outcomes compared to  similar individuals who do not participate in the WIC program.
We conducted our work between May 2000 and March 2001 in accordance  with generally accepted government auditing standards. Appendix I  provides a more detailed description of the methodology we used to  conduct this work.
subsections: section_title: Background
paragraphs: WIC, which began as a 2-year pilot program in 1972 and was authorized as a  permanent program in 1974, is part of the nutrition safety net available to  low-income women and their children. FNS provides annual cash grants for  food benefits and nutrition services to fund program operations at 88 state- level WIC agencies (including agencies in all 50 states, the District of  Columbia, American Samoa, the Commonwealth of Puerto Rico, Guam, the  U.S. Virgin Islands, and 33 Indian Tribal Organizations). Some of these  state-level agencies—those that operate the program at both the state and  local levels—retain all of their federal WIC grants. Most state-level  agencies, however, retain a portion of their grants and pass the remaining  funds to over 1,800 local WIC agencies.
In fiscal year 2000, about $2.8 billion in federal program funds were used to  provide food benefits to participants. Typically food benefits are in the  form of vouchers or checks that participants can use to obtain approved  foods at authorized retail food stores. An additional $1.1 billion in federal  funds were used for nutrition services and program administration.  Program administration includes, among other things, activities related to  accounting and record keeping, outreach, monitoring and financial audits,  and general management. Nutrition services include activities related to  determining participants’ eligibility and issuing food benefits, as well as the  following:  Nutrition education: WIC offers classes, counseling, and other activities  to teach participants about proper nutrition, positive food habits, and  the prevention of nutrition-related problems.
Breastfeeding promotion and support: To promote breastfeeding, WIC  offers individual and group counseling sessions at WIC clinics or the  hospital. Breastfeeding support can include telephone or in-person  consultation with breastfeeding mothers.
Referral to health care and social services: WIC agencies provide  participants with information on health care and social services and  refer them to providers including immunization clinics and the Food  Stamp and Medicaid programs.
By law, spending for nutrition education and breastfeeding promotion and  support activities combined must equal at least one-sixth of a state’s total  annual expenditures for nutrition services and administration plus a target  amount for breastfeeding promotion and support that is established by FNS  at the beginning of each fiscal year. There is no minimum spending  requirement for referral activities.
Over the past 20 years, government agencies such as USDA, the Centers  for Disease Control and Prevention, and GAO, as well as universities and  private research organizations, have conducted a substantial body of  research on the effects of the entire WIC program. Some of the  accumulated body of WIC research and evaluations provides nationwide  assessments of WIC’s effects. Most of it has focused on the effect of  program participation on birth outcomes and the nutritional status of  program participants. USDA has a review under way describing and  assessing research on the diet and health outcomes of its nutrition  programs, including WIC. The results of this review, set for release later  this year, will provide detailed information on over 70 studies, most of  which examine WIC’s effects on birth outcomes or on the nutrition status  of participants. While the USDA review will not focus on the impacts of  specific nutrition services, it will include studies that examined the WIC  program’s effects on the initiation and duration of breastfeeding and the  immunization status of children. These two health-related outcomes are  directly linked to two of the three nutrition services addressed in this  report—breastfeeding promotion and support and referral services.  However, because the USDA review is generally focused on overall  program impacts, its report probably will not include descriptions or  assessments of many of the demonstration studies included in this report.
section_title: Most of the Recent Research Evaluates Demonstrations of Special Interventions
paragraphs: The 19 studies we identified included almost twice as many demonstration  studies as impact studies. Of the 12 demonstration studies, 3 look at special  interventions in nutrition education, 6 look at special interventions in  breastfeeding promotion and support, and 3 look at special interventions in  referral to health and social services. Of the seven impact studies, one  examines nutrition education, four assess breastfeeding promotion and  support services, and two evaluate WIC health referrals.
