1. *We will be presenting the preliminary results from the “Barriers to Retention among Infants and Children in the NYS WIC Program”. This study funded by a grant from the USDA.
*We would like to thank the USDA for funding this project. We would also like to thank the NYS DON and the 11 participating WIC agencies. Without their cooperation, this project would not be possible.
Findings are the responsibilities of authors and may not reflect the views of funding sponsor.

2. NYS DOH, Division of Nutrition Evaluation and Analysis Unit
Barriers to Retention
NYS WIC Infants and Children*
Presented by: Mary Lou Woelfel
Authors: Mary L. Woelfel, Howard Stratton, Robert Pruzek, Donald Hernandez, Gene Shackman, ShuGuang Chen
* A USDA WIC Special Project Grant. Awarded to the NYS DOH DON by the U.S. Department of Agriculture, Food and Nutrition Service, Office of Analysis and Evaluation, under grant Study results are sole responsibility of authors and may not reflect the view of the funding agency. .

3. Barriers to retention, NYS WIC
Introduction
In U.S. and NYS WIC caseload declining slightly
In NY, older the child, lower the retention
Many eligible children do not receive WIC services
*In NYS, as a child ages, retention in the WIC program decreases.
For example, among infants under 6 months old who enrolled in 1993, 29% did not return for their first recertification. An additional 30% did not return for their second recertification.
*Since retention of children is problematic, it is important to understand the experiences of the WIC participants and if these experiences may be affecting retention in the program.
*The goal of this study is to answer two questions?
1) What barriers are the parents and caretakers experiencing while on WIC?
2) Are these barriers related to the decision to discontinue WIC services?
3) Are there race/ethnic differences in barriers to retention

4. Barriers to retention, NYS WIC
Background
NY 999: WIC provided services to ,000 clients on average each month
Approximately 290,000 are infants or children
NYS provider network: 99 agencies with oversight of 570 sites
*NYS WIC Program is the third largest program in the country. Every month, the NYS WIC Program provides services to approximately 468,000 low-income pregnant of postpartum women, infants and children up to the age of five, at no cost to the participant.
*WIC services are provided to participants through a network of 99 WIC agencies across NYS. Every county and major metropolitan area in the state has access to a WIC agency.

5. Barriers to retention, NYS WIC
Objectives
Identify barriers to retention among WIC infants and children
Identify barriers specific to check redemption patterns
Present barriers by race/ethnicity .

6. Barriers to retention, NYS WIC
Methods
Focus groups with WIC participants, guidance team, lit. review used to identify potential barriers
Identified barriers used to design 20-minute survey
Survey administered one-on-one at WIC sites
Outsourced to ensure candid response
From perspective of WIC participant
11 volunteer agencies; 41 sites
3167 parents/caretakers of WIC infants/children .
*The survey questions regarding potential barriers, were identified from the results of 5 focus groups with current and former WIC participants, the research literature and a guidance team discussion. Priority was given to those barriers identified in the focus groups for inclusion in the survey.
*A 20 minute survey was conducted with parents and caretakers of WIC enrolled infants and children at 11 WIC agencies across NYS. The interviews were conducted by outside personnel to insure confidentiality and candid responses.

7. Barriers to retention, NYS WIC
Data collection and data analysis
Response rate 80%; completion rate; 94%
Data collected March through Dec 1999
Informed consent obtained
Representative of 11 agencies
Chi-square, logistic regression
80% response rate; 94% completion rate.
Differences between sample and agency characteristics minor, can make inferences to 11 agencies. Sample not representative of state as a whole, cannot make inferences about the state.
Cross-tabulation and logistic regression results significant at the <.01 level.
We collected 3167 surveys. The sample was collected to ensure we could determine if there were any differences by race and ethnicity or age of child enrolled in WIC. So, the data was collected to guarantee at least 10% of the sample was Black and 10% Hispanic. In addition, the sample slightly over-represents the percentage of parents and caretakers of children over 12 months in the populations.
*We analyzed 116 variables with regard to to race and ethnicity. The cross-tabulation results presented are statistically significant at the <.01 level.

