key: cord-0927130-jqq6z3ck
authors: Morris, Evelyn J.; Otten, Jennifer J.; Quinn, Emilee L.; Rose, Chelsea M.; Spiker, Marie; Leary, Jean O’
title: Insights from Washington State’s COVID-19 response: A mixed-methods evaluation of WIC remote services and expanded food options using the RE-AIM framework.
date: 2022-03-23
journal: J Acad Nutr Diet
DOI: 10.1016/j.jand.2022.03.013
sha: 0425a1df6415d8d66a20f2c9e80f3195b2d6c48d
doc_id: 927130
cord_uid: jqq6z3ck

Background In response to the COVID-19 pandemic, Washington WIC (WA WIC) adopted federal waivers to transition to remote service delivery for certification and education appointments. WA WIC also expanded the approved food list without utilizing federal waivers, adding more than 600 new items to offset challenges participants experienced accessing foods in stores. Objective This study aimed to assess the reach and effectiveness of the programmatic changes instituted by WA WIC during the COVID-19 pandemic; the processes, facilitators, and challenges involved in their implementation; and considerations for their continuation in the future. Design A mixed-methods design, guided by the RE-AIM framework, including virtual, semi-structured focus groups and interviews with WA WIC staff and WA WIC participants, and quantitative programmatic data from WIC agencies across the state. Participants/Setting: This study included data from 52 state and local WIC staff and 40 WIC participants across the state of Washington and from various WA WIC programmatic records (2017-2021); The research team collected data and conducted analyses between January 2021 and August 2021. Analysis An inductive thematic analysis approach with Dedoose was used to code qualitative data, generate themes, and interpret qualitative data. Descriptive statistics were calculated for quantitative programmatic data, including total participant count, percent increase and decrease in participation, percent of food benefits redeemed monthly, and appointment completion rates. Results All WA WIC participants (n= 125,279 in May 2020) experienced the programmatic changes. Participation increased by 2% 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 to 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. Conclusions 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. Some of the suggested changes to WIC, especially the continuation of remote services, would require federal policy change while others could be implemented under existing federal regulations.

Objective: This study aimed to assess the reach and effectiveness of the programmatic changes 23 instituted by WA WIC during the COVID-19 pandemic; the processes, facilitators, and 24 challenges involved in their implementation; and considerations for their continuation in the 25 future. 26 27 Design: A mixed-methods design, guided by the RE-AIM framework, including virtual, semi-28 structured focus groups and interviews with WA WIC staff and WA WIC participants, and 29 quantitative programmatic data from WIC agencies across the state. The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) is (if any) infants and children enrolled in WIC, and the WIC agency they visit. No data on 125 sex/gender or age of WIC participants were collected. 126

Seventy-two survey respondents were contacted using a maximum variation approach to aim for 127 diverse perspectives of the WA WIC participant population regarding race, ethnicity, rurality, 128 and WIC participant enrollment category (whether they were enrolled, their infant was enrolled, 129 or their child/children were enrolled). The study team made a particular effort to contact 130 participant volunteers identifying as American Indian and Black since these racial groups 131 experience the largest nutrition 17 and infant and maternal health disparities in the state. 18 132

Additionally, the aim was to recruit 10 WIC participants whose primary language was Spanish to 133 ensure that the perspectives of participants who speak a language other than English were 134 included. Spanish is the most commonly spoken language after English in Washington State, and 135 an estimated 6.5% of households receiving cash, food, and medical benefits in the state consider 136

Spanish their primary language. 19 Participant recruitment continued until the goal of 40 total 137 interviewees, 10 of whom spoke Spanish, was reached; the goal was based on prior similar work 138 that indicated 40 interviews would be sufficient to reach data saturation. 20 Of the 72 respondents 139 contacted, 40 completed interviews, 6 declined participation, 11 were scheduled but did not 140 complete interviews, and 15 were unreachable after up to four contact attempts. 141

