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National
Survey of WIC Participants: Final Report
EXECUTIVE
SUMMARY
The Special
Supplemental Nutrition Program for
Women, Infants and Children (WIC) is
administered by the Food and Nutrition
Service of the U.S. Department of
Agriculture (USDA). WIC was established
in 1972 to counteract the negative
effects of poverty and poor nutrition on
prenatal and pediatric health. WIC
provides a combination of direct
nutritional supplementation, nutrition
education and counseling, and increased
access to health care and social service
providers for pregnant, breastfeeding,
and postpartum women; infants; and
children up to age five.
Since 1992, FNS
has produced biennial reports on WIC
participant and program characteristics
based on the WIC Minimum Data Set (MDS)
compiled from state management
information systems. The 20 items
included in the MDS are collected as
part of ongoing WIC operations and
consist primarily of information related
to participant eligibility.
This report
presents findings from the National
Survey of WIC Participants and Their
Local Agencies (NSWP). The NSWP was
fielded in spring of 1998 and collected
information about WIC participants and
their families, through interviews
conducted in WIC service sites
throughout the country. The NSWP was the
first national survey of WIC enrollees
since 1988. Over that ten-year period,
the WIC program vastly expanded, with
the number of enrollees growing from
approximately 3.4 million in 1988 to
over 8 million in 1998.
Purpose
of the Study
The NSWP had
two primary goals: to provide
demographic information about WIC
participants and their families, and to
provide national estimates of the case
error rate and dollar error within the
WIC program.
To achieve the
first goal, NSWP interviewed
approximately 3,000 WIC participants at
178 WIC service sites throughout the
country. These interviews collected
information about household composition,
family income, nutrition and health
risks, participation in other food
assistance programs, food security,
health insurance coverage, and the
family’s history of WIC enrollment.
Estimates of
the WIC case error rate are based on a
second, follow-up survey conducted in
the homes of approximately 900 WIC
participants. This second survey
collected detailed information about
family income and sought documentation
of family income for verification.
Study
Methods
The NSWP was
designed to provide information on the
characteristics of a nationally
representative sample of WIC
participants in the contiguous United
States, certified for WIC during spring
1998. The sample is based on a
multi-stage sample design, with 50
geographic primary sampling units (PSUs)
selected at the first stage, 79 local
WIC agencies selected at the second
stage, and 178 WIC service sites
selected at the third stage. WIC
participants were randomly sampled for
the study at the 178 WIC service sites
as they appeared for WIC certification.
The NSWP
consists of three surveys of WIC
participants and a survey of the local
WIC agencies certifying those WIC
participants:
-
In-person
survey. In-person interviews
were completed with 3,114 WIC
participants at 178 WIC service
sites throughout the contiguous
United States. WIC participants were
randomly sampled at the time of
their WIC certification and most
interviews were conducted in WIC
clinics following certification.
This survey achieved a response rate
of 77 percent and provides most of
the information for the first goal
of the study¾ to describe the
demographic characteristics of WIC
participants and their families.
-
In-home
survey. Approximately one out of
every three persons selected for
in-person interviews was also
selected for a follow-up interview
in their home. The in-home survey
was designed to verify income
information through review of
household income documents. In-home
interviews were completed with 931
respondents. Data from this survey
were used to estimate WIC
certification error rates¾ the
second goal of the study.
-
Telephone
follow-up. Approximately
two-thirds of respondents to both
the in-person and in-home surveys
were chosen for telephone follow-up
interviews. The telephone follow-up
survey collected information about
employment status and participation
in adjunct programs four months into
the WIC certification period. This
survey was completed with 558
respondents.
-
Local
agency survey. The local agency
survey was conducted with the 79
agencies certifying WIC participants
selected for the in-person survey.
This mail survey collected
information about local WIC agency
organization and operations.
In addition to
these surveys, WIC clinic staff
completed nutritional risk checklists
for each WIC participant with a
completed in-person interview.
Findings
Key findings of
the study are summarized here in an
order corresponding to the structure of
the report. A summary of caseload
composition and growth is based on
administrative data, followed by key
findings from the NSWP surveys for the
following topics:
Participant
Characteristics
-
Characteristics
of WIC women and mothers of WIC
infants and children
-
Characteristics
of the WIC economic unit
-
Income of
WIC participants
-
Food
assistance, food spending, and food
security
-
Nutritional
risk factors
-
Incidence
and duration of breastfeeding
-
Health
insurance coverage
-
Factors
affecting enrollment and continued
participation
WIC
Income-Eligibility Determination and
Errors in Income Certification
NSWP findings
should be interpreted with the knowledge
that a substantial number of WIC
participants had prior WIC
participation. Determining WIC's
potential influence on patterns of
participant characteristics is outside
the scope of the NSWP report.
