Making WIC Work in Multicultural Communities: Best Practices in ...

Making WIC Work for Multicultural Communities Best Practices in Outreach and Nutrition Education

FOOD RESEARCH AND ACTION CENTER FRAC 1875 Connecticut Avenue, NW Suite 540 Washington, DC 20009 (202) 986-2200 www.frac.org

About FRAC The Food Research and Action Center (FRAC) is the leading national organization working for more effective public and private policies to eradicate domestic hunger and undernutrition. For more information about FRAC, or to sign up for FRAC’s Weekly News Digest, visit www.frac.org. For information about the Special Supplemental Nutrition Program for Women, Infants and Children, go to www.frac.org/WIC/index.htm.

Acknowledgements This guide was prepared by Madina Agenor, Kate Pettitt Callahan and Geraldine Henchy. The Food Research and Action Center gratefully acknowledges support of the A.L. Mailman Foundation and the General Mills Foundation. FRAC also appreciates the assistance of the WIC community in preparing this guide: Kristen Sasseen, Washington Department of Health, Nenebah Jalloh, Mary’s Center for Maternal and Child Health, Jayasri Janakiram, Children National Medical Center, Sabrina Lewis, District of Columbia Department of Health, WIC Agency, Anna Kanianthra, Fairfax County Health Department, Betsy Clark, Minnesota Department of Health, Monique Stovall, California Department of Public Health, WIC Program, Rachel Colchamiro, Massachusetts Department of Public Health, Nutrition Division, Karan DiMartino, Massachusetts Department of Public Health, Nutrition Division, Judith Anderson, Michigan Department of Community Health, Ann Barone, Rhode Island Department of Health, Evalyn Carbrey, District of Columbia Department of Health, WIC Agency and the National Association of WIC Directors’ Cecelia Richardson. The assistance of United States Department of Agriculture, Food and Nutrition Service experts, Debra Whitford and Patty Davis, has been invaluable. Megan Elsener’s work on the cultural competency components summary is also appreciated. 2009

Making WIC Work for Multicultural Communities Best Practices in Outreach and Nutrition Education Table of Contents Introduction ...............................................................................................................................1 Best Practices in Outreach to Families of Diverse Cultures ......................................................3 District of Columbia WIC....................................................................................................... 4 Mary’s Center for Maternal and Child Care Outreach .................................................... 4 Children’s National Medical Center ............................................................................. 6 Families Growing Healthy with WIC (California) ...................................................................... 7 Navajo Nation Outreach...................................................................................................... 11 Reaching Out to Immigrant Families (Minnesota) .................................................................. 13 Responding to Demographic Changes (Fairfax County, Virginia) ............................................. 14 Social Marketing Campaign (Massachusetts) ......................................................................... 16 Washington WIC ................................................................................................................ 19 Outreach Project .................................................................................................... 19 African American Outreach Project ........................................................................... 21 Best Practices Nutrition Education for Families of Diverse Cultures ......................................24 California Fit WIC ............................................................................................................... 25 Incorporating Traditional Foods and Recipes into Nutrition Education (Navajo Nation).............. 28 Motivational Interviewing (District of Columbia) .................................................................... 30 Texas WIC ...................................................................................................................................... 33 African American Breastfeeding Initiative.................................................................. 33 Nutrition Education Partnerships .............................................................................. 35 From the Food Guide Pyramid to Cooking Practices in Your Kitchen ............................ 36 Veggin’ Out (Rhode Island) ................................................................................................. 37 Weigh of Life…Taking Action Together (Massachusetts)......................................................... 39 Wichealth.org (Michigan) .................................................................................................... 42 National WIC Survey ................................................................................................................45 National WIC Survey .......................................................................................................... 46 Outreach ........................................................................................................................... 46 Nutrition Education............................................................................................................. 47 Resources .................................................................................................................................49 Outreach ........................................................................................................................... 50 Nutrition Education............................................................................................................. 50 WIC ................................................................................................................................. 51 USDA WIC Nutrition Services Standards: Cultural Competency Components ............................ 52 USDA WIC Value Enhanced Nutrition Assessment: Cultural Competency Components .............. 53

Introduction

Introduction This guide highlights successful outreach strategies and nutrition education methods for making WIC work in multicultural communities. These include effective best practices for targeting hard-to-reach communities, addressing language barriers and emphasizing quality services and participant access. In addition, FRAC’s national WIC survey results provide an overview of WIC outreach and nutrition education efforts to WIC participants of all cultural backgrounds. The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) is a very important source of nutritious foods and nutrition education for many pregnant women, new mothers, infants and children up to age five in multicultural communities. The program provides a monthly package of WIC checks that can be used in the grocery store to buy specific healthy foods. WIC’s new food package, which expands cultural food options by offering fruits and vegetables, whole grains, and the option of soymilk and tofu, is an important marketing and nutrition education tool. WIC is a federally funded public health and nutrition program administered by the United States Department of Agriculture, Food and Nutrition Service through WIC State Agencies and Indian Tribal Organizations (ITOs). At the local level, services are provided by local agencies and clinics. In 2009, over 9 million women, infants, and children were enrolled in the WIC program. While many potential participants in multicultural communities are enrolled in WIC, others face significant barriers to accessing and fully utilizing WIC services. The guide can be used as a tool and resource for developing innovative outreach and nutrition education efforts focused on families from these communities. Outreach Targeted outreach is essential to increasing access to WIC services in underserved diverse communities. State, local, and ITO agencies throughout the United States have found that comprehensive multicultural and multilingual outreach and social marketing campaigns increase participation among these underserved populations. This guide focuses on the following nine successful outreach campaigns: • • • • • • •

District of Columbia WIC Children’s National Medical Center Outreach Mary’s Center for Maternal and Child Care Outreach Families Growing Healthy with WIC (California) Navajo Nation Outreach Reaching Out to Immigrant Families (Minnesota) Responding to Demographic Changes (Fairfax County Virginia) Social Marketing Campaign (Massachusetts) Washington WIC Outreach Project African American Outreach Project

At the state level, some of the most successful outreach strategies for reaching diverse underserved communities include: producing outreach materials in a range of languages and for various cultural/ethnic groups; collaborating with other statewide agencies and organizations serving WIC eligible families; working with the media; branding WIC to increase recognition; direct mailings to potential participants; working with employers; working with WIC vendors; establishing an automated WIC hotline; promoting income eligibility guidelines; and collaborating with health, foster, and child care providers. At the local level, successful outreach strategies include: attending conferences and local community events; distributing outreach materials to local community groups and organizations; conducting door-todoor outreach; and staffing a mobile unit.

Making WIC Work for Multicultural Communities: Best Practices Outreach and Nutrition Education

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Nutrition Education WIC has undergone a process of “Revitalizing Quality Nutrition Services”. Central to the success of this initiative are USDA’s guidelines for Value Enhanced Nutrition Assessment and Nutrition Services Standards which focus on a participant-centered approach to nutrition education including cultural competency. This guide provides case studies highlighting best practices integrating this approach to providing quality nutrition services. These model programs take into account the WIC participants’ cultural preferences, eating patterns and traditions consistent with the cultural competency requirements. WIC nutritionists integrate an understanding of how socio-cultural issues (race, ethnicity, religion, group affiliation, socioeconomic status, and world view) affect nutrition and nutrition-related health problems. The resource section of this guide contains a summary of the guidelines for Value Enhanced Nutrition Assessment and Nutrition Services Standards related to cultural competency. Obesity is an increasingly serious and widespread health problem in the United States, and, very significantly, is becoming increasingly common among young children. The Centers for Disease Control reported that in 2008, 14.6 percent of American children between two and five years old were obese, which is almost triple the rate in 1971. In light of the obesity epidemic in the United States, WIC has expanded nutrition education to promote physical activity and good exercise habits. It is important that these initiatives address the needs of families from diverse cultural and ethnic backgrounds. Indeed, according to the Food and Nutrition Service, Latino and Native American children have the highest overweight prevalence (16.4% and 18.6% respectively) compared to all other WIC children. This guide highlights seven State and ITO agencies whose nutrition education has successfully addressed the needs of multicultural communities: • • • • • • •

California Fit WIC Motivational Interviewing (District of Columbia) Weigh of Life…Taking Action Together (Massachusetts) Wichealth.org (Michigan) Incorporating Traditional Foods and Recipes into Nutrition Education (Navajo Nation) Veggin’ Out (Rhode Island) Texas WIC African American Breastfeeding Initiative From the Food Guide Pyramid to Cooking Practices in Your Kitchen Nutrition Education Partnerships

Effective strategies included producing multilingual flyers, DVD’s, and shopping guides, using multicultural images in their outreach and nutrition education materials, developing new logos and taglines to increase recognition, working with WIC vendors and collaborating with community partners. Many states have utilized their most successful multicultural outreach and nutrition education strategies to market the new healthier WIC food package to diverse families. A separate FRAC publication, Time for a Change, includes additional information on these efforts. WIC Nutrition Services funding is essential to the successful implementation of such innovative outreach and nutrition education initiatives. Other sources of funding include WIC Special Project Grants and Operational Adjustment Grants from the Food and Nutrition Service regional offices. National WIC Survey Findings from the FRAC’s WIC Directors’ Survey provide important insight into ongoing efforts to increase access to services by conducting outreach, and providing nutrition education and referrals to WIC participants of all cultural backgrounds.

Making WIC Work for Multicultural Communities: Best Practices Outreach and Nutrition Education

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Best Practices in Outreach to Families of Diverse Cultural Backgrounds

Making WIC Work for Multicultural Communities: Best Practices in Outreach and Nutrition Education

District of Columbia WIC The District of Columbia WIC State Agency has a comprehensive multicultural and multilingual outreach campaign that targets a range of populations in the District, including the African American, Latino, White, Ethiopian, West African, Chinese, and Vietnamese communities. In partnership with Houston Association, Inc., DC WIC developed outreach materials in a number of languages as part of their WIC: Working in Communities campaign. The materials developed included: • flyers in English, French, Spanish, Mandarin, Amharic, and Vietnamese; • posters in English, Spanish, and Vietnamese; • brochures in both English and Spanish; and • a postcard and factsheet in English. All of these materials are available on the WIC Works Sharing Center website. Of the 22 WIC clinics in DC, two are particularly successful at reaching out to families of diverse cultural and linguistic backgrounds: Mary’s Center for Maternal and Child Care and Children’s National Medical Center. Agency Name Mary’s Center for Maternal and Child Care

“We basically go anywhere a pregnant woman, mom, or dad with young children may be.” -Anne Spaulding

Project Description

Door to Door Outreach

At Mary’s Center, 20 percent of the staff are fluent in Chinese and 30 percent are fluent in Spanish. In addition to State outreach initiatives (attending health fairs and staffing the DC WIC mobile unit) Mary’s Center increases awareness of WIC by conducting door to door outreach in the community. Clinic staff distribute the promotional flyers and brochures provided by the State Agency based on language needs. While all of the staff is involved in outreach, if the goal is to target a specific group of people (e.g. Latinos), staff members who speak that language (e.g. Spanish) will conduct the outreach.

The Mama and Baby Bus

The clinic also relies on the Mama and Baby Bus, a mobile unit that does outreach for all Mary’s Centers programs, to provide eligible families with information about WIC. Outreach through the Mama and Baby Bus is done in English, Spanish, and Vietnamese.