Non-identifiable, programmatic data were provided by WA WIC to examine reach and 144 effectiveness through temporal trends in participation and food benefit redemption. WA WIC 145 also shared reports from local WIC agencies from May and August 2020 with data on WIC 146 service status (e.g., number of staff; and number of sites offering curbside or face-to-face 147 J o u r n a l P r e -p r o o f services), supports needed, and challenges experienced. These data were explored so emergent 148 quantitative trends could inform questions during qualitative data collection and to help 149 triangulate focus group and interview findings. 150

Ten focus groups were organized to include staff members with similar roles within WIC 152 as able: one included state staff managing the transition to remote services (n=5), one included 153 state staff managing the food list expansion (n=5), two included local program coordinators 154 (n=7, n=6 ), two included breastfeeding support staff (n=3, n=2), one included nutrition 155 educators (n=5), one included certification staff (n=4), and two included staff from a variety of 156 positions (n=7, n=6). Additionally, two local staff participants (program coordinator, nutrition 157 educator) were not able to participate in focus groups due to scheduling constraints, so key 158 informant interviews were conducted with these individuals. The study team developed the semi-159 structured focus group guide (Supplemental Figure 2 ) using the study aims and the RE-AIM 160 framework; this guide was also used for the key informant interviews. The questions asked about 161 processes, facilitators, and challenges that accompanied the switch to remote services and the 162 expanded food list. Staff were also asked about the feasibility and support needed to continue 163 aspects of remote services. Two female researchers with masters-or doctoral-level training and 164 experience conducting research in public health/nutrition conducted and recorded ~70-minute 165 focus groups via the Zoom platform from January 2021-February 2021. 166

The semi-structured interview guide for WIC participants was informed by the study 168 aims, RE-AIM framework, and emerging themes from the staff focus groups. Questions were 169 developed by the research team and reviewed by WA WIC. Participants were asked about their 170 prior history with WIC, their most recent remote WIC appointments, their experiences with the 171 expanded food list, their interest in continuing remote appointments, and how WIC could be 172 improved in the future (Supplemental Figure 3 ). Interviews were conducted by the same 173 researchers from March-April 2020 via Zoom and were recorded with interviewees' permission. 174

Participants were aware that researchers were affiliated with the local University and were 175 working in partnership with the state WIC program. Interviews were conducted in English or 176

Spanish (with a professional interpreter). Interviews with English-speaking WIC participants 177 averaged around 20 minutes whereas interviews with Spanish-speaking WIC participants and 178 interpreters averaged around 40 minutes. There were no repeat interviews with any participants. 179

Interviewees were compensated differentially for this additional interview duration (English-180 speaking participants received $20 and Spanish-speaking participants received $40), but 181 participants were not aware of the compensation differentials. 182

Programmatic data were analyzed in Microsoft Excel 21 (ver. 16.30) using descriptive statistics 185 and visualized in Tableau 22 (ver. 2021.1) to assess trends over time for total participation by 186 women, infants, or children; percent increase and decrease in participation; percent of food 187 benefits redeemed monthly; and appointment completion rates. 188

Focus groups and interviews were transcribed using the Zoom automated transcript 190 function. Study team members reviewed and cleaned transcripts for accuracy, referring back to 191 the audio recording as necessary. Transcripts were not reviewed by participants. The team used 192

Dedoose 23 software to apply deductive codes generated from the RE-AIM constructs, adapting 193 the codebook to include emergent parent and child codes. 194

Four team members engaged in an iterative process of independently coding a small 195 subset of the transcripts, then comparing code applications to refine code definitions. Coding 196 inter-rater reliability (IRR) between two pairs of coders was assessed in Dedoose; upon reaching 197 Kappa statistics signifying "good" IRR (i.e., .79 or greater), team members coded independently. 198

Data saturation, meaning no new themes emerged from the data, 24 occurred before all transcripts 199 were coded; however, the remaining transcripts were coded because the staff and participant 200 samples intentionally captured a diverse set of experiences with WIC. After coding, team 201 members summarized coded text. 202