The NSWP sample
is a nationally representative sample of
WIC participants in spring 1998,
interviewed at the time of WIC
certification. Most WIC participants are
certified for periods of 6 months;
States may certify infants for up to one
year and pregnant women for the duration
of their pregnancy. Administrative data
for spring 1998 show that 88 percent of
WIC infants were certified for WIC
within three months of birth; however,
only 79 percent of WIC infants in the
NSWP sample were certified within three
months of birth. The characteristics of
infants described in this report should
be viewed in this context.
Participant
Characteristics
WIC
Caseload Composition and Growth, 1988 to
1998
The NSWP
provides the first detailed picture of
WIC participant characteristics and
family circumstances since 1988. Over
the ten years from 1988 to 1998, the WIC
program more than doubled in size.
Average monthly WIC enrollment grew from
about 3.4 million in 1988 to 8.0 million
in 1998; over the same period annual WIC
food expenditures grew from about $1.4
billion to $2.8 billion.
Along with
caseload growth, there were substantial
changes in the composition of the WIC
caseload, as documented throughout the
period by WIC administrative data. A
disproportionate amount of WIC caseload
growth occurred in the Western states,
which accounted for 13 percent of total
WIC participants in 1988, and 24 percent
of WIC participants in 1998. This
regional shift is reflected in the
racial/ethnic distribution of WIC
participants, with Hispanics becoming a
larger proportion of the caseload
(Hispanics were 21 percent of the
caseload in 1988 and 32 percent in
1998).
From 1988 to
1998, pregnant women and infants
decreased slightly as a percent of all
WIC participants; breastfeeding women
more than doubled; and children rose as
a percentage of all WIC participants,
from 47 percent in 1988 to 51 percent in
1998.
Characteristics
of WIC Participants
The strength of
the NSWP, in contrast to data available
from WIC administrative files, is the
detailed picture it provides of WIC
participants and their families. This
report describes the characteristics of
WIC families in a consistent manner
regardless of whether the sampled WIC
participant was a woman, infant, or
child. In particular, the report
describes the characteristics of the
mothers and mothers-to-be who come to
the WIC program¾ that is, the WIC women
(pregnant, breastfeeding, or postpartum)
and mothers of WIC infants and children.
Most women
enrolled in WIC are in the prime
childbearing years, ages 18 to 34. In
1998, less than 10 percent of women in
WIC were under age 18 years, and only 7
percent were over age 35. Mothers of WIC
infants and children were somewhat
older, with less than 5 percent under
age 18 and about 16 percent over age 35.
Only 44 percent of women enrolled in WIC
were married, whereas 51 percent of
mothers of WIC infants and children were
married.
The majority of
WIC women and mothers have completed 12
years of education, but approximately 30
percent are beyond high school age and
have not completed high school.
Approximately 13 percent of WIC women
are enrolled in college full-time or
part-time at the time they enroll in
WIC; and 15 percent of mothers of
infants and children are enrolled in
college full-time or part-time.
Approximately
one-quarter of WIC women are employed at
the time that they apply to the WIC
program, and about 28 percent of WIC
mothers are employed. The employment
rate is highest among WIC pregnant
women, with 32 percent employed.
For both WIC
women and WIC mothers, more than half of
those not employed were employed in the
past year. The most common reason for
not working is "keeping house"
(this reason was given by 44 percent of
pregnant women who were not working and
over 60 percent of breastfeeding women,
postpartum women, and mothers of infants
and children who were not working).
Characteristics
of the WIC Economic Unit
The average
size of the WIC family or economic unit
is 4.0 persons. Most WIC participants
reside in single-family households, but
15 percent reside with extended family
in multi-family households.
The majority of
WIC participants (58 percent) have at
least one other family member also
participating in WIC. Evidence shows
that WIC provides continuity of care for
participants and their families.
Nearly 80
percent of mothers of WIC infants and
children participated in WIC when
pregnant with their children. When
pregnant women participate in WIC while
pregnant, both mother and child benefit;
additionally, prenatal WIC enrollment is
associated with earlier WIC enrollment
for infants. Enrollment of infants
within the first month of life is twice
as likely to occur when the mother
participated in WIC while pregnant.
