Established Evidence Results

Intervention Components (click on component to see a list of all articles that use that intervention): STATE/NATIONAL, WIC Food Package Change, POPULATION-BASED SYSTEMS, STATE

Intervention Description: This study assessed the impact of revisions to the USDA Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food packages on nutritional behavior and obesity in children 0- to 4-years-old participating in the New York State (NYS) WIC program.

Intervention Results: Significant increase in breastfeeding initiation between JulyDec 2008 (72.2%) and July-Dec 2011 (77.5%) (p<.05)

Conclusion: These findings demonstrate that positive changes in dietary intake and reductions in obesity followed implementation of the USDA-mandated cost-neutral revisions to the WIC food package for the hundreds of thousands of young children participating in the NYS WIC program.

Study Design: Time trend analysis

Setting: New York State (NYS)

Population of Focus: Mothers of infants and children through 4 years enrolled in the NYS WIC program between July 1, 2008-December 31, 2008

Data Source: New York State WIC Statewide Information System; Mother self-report

Sample Size: Pre-Implementation • July-Dec 2008 (n=179,929) During and Post-Implementation • Jan-Jun 2009 (n=186,451) • July-Dec 2009 (n=188,622) • Jan-Jun 2010 (n=186,663) • July-Dec 2010 (n=186,012) • Jan-Jun 2011 (n=184,262) • July-Dec 2011 (n=183,656)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): WIC Food Package Change, Food Supports

Intervention Description: Between January 2017 and March 2018, treatment households on SNAP received additional monthly benefits ranging from $1 to $122 based on distance to grocery store and earned income.

Intervention Results: The Kentucky Ticket to Healthy Food project did not reduce the primary outcome, FI-C (treatment=37.1%, control=35.2%; P=0.812), or secondary outcomes of very low food security among children (treatment=3.7%, control=4.4%; P=0.204) or food insecurity among adults (treatment=53.9%, control=53.0%; P=0.654). The project increased households' monthly food spending by $20 (P=0.030) and led more households to report that monthly benefits lasted at least 3 weeks (treatment=65%, control=56%; P=0.009).

Conclusion: A demonstration project to reduce FI-C by raising SNAP benefits for Kentucky households with children did not reduce FI-C or other food insecurity measures. Future research should explore the effect of different increases in SNAP benefits and collect repeated measures of FI-C to assess whether intervention effects change over time.

Study Design: randomized control trial

Setting: Community-based

Population of Focus: Rural low income households

Sample Size: 2202

Age Range: n/a

Intervention Components (click on component to see a list of all articles that use that intervention): Referrals, STATE, WIC Food Package Change, PATIENT_CONSUMER

Intervention Description: Based on Centers for Disease Control and Prevention’s Learn the Signs. Act Early. campaign, the program was developed and replicated in two phases at 20 demographically diverse WIC clinics in eastern Missouri. Parents were asked to complete developmental milestone checklists for their children, ages 2 months to 4 years, during WIC eligibility recertifcation visits; WIC staf referred children with potential concerns to their healthcare providers for developmental screening. WIC staf surveys and focus groups were used to assess initial implementation outcomes.

Intervention Results: In both phases, all surveyed staff (n = 46) agreed the program was easy to use. Most (≥ 80%) agreed that checklists fit easily into clinic workflow and required ≤ 5 min to complete. Staff (≥ 55%) indicated using checklists with ≥ 75% of their clients. 92% or more reported referring one or more children with potential developmental concerns. According to 80% of staff, parents indicated checklists helped them learn about development and planned to share them with healthcare providers. During the second phase, 18 of 20 staff surveyed indicated the program helped them learn when to refer children and how to support parents, and 19 felt the program promoted healthy development. Focus groups supported survey findings, and all clinics planned to sustain the program.

Conclusion: Initial implementation outcomes supported this approach to developmental monitoring and referral in WIC. The program has potential to help low-income parents identify possible concerns and access support.