Most of the studies have a relatively limited geographic scope. Among the  12 demonstration studies, 11 are at the substate level. They generally study  multiple WIC sites and/or multiple counties, but without sufficient  sampling rigor to draw valid statewide conclusions. The results of one  demonstration study are generalized to an entire state. Among the seven  impact studies, three are at the substate level, one is statewide, and three  are national in scope.
The 19 studies received funding from various sources. Table 1 provides  details on project funding for the 12 demonstration studies and 7 impact  studies.
Appendix II provides detailed information on the funding sources for the 19  studies reviewed for this report.
section_title: Special Interventions Improve Participant Outcomes but Research Says Little About the Effectiveness of Individual Nutrition Services
paragraphs: While all 19 studies suffer from methodological limitations, those  limitations have varying consequences. Despite their limitations, the results  of the 12 demonstration studies suggest that special interventions have  some potential to improve nutrition service effectiveness over WIC  interventions typically used; though, based on our analysis of these studies,  it appears that additional resources may have to be committed to achieve  this added effectiveness. However, the methodological limitations of the  seven impact studies enable them to provide only very limited information  on the effects of any one nutrition service. Appendixes III and IV contain  lists of the demonstration and impact studies, respectively, reviewed for  this report.
subsections: section_title: Demonstration Studies Indicate Some Special Interventions Improve Participant Outcomes
paragraphs: The 12 demonstration studies evaluate a range of different special  interventions. To varying degrees, all were more effective than usual WIC  interventions. Examples of the special interventions include the following:  Breastfeeding promotion and support. Gross and others evaluated  special interventions designed to encourage breastfeeding among  African-American WIC participants. Mothers in the three special  intervention groups were provided a motivational video or peer  counseling or a combination of the video and counseling. Mothers in the  control group received the standard WIC service that incorporated  encouragement and support to breastfeed and brochures about  breastfeeding during discussions about infant feeding. Mothers in the  special intervention groups were twice as likely as mothers receiving  the standard WIC infant feeding education to be breastfeeding 8 weeks  and 16 weeks after giving birth, even accounting for factors that could  increase breastfeeding duration, such as prior breastfeeding experience.
Health referrals. Birkhead and others evaluated two special  interventions designed to increase the number of WIC-eligible children  who receive measles immunizations. The special interventions included  having WIC staff escort children to an on-site immunization clinic and a  food voucher incentive in which WIC staff provided only a 1-month  supply of vouchers to parents, rather than the usual 2-month supply,  until the parents provided documentation that their children’s  immunizations were up-to-date. The standard WIC immunization  referral consisted of notifying parents that immunizations were due,  providing information on the benefits of immunizations, and providing  the names and telephone numbers of local health facilities that  immunize children. Children at escort sites were about five times more  likely to be immunized than children at standard referral sites; children  at voucher incentive sites were about three times more likely to receive  immunizations.
Nutrition education. Havas and others evaluated a special intervention  designed to increase WIC participants’ consumption of fruits and  vegetables. The special intervention—Maryland’s “5-A-Day” program— was a series of three 45-minute group sessions taught by former WIC  participants, or “peer educators,” that incorporated special visual  materials and included direct mailings to participants. The standard  service generally included less than 10 minutes of nutrition education  conversation between WIC staff and participants when they picked up  their food voucher every other month. Compared to participants  receiving the standard WIC nutrition education program, participants  exposed to the special intervention displayed a significant increase in  nutrition knowledge and in the consumption of fruits and vegetables.
Each of the demonstration studies we reviewed suffers from  methodological limitations that, while not invalidating the study’s findings,  should be taken into account. The limitations we identified are common in  studies that attempt to assess the extent to which social or health program  interventions—not other factors—are responsible for changes in program  participants’ behaviors or health. The major methodological limitations of  the demonstration studies we reviewed include the following:  Lack of control group. To help isolate the effects of an intervention, an  evaluation study must compare people receiving the special  intervention to similar people receiving standard WIC services. The  difference between these groups can provide insight into whether the  special intervention is more effective than standard WIC practice. Not  having such a comparison obscures the relationship between the  intervention and participant outcomes. Four of the studies we reviewed  had a weak research design associated with a lack of control group. For  example, Hoekstra and others attempted to evaluate the effectiveness of  a new voucher incentive program in increasing WIC children’s rates of  immunization. However, the researchers did not compare the group  receiving the special intervention to a group receiving standard services.  Instead, they compared three special intervention groups to themselves  at different points in time over a period of 14 months. Without a control  group that does not participate in the voucher intervention, it is difficult  to attribute any changes the researchers noticed to the special  intervention.