Slightly less
than half (45 percent) of WIC infants
and children have siblings who are also
age-eligible for WIC. Most age-eligible
siblings also participate in WIC. The
likelihood of a sibling’s
participation, however, declines with
the sibling’s age: 94 percent of
siblings under 1 year old participate in
WIC, compared to 70 percent of siblings
who are 4 years old.
Income
of the WIC Economic Unit
The income
cutoff for WIC eligibility is 185
percent of the federal poverty level.
Nearly two-thirds of WIC participants
reside in families with income below the
poverty level and 23 percent have income
between 100 and 150 percent of the
poverty level (Figure 8). Six percent of
WIC participants have income above 185
percent of poverty; some of these
participants qualify for WIC on the
basis of established eligibility for
Medicaid, whereas others were certified
in error, as is discussed further in a
later section.
Although WIC
families are low-income, nearly
three-fourths of all WIC participants
reside in families with wage earners. In
addition to wages, the most common
sources of income for WIC families are
TANF (received by 15 percent of
families) and alimony or child support
(received by 11 percent). Income from
unemployment insurance, social security,
Supplemental Security Income (SSI), or
other welfare programs is received by
fewer than 6 percent of WIC families.
On average, WIC
families with wage income receive about
$1,400 per month in wage income. For
other income sources, the average
amounts received by those with income
are: TANF ($386), alimony ($289), Social
Security ($635), other welfare ($385),
and SSI ($529). Due to the low rates of
receipt of non-wage income, the average
receipt of non-wage income is less than
$200 per month when measured across all
WIC families.
Food
Assistance, Food Spending, and Food
Security
The NSWP found
that nearly one-half (47 percent) of
families with WIC participants received
some other source of food assistance at
the time that they enrolled in WIC. USDA
programs were the most common source of
assistance, with 33 percent of families
receiving food stamps, 27 percent
participating in the National School
Lunch Program, and 21 percent
participating in the School Breakfast
Program. Local food pantries were a
source of food assistance for fewer than
5 percent of WIC families.
On average, WIC
families spend 25 dollars per person on
food each week, with the great majority
(85 percent) of food spending for food
at home. Based on their experiences in
the 12 months prior to WIC
certification, slightly less than
one-fourth of WIC families lack food
security. Food security is a new
composite measure based on responses to
18 survey questions developed by USDA.
Fifteen percent of WIC participants are
"food insecure without
hunger," 7 percent are "food
insecure with hunger, moderate" and
about 2 percent are "food insecure
with hunger, severe".
Nutritional
Risk Factors
Applicants to
the WIC program must demonstrate
nutritional risk, defined by detrimental
or abnormal nutritional conditions,
nutritionally related medical
conditions, dietary deficiencies that
impair or endanger health, or conditions
that predispose persons to inadequate
nutritional patterns or nutritionally
related medical conditions. One of the
goals of NSWP was to collect comparable
data on the incidence of nutrition risks
for all sampled persons.
NSWP found that
the majority of WIC participants have
more than one nutrition risk at the time
they enroll in the program. The number
of nutrition risks varies substantially,
however, by participant category. Only
15 percent of all women have a single
risk, whereas 42 percent have four or
more risks. In contrast, 44 percent of
infants and children have a single risk,
and 13 percent have four or more risks.
By far, the
most prevalent nutrition risk among all
WIC enrollees is the failure to meet
dietary guidelines. More than two-thirds
of all women and children who enroll in
WIC are at dietary risk. Other common
risks for women are overweight (43
percent) and risk of anemia (30
percent). The risks most common among
children, other than failure to meet
dietary guidelines, are risk of anemia
(24 percent), overweight (17 percent),
and short stature (14 percent). Many
infants do not exhibit a specific
nutrition risk but are enrolled in WIC
on the basis of their mother’s current
enrollment and documented risk; 42
percent of all infants have no other
risk.
Incidence
and Duration of Breastfeeding
NSWP examined
the breastfeeding experience of WIC
participants and their siblings.
One-half of WIC children and 56 percent
of WIC infants had been breastfed for at
least some period of time. Among WIC
children who were breastfed, the median
duration of breastfeeding was about 4
months and 85 percent were breastfed at
least one month. The median duration of
breastfeeding among infants was not
determined because 60 percent of infants
who were breastfed were still
breastfeeding at the time of the NSWP
interview.