Outreach in the Community

Mary’s Center conducts outreach for WIC in churches, schools, community centers, day care centers, grocery stores, laundromats, and all other sites where women, infants, and children are likely to be found. In addition to disseminating information about the program, the WIC staff


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screens potential participants for eligibility and enrolls those who meet the program guidelines. When staff members are on the Mama and Baby Bus, they are able to enroll families on the spot; if they are conducting outreach on foot, they take eligible families back to the clinic or schedule an appointment. Resources Mary’s Center’s WIC outreach efforts are funded through Nutrition Services funds from the United States Department of Agriculture, Food and Nutrition Service. Languages Used English, Spanish, French, and Mandarin Populations Served Latino, Black/African American, and Chinese Website www.maryscenter.org

Contact Information Nenebah Jalloh Director of WIC Mary’s Center for Maternal and Child Health 2333 Ontario Rd., NW Washington, DC 20009 (T) 202-420-7156 (F) 202-420-7156 [email protected] Sabrina Lewis Community Health Administration District of Columbia Department of Health WIC State Agency 2100 MLK, Jr. Avenue, SE, Suite 409 Washington, DC 20020 (T) 202-645-0505 (F) 202-645-0516 [email protected]


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Agency Name Children’s National Medical Center Project Description The WIC program at “Word of mouth is Children’s has found that essential to outreach.” one of the best ways to reach eligible families is to - Jayasri Janakiram target other agencies and organizations serving low-income communities. These include the Medicaid program, free meals sites, free primary care clinics, and prenatal and pediatric care clinics for low-income families, among others. WIC staff distributes State Agency flyers and brochures; enrolls eligible families on site; provides in-services and workshops on WIC for the staff; and sends direct mailings with information about WIC. Children’s WIC also sits on a Community Board, which includes free health care clinics, child care, schools, and Head Start, among other groups serving WIC eligible families. In addition, Children’s conducts outreach at local health fairs (Expo Time, Wise to Humanize etc.), where WIC nutritionists and paraprofessionals staff a table and distribute State Agency flyers to potential participants. Yet another effective outreach strategy is intra-agency cross-referrals, one of the many benefits of being located in a hospital. The WIC clinic at Children’s orients medical students and residents, who in turn refer potential participants to WIC. The WIC program also frequently makes crossreferrals with other Children’s hospital programs, including the Generations Program (teen mother and child clinic), Child Health Centers, and the Family Help Desk. Resources The WIC clinic at Children’s National Medical Center funds its outreach efforts through Nutrition Services funds from the United States Department of Agriculture, Food and Nutrition Service. Languages Used English and Spanish Populations Served Black/African American, Latino, Chinese, and Vietnamese Website: www. cnmc.org

Contact Information Jayasri Janakiram WIC Coordinator Children’s National Medical Center 111 Michigan Ave., NW Washington, DC 20010 (T) 202-476-5594 (F) 202-476-4126 [email protected]

Wherever low-income families are being served, an opportunity for outreach exists. - Jayasri Janakiram


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Families Growing Healthy with WIC (California) The California WIC program has a comprehensive outreach strategy that reaches out to the Latino, White, African American, and Asian communities throughout the state. Latinos currently comprise the majority of WIC participants in California (78%). The State Agency is increasing its efforts to target underserved communities, specifically the African American, Caucasian, Chinese, Vietnamese, and Hmong populations. California’s outreach goal is to expand and enhance collaboration between the WIC program and other statewide agencies and organizations serving WIC eligible families in order to promote local WIC referrals. An Outreach Committee advises the California WIC program on state and local outreach efforts, including: • distributing outreach materials, • having an automated WIC hotline, • attending conferences and community events, • working with the media, and • branding the WIC program to increase recognition. Agency Name California Department of Health Services, WIC Supplemental Nutrition Branch Project Description

Outreach Committee

The state’s outreach committee consists of approximately ten local agency members representing WIC directors, nutritionists, and outreach coordinators. The group meets quarterly to advise the California WIC State Agency in designing statewide outreach materials and shaping outreach efforts. Their mission includes helping all local agencies reach WIC eligible persons, particularly the underserved, working poor, and hard to reach populations, as well as improve retention of current participants.

Outreach Materials

The California WIC program developed a wide range of outreach materials in a number of languages. Materials are available in English, Spanish, Chinese, Vietnamese, Russian, Hmong, Korean and Armenian. •

The State Agency produced outreach pamphlets, which provide potential participants with detailed information about WIC services, benefits, and income eligibility guidelines in English, Spanish, Chinese, and Vietnamese. California WIC is also planning to translate the pamphlet into both Russian and Hmong in an effort to reach more of the many cultural and linguistic communities in California. Each version of the pamphlet is targeted to a specific area based on language needs.

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The State Agency produced additional outreach and education materials in English, Spanish, Chinese, and Vietnamese, Russian, Hmong, Armenian, and Korean. These materials included information about WIC clients’ rights and responsibilities, breastfeeding, and formula feeding.

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The California WIC program also developed a one-page envelope stuffer intended to be sent to eligible families along with materials from other agencies, including electricity bills and MediCal (Medicaid) application forms. The stuffers are an Agency favorite and provide outreach information, as well as a simple nutrition education message

“The envelope stuffer is one of our most effective outreach tools. It’s quick, simple, and direct.” -Carol Chase


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on limiting juice consumption. One side is printed in English and the other in Spanish. •

Yet another California WIC outreach material is a half-page flyer providing information about WIC benefits, services, and income eligibility guidelines, as well as nutrition tips about healthy snacks.

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The WIC program also produced a limited number of English and Spanish WIC posters for organizations serving low-income families, as a well as materials for health care providers. The clinician outreach packet included a WIC fact sheet and referral guide, including a rolodex card with the State Agency’s number and website.

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The California WIC program also distributes incentive items during conference exhibits and health fairs.

1-888-WIC-WORKS

All outreach materials include the number for the California WIC automated phone line, 1888-WIC-WORKS, which is a critical component of the State Agency’s outreach campaign. The hotline provides callers with information about the nearest WIC clinic, WIC benefits, and access to other services (health care, schools etc.) in five languages: English, Spanish, Vietnamese, Hmong, and Chinese.

Outreach Strategy

The California WIC program reaches potential participants by collaborating with other social services agencies that serve WIC eligible families. For instance, the State Agency conducts outreach to MediCal (Medicaid) enrollees and provides outreach materials free of charge to child care providers, Head Start, food banks, and health care providers, among others. The State Agency also partners with social services agencies through efforts such as mailing outreach letters to local MediCal and Food Stamp Program directors. Another important outreach strategy is using geo-mapping software in order to identify underserved areas throughout the state. In addition, California WIC also attends state and local events and promotes WIC in the media: •

Attending Conferences and Other Community Events At the state level, California WIC attends large conferences where they can staff an exhibit about the WIC program. They specifically target conferences hosted by organizations that serve the WIC population, including the American Academy of Pediatrics, the California Department of Education, the American Academy of Nurse Practitioners, and the California School Nurses Association. Local agency staff members help with state conference exhibits and also attend local health fairs in their area. In an effort to improve outreach to African Americans, who are an underserved population in California, the State Agency attends conferences and events such as the National Association for the Advancement of Colored People (NAACP) Annual State Conference in Los Angeles and the Annual Black Expo in Sacramento.


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The California State Agency carefully targets the conferences and other community events they attend. When deciding what events to attend, they ask themselves: •

“Who is the sponsor?” “Where is the event being held?” “Who is the sponsor targeting?” “Is this a state or local event?” “Will WIC eligible families be attending the event?” “Will those who serve WIC eligible families be attending?” “What is the average attendance?” “Is this event the best use of our funds?” “How will this event further our outreach efforts?”

Working with the Media At the request of local agencies, the California WIC State Agency developed a media outreach kit. Working with the media can be too expensive for many state agencies, so California WIC encourages local agencies to advertise in their community by providing them with the resources they need.

“Some media opportunities exist at the local level that don’t exist at the state level.” - Monique Stovall

The local agency media kit includes camera ready advertising for billboard ads, print inserts, flyers, draft press releases, and a user guide on media advocacy strategy. Local agencies throughout California have worked with public television stations, local cable stations, and local radio stations to promote WIC in the media. The State Agency regularly runs print advertisements in statewide publications that target WIC eligible families, such as the Child Support Handbook for foster parents, and writes nutrition articles with an outreach message for health provider newsletters.

Branding WIC

The State Agency has branded WIC in order to raise awareness of the program throughout the state. The campaign’s major goal is to enroll all WIC eligible families who are not participating in the program by increasing their knowledge of WIC and dismantling any misconceptions about eligibility. For example, many families are unaware of the income eligibility guidelines and mistakenly believe they do not qualify. Since this is often a deterrent for working families, California WIC promotes income guidelines in its promotional materials. The State Agency also designed a new, more recognizable logo for the California WIC Program. The new logo was launched on October 1, 2006. The logo includes the tagline “Families growing healthy with WIC.” The new logo is used on all education materials, promotional items and WIC letterhead. In addition, all authorized WIC vendors are encouraged to display the WIC decal at their entrance to help families identify stores where WIC foods are available. The WIC branding campaign was informed by focus groups with WIC participants and local agency WIC staff.

“All WIC programs should consider doing informal focus groups to plan their outreach activities. They’re an inexpensive way to assess what participants’ value about WIC and what is keeping others from applying. California could provide other states with focus group questions.” -Carol Chase


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Project Evaluation The California WIC State Agency has conducted a number of informal process evaluations to determine how to better reach and improve WIC services for underserved populations, including focus groups with WIC participants and local agency staff. In addition, the state monitors requests for outreach resources to measure the success of California’s collaboration efforts with other state programs. These evaluations taught the California WIC program valuable lessons about effective outreach strategies. Lessons Learned Both the surveys and focus groups revealed that the most effective strategy for increasing awareness of the WIC program was word of mouth. The focus groups also showed that health care providers were crucial to informing eligible patients of WIC services and benefits. These findings also led the California WIC State Agency to conclude that major statewide paid TV advertising campaigns were not the most effective outreach strategy in California. Resources The California WIC program uses Nutrition Services funding from the United States Department of Agriculture, Food and Nutrition Service for all of its outreach efforts. Languages Used English, Spanish, Chinese, Vietnamese, Russian, Hmong, Armenian, and Korean Populations Served Latino, White, African American, Chinese, Vietnamese, Hmong, Korean, Russian, and Armenian State WIC Participation by Race/Ethnicity: 78 percent Latino, 8 percent White, 5.5 percent Black/African American, 5 percent Asian/Pacific Islander, and 0.87 percent American Indian/ Alaska Native Website www.wicworks.ca.gov Contact Information Monique Stovall Chief, Nutrition Education, Marketing and Outreach Section California Department of Public Health-WIC Program P.O. Box 997375 West Sacramento, CA 95899-7375 (T) 916 928-8604 [email protected]


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Navajo Nation Outreach All WIC clinics in the Navajo Nation in Arizona are required to draft a bi-annual outreach plan. Each plan is shaped by the specific needs of community members and varies based on locality. Outreach is the responsibility of all WIC staff members and everyone is involved in the process regardless of their role in the clinic. Outreach is conducted in English and Navajo. Some materials are also available in Spanish, which increases access to the program for Latino participants. Outreach efforts are conducted on a monthly basis, usually after a staff in-service or workshop when WIC clinics are closed. The Navajo Nation WIC program’s goal is to set high standards for outreach and to empower WIC clinic staff to reach them. Their outreach strategy involves attending community events and working with other agencies serving WIC eligible families in the Navajo Nation. Agency Name Navajo Division of Health, Navajo Nation WIC Program Project Description

Working in the Community

Each clinic’s outreach plan needs to be tailored to the needs of the community.” -Doris McGuire

Navajo Nation WIC attends as many local events as possible in order to increase awareness of the program in the community. For example, when appropriate, clinics attend tribal fairs, traditional ceremonies, and health fairs. WIC staff distributes flyers, which include information about WIC services and benefits, clinic locations, income eligibility guidelines, and the toll free number for the central office (1-800-307-4231). The Navajo Nation WIC program also prints ads in the reservation’s three biggest newspapers: the Navajo Times, the Gallup Independent, and the Farmington Daily Times. In order to reach families in rural areas, they produce monthly Public Service Announcements (PSAs) on the radio in both English and Navajo. Outreach in more isolated rural areas is only conducted in Navajo. The Navajo Nation WIC program also has some outreach materials in Spanish to distribute to the Latino population.