Inappropriate data analysis techniques. The analytic techniques used in  a study must suit the available data and the research design—in  particular, they should be selected for their ability to help isolate the  effects of the intervention. Three of the demonstration studies we  reviewed used questionable analytic techniques. For example, Havas  and others found that a special peer counselor program was effective in  increasing nutrition knowledge and the consumption of fruits and  vegetables. To reach this finding, Havas and others compared the  average fruit and vegetable consumption of the special “5-a-Day” group  to the average fruit and vegetable consumption of a group exposed to  the standard WIC nutrition education. The comparison, which examined  the linkage between demographic characteristics, such as race, and fruit  and vegetable consumption, did not take into account the simultaneous  influence of other characteristics, such as education level, on  consumption. Without an analysis technique, such as multiple  regression, that can account for the influence of several factors at once,  determining the extent to which the observed differences in fruit and  vegetable consumption are the result of the “5-A-Day” program is greatly  complicated.
Selection bias. Ideally, study participants should be randomly assigned  to intervention and control groups to ensure that all participant  characteristics will, on average, be the same from one group to another.  A selection bias exists if the two groups differ in some systematic way.  Selection bias makes it more difficult to attribute an observed difference  in outcomes between the two groups to any one factor, such as the  intervention. Six of the demonstration studies we reviewed have a  possible selection bias. For example, Tuttle and Dewey examined the  influence of a new, culturally sensitive breastfeeding education  intervention on the initiation and duration of breastfeeding among  Hmong WIC participants in Northern California.10,  However, the  study’s research design depended on women to volunteer to participate  in the study—the women self-selected themselves to participate in the  special intervention. Thus, those choosing to participate in the special  intervention may have shared characteristics (for example, an already  existing inclination to breastfeed) that did not exist in those women  who chose not to participate. If present, selection bias could lead the  researcher to overstate the benefits of the special intervention.
Cynthia Reeves Tuttle and Kathryn G. Dewey, “Impact of a Breastfeeding Promotion  Program for Hmong Women at Selected WIC Sites in Northern California,” Journal of  Nutrition Education, Vol. 27, No. 2 (1995), p. 69. to agree. Excessive missing data, or poor response rates, may skew  research findings. Missing data or poor response rate was a limitation in  five of the demonstration studies. For example, Ahluwalia and others  evaluated five new breastfeeding interventions, and attributed  significant improvements in breastfeeding initiation to them. However,  the database employed by the study contained breastfeeding initiation  data for only 52 percent of the women in the sample.
Measurement error. For an analysis to produce reliable results, the  measures in the analysis must be accurate. Measurement error is the  difference between a measured value and its true value. Five of the  studies have potential measurement errors. For example, Shaw and  Kaczorowski sought to examine the effectiveness of a peer counseling  program on breastfeeding initiation and duration by asking new mothers  to recall interactions with breastfeeding peer counselors that took place  at the time of birth. Mothers were interviewed 6 weeks to 6 months  after giving birth. If memory lapses occurred, new mothers may have  incorrectly recalled their dealings with peer counselors, thereby  potentially introducing measurement error into the data.
Appendix V shows the major findings and methodological limitations of  each of the 12 demonstration studies.
Our analysis suggests that the effective interventions described in the  demonstration studies may cost more than standard WIC approaches. For  example, most breastfeeding special interventions were specifically  designed to increase the amount of counseling and support provided to  prenatal and postpartum women. Although only one of the demonstration  studies provided information about the additional costs associated with  such interventions, it is reasonable to expect that such one-on-one support  will cost more than the standard WIC program.