Setting: WIC clinics

Population of Focus: WIC clinic staff

Intervention Components (click on component to see a list of all articles that use that intervention): WIC Food Package Change, Food Supports

Intervention Description: Between June 2016 and May 2017, treatment households on SNAP received an additional $40 in monthly SNAP benefits per child under age 5 years.

Intervention Results: The Nevada HHFK project did not reduce FI-C (treatment=31.2%, control=30.6%; P=0.620), very low food security among children (P=0.915), or food insecurity among adults (P=0.925). The project increased households' monthly food expenditures (including SNAP and out-of-pocket food purchases) by $23 (P<0.001).

Conclusion: A demonstration project to reduce FI-C by increasing SNAP benefits to Las Vegas households with young children and very low income did not reduce FI-C or other food-insecurity measures. This finding runs counter to prior research showing that SNAP and similar forms of food assistance have reduced food insecurity. This project was implemented during a period of substantial economic growth in Las Vegas. Future research should explore the role of the economic context, children's ages, and household income in determining how increases in SNAP benefits affect food insecurity.

Study Design: RCT

Setting: Community-based

Population of Focus: Low-income households with young children.

Sample Size: 3088

Age Range: n/a

Intervention Components (click on component to see a list of all articles that use that intervention): Text Messaging, STATE, WIC Food Package Change, PARENT_FAMILY

Intervention Description: Low-income mothers of infants aged 8-10 months were recruited from the Women, Infants and Children Program clinics in Prince George’s County, MD. Once enrolled, participants used text messages to receive and respond to six developmental screening questions from the Parents’ Evaluation of Developmental Status: Developmental Milestones. After confirming their responses, participants received the results and feedback. Project staff conducted a follow-up phone survey and invited a subset of survey respondents to attend focus groups. A representative of the County’s Infants and Toddlers Program met with or called participants whose results indicated that their infants “may be behind.”

Intervention Results: Eighty-one low-income mothers enrolled in the study, 93% of whom reported that their infants received Medicaid (75/81). In addition, 49% of the mothers were Hispanic/Latina (40/81) and 42% were African American (34/81). A total of 80% participated in follow-up surveys (65/81), and 14 mothers attended focus groups. All participants initiated the screening and responded to all six screening questions. Of the total, 79% immediately confirmed their responses (64/81), and 21% made one or more changes (17/81). Based on the final responses, 63% of participants received a text that the baby was "doing well" in all six developmental domains (51/81); furthermore, 37% received texts listing domains where their baby was "doing well" and one or more domains where their baby "may be behind" (30/81). All participants received a text with resources for follow-up. In a follow-up survey reaching 65 participants, all respondents said that they would like to answer screening questions again when their baby was older. All but one participant would recommend the tool to a friend and rated the experience of answering questions and receiving feedback by text as "very good" or "good."

Conclusion: A mobile text version of a validated developmental screening tool was both usable and acceptable by low-income mothers, including those whose infants "may be behind." Our results may inform further research on the use of the tool at older ages and options for a scalable, text-based developmental screening tool such as that in Text4baby.

Setting: Community-based

Population of Focus: Low-income mothers

Intervention Components (click on component to see a list of all articles that use that intervention): STATE/NATIONAL, WIC Food Package Change, POPULATION-BASED SYSTEMS, STATE

Intervention Description: We analyze changes in breastfeeding among WIC participants from the period before to period after implementation of the new food package.

Intervention Results: No statistically significant trends in breastfeeding after implementation of the new WIC food package

Conclusion: Rates of ever breastfed children are rising nationally but the increase is not associated with changes in WIC's new food package as evidenced in national and state surveys of postpartum women.

Study Design: Time trend analysis

Setting: National

Population of Focus: Intervention: women who participated in WIC during pregnancy Control: women not on WIC during pregnancy of similar socioeconomic status

Data Source: PRAMS, National Immunization Survey and the Pediatric Nutrition Surveillance System

Sample Size: N/A8

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): WIC Food Package Change, STATE-BASED, Policy/Guideline (National), NATIONALLY-BASED,

Intervention Description: The 2009 WIC food package revisions were intended to incentivize breastfeeding among the WIC population. To examine the effectiveness of this policy change, we estimated an intent-to-treat regression-adjusted difference-in-difference model with propensity score weighting, an approach that allowed us to control for both secular trends in breastfeeding and selection bias.