Working with Partners

A key component of the Navajo Nation’s outreach strategy is partnering with other groups and agencies on the reservation. For example, Navajo Nation WIC collaborates with area food banks and other food distribution sites, the Navajo Special Diabetes Project, and the local Breastfeeding Task Force. They also make referrals to Medicaid and the Food Stamp Program. In addition, they partner with dietitians at the Indian Health Service to provide the same messages on nutrition and physical activity and disseminate community resource guides in which WIC is listed to health care providers. The goal is to educate others working with low-income families about WIC so that they can refer them to the program.

“Strong partnerships are a key component of our successful outreach strategy.” -Adele King Making WIC Work for Multicultural Communities: Best Practices in Outreach and Nutrition Education

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Project Evaluation All WIC clinics on the reservation keep a record of their outreach activities. The records are evaluated by the state’s Quality Assurance Review (QAR) team. Every clinic nutritionist also conducts an in-house evaluation of outreach efforts for self-regulation. Resources The Navajo Nation WIC program uses Nutrition Services funding from the United States Department of Agriculture, Food and Nutrition Service to produce outreach materials and conduct outreach efforts. Languages Used Navajo, English, and Spanish Populations Served Navajo, Latino, and White Contact Information Adele King WIC Program Manager Navajo Division of Health-Navajo Nation WIC Program P.O. Box 1390 Window Rock, AZ 86515 (T) 928-871-6698 (F) 928-871-6255 [email protected]

“If it wasn’t for the WIC program, I wouldn’t have made it. You know with the milk and stuff how expensive it is these days. Thank goodness that you guys are here because it’s just me and my baby.” -WIC Participant


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Reaching Out to Immigrant Families Minnesota has become home to many immigrant groups from all over the world, including Hmong immigrants from Southeast Asia, Africans from Somalia and Ethiopia, Karen people from Burma, and many Spanishspeaking immigrants from Mexico and various other regions of Latin America. Minnesota WIC has developed outreach strategies to reach out to and better serve these populations. The State Agency has developed culturally appropriate outreach materials in four languages, hired multilingual and multicultural staff and has a clinic located in the Hmong American Center in St. Paul. Agency Name Minnesota Department of Health, WIC Program Project Description Minnesota WIC has developed and disseminated outreach flyers in English, Spanish, Hmong, and Somali. The outreach flyers, WIC’s food list brochure, and WIC’s direct mail postcards all feature pictures of culturally diverse women, infants, and children. WIC has just recently developed New WIC food package brochures in seven languages including English, Spanish, Hmong, Somali, Chinese, Russian, and Vietnamese. The brochure can also be translated into Arabic, Bosnian, Burmese, French, Hindi, Korean, Polish, and Urdu at the request of local agencies. In addition to the print materials the WIC state website has participant information pages in English, Spanish, and Somali. To enhance their ability to serve the state’s diverse population Minnesota WIC has also hired Hmong, Somali, Mexican, and Karen staff to ensure effective communication and cultural understanding amongst WIC staff and Minnesota’s immigrant populations. To further reach the Hmong immigrant population Minnesota WIC opened a clinic in the Hmong American Partnership (HAP) Center in St. Paul. In the early 1980s many Hmong fleeing Southeast Asia after America’s withdrawal after the Vietnam War immigrated to Ramsey County, Minnesota and there is now a large Hmong population in St. Paul. When WIC was searching for a larger space for their St. Paul Clinic they took the opportunity to partner with the Hmong American Partnership Center. The center had a large space available in their building that was perfect for WIC’s clinic. Having the clinic located in the HAP center has allowed Ramsey County WIC to successfully serve the Hmong population. Not only can HAP staff easily refer their clients to the WIC clinic but WIC staff can refer participants to the many services that HAP offers, including job counseling, English classes, job fairs, and teen youth groups. Ramsey County WIC considers their partnership with HAP a “win-win relationship.” Project Evaluation The primary way Minnesota evaluates their outreach efforts is by tracking participation. They track participation trends over time and participation by race and ethnicity.

Resources Minnesota’s WIC allocates a portion of their budget to outreach efforts. Languages Used English, Spanish, Hmong, and Somali Populations Served White, Black/African American, Latino, Southeast Asian, and East African Website: http://www.health.state.mn.us/divs/fh/wic

Contact Information Betsy Clark WIC Director Minnesota Department of Health P.O. Box 64975 St. Paul, MN 55164-0975 (T) 651-201-4403 [email protected]


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Responding to Demographic Changes The population of Fairfax Country has become increasingly diverse over the last several years. Fairfax County WIC has developed a comprehensive multicultural outreach campaign to respond to these demographic changes to ensure they are serving the diverse families that are now residing within the county. The campaign includes both external partnerships with area organizations and internal integration efforts with other county programs. The outreach efforts of Fairfax county staff contributed to a 5 percent growth in WIC participation from October 2008 to April 2009. Agency Name Fairfax County Health Department, WIC Program Project Description

External Outreach

Fairfax County WIC currently partners with 21 local organizations to reach potential WIC participants. These community partners included resources centers, schools, religious organizations, and other community programs. Some of the partnerships include: •

Bryant Adult Alternative High School: WIC partners with Bryant, an alternative school for pregnant teens, to educate students about the WIC program and work with school nurses to refer eligible students to WIC.

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Catholic Charities: Fairfax County WIC partners with Catholic Charities in Springfield to reach out

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Dar Al Hijrah Islamic Center: WIC staff will plan to hold clinics at the Islamic Center following

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Grace Ministries: WIC staff works with the Grace ministries of Herndon Methodist Church to reach

to the families with adopted children. Adopted children are eligible for Medicaid and therefore are automatically eligible for WIC services but adoptive families are often uncomfortable or unwilling to visit a WIC clinic. Fairfax County WIC requires that a child’s adoptive parents bring the child in for just his or her first visit for a nutrition assessment. After the initial visit a Catholic Charities social worker picks up the WIC food vouchers for the family of the adopted child. WIC staff also provides the social workers nutrition education that they then pass along to adoptive families.

Saturday services to disseminate information about the programs, screen potential participants for eligibility and enroll those who meet the program guidelines. This initiative will start in August 2009.

out to Hispanic families. On the first Saturday of every month Grace Ministries opens their doors to roughly 200 families in need, offering them food pantry bags, clothing, and other necessities. On each of these Saturdays WIC staff is present to educate families about WIC and schedule eligible families for an appointment at the local WIC clinic.


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Internal Outreach

WIC partners with other County programs to reach additional WIC participants. WIC staff educates providers about WIC benefits and eligibility guidelines to ensure they are able to appropriately refer potentials participants to WIC. Fairfax County WIC coordinates outreach efforts with the Department of Family Services Special Nutrition Assistance Program (formerly the Food Stamp program), dental clinics, the Public Health Nurses Fairfax Hospital Liaison, Medicaid workers, and the Health Department clinic staff. Project Evaluation Fairfax county WIC measures the effectiveness of their outreach efforts by tracking WIC enrollment. In April 2009, the Fairfax County WIC program assisted 18,513 participants, a 5 percent growth since October 2008. Lessons Learned Fairfax county WIC identified health care providers’ and potential participants’ lack of knowledge of the WIC benefits and eligibility guidelines as a barrier to participation. Fairfax County WIC outreach efforts have helped increase knowledge of the WIC program and helped reach out to underserved populations which Fairfax county WIC has learned is the key to serving potential WIC clients. Languages Used English, Spanish, Korean, Chinese, Vietnamese, and Russian Populations Served White, Black/African American, Latino, Chinese, East African, South East Asians, Indians, and Pakistanis Website http://www.fairfaxcounty.gov/hd/wic/ Contact Information Anna Kanianthra WIC Nutrition Coordinator Fairfax Country Health Department (T) 703-246-8657 (F) 520-871-6255 [email protected]


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Social Marketing Campaign The Massachusetts WIC program developed a comprehensive, statewide outreach campaign with the goal of increasing awareness of WIC among eligible families of all racial, ethnic, cultural, and linguistic backgrounds. Massachusetts’ outreach plan is based on the success of a three-year multicultural social marketing campaign launched in 2001. Their outreach efforts include: • partnering with employers to reach working families, • working with the media, • partnering with child care, health and foster care providers, • partnering with WIC vendors, • direct mail campaigns to potential participants, and • targeting local organizations and events. Agency Name Massachusetts Department of Public Health, WIC Nutrition Program Project Description

Social Marketing Campaign

The Massachusetts WIC program had a three-year statewide, multicultural social marketing campaign to increase enrollment and the retention of current WIC participants. In partnership with Policy Studies, Inc., the State Agency branded WIC as a “health and nutrition program for all types of families.” Based on focus groups with both current and potential participants, they designed a new WIC logo, changed the WIC tag line to “Good Food and a Whole Lot More,” and produced a wide variety of both written and audiovisual outreach materials. Many of the Massachusetts WIC outreach materials were “Focus groups are how developed in nine languages: Chinese, English, French, Khmer, Portuguese (Brazil), Portuguese (Portugal), Russian, Spanish, and you come up with the Vietnamese. All others are available in both English and Spanish. best ideas.” This allows the Massachusetts State Agency to reach a range of -Karan DiMartino populations throughout the state, including the Latino, Brazilian, Vietnamese, Cambodian, Portuguese, Russian, White, African American, East and West African, Chinese, and Haitian communities. The materials range from brochures, poster, flyers, toolkits, transit and TV advertisements, and radio spots to direct mail postcards. All of the written outreach materials include the number for the WIC phone line (1-800-WIC1007), which provides Massachusetts residents with information about the program. Target audiences for the social marketing campaign include employers (human resources offices), local WIC agencies, WIC vendors, health care providers, foster and child care providers, WIC participants, and eligible families not enrolled in the program. The materials developed are permanent components of the State Agency’s outreach efforts. They can be found on the WIC Works Sharing Center website.

Partnering with Employers to Reach Working Families

An essential outreach tool developed during the social marketing campaign was the human resources package. After identifying companies that hire low-income employees (e.g. hotels, restaurants), Massachusetts WIC conducted focus groups with employers in order to identify how the WIC program could work for them. The goal was to market WIC as an employee benefit and enlist employers to educate employees about WIC income eligibility guidelines since many working families mistakenly believe they are ineligible for the program.


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The State Agency sent information about WIC to human resources offices in over 40,000 companies throughout Massachusetts. The information packets included an “Information for Employers” folder; a “WIC is for Working Families” poster; a “WIC Fast Facts for Employers” factsheet; a letter to employers; a sample email for employees; and a general WIC brochure.