8. Barriers to retention, NYS WIC
Measured variables
Demographic and economic
Public assistance programs
Fast food consumption
Food insecurity
Employed due to welfare reform
Benefits of WIC
68 individual level barriers
Dependent variables
Cashing or picking up checks

9. Figure 1. Barriers by organization category
Scheduling
Getting
there
Facility
Waiting
General Bureaucracy
Nutrition Education
Certifi- cation
Agency
staff
68 barriers to retention were identified and grouped by organizational category by consensus among WIC nutritionists and WIC operations staff.
ORGANIZATIONAL CATEGORY SYSTEM LOOKS LIKE THIS.
FOR EACH CATEGORY, COLLECTED A NUMBER OF MEASURES.
Measures for each organizational category are displayed in next slideWe
Food procurement
Food package

10. Specific barrier items by organization category
Scheduling. Inconvenient times, work problems, rescheduling, no specific appointment time, separate family appointments.
Getting there. Parking, neighborhood safety, transportation
Facility. Overcrowding, noisy, lack of children’s activities.
Waiting - Too long, > 1 hr for checks; > 1 hr to recert.
Bureaucracy. Rules unclear, rigid, changing food package, bringing child, paperwork, replacing checks, blood work, proxy.
Nutrition Education. Long, boring, repetitive, useful
Agency staff. Negative treatment, customer friendly, speaking your language, insensitive to culture, not listening, giving conflicting info.
Food procurement. Store policy diff. than WIC policy, negative treatment by store staff; food availability-finding food, food not in stock, not getting all WIC food. Food package size-matching check to container in store, cereal box size, milk size.
Food package. Variety, quantity (too little, too much of each item)

11. Table 1. Demographic/economic characteristics of study participants
(%)
< 1 year
1 year old
2 year olds
3 year olds
4 year olds
White non-H 46
Black non-H 34
Hispanic 15
(%) Rent 78
Single 65
Employed 45
< 50% pov 28
< 100% pov 64
HS or less 64
Food insecure 10
The key variable here is race/ethnicnity. In this sample, 46 percent are white, non-Hispanic, 34 percent are black, non-Hispanic and 15 percent are Hispanic. This information is relevant since we want to look at race/ethnic differences in barriers to retention. Also important because addressed the issue of generality.
The race/ethnic breakdown in the sample, for example, is not representative o the state as a whole. Statewide the distribution of the major ethnic groups are pretty much equally distributed -- about 30, 30, 30, on average.
The majority rent, are single and are below 100 percent of poverty.
While not a specific to this presentation, 10 percent of those interviewed reported that in the past few months, members of their household sometimes or frequently did not have enough to eat. This is higher in NYC than upstate (17 vs 6%).

12. Table 2. Public assistance
(%)
Medicaid
TANF
Food stamps*
Head Start*
Free/Reduced lunch*
WIC and other food programs
WIC only
WIC plus
WIC plus
WIC plus
This slide shows that the majority in this study population are on Medicaid but the majority are not on each of the other public assistance programs.
In terms of food programs, 51 percent of those interviewed received only WIC. Or, looking at it another way, 49 percent received WIC and at least one other food program.

13. Table 3. Number and participant type on WIC
(%)
Number in household on WIC
1 on WIC
2 on WIC
3 on WIC
4 or more
WIC composition
Infant only
Child only
Infant & child
Missed pickup/cash checks 46
In this sample, 24 percent are only an infant on the program, 76 percent had at least one child on WIC.
Key point here is that 46 percent reported not cashing or picking up all their checks.

14. Table 4. Socio-demographics by race/ethnicity. NYS WIC
W B H (%) (%) (%)
Rent
Single
< 50% poverty
< 100% poverty
Employed
HS or less
Medicaid
TANF
Food stamps
Free/Red lunch
Food insecurity
Missed pickup/cash checks
This slide is not a focus of this presentation, but include interesting data that we will be addressing in future analysis. For example, 18 percent of Hispanics report food insecurity. That is, 18 percent responded that they often or frequently do not have enough to eat.

15. Barriers to retention, NYS WIC
Results GO LA STAFF!
In upstate and NYC, across all
organization categories, local
WIC agency staff received the
highest ratings.
Examining barriers by organizational category; that is, on how WIC is organized, the organizational unit with the fewest barriers to retention and therefore the highest marks is the LA WIC staff. LA Agency staff interface well with WIC participants. This results hold in upstate and in NYC.
According to NYC participants and upstate participants, LA staff are culturally sensitive, listen to them, they are customer friendly, they don’t give out conflicting information, not treated negatively.

16. Barriers to retention, NYS WIC
The most important benefit of WIC participation from participant’s perspective
In Upstate: Good nutrition and formula
In NYC: Formula and milk
Slide looks at most important benefit of WIC from perspective of participant. In upstate, the most important benefit reported was good nutrition and formula. In NYC, the most important benefit was milk and formula.