Reflexivity, an evaluation of researcher's experiences and identities that could influence 203 the research, is important in qualitative research. 25 There were ways in which the study team's 204 experiences and identities differed from the study participants, which had the ability to influence 205 study design, data collection, and interpretation. To account for these differences, the team 206 debriefed regularly throughout the research process; wrote reflections after focus groups and 207 interviews; consulted with co-researchers to ensure precise analysis; and discussed findings with 208 WA WIC staff to cross-check interpretation, a process known as member-checking. 26 209 210

Characteristics collected for WIC staff and WIC participants are detailed in Table 1 . The 213 majority of WIC participants interviewed for this study were enrolled with one or more children 214 and had experience with WIC prior to the beginning of the COVID-19 pandemic. The majority 215 of WIC staff who participated in interviews or focus groups were employed at the local level. 216

Based on data reported by agencies and focus group respondents, all WIC participants 218 who had an appointment or were certified during the COVID-19 pandemic experienced some 219 aspect of remote services. Because the food list expansion was implemented statewide, all WIC 220 participants also experienced the additions to the allowable food list. By May 2020, the WIC 221 participant population reached with these changes included 26,891 women, 26,378 infants, and 222 72,010 children in Washington State; the population was predominantly white (70%), followed 223 by multi-race (10%), Black or African American (8 %), American Indian or Alaskan Native 224 (5%), Asian (5%), and Native Hawai'ian or Pacific Islander (2%); 42% of WIC participants 225 identified as Hispanic. 226

Effectiveness 227

As seen in Figure 4 , participation had been steadily declining since 2017. Participation 229 began increasing just before the start of the COVID-19 pandemic and continued to increase after 230 the programmatic changes were made to WIC in March 2020. There was a 5.9% increase in 231 participation from December 2019 to December 2020, and from March 2020 (when the COVID-232 19 pandemic began) to December 2020 participation increased by 2%. 233

Between December 2019 and December 2020, participation increased for children by 234

11%, but decreased slightly for women (0.1% decrease) and infants (0.1% decrease). 235

Participation growth also differed by race; from December 2019 to December 2020, participation 236 increased among children identifying as Native Hawai'ian or Pacific Islander (18% increase), 237

Black or African American (17 % increase), Multi-Race (14 % increase), Hispanic (12% 238 increase), White (11% increase), and Asian (9% increase), but participation decreased for 239 children identifying as American Indian or Alaskan Native (6% decrease). 240

Local and state staff described increased appointment completion rates after 242 implementing the programmatic changes, hypothesizing that the increase related to the 243 convenience of remote services. As described by one WIC staff, "Our show rates are much 244 higher because there isn't the barrier of gathering all of your kids and your things and either 245 driving or taking public transportation to get to WIC." (Staff 02) Programmatic data from 246 sample months before and during the implementation period corroborated this statement; 247 nutrition education completion rates increased from 78% in June 2019 to 96% in June 2020 and 248 the certification completion rate increased from 72% in June 2019 to 77% in June 2020. 249

Staff reported that the expansion of the allowable foods helped increase access to 251 approved foods during COVID-19 pandemic-related food shortages. Participant interviewees 252 echoed this statement. One participant shared: "at the beginning, it was hard to get milk, cheese, 253 and cereal, but then WIC updated the list of available foods and now I am able to get them with 254 no problem." (Participant 30S) 255