Working with the Media

During the social marketing campaign, Massachusetts WIC developed TV, radio, and transit advertisements. The TV and radio ads were designed to provide all listeners with nutrition information, while dismantling any stigma of WIC being a “welfare program”. They were produced in both English and Spanish. The radio spot features a variety of speakers who discuss child eating habits, breastfeeding, and WIC services, including health and social services referrals. The TV ad features happy children from diverse backgrounds eating healthy WIC foods. The State Agency also developed transit ads to put throughout the Massachusetts Bay Transportation Authority bus and train system. The Massachusetts WIC program’s media outreach strategy emphasized radio spots since they are significantly less expensive than TV ads and allow for more repetition. Since 2002, the State Agency has partnered with the radio station Magic 106.7 FM to conduct a weekly nutrition minute. The goal is to give listeners healthy eating tips and brand WIC as a nutrition program. Massachusetts WIC has also partnered with other local radio stations to conduct outreach at free summer concerts and events, give information about WIC on air, and post their hyperlink on the stations’ website.

Partnering with Health, Foster, and Child Care Providers

Massachusetts WIC developed a clinician brochure, which provides health care providers with information about WIC services and how to refer patients to the program. They also developed brochures for foster care and child care providers. These materials are available in English and Spanish and outline WIC benefits, eligibility requirements, and referral and enrollment procedures.

Partnering with Vendors

The vendor materials package provides vendors with information about the WIC program and highlights their role in WIC transactions. The package includes a picture guide of WIC-approved foods; factsheets for cashiers (available in English and Spanish) and bookkeepers; a brochure explaining WIC transactions; and a poster thanking cashiers for making WIC work for families.

Reaching Out to Eligible Families

In addition to the strategies outlined above, the Massachusetts WIC program reaches out to eligible families through direct mailings and community coordinators. In order to reach potential WIC participants, two postcards were developed and distributed via mail. The first was sent out to all residents enrolled in the MassHealth program (Medicaid). The second postcard was sent to all families earning under $40,000 per year with at least one child under the age of five. The WIC State Agency purchased this mailing list from a local company that sends value pack offers to low-income families in Massachusetts. At the local level, community coordinators are a crucial part of outreach to eligible families. A total of 36 coordinators (one per local agency) distribute posters, flyers, and brochures containing information about the WIC program to various sites throughout the state.


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Target sites include welfare offices, libraries, preschools, utility companies, doctor’s offices, pharmacies, local health fairs, and other community events. These coordinators have a limited budget and usually attend community events free of charge. Project Evaluation After the outreach materials were developed in partnership with Policy Studies, Inc., the Massachusetts WIC program conducted focus groups to evaluate their effectiveness. They found that more families were aware of WIC as a result of the social marketing campaign.

“You need to step outside the box and see what’s going on in the community.” -Karan DiMartino

Lessons Learned Some of the campaign’s challenges included tackling the misconception that WIC is a “welfare program” and reaching dads. In response to this last challenge, the Massachusetts State Agency created outreach materials specifically targeting fathers and used words like “families” instead of “moms” and “women” in all outreach materials.

Massachusetts WIC also learned that investing time and money in focus groups was essential to developing a successful outreach campaign. They found that focus groups were the only way to know what the community’s needs and wants were. They also learned that focus groups were crucial to determining which populations to target during an outreach campaign. Massachusetts WIC noted that in order to be most useful, focus groups should be conducted with both participants and eligible families not enrolled in the program. They recommend that State Agencies that cannot conduct focus groups before launching an outreach campaign conduct phone interviews instead. A creative and forward-thinking State Director with a “big picture” vision of WIC was also crucial to the success of the social marketing campaign in Massachusetts. Indeed, the Massachusetts WIC staff insisted that without Mary Kelligrew Kassler’s leadership, these outreach initiatives would not have been possible. Resources The Massachusetts State Agency receives 85 percent of its funding from the Federal government and 15 percent from the State in Supplemental WIC funds. Outreach initiatives are funded through Nutrition Services funding from the United States Department of Agriculture, Food and Nutrition Service. Languages Used Chinese, English, French, Khmer, Portuguese (Brazil), Portuguese (Portugal), Russian, Spanish, and Vietnamese Populations Served White, Latino, African American, Haitian, Chinese, West African and East African, Portuguese, Brazilian, Russian, Vietnamese, and Cambodian Websites www.nal.usda.gov/wicworks/Sharing_Center/statedev_soc_market_ma.htm Contact Information Karan DiMartino Marketing and Media Coordinator Nutrition Division-WIC Nutrition Program Massachusetts Department of Public Health (T) 617-624-6121 [email protected]


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Washington WIC The Washington State WIC agency has a comprehensive multicultural and multilingual outreach strategy designed to reach diverse families across the state. Through multilingual outreach materials and activities, the Nutrition Program Outreach Project has welcomed many new families to the Washington State WIC program. The WIC African American Outreach Project, focused on positive messages disseminated through media and other channels in the community, has been successful in increasing the participation of African American families. This work is done through a public/private partnership with WithinReach, a nonprofit organization working to improve maternal, child and family health in Washington State. Agency Name • Washington Department of Health, WIC Nutrition Program for Women, Infants and Children (WIC) Project Name Washington State WIC Nutrition Program Outreach Project Project Description Washington developed numerous culturally appropriate outreach materials and resources to increase eligible families’ access to WIC services. The project includes outreach materials in 11 languages, a statewide family health hotline with bi-lingual operators, an online WIC clinic search tool and an interactive website where families apply for state-sponsored health and nutrition services.

Outreach Materials

Messaging: Outreach materials are worded to overcome barriers and encourage people to apply. Most of the materials include the following information: • WIC income guidelines because many people do not realize they are eligible. • WIC services and the value of the WIC foods as an incentive for applying. • The message “It’s easy to apply. It just takes a phone call. WIC even takes care of the paperwork.” This is based on information from focus groups on what would encourage people to apply and overcome perceived barriers. • The statement “Getting WIC does not affect your immigration status.” so immigrants are not afraid to apply. • The address and phone numbers of local WIC clinics for the county. These are printed on the back of the flyers. • The toll free, statewide WithinReach Family Health Hotline number Materials: The Washington State WIC Nutrition Program and WithinReach developed and disseminated the following multilingual outreach materials: •

WIC outreach flyers in 11 languages including English, Spanish, Chinese, Somali, Amharic, Tigrinya, Vietnamese, Korean, Ukrainian, Russian, and Arabic.

•

A four-language outreach flyer in English, Spanish, Russian, and Vietnamese.

•

Counter cards in both English and Spanish that encourage WIC clients to tell their friends and families about the WIC program. Making WIC Work for Multicultural Communities: Best Practices in Outreach and Nutrition Education

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•

Including an 8-language Medicaid insert in mailings to all pregnant women and households with children under 5. The insert messages are in English, Spanish, Russian, Vietnamese, Somali, Chinese, Korean, and Cambodian. Income guidelines are not included because all Medicaid clients are income eligible for WIC.

•

New food package flyers in English, Arabic, Chinese, Korean, Russian, Somali, Spanish, Vietnamese that include a New Food Choices 2009 logo.

WIC outreach materials can be ordered from The Washington State WIC Nutrition Program and WithinReach.

On-line WIC Clinic Search Tool in English and Spanish

The search toll is maintained by WithinReach on their website. There is a link to this from the WIC website, the Basic Food Website, and the Parent Help 123 site. The search tool allows families find the address, phone number and hours of operation of a WIC clinic close to where they live. The tool includes a system for locating a WIC approved grocery store. The clinic search tool site gets over 45,000 hits per year.

Family Health Hot Line

Through a multi-program contract with the Washington State Department of Health, WithinReach operates a toll Family Health Hotline. This creates a one-stopshopping opportunity because all callers are screened and referred as needed to a number of programs including WIC, Medicaid, Basic Food, Immunizations, and Family Planning. All the participating programs benefit from each others’ outreach efforts since all callers get referred to an array of services. This is a very cost effective way to operate and fund a statewide toll free line.

Parenthelp123.org

Patenthelp123.org is an interactive website to help families find and apply for local services available to them including WIC. The website is available in English and Spanish. www.ParentHelp123.org includes a “benefit finder” that guides families as they enter specific information so the system can determine if they are eligible for free and low-cost health insurance and a number of food programs. The website also has a resource finder, a new search tool that allows families to search by zip code for services including low-cost medical clinics, immunizations, child care referral agencies and food assistance programs. The website has an easy online interview tool that can be used to complete the applications for programs for which families are eligible. Families can choose to print and send the applications in by mail or submit them online. Project Evaluation Washington WIC and WithinReach track the family health hotline calls by race and language and collect information about how callers learned about the hotline number. In 2006, Washington WIC conducted a call back survey of hotline callers to gather information about the usefulness of the hotline. They also tracked caller’s responses to the various outreach methods and materials and make changes based on this. Over 60 percent of callers to the toll free line report getting the WIC number from the phone book. Lessons Learned The “how learned” hotline information revealed that the two most effective ways to publicize the hotline number are in the phone book and through print materials. Provider referrals are also an important Making WIC Work for Multicultural Communities: Best Practices in Outreach and Nutrition Education

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source for callers. The on-line WIC clinic search tool in English and Spanish has been well received and gets over 45,000 hits per year. The number of hits continues to increase each quarter. The most effective way to reach non-English speaking clients was the eight language Medicaid insert. Medicaid is changing their system and will be using “debit type cards” instead of mailing out Medical coupons. WIC will be looking for other ways to reach this population in the future. All of the clients responding to the call back survey indicated that they found the hotline helpful and 99% of them were successful in enrolling in WIC. Washington WIC plans to repeat this survey in 2011. Resources WithinReach and all the partnering programs and organizations contribute funding to operate the Family Health Hotline. WIC also funds WithinReach to: • Conduct outreach activities publicizing the line. • Maintain up to date addresses etc. on the on-line WIC clinic search tool. • Support the development of the Spanish version of ParentHelp123. WithinReach obtained most of the funding by writing grant requests. Languages Used • Washington WIC Outreach Materials are available in these languages: English, Spanish, Chinese, Cambodian, Somali, Amharic, Tigrinya, Vietnamese, Korean, Ukrainian, Russian, and Arabic. • WIC tracks the languages that WIC clients read in their data system. They review this data regularly and create materials in new languages based on this information. • WithinReach and the local WIC agencies use a “language line contract” so they can meet the needs of callers in over 50 languages. Populations Served Native American, African American, Hispanic, and Asian Websites Washington State WIC Program: http://www.doh.wa.gov/cfh/WIC/default.htm Washington State WIC Clinic Search Tool: http://www.withinreachwa.org/wicsearch WithinReach – Essential Resources for Family Health: http://www.withinreachwa.org/ Parent Help 123: http://www.parenthelp123.org/ Project Name Washington State WIC African American Outreach Project Project Description

Key Informant Meeting

In February 2005, Washington WIC convened an African American key informant brainstorming session to explore barriers to African American participation in WIC, and to gather information on effective messages and outreach activities to reach eligible pregnant African American women and parents of African American children under age 5. The key informants included health and social service providers who work with African American families. Through active idea generation the attendees identified and prioritized recommendations for key messages and images: • Include images of healthy African American children of various ages and African American pregnant women Making WIC Work for Multicultural Communities: Best Practices in Outreach and Nutrition Education

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• • •

Tell them it is easy to access and then make sure it is. Develop and highlight “drop in days” or “new enrollment days.” Highlight the benefits of the program (i.e. saves money, provides healthy foods, and supplements their diets). Stress presence of ethnically diverse and bilingual providers.