Two of the demonstration studies help to illustrate the linkage between  resource commitment and results achieved. The first, Ahluwalia and  others, which found that a hospital-based strategy providing bedside  support and counseling to women who had just given birth, was the most  effective at increasing breastfeeding initiation rates out of five new  strategies evaluated. This strategy clearly required more resources than the  standard practice of providing counseling and brochures to participants  during a visit to the WIC clinic. The second study, Weimer, which was  funded by USDA, focused on a special intervention that was similarly  resource-intensive. It reported that providing one-on-one support in the  hospital after delivery, followed by an in-home visit within 72 hours of  birth, increased breastfeeding duration. However, neither study provided  any information about the additional costs needed to implement these  special interventions.
Only one of the 12 demonstration studies we reviewed, Hutchins and  others, provided any information about the costs associated with the  implementation of the special intervention. This study reported that  vaccinations increased at sites providing vaccination screening and  voucher incentives (until their children are immunized, a family must visit  the clinic monthly—rather than every 3 months—to pick up WIC  vouchers). This study uses what its authors term “crude” cost-effectiveness  ratios to estimate the average cost for each additional child with up-to-date  immunizations. These costs range between $30 and $73, depending on the  number of enrolled children and rates of active participation.
section_title: Impact Research Provides Very Limited Information on the Effectiveness of WIC’s Individual Nutrition Services
paragraphs: The seven impact research studies we reviewed provide few conclusive  insights into the recent effectiveness of WIC breastfeeding promotion and  support, referral services, or nutrition education services.
section_title: Breastfeeding Promotion and Support
paragraphs: Three of the four impact studies that focused on breastfeeding promotion  and support—Schwartz and others, Balcazar and others, and Timbo and  others—use old data from the 1988 National Maternal and Infant Health  Survey. Although, according to FNS officials, this survey represents the  most recent data available, much has changed in the program since 1988,  including the characteristics of WIC participants and the emphasis the  program places on breastfeeding. As a result, these studies’ findings shed  little light on the program’s current effects. Although the fourth study,  Wiemann and others, uses data from the mid-1990s, its limited scope, in  terms of geography and participants, constrains the applicability of its  findings. This study, with data collected from 684 adolescent mothers who  gave birth at a hospital in Galveston, Texas, could have some specialized  usefulness, but would have to be replicated at many other sites to provide  insights into the broader effectiveness of WIC’s breastfeeding promotion  and support services. In addition, since adolescent mothers comprise only  about 11 percent of all WIC mothers, the study’s focus on them further  compromises its more general usefulness.
Taken as whole, the inconsistency in the findings of these four studies  further limit their usefulness in assessing the effects of WIC’s breastfeeding  promotion and support program. For example, Wiemann and others and  Balcazar and others find that WIC enrollment is a significant factor in some  mothers’ decision to bottle-feed, while Timbo and others, and Schwartz and  others, conclude that WIC participation increases breastfeeding. No  consistent message emerges from the studies.
subsections: section_title: Referral Services
paragraphs: The two referral service impact studies have methodological constraints  that, to varying degrees, limit their usefulness in assessing the effectiveness  of WIC referral services. The first study, Suarez and others, using survey  data from 30 counties in Texas, found that children who are enrolled in  WIC are significantly more likely than children who are not enrolled to be  up-to-date on their immunizations, regardless of other intervening factors  such as the child’s age, ethnicity, or the family’s income. Although this  study likely contains some measurement error, it provides at least limited  evidence that WIC referral services are effective in increasing  immunization rates. In contrast, due to major methodological problems,  the second referral study, McCunniff and others, provides little useful  information on the effectiveness of WIC referral services. This study is  based on self-administered questionnaire data collected from a sample of  mothers at three WIC sites in Kansas City, Missouri. The study found that  when taking into account factors such as WIC referral, child’s age,  household size, and availability of dental insurance, only the age of the  child had a significant, independent effect on the likelihood that children  will visit a dentist. There are two principal limitations to this study. First,  almost 40 percent of the sampled children were younger than 1 year old.  Because many children less than 1 year of age do not yet have teeth, they  are much less likely to have made a dental visit, thus reducing the study’s  ability to identify factors associated with dental visits other than age. The  second major limitation is the measurement error associated with the  reliance on self-reported questionnaire data about visits to the dentist. The  study did not attempt to verify questionnaire responses through a review of  dental records. The authors suggested that such reviews would have  increased the accuracy of the self-reported data. As a result of these  serious methodological problems, it is likely that McCunniff and others has  only limited relevance to understanding the effectiveness of WIC referral  services.