Food benefit redemption data throughout 2020 ( Figure 5 ) demonstrated that the average 256 percent of all food benefits redeemed by WIC participants declined at the start of the COVID-19 257 pandemic from March to April, then increased almost back to pre-COVID-19 pandemic levels 258 right after the food list was expanded. Redemption rates then dipped once more before returning 259

to rates near those experienced in early 2020. 260

State staff described three federal waivers that made remote services possible during the 262 COVID-19 pandemic, listed in Figure 6 . 27-29 These waivers allowed WIC services to continue 263 while offices were closed to the public and reduced the administrative burden on clinics that had 264 staff pulled away to COVID-19 pandemic response. Additionally, WA WIC had transitioned to 265 an EBT-based system for benefit issuance throughout 2019 and had just started loading benefits 266 remotely in the beginning of March 2020; WA WIC was able to continue remote benefit 267 issuance throughout the transition to remote appointments. The other major programmatic 268 change was a large-scale expansion of the approved WIC food list. The food list is updated 269

annually, but typically 40-60 items are added; in response to COVID-19 pandemic-related food 270

shortages and challenges finding WIC-allowed foods in the store, WA WIC staff approved 271 approximately 600 new foods. WA WIC staff explained that they chose not to utilize the waivers 272 related to food items so that added foods would not be revoked when the waivers expire. 273

Phone appointments were mentioned by all staff as the most common way of reaching 276 clients remotely. While some local staff had attended state or agency-led training on using video 277 conferencing, nearly all local staff said that video appointments had not yet been offered to WIC 278 participants. Perceived challenges to offering video appointments included hesitancy from staff 279 related to embarrassment interacting on camera, a lack of training, and limited access to video 280 equipment. To help maintain contact with WIC participants, local staff, especially breastfeeding 281 support staff, reported texting participants more frequently between appointments. 282

To supplement remote services, many local staff reported mailing handouts to 283 participants either prior to some appointments so participants could follow along with the content 284 while on the call, or after appointments when participants requested additional information. Staff 285 also discussed implementing pick-up services for breast pumps and educational materials. A 286 small subset of staff mentioned putting infant scales outside of homes so parents could measure 287 their child if growth was concerning. 288

Transitioning to remote services required numerous supports from federal, state, and 290 local agency staff. A federal waiver to defer measurements combined with state-level policy to 291 defer submitting proofs and signatures on documents improved the flexibility of the 292 certifications. As a result, staff reported that appointment efficiency increased; one said, "when 293 you're doing everything over the phone things are just a bit quicker. You're talking to them, but 294 you can kind of write your notes simultaneously... so that saves a lot of time." (Staff 28) State 295 staff also initially provided bi-weekly webinars for agency staff to share information and assess 296 needs related to virtual appointments; these webinars tapered to monthly by December 2020. At 297 the local level, common requests from staff included cell phones, laptops with cameras, and 298 attachable webcams for desktops. 299

Both staff and participants expressed high satisfaction with remote service delivery. 301 Table 2 summarizes a subset of the most common advantages and disadvantages of remote 302 services from staff and participant perspectives and presents a selection of illustrative quotes. 303

The advantages of remote services were mentioned more often and outweighed the 304 disadvantages presented. 305

Both local and state staff appreciated remote services as a way to reduce longstanding 306 participation barriers. Phone calls worked well for most appointment types according to most 307 local staff. The appointment types that were mentioned as more difficult remotely included 308 enrollment appointments (especially for first-time WIC participants) and some breastfeeding 309 appointments addressing latch and positioning support. For example, one staff member shared 310 that "it's been very challenging offering these breastfeeding support services remotely. It's hard 311 to…convey the different positions or movements just, you know, over the phone." (Staff 29) 312

While enrollments and breastfeeding support appointments were brought up by some staff as 313 challenging, these opinions were not unanimous. For example, one breastfeeding educator said "I 314 feel like even for breastfeeding they're more relaxed when they are talking, because... we have 315 the luxury to choose any time at their convenience and they can call me." (Staff 39); in this way, 316 remote services helped the participant feel comfortable, and engage with breastfeeding staff 317 when they needed it. The most reported element of remote services that detracted from staff 318 satisfaction was the inability to consistently obtain height, weight and hemoglobin measurements 319 from participants. However, these challenges were mentioned less than the success of increasing 320 convenience for participants with remote services. 321