The groups’ prioritized list of “best outreach methods” for African Americans included: • Putting materials in places where people visit: barber shops, beauty supply and grocery stores, churches, hair salons, clinics, schools, libraries, metro buses, and public markets. • Partnering with other groups for outreach: Basic Food outreach workers, food banks, meal sites, senior centers to reach grandparents who have taken in their grandchildren, and locations in ethnic neighborhoods. • Airing radio PSAs on stations popular with African American families • Putting ads in community newsletters such as: In Time Production, FACTS, and Color Magazine

Outreach to African Americans

Based on the findings above, the Washington WIC Nutrition Program partnered with WithinReach to develop materials and activities for an African American Outreach Project.

Outreach Material Revisions

WIC revised many of their English outreach materials to feature additional pictures of African American women, infants and children. They hired a photographer to take professional photographs for the materials. The revised materials included the WA WIC general outreach flyer, a “Tell your Friends” appointment folder insert, and the 8-language Medicaid Flyer.

New Outreach Materials

WIC and WithinReach also developed and disseminated new direct mail post cards and Valpak coupons book inserts with images of African American women, infants, and children. WIC sent the post cards and ValPak inserts to African American and low-income families across the state. One of the Valpak stuffers featured a picture of an African American WIC provider on the phone that urged women to “call me to get on WIC as soon as you know you are pregnant!”

Working with the Media

As recommended by the key informants, Washington developed radio, newspaper and transit advertisements. They partnered with Kent Stevenson, a successful African American producer and Debbie Cavitt, an African American gospel singer and director of Leschi Children’s Choir to produce a public service announcement. The PSA aired on local radio stations African Americans listen to. Debbie Cavitt


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and the Leschi choir were featured on the PSA. Two newspaper advertisements, featuring an African American mother and child and a pregnant African American woman, were developed and placed in local African American Newspapers. Bus signs were also developed and posted in 126 buses in Pierce County and 126 buses in King County on routes in African American communities. One bus sign featured a picture of a pregnant African American woman and the other a preschool aged African American child. The signs included the ParentHelp123.org web address and the Family Health Hotline number.

Outreach in the Community

The WIC outreach team established and maintained relationships with local African American churches by making one-on-one phone calls and personal visits. They educated church leaders about WIC services and eligibility and encourage them to post WIC outreach materials on church bulletin boards. The churches also put WIC outreach flyers in with their church bulletins. Free materials were provided. WIC information was also provided at African American health fairs. Small teddy bears and lip gloss with outreach messages were given out to attract families to the booth. Project Evaluation WithinReach provides Washington WIC with a yearly report about the reach of their outreach efforts. WA WIC has seen a steady increase in African American enrollment since they began their outreach efforts in 2006. From February 2006 to February 2007 there was a 3.5 percent increase in the percent of African Americans served. During the outreach project, February 2008 to February 2009, African American WIC participation increased by 9 percent. Lessons Learned The brainstorming sessions revealed that when trying to reach African American populations it is important to develop relationships within the African American community and develop materials and outreach activities that include targeted messages and culturally appropriate images. It is also imperative that the outreach efforts are ongoing and involve members of the community, especially African American churches. Resources Washington WIC received a Operational Adjustment Grant for $75,000 from the Western Region United States Department of Agriculture, Food and Nutrition Service to fund their African American Outreach Project. In addition, Washington WIC allocated $20,000 for this project. Languages Used English Populations Served African American Websites Washington State WIC Program: http://www.doh.wa.gov/cfh/WIC/default.htm Contact Information Kristin Sasseen Washington State WIC Outreach Coordinator Washington State Department of Health PO Box 47886 Olympia, Washington, 98504-7886 (T) 360-236-3633 [email protected]


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Best Practices Nutrition Education for Families of Diverse Cultural Backgrounds Making WIC Work for Multicultural Communities: Best Practices in Outreach and Nutrition Education

California Fit WIC This case study specifically focuses on the California Fit WIC project because of its efforts to make nutrition and physical activity accessible to WIC families of diverse cultural backgrounds. California’s program takes a holistic, community-centered approach to healthy eating and exercise, with a particular focus on Latino communities. This case study also highlights the Fit Families Novela series, a set of bilingual video and fotonovelas promoting nutrition and physical activity. Project Name California Fit WIC Agency Name California Department of Health Services, WIC Branch Project Description

California Fit WIC

The Fit WIC program in California seeks to increase WIC’s role in preventing childhood obesity/overweight in the community as a whole. The California team implemented intervention strategies that not only targeted WIC staff and participants, but also members of the entire community. California developed resources for the project in both English and Spanish.

Targeting WIC Participants

One of the main goals was to integrate physical activity into nutrition education for WIC participants. For instance, California Fit WIC developed a training manual entitled “FitWIC: Active Play for Families,” which encouraged families to be more active by doing easy and fun physical activities. California Fit WIC also produced parent handouts in both English and Spanish discussing active child play (“Playing With Your Baby, Playing With Your Toddler, Playing With Your 3 to 5 Year Old”) and healthy eating habits for children (“Healthy Choices for Kids”). They also promoted child education resources, such as children’s books, music, and videos addressing healthy eating and physical activity in both English and Spanish. In addition, the lesson plans used during nutrition education sessions covered topics such as gardening (“Grow Your Own Garden”), healthy snacks (“Making Snacks Count”), and fast food (“Super-Sized!”), and TV watching (“What’s On TV?”).


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Targeting WIC staff

Yet another California Fit WIC program goal was to increase staff awareness of childhood overweight/obesity and help them improve their own health behaviors, as outlined in the staff training manual “Fit WIC: Supporting WIC Families and Staff.” For instance, the project included special trainings and workshops to assist staff in discussing weight, healthy eating, and physical activity with WIC participants. The project also encouraged all local WIC agencies to develop staff wellness programs. California WIC believes WIC staff are the best role models for WIC families so it is important to support staff to make health lifestyle choices.

Targeting Other Community Members

In the community, California Fit WIC developed gardens, implemented task forces on physical activity and nutrition, and drafted physical activity resource guides. For example, the program produced a training kit for communities to address overweight/obesity among children entitled “Children and Weight: What Communities Can Do.” The Fit WIC program also promoted farmers’ markets near WIC clinics and established a partnership with local restaurants to increase community members’ fruit and vegetable consumption.

The Fit Families Novela Series

In an effort to make Fit WIC accessible to families of diverse cultural and racial/ethnic backgrounds, the Center for Weight and Health at the University of California, Berkeley created the Fit Families Novela Series, a set of three videonovelas and three fotonovelas addressing Fit WIC topics in both English and Spanish. This allows Fit WIC to reach the three largest WIC populations in California, the Latino, White, and African American communities. These bilingual materials depict realistic characters striving to create healthy snacks, limit their TV watching, and increase their physical activity. The California WIC State Agency distributed the video and fotonovelas to all of their local agencies (over 600 sites). The intent was to incorporate them into nutrition education classes for WIC participants throughout the state.

National Fit WIC

In 1999, the Food and Nutrition Service (FNS) at the United States Department of Agriculture launched Fit WIC, a three-year research and evaluation project, in five WIC Agencies: California, Kentucky, Vermont, Virginia, and the Intertribal Council of Arizona (ITCA). According to FNS, Fit WIC is “a collection of social-environmental strategies to promote healthy weight [and prevent obesity/overweight] among children enrolled in WIC.” The Fit WIC implementation manual contains more information about all of these initiatives, as well as lessons learned and recommendations. Project Evaluation The California Fit WIC program administered a survey to all staff in order to assess “staff knowledge, practices, intervention ideas, and perceived barriers to implementation of programs to prevent overweight among WIC children.” The survey instrument was developed by the WIC State Agency, the University of California, Berkeley, and Samuels and Associates consulting group. The State Agency and Berkeley also administered a similar survey to WIC participants in order to assess the effectiveness of the Fit WIC project on WIC families. They compared survey findings from three Fit WIC intervention sites (Pico Rivera, Santa Paula, and Grand Avenue) and three control sites (Flower Street, Ventura, and County Main). The surveys were distributed in both English and Spanish.


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Survey results showed that the Fit WIC program was very effective in improving the nutrition and increasing the physical activity level of participants. Findings from both the staff and participant surveys are available on the California Fit WIC website. http://www.cdph.ca.gov/PROGRAMS/WICWORKS/Pages/WICNEFITWIC.aspx Resources The Fit WIC projects in all five Agencies were funded by $1.8 million in Federal funds from the United States Department of Agriculture, Food and Nutrition Service, under WIC Special Projects Grants. In addition, California Fit WIC received a $300,000 operational adjustment grant from the United States Department of Agriculture, Food and Nutrition Service Western Regional Office to develop a community garden. Languages Used English and Spanish Populations Served Latino, White, and Black/African American State WIC Participation by Race/Ethnicity 78 percent Latino, 8 percent White, 5.5 percent Black/African American, 5 percent Asian/Pacific Islander, and 0.87 percent American Indian/ Alaska Native Websites

California Fit WIC

www.wicworks.ca.gov/education/nutrition/FitWIC/FitWICIndex.htm

The Fit Families Novela Series

http://anrcatalog.ucdavis.edu/InOrder/Shop/ItemDetails.asp?ItemNo=3496

New WIC Food Package Campaign

Building on their Fit WIC project and other work, the California WIC agency created a comprehensive nutrition education campaign marketing the new WIC food package nutrition messages. http://ww2.cdph.ca.gov/programs/wicworks/Pages/WICNewFoodPackages.aspx

Maximizing the New WIC Food Package

The California WIC Association launched a strategic campaign to maximize the new WIC food package including a variety of materials that can be used in California and other states. http://www.calwic.org/ Contact Information Monique Stovall Chief Nutrition Education, Marketing and Outreach Section California Department of Public Health-WIC Program P.O. Box 997375 West Sacramento, CA 95899-7375 (T) 916 928-8604 [email protected]


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Incorporating Traditional Foods and Recipes into Nutrition Education Navajo Nation WIC has a comprehensive nutrition education program in both Navajo and English. Although the program is open to all WIC participants, it is specifically geared towards the Navajo. In turn, nutritionists incorporate information about traditional foods and recipes into nutrition education classes. They also provide nutrition education to children because, as in many other areas in the United States, child obesity is a major concern on the reservation. Agency Name Navajo Division of Health, Navajo Nation WIC Program Project Description

Incorporating Traditional Foods

You have to really involve the client and get them to identify their own goals. You can’t just lecture.” -Doris McGuire

When appropriate to the geographic location and topic, the Navajo Nation WIC Program incorporates traditional foods into nutrition education lesson plans. For instance, during the session on anemia, nutritionists discuss the recipe for making the traditional food blue corn mush, which is very high in iron. Similarly, during Five-A-Day month in September, Navajo Nation WIC distributes a handout on traditional fruits and vegetables, such as lychee, sumac berries, and yucca fruit. In addition, traditional recipes for Navajo cake, shape blue corn bread, and chiilchin berry pudding, among others, are made available in the clinic waiting room. Recipes using WIC foods to make snacks for kids are also available in an effort to encourage participants to use all of their WIC foods.

Nutrition Education for Children

In addition to nutrition education for adults, the Navajo Nation WIC Program also conducts nutrition education sessions for children on a monthly basis. They specifically target kids between the ages of three and five years old, many of whom are at risk for overweight (11%). This initiative is based on classes developed by the Fit WIC Inter Tribal Council of Arizona (ITCA) project, which involved children in reading stories about nutrition, preparing healthy snacks, and engaging in physical activities. In addition, Navajo Nation WIC uses SPARK (Sports, Play, and Active Recreation for Kids) activities to engage children in nutrition education and physical activity.