section_title: Nutrition Education
paragraphs: The one study that primarily focused on the impact of nutrition education,  Fox and others, also examined breastfeeding programs and their  effectiveness. However, Fox and others was limited geographically, and  had other limitations that reduce its usefulness in assessing the  effectiveness of WIC’s nutrition education. For example, its scope was  limited in that it focused on pregnant and postpartum women at six WIC  sites, in three states. Within this limited context, the study describes  program and participant characteristics; the nutrition services offered  (including breastfeeding promotion and support); participants’ receipt of  and satisfaction with these services; and changes in participants’  knowledge and behaviors between the time of prenatal WIC certification  and 4 to 6 months postpartum. The study also attempted to assess the  impact of WIC nutrition education on participants’ knowledge and  behavior. Although the study concluded that participants’ nutrition  knowledge and behavior improved significantly over the course of the  study, attributing these changes to WIC is problematic because the study  did not use a control group. Instead, Fox and others compared intervention  groups at different points in time. The study also concluded that (1) WIC  participation did not significantly increase breastfeeding initiation or  duration; and (2) women’s decisions regarding infant feeding are strongly  associated with intentions formed during pregnancy.
section_title: Conclusion
paragraphs: Demonstration studies, despite some methodological limitations, provide  program managers and policymakers with some useful information about  the types of WIC nutrition service interventions that can have positive  impacts on participants. However, only one recent demonstration study  provides any information on the costs associated with implementing  various interventions. Given the limited resources available to provide WIC  nutrition services, information about the costs to provide effective services  could play a critical role in managers’ decisions to implement the  intervention and policymakers’ decisions about funding the intervention.
section_title: Recommendation
paragraphs: In order to maximize the value of nutrition education, breastfeeding  promotion and support, and referral service demonstration and evaluation  research funded by USDA, we recommend that the Secretary of Agriculture  direct officials responsible for implementing such research to require that  this research include an assessment of the costs associated with the special  intervention being evaluated.
section_title: Agency Comments and Our Response
paragraphs: We provided a draft of this report to the Department of Agriculture’s Food  and Nutrition Service for review and comment. We met with Food and  Nutrition Service officials, including the Acting Associate Deputy  Administrator for Special Nutrition Programs. The agency officials  generally agreed with the report’s findings and recommendation. However,  the officials questioned why our recommendation did not address actions  that WIC researchers should take to deal with some of the methodological  limitations we identified in research evaluating the effectiveness of WIC  services. We believe that USDA has a responsibility to ensure that the WIC  and other nutrition program research it funds are of high quality. However,  our review was not designed to examine USDA’s policies and procedures to  ensure the quality of the research it funds or the practices it employs to  promote high-quality research in studies it does not fund. As a result, we  are not making any specific recommendations concerning how USDA  might improve the quality of WIC research at this time.
The officials also provided some technical changes and clarifications to the  report, which we incorporated as appropriate.
We are sending copies of this report to the appropriate congressional  committees; interested Members of the Congress; the Honorable Ann M.  Veneman, Secretary of Agriculture; the Honorable Mitchell E. Daniels, Jr.,  Director of the Office of Management and Budget; and other interested  parties. We will also make copies available upon request.