NSWP found that
the decision to breastfeed carries over
multiple children in a family. Among WIC
infants with siblings, 78 percent of
breastfed infants had siblings who were
breastfed, whereas only 17 percent of
non-breastfed infants had siblings who
were breastfed. Similarly, among WIC
children with siblings, 86 percent of
breastfed children had siblings who were
breastfed, whereas only 18 percent of
non-breastfed children had siblings who
were breastfed.
Health
Insurance Coverage
WIC is not a
health care provider, but to ensure that
WIC participants receive health care,
WIC provides screening and referrals to
other health, welfare and social service
agencies. NSWP found that 83 percent of
WIC enrollees had health insurance at
the time that they applied to WIC. Most
WIC enrollees receive health insurance
from the government’s Medicaid program
(58 percent); about one-fourth have
employer-provided insurance.
Because
Medicaid eligibility varies across
states, all WIC enrollees are not
eligible for Medicaid. At the time NSWP
was fielded, Medicaid income-eligibility
was at or above the WIC income limit in
29 of the 50 states.5 NSWP found that
even in states where all WIC
participants are eligible for Medicaid,
14 percent of WIC participants have no
health insurance.
The potential
impact of WIC referrals on health
insurance coverage can be seen in the
different rates of health insurance for
NSWP respondents enrolling in WIC for
the first time, compared to those
recertifying in WIC. In states where all
WIC participants are Medicaid-eligible,
prior WIC experience is associated with
a statistically significant
ten-percentage point increase in the
Medicaid enrollment rate; 57 percent of
first-time WIC participants were
enrolled in Medicaid, compared to 67
percent of WIC re-enrollees.
Factors
Affecting Enrollment and Continued
Participation
NSWP included a
"customer satisfaction" module
to ask respondents how they learned
about the WIC program and whether they
perceived barriers to WIC participation.
Respondents with prior WIC experience
were also asked about their satisfaction
with WIC food benefits, their rating of
the value of WIC services, whether they
ever missed WIC appointments, and their
experience shopping for WIC foods.
Most WIC
enrollees learn about WIC from friends,
family members, and doctors (each was
cited by about one-third of
respondents). Relatively few WIC
participants cited program
advertisements as a source of
information referring them to the WIC
program.
Few NSWP
respondents perceived "big
problems" or barriers to WIC
participation. Respondents were asked
about several categories of potential
problems. Only "transportation to
the clinic" was perceived as a big
problem by more than 5 percent of
respondents. Between 10 and 15 percent
of respondents reported "somewhat
of a problem" with factors
affecting access to WIC clinics, but
overall, the majority of respondents did
not perceive barriers to WIC
participation.
NSWP
respondents who had prior WIC experience
were asked about satisfaction with WIC
foods. Except for breakfast cereals,
more than 80 percent reported being
"very satisfied" with brands,
and less than 15 percent reported they
were only "fairly satisfied."
Breakfast cereals received the greatest
dissatisfaction response, with 10
percent of respondents "not
satisfied" with brands of cereals,
and 28 percent only "fairly
satisfied."
The
distribution of satisfaction with food
quantities was consistent across all
food categories. More than 80 percent of
respondents were "very
satisfied" with quantities of food,
including breakfast cereal. These high
levels of satisfaction with brands and
quantities of food correlate well with
respondents’ answers to questions of
whether they usually purchased all food
items listed on the food voucher. Nearly
93 percent of respondents said they
usually purchased all items. No single
WIC food category was identified as
being particularly prone to being not
purchased. With respect to prior
use of food vouchers at the store, 83.9
percent of respondents said it was
"easy" to use the vouchers,
14.2 percent said "sometimes
confusing," and 1.9 percent said
shopping with vouchers was "often
confusing."
The WIC program
may yield many intangible benefits for
participants in addition to the tangible
benefits of supplemental foods,
nutrition education, and referrals to
other health and social service
agencies. NSWP asked those respondents
with prior WIC experience to rate the
value of potential WIC benefits on a
scale of 0 to 5. Of the 12 potential
benefits presented to respondents, only
2 received an average rating below 4:
"time to talk with other
mothers" and "taught me about
breastfeeding." The highest rated
benefits are "vouchers for foods I
know are nutritious" (4.7),
"money saved on grocery bills"
(4.5), "nutrition
information"(4.4), and
"checking blood, height, and
weight" (4.4).