Addressing Language Barriers

Nutrition education sessions are usually conducted in English. However, in more isolated areas where English is not spoken by all participants, Navajo is used. Project Evaluation The Navajo Nation WIC Program administers annual surveys assessing participant satisfaction with nutrition education, as well as customer service, the food package, their grocery store experience, parking, and clinic wait time, among other issues.


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Some of the challenges in nutrition education include lack of participant involvement, lack of participant access to transportation (which often results in missed appointments), and nutritionists not having enough time to conduct sessions. Lessons Learned Some of the solutions adopted to address the lack of participant involvement in nutrition education include requiring participants to establish one nutrition goal with a paraprofessional before seeing the nutritionist; asking participants questions during classes; empowering participants to express their needs; and encouraging WIC staff to listen to them. Resources Navajo Nation WIC uses Nutrition Services funds from the United States Department of Agriculture, Food and Nutrition Service to support these initiatives. Languages Used Navajo and English Populations Served Navajo, Latino, and White Contact Information Adele King WIC Program Manager Navajo Division of Health Navajo Nation WIC Program P.O. Box 1390 Window Rock, AZ 86515 (T) 928-871-6698 [email protected]

“For my son, I just want to find out all the information that I need for him to grow up healthy without ever getting into junk food and stuff.” -WIC Participant


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Motivational Interviewing Counseling Techniques The District of Columbia WIC (DC WIC) State Agency is implementing a comprehensive multicultural nutrition education strategy with the goal of changing the health and nutrition behaviors of African American and Latino children between the ages of two and five. The strategy has two phases: a pilot phase during which motivational interviewing nutrition education techniques will be pilot-tested in selected WIC clinics and an implementation phase during which the pilot’s successful components will be implemented in all DC WIC clinics. Project Name Impact of Motivational Interviewing Counseling Techniques on Health and Nutrition Behaviors in Urban Multi-Ethnic WIC Participants Agency Name DC Department of Health, WIC State Agency Project Description

Motivational Interviewing

Motivational interviewing is a participant-centered counseling tool that aims to elicit behavior change. By using motivational interviewing in nutrition education, DC WIC seeks to change the nutritional habits of African American and Latino children between the ages of two and five. The project targets children’s moms, guardians, and other primary caretakers and provides them with nutrition education on five child nutrition topics: (1) increasing consumption of fruits and vegetables; (2) decreasing consumption of fast foods; (3) decreasing consumption of sugary beverages; (4) increasing physical activity; and (5) decreasing TV watching.

“DC WIC held focus groups with WIC nutritionists before launching the study. They spoke about how they wanted more client input and participation, and how helping clients find the desire to change from within would lead to healthier behaviors.” -Evalyn Carbrey

Phase One: Pilot-Testing

DC WIC launched a three-year motivational interviewing pilot involving seven clinics. Two clinics replaced their traditional nutrition education with motivational interviewing (Mary’s Center for Maternal and Child Care and DC General Hospital). Two others (Upper Cardozo Clinic and Children’s Health Center at Good Hope Road) adopted “motivational interviewing plus.” The “motivational interviewing plus” format consists of motivational interviewing nutrition education combined with a traditional nutrition education activity, such as a group session or mailing. The pilot also included three control sites using current nutrition education methods (Marie Reed Clinic, Adams Morgan Clinic, and Howard University Hospital). “The states that have

already done motivational interviewing pilots have been very open about sharing their resources.” -Evalyn Carbrey

Training for the nutritionists in the four clinics implementing motivational interviewing nutrition education techniques began with a two-day workshop led by motivational interviewing expert Ken Resnicow, Professor of Health Behavior and Health Education at the University of Michigan, School of Public Health.


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Targeting African American and Latino Children

The pilot specifically targets Latino and African American WIC participants, the two largest WIC populations in DC. One motivational interviewing and one “motivational interviewing plus” pilot clinic (Mary’s Center and Upper Cardozo) are predominately Latino, while the two others (DC General Hospital and Good Hope Road) are predominately African American. The goal of the pilot is to see if motivational interviewing is more effective in one group over the other.

Phase Two: Implementation

If the pilot is successful, the nutritionists trained during the pilot will help train all other WIC nutritionists in DC. In addition, the State Agency will develop a motivational interviewing training manual and tool kit for nutritionists in other states to use. Similar motivational interviewing pilots have been conducted in North Dakota and Nebraska. Project Evaluation A piloted evaluation questionnaire will be given to all moms, guardians, and primary caretakers who wish to participate in the study. Participants will be recruited from all seven sites. In addition, the State Agency will conduct a cost-benefit analysis of motivational interviewing and “motivational interviewing plus.” Lessons Learned Although they are still in the early stages of the project, the DC WIC State Agency has already learned several valuable lessons while conducting the motivational interviewing pilot. First, they learned that in order for motivational interviewing to be successful, it is necessary that the nutritionists implementing the technique speak the same language as participants. If not, a translator would be useful in decreasing language barriers. In addition, although the grant targets children between the ages of two and five, staff still needs to meet the needs of the other children who come into the pilot clinics, which is often a challenge. Resources In FY 2005, the DC WIC State Agency received a three-year Special Project Grant ($130,000) from the United States Department of Agriculture (USDA), Food and Nutrition Service (FNS) to pilot motivational interviewing in DC. The initiative is also supported by a $10,000 General Mills grant, which funds the additional nutrition activities used in the “motivational interviewing plus” pilot clinics. States interested in this initiative could also use training funds from their regular WIC budget (Nutrition Services and Administration funding) to train nutritionists in motivational interviewing. Languages Used English and Spanish Populations Served Black/African American, and Latino


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Motivational Interviewing Pilot Participation Data by Race/Ethnicity

Motivational interviewing pilot clinics: • • • • • •

Mary’s Center for Maternal and Child Care 75% Latino 21% Black/African American DC General Hospital 99% black/African American 1% Latino

“Motivational interviewing plus” pilot clinics: • • • • • •

Upper Cardozo Clinic 67% Latino 29% Black/African American Children’s Health Center 99% Black/African American 1% Latino

Control clinics: • • • • • • • • •

Children’s Hospital Marie Reed Clinic 61% Latino 25% Black/African American Children’s Hospital Adams Morgan Clinic 64% Latino 24% Black/African American Howard University Hospital 91% Black/African American 4% Latino

Website http://app.doh.dc.gov/services/wic/index.shtm Contact Information Evalyn Carbrey Project Manager, Special Project Grants Nutrition Programs Administration WIC State Agency DC Department of Health 2100 Martin Luther King Jr. Avenue, SE Suite 409 Washington, DC 20020 (T) 202-645-5663 (F) 202-645-0516


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Texas WIC In an effort to make nutrition education services accessible to families of all cultural and linguistic backgrounds, the Texas WIC program has adopted a comprehensive, multicultural approach to tackling language barriers and low literacy levels among WIC participants. For instance, all written and audiovisual nutrition education materials are available in both English and Spanish and up to 20% are also available in Vietnamese. In addition, nutrition education materials, such as fact sheets, pamphlets, and brochures, are all written at a 5th to 6th grade literacy level. The Texas WIC State Agency oversees a range of projects targeting diverse populations throughout the state. This case study highlights three models that successfully address the specific needs of various racial, ethnic, cultural, and linguistic communities in Texas. They include: • the African American Breastfeeding Initiative, • nutrition education partnerships with other groups and agencies, and • a local agency obesity prevention project for Latino children: “From the Food Guide Pyramid to Cooking Practices in Your Kitchen”. Project Name African American Breastfeeding Initiative Agency Name Texas Department of State Health Services, WIC Nutrition Services Project Description In 2003, the Texas WIC program developed an African American Breastfeeding Initiative based on national and Texas WIC research regarding infant feeding attitudes and beliefs among African American families. The goal of the project was to raise awareness about breastfeeding and increase the breastfeeding rates among African American WIC participants in Texas. By working with an advertising agency, Texas WIC produced a range of social marketing materials that promote breastfeeding, including brochures, posters, radio spots, a TV commercial, outdoor spots, and newspaper columns. These materials targeted pregnant women, moms, dads, partners, grandparents, health care providers, and the general public. The Texas WIC program also developed a logo for the campaign, which later became the statewide breastfeeding brand. The project was piloted from January to September 2004 in South East Texas and implemented statewide in 2005. The campaign’s media component has run for three consecutive years and is scheduled to end in August 2006. All other components of the campaign are permanent. Project Evaluation The Texas WIC program contracted with SUMA/Orchard Social Marketing, Inc. to evaluate the project’s effectiveness. They found that the initiative was very popular with all participants and that radio spots were especially successful in reaching young moms. They also identified that outreach to churches was particularly useful for getting older community members involved in the initiative. In addition, post-campaign interviews revealed an increased awareness of the benefits of breastfeeding among African American women involved in the project. Similarly, many health care providers and WIC staff reported fielding more questions about breastfeeding from African American participants. Many Making WIC Work for Multicultural Communities: Best Practices in Outreach and Nutrition Education

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noted that the most significant change in attitude came from teen moms who had previously shown little interest in breastfeeding. Furthermore, breastfeeding rates in two local agencies increased and a hospital lactation support program was implemented as a result of this initiative. The Texas WIC program is very willing to help other WIC Agencies interested in implementing an African American breastfeeding campaign in their state. All print and audiovisual materials are available online for duplication free of charge. Resources In order to fund the African American Breastfeeding Initiative, the Texas State Agency requested an operational adjustment grant from the United States Department of Agriculture, Food and Nutrition Service Southwest Regional Office. They submitted a brief description of their project, as well as midyear and end-of-year reports. Languages Used Materials for the African American Breastfeeding Initiative were produced in English. All other breastfeeding materials are also available in Spanish and a few are printed in Vietnamese. Populations Served Black/African American Website www.dshs.state.tx.us/wichd/bf/african_americanbf.shtm

Contact Information Tracy Erickson Breastfeeding Coordinator WIC Nutrition Services Texas Department of State Health Services 1100 West 49th Street Austin, TX 78756-3199 (T) 512-458-7444 [email protected]


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Project Name Nutrition Education Partnerships Agency Name Texas Department of State Health Services, WIC Nutrition Services Project Description The Texas WIC program has partnered with various groups and agencies to develop high-quality nutrition education materials, including a video on dental care with the Oral Health Program at the Texas Department of State Health Services and the Zowzoo fitness video for kids with the University of Texas at Austin. This bilingual video presents information in both English and Spanish, allowing the WIC program to reach the three largest WIC populations in Texas, notably Latinos, Whites, and African Americans. Participants take the Zowzoo video home to use with their children and fill out a survey and evaluation for WIC. A classroom version of the video is also available for use during nutrition education group sessions. In addition, Texas WIC made a cooking video, which features recipes and chefs from the Sustainable Food Center in Austin. In preparation for implementing the new food package Texas WIC mailed health care providers and other WIC partners across the state selected materials related to the new food package including a 16 page brochure, Your Guide to WIC Foods. Health Care providers also received an educational DVD with details about the new WIC food package. Among other initiatives to increase access to services for working women, the Texas WIC program has developed a series of home-based nutrition education and fitness activities. A highlight is the internetbased nutrition education on TexasWIC.org. The website includes lessons on pregnancy, food safety, physical activity, smart snacking, and breastfeeding. New lessons have just recently been added to educate WIC participant about the new WIC food packages. These lessons include Moove to Low-Fat Milk, Cooking with Fruits and Vegetables, New Food Package and the Importance of Exclusively Breastfeeding in the First Month, and Whole Grains. All lessons are available in both English and Spanish. Project Evaluation All Texas WIC nutrition education lessons and classes have oral or written evaluations completed by WIC participants. For other special projects, the WIC program contracts with various agencies to conduct both qualitative and quantitative evaluations. Resources In order to provide nutrition education, the Texas WIC program uses nutrition education funding from the Nutrition Services funds administered by the United States Department of Agriculture, Food and Nutrition Service. Languages Used English, Spanish, and Vietnamese Populations Served Latino, White, Black/African American, and Vietnamese