If you or your staff have any questions about this report, please contact me  or Thomas E. Slomba at (202) 512-7215. Key contributors to this report are  listed in appendix VI.
section_title: Scope and Methodology
paragraphs: To identify recent studies that examine the effectiveness of the Special  Supplemental Nutrition Program for Women, Infants and Children (WIC)  nutrition education, breastfeeding promotion and support, and referral  services, we searched relevant databases, such as National Technical  Information Service, Sociological Abstracts, and Wilson Social Science  Abstracts. We also consulted with the U.S. Department of Agriculture  (USDA) WIC program staff and other program stakeholders, including  officials from the National Association of WIC Directors. Through this  process, we identified 209 items published from 1988 through 2000 dealing  with various aspects of the WIC program. To be used in our review,  individual items had to meet each of the following criteria:   publication in a refereed medium (for example, a journal article, book or  book chapter, USDA-issued report);   publication date of 1995 or later;   examination of one or more of WIC’s nutrition services (breastfeeding  promotion and support, nutrition education, or health referrals); and   original analysis of a specific nutrition service’s effectiveness.
Altogether, only 19 items met all four criteria. Many—86 of the 190 items  we rejected—were published prior to 1995, and therefore do not satisfy our  definition of recent studies. (We established 1995 as the cutoff to enable us  to better examine the program as it currently operates.) We eliminated the  remaining 104 items because they did not meet one or more of our criteria.  For example, some items appeared in our literature search as professional  papers delivered at conferences; thus, they did not undergo any formal  referee process. Other items were published as reviews or summaries of  original research, but did not include any original research of their own.  Some items do not focus on the effectiveness of specific WIC nutrition  services. For example, one study examines the general effects of food  programs—including WIC and other food assistance programs such as food  stamps—on diet, but does not evaluate the effectiveness of specific WIC  nutrition service programs.
Once we narrowed the scope of our study, we met with staff in the USDA’s  Food and Nutrition Service Office of Analysis, Nutrition and Evaluation to  ensure that our methodology did not exclude any important studies.  According to these officials, our approach successfully identified all of the  major recent evaluation studies on WIC nutrition services.
We then conducted detailed reviews of the 19 studies. These reviews  entailed an evaluation of each study’s research methodology, including its  data quality, research design, and analytic techniques, as well as a summary  of its major findings and conclusions. We also assessed the extent to which  each study’s data and methods support its findings and conclusions.
section_title: Research Funding Sources
paragraphs: Funding source(s)
section_title: Bibliography of Demonstration Studies
subsections: section_title: Breastfeeding Promotion and Support
paragraphs: Ahluwalia, Indu B., Irene Tessaro, Laurence M. Grummer-Strawn, and  others. “Georgia’s Breastfeeding Promotion Program for Low-Income  Women.” Pediatrics, Vol. 105, No. 6 (2000), pp. 85–91.
Shaw, Elizabeth, and Janusz 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.
Gross, Susan M., Laura E. Caulfield, Margaret E. Bentley, and others.  “Counseling and Motivational Videotapes Increase Duration of Breast- Feeding in African-American WIC Participants Who Initiate Breast- Feeding.” Journal of the American Dietetic Association, Vol. 98, No. 2  (1998), pp. 143–148.
Weimer, Jon P. Breastfeeding Promotion Research: The ES/WIC Nutrition  Education Initiative and Economic Considerations. Washington, D.C.: U.S.  Department of Agriculture, Economic Research Service, 1998.
Grummer-Strawn, Laurence M., Susan P. Rice, Kathy Dugas, and others. “An  Evaluation of Breastfeeding Promotion Through Peer Counseling in  Mississippi WIC Clinics.” Maternal and Child Health Journal, Vol. 1, No. 1  (1997), pp. 35–42.
Reifsnider, Elizabeth, and Donna Eckhart. “Prenatal Breastfeeding  Education: Its Effect on Breastfeeding Among WIC Participants.” Journal  of Human Lactation, Vol. 13, No. 2 (1997), pp. 121–125.