Participants viewed phone appointments as easy to complete, convenient, and sufficient 322

for both sharing and receiving information. Participants reported they could connect, hear, and 323 complete the appointments over the phone and felt as or more comfortable receiving services on 324 the phone compared to in-person. About half of the participants interviewed indicated they 325 occasionally took appointments away from home, including at work and while running errands. 326

One participant noted that phone appointments "just made it really easy. It was 327 convenient that as I'm doing my normal everyday things that I can still do my appointment." 328 (Participant 36E) None of the participants interviewed had conducted a video appointment and 329 thus did not discuss satisfaction regarding video appointments. 330

When asked about their experience with the expanded food list, about half of participants 332

were aware of the additional foods. Those participants were happy with the expansion, and 333 especially appreciated the increased variety of kid-friendly foods like string cheese, yogurt, 334 cereal, milk, and juice. One participant said "Yes, I like them, because we have more and more of 335

The WICShopper app was mentioned by participants as helpful while planning for and 337 actively shopping, especially alongside the expanded food list. The scanning feature made it 338 easier for participants to confirm allowable foods. While the WICShopper app was useful for a 339 majority of the participants interviewed, some still noted difficulties around determining which 340 foods were added to the food list and having items deemed not allowable at the register. 341

Interest in maintaining remote services 343

Both staff and participants expressed hope that remote services would continue beyond 344 the COVID-19 pandemic. Almost all state and local staff advocated for a hybrid model including 345 both remote and in-person appointments. They recognized the increased convenience of remote 346 appointments, and also noted that an in-person option could be useful for certain services and for 347 parents needing to share sensitive information including disclosures of domestic violence. One 

The staff proposed many ideas for creating a hybrid service delivery model including: including improved data sharing amongst health providers and programs that capture 375 measurements and technology for at-home measuring. Staff expressed strongly that consistent 376 and accurate measurements are essential to assessing nutritional risk and, further, that WIC is 377 unique in its ability to collect and use this information, especially amongst families that do not 378 have insurance. From the participant perspective, perceived advantages included seeing demonstrations, having 387 staff interact with children, and feeling more comfortable seeing the staff member. The most 388 common perceived disadvantage of video calls described by participants was that they would not 389 be able to take calls "hands free" which was an important convenience of phone appointments. 390

Staff also suggested developing video orientations for utilizing the WIC Shopper App and WIC 391 EBT card translated into numerous languages to help supplement the education they give to new 392 participants during their first appointment. 393

Participants made clear that they would like the list of allowable food to remain 395 expanded, with even more foods added. Participants said they would appreciate additional 396 approved food brands, more organic options, and more flexibility in allowable food package 397 sizes. Some WA WIC participants said that while the number of approved brands of certain 398 foods increased, the allowable sizes of food items remained a constraint because food packaging 399 sizes in stores differed. Participants also suggested improvements to the WICShopper app, 400 including improved search features, increased scanning reliability, and additional meal planning 401

features. Both staff and participants mentioned that participants should be able to order WIC 402 groceries online and pick-up curbside. 403 404