Website www.dshs.state.tx.us/wichd/nut/nut1.shtm


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Project Name From the Food Guide Pyramid to Cooking Practices in Your Kitchen Agency Name Cameron County Department of Health and Human Services, WIC Program Project Description In June 2006, the Texas WIC State Agency administered obesity mini-grants to 19 of the 22 local agencies that applied. The grants provide $1,000 to $15,000 from June 2006 to September 2006, with the possibility of being extended or renewed. A notable mini-grant project is being implemented by the Cameron County Department of Health and Human Services Brownsville area WIC clinics. Their “Desde la Guia de la

Piramide Hasta Su Cocina” (“From the Food Guide Pyramid to Cooking Practices in Your Kitchen”) initiative

targets overweight Latino children and their families. A series of twelve classes, all taught in Spanish, address issues related to obesity prevention and healthy food preparation. Topics include the Food Pyramid; the importance of physical activity and inexpensive ways to exercise; understanding food labels; making the most of a limited food budget; and maintaining a healthy life balance. The classes use a combination of previously developed WIC and ENP materials. They are held twice a week and in the evenings in order to accommodate working parents. Project Evaluation All grantees are expected to conduct a formal evaluation of the project and present their findings in a poster at the Nutrition and Breastfeeding Annual Conference. Resources In order to fund the obesity mini-grants, the Texas State Agency requested an operational adjustment grant ($200,000 in FY06) from the United States Department of Agriculture, Food and Nutrition Service Southwest Regional Office. Languages Used Spanish Populations Served Latino children Website www.co.cameron.tx.us/health/wic.htm

“All of the grant project ideas

came from local agencies. But we also talked to leaders in the community to understand what the needs were.” -Amanda Hovis

Contact Information Amanda Hovis Nutrition Education Consultant WIC Nutrition Services Texas Department of State Health Services 1100 West 49th Street Austin, TX 78756-3199 (T) 512-458-7111 x3411 [email protected]


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Veggin’ Out Since 1998, chefs from Johnson and Wales University (JWU) have worked with the Rhode Island Department of Health and the Rhode Island Department of Environmental Management to put on bilingual cooking demonstrations at ten WIC Farmers’ Market Nutrition Program (FMNP) sites throughout Rhode Island in July and August. During each two-hour cooking demonstration, JWU chefs showcase four creative yet simple recipes, all made with fresh vegetables from the markets. A translator, provided by WIC, ensures that the sessions are conducted in both English and Spanish and accessible to both the English-speaking and Spanish-speaking communities in Rhode Island. Project Description Nutritionist from both JWU and WIC are always present to highlight the nutritional content of each recipe and answer any nutrition questions from the audience. Nutrition education is fully integrated into the demonstrations and seeks to promote participant involvement. The nutritionists cover the benefits of local produce, including freshness and supporting local farmers.

“We look for interactive ways to add nutrition education into our cooking demonstrations. We may ask people “Why are beans good for you?” or ask kids to volunteer to help. -Linda Kane

All audience members receive a Veggin’ Out Cook Book, printed in English and Spanish. The Cook Book includes 20 simple recipes, all made with fresh fruits and vegetables, as well as nutrition information for each recipe. In addition, WIC and JWU raffle off gift bags filled with kitchen utensils, two $5 farmers’ market gift certificates, storybooks entitled “Vegetable Friends,” and a Veggin’ Out T-shirt. The Feinstein Community Service Center at JWU and the Rhode Island WIC program have graciously offered to provide assistance to those interested in replicating this project in their state. Veggin’ Out cook books are available free of charge upon request.

Project Evaluation At the end of each farmers’ market season, JWU and WIC meet to discuss any problems and brainstorm solutions for the following year. In addition, WIC follows up with program participants for feedback. Some of the challenges include strict Health Department standards regarding the proper handling of food in an outdoor venue. Yet another challenge arises when participants want to follow-up with chefs about the cooking demonstrations, but only one translator is on-hand. One solution would be having multiple translators or bilingual chefs.

Language can be a barrier. But we strive to make people feel comfortable enough to ask questions, regardless of what language they speak.” -Linda Kane

Resources JWU and WIC meet every April to discuss the Veggin’ Out budget. WIC pays for the printing and translation of the cook books, the gift bags, and the translator. These services are funded through WIC Farmers’ Market Nutrition Program (FMNP) money (if available) or the nutrition education budget. Chefs from JWU use money from the University’s United Way DownCity fund to buy vegetables from the farmers ($30 per market; $500 for the entire season). Other necessities, such as cooking staples and utensils, are also included in that budget. JWU suggests that those interested in replicating the project in their state could ask farmers to donate produce at first; however, they recommend eventually establishing a permanent food budget.


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Languages Used English and Spanish Populations Served White, Latino, Black/African American, Asian/Pacific Islander, Portuguese, and Cape Verdean WIC Participation by Race/Ethnicity White: 44.1% Latino: 37.2% Black/African American: 14.4% Asian/Pacific Islander: 3.8% American Indian/Alaskan Native: .4% Website www.health.ri.gov/family/wic/veggin.php Contact Information Linda Kane Community Service Chef Feinstein Community Service Center Johnson and Wales University 8 Abbott Park Place Providence, RI 02903 (T) 401-598-1323 (F) 401-598-1277 [email protected]

Ann Barone WIC Client Services Manager WIC Program Rhode Island Department of Health 3 Capitol Hill Room 302 Providence, RI 02908 (T) 401-222-4623 (F) 401-222-6548 [email protected]


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Weigh of Life…Taking Action Together In 2001, the Massachusetts WIC Nutrition Program was awarded a USDA Special Project Grant entitled, “Cultural

Perspectives on Childhood Overweight Among Hispanic WIC Participants in Massachusetts.” The grant was used to fund a project with the overall goal to strengthen the ability of Massachusetts WIC program staff to provide culturally sensitive services that promote healthy eating behaviors, particularly for Dominican and Puerto Rican children, among whom the problem of overweight is particularly acute. Project Name Weigh of Life...Taking Action Together Agency Name Massachusetts Department of Public Health, WIC Nutrition Program Project Description The project began with the collection of anthropometric and body composition measurements of approximately 400 Hispanic children and the facilitation of 24 focus groups with WIC mothers to identify the cultural beliefs that affect what mothers believe constitutes healthy body weight and influence the dietary behavior of children. The results of the focus groups were used to identify culturally sensitive key themes related to health. The themes were used to develop educational messages and materials for WIC staff and healthcare providers to enhance their efforts to prevent childhood overweight. The culmination of the project was the development of the Weigh of Life...Taking Action Together initiative. The initiative included the development of emotion-based educational messages, a program implementation manual for WIC nutrition counselors, and a provider toolkit.

Key Messages

The initiative focused on six emotion-based messages for Hispanic families based on the focus group findings that addressed the cultural beliefs and assumptions of Hispanic families surrounding weight and dietary practices. Emotion-based messages focus on universal health points that trigger behavior change. These messages were: • A slender looking child is a healthy child. • Developing good eating habits makes a lifelong difference. • Eat together as a family. • Offer your child a variety of foods instead of a steady diet of milk and juice. • Mom knows what is best for her child. • Mothers will be surprised that children enjoy eating healthy foods- this will make mothers happy. Both wall-sized and miniature posters were developed in English and Spanish to convey each of the six key messages. The wall posters were produced for display in health care providers’ offices and the miniposters were produced for use by WIC nutritionists during counseling sessions. In addition, a child-sized placemat was developed to communicate a seventh targeted message that child-sized servings provide all the nutrients necessary for growth.


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Project Implementation Manual

A project implementation manual was developed as a resource and training tool for WIC staff. The manual included: •

Key findings from the WIC participant focus groups.

•

Strategies to successfully coordinate and collaborate with health care providers to provide consistent messages about dietary habits and healthy body weight to Hispanic families.

•

Introduction on a new culturally sensitive nine-step approach to discussing a child’s weight with families.

•

Nutrition education materials.

Physician Tool Kit

A provider took kit was developed to foster successful partnerships with health care provider to deliver consistent positive messages about weight and dietary practices to Hispanic families. The tool kit was distributed by WIC nutritionists on personal visits to physicians and other health care personnel. The tool kit includes the following materials: • Steps to Healthy Weight in Children: a guide to providing standardized, age-appropriate nutrition messages to Hispanic families and children. • A CD containing electronic versions of the nutrition education materials for health care providers to use. • A mock prescription pad, “Prescription for Your Healthy Child”, allowing physicians to “prescribe” diet and physical activity changes and refer parents to the nearest WIC office. Project Evaluation All local WIC agencies were responsible for delivering the physician’s tool kits to health care providers in their area. After the tool kits were delivered the state agency made follow-up calls to the providers. The call revealed that of the physicians that utilized the toolkit materials about 60% displayed the wall posters in their offices and about 20% were using the tool kits to help facilitate discussions about body weight with families. The focus groups revealed two important issues that the initiative addressed. The first was that WIC’s health messages, based mostly on logic and facts, were not resonating with WIC mothers. WIC found behavior change is more likely to happen when WIC counselors speak to people’s feelings and highlight the emotional benefits of taking action in addition to providing facts. The focus groups also revealed that WIC and the medical community were not delivering consistent messages to Hispanic families which led Massachusetts WIC to realize the importance of collaborating with health care providers. Lessons Learned The focus group results made it apparent that is was important for Massachusetts WIC to improve their delivery of health messages. Based on the finding of the focus group WIC developed an untraditional approach to nutrition education that focused on emotions rather than logic and fact alone. WIC’s emotion-based approach to counseling uses messages and materials that highlighted the emotion-based benefits of making health eating and activity changes in addition to the logical, rational benefits of taking action. Through the implementation of the Weigh of Life…Taking Action Together Initiative it became apparent that the emotion-based messaging could be applied to all WIC clients and in 2003 they began the Touching Hearts….Touching Minds project. Massachusetts WIC was awarded a second USDA grant, and conducted additional focus groups to identify what emotions drove mothers behaviors and integrated these emotional “pulse points” into 30 nutrition education messages. Massachusetts WIC now uses emotion-based materials and counseling to touch people’s hearts first and then provide factual information to act on. Making WIC Work for Multicultural Communities: Best Practices in Outreach and Nutrition Education

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Resources

The Weigh of Life…Taking Action Together Initiative was funded by a USDA Special Project Grant entitled, “Cultural Perspectives on Childhood Overweight Among Hispanic WIC Participants in Massachusetts.” Languages Used English and Spanish Populations Served Dominican and Puerto Rican Website www.mass.gov/wic The nutrition education materials are available on the Touching Hearts Touching Minds website http://www.touchingheartstouchingminds.com/index.php.