In an effort to
operate efficiently, most WIC service
sites schedule appointments with
participants for measurement of health
and nutrition status, nutrition
education, and voucher pickup. Nearly
one-half (45.6 percent) of prior WIC
participants said they had missed one or
more appointments at the WIC clinic,
although 19.3 percent said that they had
missed only one appointment. The most
common reasons given for missing an
appointment were "forgot to
go" (42.5 percent) and
"trouble finding
transportation" (29.9 percent).
WIC
Income-Eligibility Determination and
Errors in Income Certification
The NSWP
provided data for estimating the
national case error rate in WIC
certification. Incidence of errors in
income eligibility were determined by
collecting information about
participants’ family income and
comparing income to WIC
income-eligibility guidelines. The
report reviews WIC income-eligibility
guidelines for the 26 states and 79
local WIC agencies represented in the
NSWP sample, and presents estimates of
certification error.
WIC
Income Eligibility Guidelines
In 1988, the
WIC Income Verification Study reviewed
policies and procedures for WIC income
eligibility determination in 25 states.
That study found policies and procedures
for determining WIC countable income
showed near complete agreement across
states, but policies and procedures for
determining an applicant’s economic
unit (family size) indicated significant
state-to-state variation, sometimes due
to contradictory guidelines.In 1998, the
NSWP found that policies for determining
WIC countable income remained nearly
unchanged since 1988, still showing near
complete agreement across states.
Policies for determining an
applicant’s economic unit (family
size) again showed state-to-state
variation. In contrast to 1988, however,
most of the variation across states
stems from rules regarding households
with separate economic units and
applicants who are minors, and remaining
variation is due to differences in the
comprehensiveness of guidelines and not
from contradictory guidelines.
In 1998, state
WIC agency policies did not reveal
contrary guidelines, as they had in
1988. Most of the uniformity in
guidelines that developed during the
ten-year period between studies appears
to be due to FNS instructions and
written guidelines, which are evident in
state WIC manuals.
Estimates
of WIC Income Certification Error for
the Contiguous United States
The WIC case
error rate is the percentage of
enrollees certified to receive, but not
eligible for, WIC benefits; the dollar
error is the amount of total WIC food
funds spent on ineligible participants.
Estimates of certification error are
based on in-home interviews with a
national sample of WIC participants in
the contiguous United States in spring
1998. In FY98, the contiguous United
States accounted for 96 percent of WIC
participants and 95 percent of federal
WIC food expenditures.
NSWP in-home
interviews were designed to verify
income information through review of
income documents, when available. This
survey preceded implementation of
provisions requiring WIC participants to
document income at WIC certification as
provided in the William F. Goodling
Child Nutrition Reauthorization Act of
1998.
Analysis of WIC
certification case error yielded an
estimate of the error rate for the
contiguous United States of 4.5 percent.
This estimate is associated with a 95
percent confidence interval. The
confidence interval indicates that we
are 95 percent confident that the
national WIC income-eligibility error
rate falls between 2.8 and 6.2 percent,
with the most likely value at 4.5
percent.
The estimate of
the case error rate yields a
corresponding estimate of annual dollar
error for the contiguous U.S. of $120
million, out of a total of $2.6 billion
in WIC food benefits disbursed in FY98.
The 95 percent confidence interval
extends from $68.9 to $171.9 million
dollars, or from 2.3 to 5.7 percent of
annual WIC food costs.
NSWP findings
show that most applicants certified for
WIC are correctly determined to be
income-eligible. For those found
ineligible, it is not possible to make
statements about sources of error
because the sample size of ineligible
participants is not large enough to
yield statistical precision.
An important
finding of this study is that the WIC
certification error rate estimate for
FY98 is not statistically different from
the error rate estimate for FY88. During
this ten-year period the WIC program
experienced enormous growth. For FY88 -
the last time that WIC certification
error was analyzed - findings revealed a
case error rate of 5.7 percent and
dollar error of $84 million out of total
WIC food costs of $1.5 billion. For
FY98, we estimate a case error rate of
4.5 percent for the contiguous United
States and dollar error of $120 million
out of total WIC food costs of $2.6
billion. In addition, this study
found a statistically significant
relationship between the case error rate
and the income documentation policy of
WIC agencies. The error rate among cases
enrolled at agencies requiring income
documentation was 2.9%, compared to 6.4%
for those enrolled at agencies that did
not require income documentation. The
provisions of the William F. Goodling
Child Nutrition Reauthorization Act of
1998, requiring income documentation at
all WIC agencies, became effective in
2000.
October
2001
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