17. Table 5. Barriers to retention
Barrier Percent reporting barrier
Waiting too long
Waiting area/no child activities 42
Waiting area/overcrowded/noisy 36
Waiting more than 1 hr to recertify 27
Cereal box size
Matching check to foods 23
Too little WIC formula 38
Too little WIC juice
Nutrition education repetitive 33
Nutrition education boring 27
Different policies WIC/Vendor 29
Slide shows most frequently cited barriers to retention- includes barriers reported by at least 20% of those interviewed.
Waiting too long is most frequently cited problem. 48% of respondents indicated waiting too long was a problem. Waiting was followed by a lack of activities for children and not being able to get the cereal box size you want.
Will not cite every barrier. Intent is to determine if most frequently cited barriers clustered in any of the organization categories that represent how WIC is organized. The most frequently cited barriers to cluster as will be presented.

18. Table 6. Most frequently cited barriers to retention by Race
Barrier White Black Hisp. Other
Waiting too long 47% 50% 46% 51%
Waiting area lacking children’s activities 38% 50% 39% 41%
Not getting right cereal box size 43% 41% 35% 41%
Too little formula 36% 40% 43% 40%
Waiting room overcrowded and noisy 31% 40% 41% 35%
Nutrition education repetitive 34% 35% 29% 23%
Stores having different WIC policies 26% 35% 25% 28%
Too little juice 24% 29% 26% 30%
Waiting more than one hour to re-certify 25% 27% 34% 29%
Nutrition education boring 26% 29% 25% 22%
Matching check amount to food container 24% 24% 17% 26%
*Slide addresses third objective: Are there cultural differences in barriers to retention
There is no difference in the top 11 most frequently cited barriers to participants by race/ethnicity. There is some difference in rank ordering.
Although there is no difference in most frequently cited barriers, there are some statistically significant difference in reporting of some barriers, as shown in next slide.

19. Table 7. Barriers by race/ethnicity Statistically significant differences among less cited barriers
W(%) B(%) H(%)
Language barrier
Inconsistent w/culture diet
Too little milk
Too little dry beans
Getting off work
Transportation
Safety
Starting with 95 potential barriers and using a chi square test of significance of LT .01, there were 13 significant differences. This slide reports only on barriers cited less often.
(The other barriers were among those most frequently cited and include waiting too long, overcrowded, nothing for kids to do, matching box to vouchers, different store/vendor policies, wait more than 1/2 hr..
*Differences included
African-Americans have more difficulty getting off work-also more likely to be working.
Language and food barriers. Hispanics more likely to report language barriers and that WIC foods are inconsistent with their diet. Hispanics more likely to report transportation and neighborhood safety problems.

20. Figure 1. Barriers by organization category
Overcrowded, noisy
nothing for kids
to do
Wait too long
Schedule
Getting
there
Facility
Waiting
Boring, repetitive
Nutrition Education
Certifi- cation
Agency
staff
General Bureaucracy
Most frequently cited barrier categories in red.
Waiting. Waiting too long the most frequently cited barrier to retention.
Local agency facility. Overcrowded, noisy sites with no activities for children.
Nutrition education. Many participants reported nutrition as boring and repetitive. 85% of participants also reported nutrition education was very useful.
Package size availability. Cereal box size a problem and participants report difficulty matching vouchers to cereal box size.
NYS has a minimum box size (a cost containment effort). Increasing number of oz may affect NTE amount.
Too little food. Participants want more formula and juice.
package
Cereal box size
Too little food
Food procurement
Food package

21. Table 8. Barriers and check patterns
Failure to pick-up or cash checks reported by
46% of parent/caretakers
Variables asso. w/failure to pick-up/cash chks
Child’s age
As child’s ages, failure to pick-up/cash checks increases
Parent’s age
Younger parents more likely to fail to pick up/cash checks.
Problems getting checks replaced
Problems rescheduling
Too much milk
age of parent/caretaker - younger theparent/caretaker, less likely cash check.

22. Highlights
Barriers to retention - participant’s perspective
Long waits, overcrowded, noisy facilities with nothing for kids to do
Nutrition education boring and repetitive
Cereal box size; problems matching voucher to cereal box size (Cost containment effort)
Too little formula
Too little juice

23. Highlights Race/ethnic similarities
Whites, Blacks, Hispanics cite same top barriers
Race/ethnic differences
Inconvenient hrs for employed Blacks
More Blacks work than whites and Hispanics.
Language and food barriers for Hispanics
Failure to pick up/cash checks
Children’s food package
Young mothers
A higher proportion of minorities than non-minorities report waiting, overcrowded and noisy sites. This is probably a urban/rural difference.
A higher proportion of African-Americans reported difficulty getting off work. A higher proportion of African-American women in our study also worked.
Hispanics more likely to report language barriers and that WIC foods are inconsistent with their diet. Hispanics more likely to report transportation and neighborhood safety problems.
Check cashing

24. Thank you