Tuttle, Cynthia Reeves, and Kathryn G. Dewey. “Impact of a Breastfeeding  Promotion Program for Hmong Women at Selected WIC Sites in Northern  California.” Journal of Nutrition Education, Vol. 27, No. 2 (1995), pp. 69–74.
section_title: Nutrition Education
paragraphs: Abusabha, Rayane, Cheryl Achterberg, and Jeannie McKenzie. “Evaluation  of Nutrition Education in WIC.” Journal of Family and Consumer Sciences,  Winter (1998), pp. 98–104.
Havas, Stephen, Jean Anliker, Dorothy Damron, and others. “Final Results  of the Maryland WIC 5-A-Day Promotion Program.” American Journal of  Public Health, Vol. 88, No. 8 (1998), pp. 1161–1167.
section_title: Referrals
paragraphs: Hutchins, Sonja S., Jorge Rosenthal, Pamela Eason, and others.  “Effectiveness and Cost-Effectiveness of Linking the Special Supplemental  Program for Women, Infants, and Children (WIC) and Immunization  Activities.” Journal of Public Health Policy, Vol. 20, No. 4 (1999), pp. 408– 426.
Hoekstra, Edward J., Charles W. LeBaron, Yannis Megaloeconomou, and  others. “Impact of a Large-Scale Immunization Initiative in the Special  Supplemental Nutrition Program for Women, Infants, and Children (WIC).”  Journal of the American Medical Association, Vol. 280, No. 13 (1998), pp.  1143–1147.
Birkhead, Guthrie S., Charles W. LeBaron, Patricia Parsons, and others.  “The Immunization of Children Enrolled in the Special Supplemental Food  Program for Women, Infants, and Children (WIC).” Journal of the American  Medical Association, Vol. 274, No. 4 (1995), pp. 312–316.
section_title: Bibliography of Impact Studies
subsections: section_title: Breastfeeding Promotion and Support
paragraphs: Fox, Mary Kay, Nancy Burstein, Jenny Golay, and others. WIC Nutrition  Education Assessment Study: Final Report. Alexandria, Va.: U.S.  Department of Agriculture, Food and Nutrition Service, 1999.
Wiemann, Constance M., Jacqueline C. DuBois, and Abbey B. Berenson.  “Racial/Ethnic Differences in the Decision to Breastfeed Among  Adolescent Mothers.” Pediatrics, Vol. 101, No. 6 (1998), pp. 11–23.
Timbo, Babgaleh, Sean Altekruse, Marcia Headrick, and others.  “Breastfeeding Among Black Mothers: Evidence Supporting the Need for  Prenatal Intervention.” Journal of the Society of Pediatric Nurses, Vol. 1,  No. 1 (1996), pp. 35–46.
Balcazar, Hector, Catherine M. Trier, and Jose A. Cobas. “What Predicts  Breastfeeding Intention in Mexican-American and Non-Hispanic White  Women? Evidence From a National Survey.” Birth, Vol. 22, No. 2 (1995), pp.  74–80.
Schwartz, J. Brad, Barry M. Popkin, Janet Tognetti, and others. “Does WIC  Participation Improve Breast-Feeding Practices?” American Journal of  Public Health, Vol. 85, No. 5 (1995), pp. 729–731.
section_title: Referrals
paragraphs: Fox, Mary Kay, Nancy Burstein, Jenny Golay, and others. WIC Nutrition  Education Assessment Study: Final Report. Alexandria, Va.: U.S.  Department of Agriculture, Food and Nutrition Service, 1999.
McCunniff, Michael D., Peter C. Damiano, Michael J. Kanellis, and others.  “The Impact of WIC Dental Screenings and Referrals on Utilization of  Dental Services Among Low-Income Children.” Pediatric Dentistry, Vol. 20,  No. 3 (1998), pp. 181–187.