Public health nutrition experts have called for evaluation of WIC service changes 406 implemented in response to the COVID-19 pandemic to strengthen WIC and inform the 407 upcoming Child Nutrition Reauthorization process. 30 This study was designed to generate 408 evidence-based suggestions for implementing, maintaining, and improving the changes adopted 409 by WA WIC for future practice. Overall, these results illustrate that appointment show rates 410 improved after the programmatic changes were implemented and that WIC participants and staff 411 were highly satisfied. Staff and participants communicated strongly that they want to see both 412 changes maintained in some form. The impact of these changes on WIC participation trends and 413 food benefit redemption is less clear given the COVID-19 pandemic context influencing WIC 414 eligibility and food shopping experiences; increased unemployment 31 , increased food 415 insecurity 31 , and decreased access to other food-related safety net programs, 32 make it difficult to 416 determine the extent to which increases in participation and food benefit redemption are 417 attributable to WIC programmatic changes as opposed to increased need. 1 were similar to WIC participant perspectives when describing the ease and convenience of 455 remote services, aspects of remote services that decrease participation barriers, and the 456 helpfulness of the WICShopper App. The main drawbacks to remote services outlined by staff 457 also aligned with the participants' perspectives: they wanted a way to capture consistent 458 measurements remotely and they missed interacting with WIC participants in the clinic. While 459 there were similarities between staff and participant perspectives, they also diverged in several 460 areas. First, some staff reported participants occasionally seemed distracted while taking phone 461 appointments away from home. Participants did discuss taking appointments away from home, 462 but within the context of convenience, highlighting the ability to multi-task or maximize breaks 463 from work as a benefit of remote services. Second, staff anticipated attrition once in-person 464 services were re-established. Participants did report wanting to continue receiving WIC services 465 There are multiple strengths of the design, methods, and analysis of this study. Key 498 strengths include the mixed-methods design, the participation of a diverse participant sample 499 including staff perspectives, the iterative approach to coding qualitative data, and the member-500 checking process with WA WIC staff. Integration of programmatic data with qualitative data 501 allowed for contextualization and explanation of quantitative trends; 45 use of both quantitative 502 and qualitative data within the RE-AIM framework has been recommended, and both were 503 employed in this study for a rigorous exploration of the changes. 14 Further, having multiple 504 coders code a subset of the transcripts, discuss discrepancies, and collaborate on themes 505 enhanced the data triangulation process 46,47 and confirmability of these results. 26 The participant 506 sample also captured a diversity of perspectives about the programmatic changes. 33 Finally, in 507 line with principles of rigor in qualitative research, the research team shared a preliminary 508 synthesis of the results with WA WIC staff participants and discussed whether the findings 509 resonated with their experiences. 26 510

There are also limitations to this study. First, the study focused on one state's WIC 511 program, limiting the national generalization of the results. Second, interviews were only 512 conducted in English and Spanish due to cost constraints; adding more languages could have 513

increased the WIC participant sample diversity. Third, some trends, such as increases in 514 participation, may have already been under way prior to COVID-19 pandemic shut down orders; 515 the team did not collect information that would elucidate if these trends were due to growing 516 awareness of the pandemic in late 2019/early 2020 or to simultaneous programmatic changes, 517 such as changes in electronic enrollment systems. Fourth, the team engaged in member-checking 518 with WA WIC staff, however there was not time to conduct a member-checking process with the 519 participant sample. 47 Fifth, demographic data on race and ethnicity, gender, or age of WIC staff 520 participants were not collected and WIC staff from diverse racial and ethnic groups were not 521 purposively sampled. The interpretation of study findings may have been enhanced in the context 522 of WIC staff participant race and ethnicity, gender, or age. Sixth and finally, the WIC participant 523 sample was recruited through the WICShopper App, which may have generated a sample that 524 would be more comfortable with the technology and experience of remote service delivery; 525 however, nearly all WIC participants in Washington state utilize the WICShopper App and all 526 have experienced remote services, so the potential for a biased sample is low. 527 528

This study explored the reach, effectiveness, adoption, implementation, and maintenance 530 of remote services and the expanded food list executed by the WA WIC program in response to 531 the COVID-19 pandemic. After these changes were implemented, participation, appointment 532

show rates, and food redemption increased. Both staff and participants were highly satisfied with 533 J o u r n a l P r e -p r o o f 

The number and proportion of WA WIC participants who experienced the program adaptations.

• Programmatic participation data Effectiveness The extent to which WA WIC adaptations were associated with maintained or improved:

• WIC participation 

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The authors would like to acknowledge the assistance of Cathy Franklin, Terri Trisler and Anh Tran for their assistance in gathering data and designing this study, and Annie Vuong for creating the figures seen in this manuscript. We have received permission to acknowledge these individuals.