Intervention Results: We observed significant increases in infants that were ever breastfed in both the treatment group (10 percentage points; p < 0.01) and the control group (15 percentage points; p < 0.05); however, we did not find evidence that the difference between the two groups was statistically significant, suggesting that the 2009 revisions may not have had an effect on any of these breastfeeding outcomes.

Conclusion: Our study did not find evidence that the 2009 WIC food package revisions had an effect on ever breastfeeding, breastfeeding through 6 months, or exclusively breastfeeding through 6 months among a sample of infants eligible for WIC based on household income. Any positive effects observed in this study and prior studies that assessed this relationship may be reflections of the upward trends in breastfeeding rates that occurred in the U.S. before and after the implementation of the revisions.

Intervention Components (click on component to see a list of all articles that use that intervention): STATE/NATIONAL, POPULATION-BASED SYSTEMS, STATE, WIC Food Package Change

Intervention Description: The effect of the new Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food package, implemented in October 2009, on breastfeeding outcomes among a predominately Latina sample of WIC participants in Los Angeles County, California.

Intervention Results: Small but significant increases from pre- to postimplementation of the new WIC food package in prevalence of prenatal intention to breastfeed and breastfeeding initiation, but no changes in any breastfeeding at 3 and 6 months. The prevalence of exclusive breastfeeding at 3 and 6 months roughly doubled, an increase that remained large and significant after adjustment for other factors.

Conclusion: The new food package can improve breastfeeding outcomes in a population at high risk for negative breastfeeding outcomes.

Study Design: QE: pretest-posttest

Setting: Los Angeles County, CA

Population of Focus: Mothers participating in WIC who spoke English or Spanish

Data Source: Mother self-report

Sample Size: 2005 (n=1772) 2008 (n=1598) 2011 (n=1650)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): WIC Food Package Change, Technology-Based Support,

Intervention Description: The intervention described in the study focused on the transition of the Washington State Special Supplemental Nutrition Program for Women, Infants, and Children (WA WIC) to remote services and the expansion of food options during the COVID-19 pandemic.

Intervention Results: All WA WIC participants (n = 125,279 in May 2020) experienced the programmatic changes. Participation increased by 2% from March to December 2020 after WA WIC adopted programmatic changes in response to the COVID-19 pandemic. Certification and nutrition education completion rates increased by 5% and 18% in a comparison of June 2019 with June 2020. Food benefit redemption also increased immediately after the food list was expanded in April 2020. Staff and participants were highly satisfied with remote service delivery, predominantly via the phone, and participants appreciated the expanded food options. Staff and participants want a remote service option to continue and suggested various changes to improve service quality.

Conclusion: Participation in WIC and appointment completion rates increased after WA WIC implemented service changes in response to the COVID-19 pandemic. Staff and participants were highly satisfied with remote services, and both desire a continued hybrid model of remote and in-person WIC appointments.

Study Design: Mixed methods design

Setting: Community-based

Population of Focus: WIC staff and participants

Sample Size: 125279

Age Range: n/a

Intervention Components (click on component to see a list of all articles that use that intervention): WIC Food Package Change, STATE-BASED, Policy/Guideline (National), NATIONALLY-BASED,

Intervention Description: To investigate the impact of the revised WIC program on maternal and child health in a large, multi-state data set.

Intervention Results: The main analysis included 331,946 mother-infant dyads. WIC recipients were more likely to be younger, Black or Hispanic/Latina, unmarried, and of greater parity. The revised WIC program was associated with reduced likelihood of more-than-recommended GWG (−1.29% points, 95% confidence interval [CI] −2.03, −0.56) and increased likelihood of ever breast fed (1.18% points, 95% CI 0.28, 2.08). We also identified heterogeneous effects on GWG, with more pronounced associations among women 35 and older. There were no associations with foetal growth.