Suarez, Lucina, Diane M. Simpson, and David R. Smith. “The Impact of  Public Assistance Factors on the Immunization Levels of Children Younger  Than 2 Years.” American Journal of Public Health, Vol. 87, No. 5 (1997), pp.  845–848.
section_title: Demonstration Studies: Major Findings, Scope, and Major Limitations
paragraphs: Major finding(s)
Scope (timeframe)
Major limitation(s)
Nutrition education lectures and facilitated group  discussions were more effective than brochures at  increasing participants’ nutrition knowledge.  Facilitated group discussion was more effective  than brochures at increasing participants’  confidence in performing specific nutrition related  behaviors.
Seven WIC clinics in  New Mexico (not  specified)
Havas and others, 1998 Consumption of fruits and vegetables increased  after an education program consisting of a series of  three 45-minute group sessions taught by paid peer  educators and incorporating special visual  materials and a direct mailing to participants.
Sixteen WIC clinics in  Maryland (not  specified)
Gross and others, 1998 The duration of breastfeeding among African- American WIC participants increased with peer  counselor support or viewing promotional  breastfeeding videos.
Four WIC sites in  Baltimore, Md. (1992– 1994)
WIC participants increased the initiation of  breastfeeding when exposed to (1) an enhanced  education program with access to a hotline, (2) a  free breast-pump loan program, (3) a hospital- based program with bedside support and  counseling after delivery, (4) community coalitions,  and (5) peer counseling provided by former  participants.
State of Georgia  (1992–1996)
1.  Breastfeeding initiation and duration rates  increased after volunteer peer counseling. 2.  Breastfeeding initiation and duration rates  in Iowa (not  specified)
1. Missing data; selection bias 2.  Lack of control group;  increased after paid peer counseling.
Michigan (not  specified)
3.  Lack of control group 4.  Selection bias postdelivery contact with mother in hospital  was followed up with support (including home  visits) by a specially trained paraprofessional.
North Carolina  (not specified) increased with culturally appropriate  breastfeeding education provided in high  school or WIC clinics.
4.  Local agency in  Guam (not  specified)
Duration of breastfeeding increased after prenatal  nutrition education classes focusing on  breastfeeding.
WIC clinics in three  rural Oklahoma  counties (1986)
Tuttle and Dewey, 1995 Breastfeeding initiation rates increased among  Hmong WIC participants after a culturally sensitive  prenatal breastfeeding class and prenatal and  postpartum counseling.
Seven WIC clinics in  three California  counties (1991–1992)
Major finding(s)
Scope (timeframe)
Major limitation(s)
Breastfeeding initiation and duration increased after  counseling and support provided by WIC  participants, trained and paid as peer counselors.
WIC programs in nine  West Tennessee  health departments  (1996–1997)
Clinics with paid peer counselors had higher rates  of breastfeeding initiation than clinics without peer  counselors. Clinics with a lactation specialist or  consultant, and peer counselors, had higher rates  of breastfeeding initiation than clinics with only peer  counselors. However, the benefits of lactation  specialists were offset when peer counselors spent  at least 45 minutes with individual participants.
Fifty-one WIC clinics in  Mississippi (1989– 1993)
Children were 5.5 times more likely to be  immunized, and immunized more rapidly, at WIC  sites where staff escorted children to a pediatric  clinic in the same facility for immunization. Children  were almost 3 times more likely to be immunized,  and immunized more rapidly, at sites with a  voucher/check incentive. (Until immunization, a  family must visit the clinic monthly, rather than  every other month, to pick up WIC voucher/checks.)
Six WIC sites in New  York City (1991)
Immunization rates increased at sites with a  voucher/check incentive (until children are  immunized, a family must visit the clinic monthly,  rather than every 3 months, to pick up WIC  voucher/checks).
Nineteen WIC sites in  Chicago (1996–1997)
Vaccinations increased at sites with vaccination  screening and a voucher/check incentive (until  immunization, a family must visit the clinic monthly,  rather than every 3 months, to pick up WIC  voucher/checks).
Seven WIC sites in  Chicago (1991–1993)
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