Conclusion: The revised WIC program was associated with improvements in women's gestational weight gain and infant breast feeding.

Intervention Components (click on component to see a list of all articles that use that intervention): STATE/NATIONAL, WIC Food Package Change, POPULATION-BASED SYSTEMS, STATE

Intervention Description: This observational study investigated whether dietary intake and feeding practices of a sample of majority-Hispanic infants and toddlers participating in a WIC clinic in south central Texas improved after the revised food package changes.

Intervention Results: Significantly fewer infants received cereal in their bottles and fewer toddlers consumed vegetables and eggs after the package changes. The observed feeding practices of infants and toddlers among this sample did not reflect the WIC package changes.

Conclusion: Strategic and comprehensive breastfeeding and nutrition education are recommended. Package modifications such as adding eggs back to the toddler package and allowing more flexibility for purchasing fresh produce and baby foods may be warranted.

Study Design: QE: pretest-posttest

Setting: WIC clinic in south central TX

Population of Focus: Spanish and English-speaking caregivers of infants and toddlers

Data Source: Mother self-report

Sample Size: 2009 (n=84) 2011 (n=112)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): WIC Food Package Change

Intervention Description: This final rule revises the WIC food packages based on public comments received on the interim rule published in 2007. The revisions aim to better align the food packages with current nutrition science, promote breastfeeding, provide more variety and choice for participants, and give state agencies more flexibility to accommodate cultural preferences. Key changes include increasing the cash-value voucher for fruits and vegetables for children, allowing yogurt and canned fish for certain food packages, providing more whole grain options, giving state agencies the option to allow cash-value vouchers for older infants, and eliminating certain medical documentation requirements.

Intervention Results: The final rule increases the cash-value voucher for children to $8 per month as recommended by the IOM. It allows state agencies to provide yogurt and canned jack mackerel as new options in certain food packages. For infants 9-11 months, it permits substituting a $4/$8 cash-value fruit/vegetable voucher along with jarred foods, rather than jarred foods alone. It eliminates the requirement for medical documentation for children to receive soy-based beverage/tofu and for women to receive more tofu. Overall, the changes aim to increase consumption of healthy foods like fruits, vegetables and whole grains while better accommodating dietary needs and personal preferences.

Conclusion: Despite overall smooth implementation of the interim rule changes, this final rule makes adjustments to improve clarity and address concerns raised during the public comment period. The revisions better fulfill the intent of following the IOM recommendations to update the WIC food packages to meet nutritional needs, increase breastfeeding support, expand food choices, and accommodate cultural preferences. The changes give state and local agencies more flexibility to tailor food packages to participants' needs while maintaining the nutritional integrity of the WIC program.

Study Design: N/A

Setting: N/A

Data Source: N/A

Sample Size: N/A

Age Range: N/A

Intervention Components (click on component to see a list of all articles that use that intervention): STATE/NATIONAL, WIC Food Package Change, POPULATION-BASED SYSTEMS, STATE

Intervention Description: The purpose of this study was to measure changes in the following 3 outcomes: WIC food-package assignments, WIC infant formula amounts, and breastfeeding initiation.

Intervention Results: There were changes in WIC food-package assignments and infant formula amounts but no change in breastfeeding initiation.

Conclusion: After the change, fewer WIC mothers of new infants received the partial breastfeeding package. More WIC mothers received the full breastfeeding package, but more mothers also received the full formula package.

Study Design: QE: pretest-posttest

Setting: 17 local WIC agencies in 10 states (CA, FL, GA, ID, IL, MN, RI, TN, TX & UT)

Population of Focus: All mothers with infants 0-5 months before and after intervention implementation

Data Source: Mother self-report

Sample Size: Months 1-2 – preintervention (n=17,597) Months 5-12 – postintervention (n=62,427)

Age Range: Not specified