Contact Information Rachel Colchamiro Acting Director, Nutrition Services and WIC Breastfeeding Coordinator MA Department of Public Health 250 Washington Street Boston, MA 02108 (P) 617-624-6153 [email protected]


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WIChealth.org The WIChealth.org website project delivers high quality web-based education on nutrition and physical activity to WIC participants. It is a partnership between the Michigan WIC State Agency, WIC State Agencies in several other states (Delaware, Illinois, Indiana, Minnesota, Ohio, North Carolina Utah, Washington, and Wisconsin), and Western Michigan University. The website provides interactive, learner-centered nutrition education to WIC participants in all of the partner states. Project Name Nutrition Education for the Internet Project Agency Name Michigan Department of Community Health, WIC Division Project Description

Addressing Language Barriers

“This is a great example of a partnership between WIC and a university.” -Judith Anderson

In an effort to be accessible to families of diverse linguistic backgrounds, the website is available in English and Spanish and will possibly be translated into Arabic and Chinese as well. The wording is kept simple in order to be accessible to participants of all literacy levels.

Increasing Access for Working Families

In addition, the website increases access to nutrition education for working families. It allows participants who cannot attend nutrition education classes because of work, school, or lack of transportation to get nutrition education at home or during breaks at work. In addition, many WIC participants lack child care and are often forced to bring their children to nutrition education classes. This can be distracting for all participants in attendance and the website allows participants to complete their nutrition education requirement in their own time and without worrying about their children.

Nutrition Education Modules

The project’s steering committee, which is comprised of representatives from all seven WIC State Agencies, develops online nutrition education modules based on participant needs and interests. The site currently includes ten modules, each covering a different child nutrition topic, including: • child feeding (“Create Good Eating Habits in Your Child”), • breastfeeding (“Support for Breastfeeding Moms”), and • physical activity (“Happy, Healthy, Active Children”). Fruit and vegetable modules have just recently been added to the website to educate WIC participants about the changes to the WIC food package. The modules are based on the stages of change theory developed by Dr. Robert Bensley at Western Michigan University (www.cdc.gov/PCD/issues/2004/oct/pdf/04_0070.pdf). Participants choose a module and answer a set of questions that places them in one of the five stages of change: (1) precontemplation; (2) contemplation; (3) preparation; (4) action; and (5) maintenance. Based on their stage of change, participants are provided with stage-specific nutrition education addressing their chosen topic. They are given easy and practical action steps to help them reach their behavior change goals.


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“Happy, Healthy, Active Children”

For example, in the physical activity module “Happy, Healthy, Active Children,” participants are asked if their child undertakes planned and/or unplanned physical activities, such as walking, bike riding, dancing, and active games. Participants who answer “no” are reassured that they are not alone. Respondents are then asked if they have an interest in someday changing their child’s lack of physical activity. Those who answer “yes” are then asked if they are willing to do so in the next few days. Possible responses include “yes” and “I’m not sure.” Participants who answer the latter are asked what barriers stand in their way. A few of their options include TV watching, lack of time, and lack of ideas about active games for their child. If participants select “TV watching,” they are provided with a simple factsheet about how to turn off the TV and increase physical activity. Project Evaluation The steering committee has quarterly, mid-year, and yearly evaluation results assessing the website’s effectiveness from 2002 to 2008. The yearly 2008-2009 evaluation results are forthcoming. The website includes a feedback page, and 95 percent of all participant responses to date have been positive. The 2008-2009 six month evaluation provides important information about the project’s challenges as well as ways in which the web education can be improved.

“One of the main challenges is getting local WIC agencies to promote the Internet. When they don’t think participants have access, we do a survey to see if they do.” -Judith Anderson

Lessons Learned In addition to a high level of user satisfaction, the evaluation results show 65.6 percent of Wichealth.org user were in the maintenance stage of behavior change. These results are not consistent with previous knowledge of the population. This inconsistency may be the result of response bias associated with the yes/no staging questions used to categorize user into stages of change and WIChealth.org has begun replacing yes/no staging questions with multiple choice questions to ensure accuracy in stage assignment. Accurate staging will improve the likeness of users showing behavior change progression. The inconsistency may also be the results of low website usage among clients in the pre-contemplation, contemplation, and action phases. It may be necessary to implement strategies to attract WIC clients in earlier stages of change to access the website and

“Thank you for the opportunity to take this class in my own time without interference from my children.” -WIC Participant

The evaluation results shows that among users in the precontemplative stage 45.4 percent advanced to the action phase by the end of their session and that 92 percent of users who began in the action or maintenance phase indicated they could make changes using what they learned. These results demonstrate that Wichealth.org is effective in promoting health behavior and continued use and further expansion to other states is recommended.

While Wichealth.org is effective in promoting behavior change amongst most users some still report resistance to change. Most users reporting unwillingness to make changes based on what they learned report that the information covered was not applicable to them at that time. These results suggest that it may be necessary to use screening questions to recommend appropriate modules for users based on their current needs. Spanish language module users did not rate the usability of WIChealth.org as highly as English language users. While 78 percent of English language module users indicated that WIChealth.org was their favorite way to receive nutrition education fewer of the Spanish language module users felt the same way. Sixty three percent Spanish language module users indicated they prefer class or group session nutrition education at a WIC clinic. These results indicate that it may beneficial to develop interactive tool on WIChealth.org to promote a sense of community and facilitate social networking. Making WIC Work for Multicultural Communities: Best Practices in Outreach and Nutrition Education

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Resources The website’s initial start-up costs were supported by an operational adjustment grant requested from the United States Department of Agriculture, Food and Nutrition Service Midwest Regional Office. Six of the Midwest States (Illinois, Indiana, Minnesota, Ohio, Michigan, and Wisconsin) collaborated in the development and pilot-testing of the project, with the WIC Division of the Michigan Department of Community Health serving as the lead agency. Currently, all ten states contribute money to keep the website up to date and make translations as needed. The project received a special project grant from USDA to add the new fruit and vegetable modules. The website is maintained and updated by Dr. Bensley’s staff at Western Michigan University. Languages Used English and Spanish; Possibility Arabic and Chinese in the future Populations Served White, Black/African American, and Latino WIC Participation by Race/Ethnicity White: 57.7% Black/African American: 28.5% Latino: 11.6% Asian/Pacific Islander: 1.5% American Indian/Alaskan Native: 0.7%

“I love being able to do this online, it saves me time, and if my son is sick, I don’t need to worry about him making other people sick. Also, I don’t need to worry about a need for a sitter, as well as him getting bored or if he is crabby.” -WIC Participant

Contact Information Judith Anderson Manager, Nutrition Services Unit and WIC Nutrition Coordinator Nutrition Program and Evaluation WIC Division MI Department of Community Health 320 South Walnut Lansing, MI 48913 (T) 517-335-8957 (F) 517-335-8835 [email protected]

Website www.wichealth.org


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National WIC Survey

National WIC Survey Findings from the Food Research and Action Center’s WIC Directors’ Survey provide important insight into ongoing efforts to increase access to services by conducting outreach, and providing nutrition education and referrals to WIC participants of all cultural backgrounds. The survey had a very good response rate: a total of 68 completed surveys were received, including 47 surveys from states and territories and 21 surveys from Indian Tribal Organizations (ITOs).

Outreach

Outreach is an important tool for decreasing access barriers and promoting participation in the WIC program by eligible families. The large majority of WIC State Agencies and ITOs (85%) undertook outreach efforts to raise awareness about WIC and increase participation in the program. More specifically, 82 percent of State Agencies conducted outreach in their state and 75 percent of ITOs lead outreach initiatives in their area. Targeting Hard to Reach Populations Hard to Reach Populations T argeted by Outreach (%) 80 60

40 20 0 Working Families

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Certain populations are harder to reach than others, and therefore harder to enroll in the program. Many WIC State Agencies and ITOs (55%) tackled this problem by conducting outreach targeting hard to reach populations in their state, including working women (69%) and women, infants, and children who speak a language other than English (69%). Other populations targeted by State Agency and ITO outreach campaigns included women, infants, and children of underserved racial and ethnic groups (50%), women, infants, and children in migrant families (41%), and immigrant families (38%). State Agency and ITO directors also mentioned reaching out to grandmothers and persons experiencing homelessness as part of their outreach efforts. 100 90 80 70 60 50 40 30 20 10

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Addressing Language Barriers In order to reach families of diverse cultural and ethnic backgrounds, many WIC State Agencies design outreach initiatives that address the specific language and cultural needs of the different communities in their state. Of those with language initiatives, Spanish was the most frequently used language for outreach by State Agencies (100%), followed by Vietnamese (26%), Chinese (20%), Somali (17%), and Arabic

Languages Other T han English Used for Outreach by State A gencies (%)


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(11%). Other less frequently used languages included Russian, Haitian Creole, Cambodian, Hmong, Laotian, Thai, and Portuguese (9%). ITOs reported conducting outreach in English, Spanish (63%), and Native American languages (38%). Outreach Strategies State Agencies and ITOs use various strategies to conduct outreach and many adopt comprehensive plans that combine a number of methods. For both State Agencies and ITOS, distributing brochures and pamphlets was the most frequently used outreach strategy (95%). Partnering with the State Medicaid office was also a popular outreach method (65%), followed by partnering with the Supplemental Nutrition Assistance Program (formerly known as the Food Stamp program) (63%), advertisements (54%), Public Service Announcements (PSAs) (49%), partnering with the TANF office (49%), and working with food banks (42%) and anti-hunger organizations (40%). Other strategies to reach WIC eligible families included press releases (47%), the National WIC Association’s Ad Campaign (37%), and partnering with religious congregations or groups (30%). Other effective outreach methods mentioned by State Agency and ITO directors included partnering with the local Head Start program, collaborating with private physicians, and launching a direct mail campaign targeting potential WIC participants. State Agencies and ITOs indicated that the four most effective outreach strategies were: • word of mouth, • the media, • partnering with other government agencies and/or local groups, and • working with health care providers.

Nutrition Education Addressing Language Barriers In an effort to make nutrition services accessible to families of diverse cultural backgrounds, WIC programs throughout the United States offer nutrition education in a range of languages. Other than English, Spanish was the most popular language for nutrition education, with 96 percent of WIC State Agencies indicating its use. The next most often used language by State Agencies was Vietnamese (28%), followed by Cambodian (20%), Chinese (17%), Russian (17%), Laotian (15%), Somali (15%), and Arabic (15%). Other less frequently used languages included Hmong (11%), Thai (9%), Haitian Creole (7%), French (7%), Panjabi (7%), and Portuguese (7%). ITOs reported using English, Spanish (75%), and Native American languages such as Zuni and Lakota in their nutrition education sessions.

Languages Other T han English Used for Nutrition Education by State A gency (%) 100 90 80 70 60 50 40 30 20 10

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Nutrition Education Topics All WIC State Agencies and Indian Tribal Organizations (ITOs) covered fruit and vegetable consumption in their nutrition education sessions. This will be particularly useful in light of the new WIC food packages, which promote fruits and vegetables for women, infants, and children. In addition, all WIC State Agencies also covered physical activity and overweight/obesity. These sessions are particularly noteworthy since many communities are struggling with overweight and obesity, especially Latinos and Native Americans. Other topics often offered by State Agencies included breastfeeding education (100%), maternal and child health (96%), increasing calcium rich foods (94%), and understanding dietary guidelines and the Food Pyramid (91%). All ITOs addressed fruit and vegetable consumption and breastfeeding education, with maternal and child health (95%), increasing whole grain consumption (90%), and understanding dietary guidelines and the Food Pyramid (90%) being other popular topics. In addition, 85% of ITOs reported addressing physical activity in their nutrition education sessions. Nutrition Education Formats For both WIC State Agencies and ITOs, the most frequently used nutrition education format was printed materials, such as brochures, pamphlets, fact sheets, calendars, day planners, and food/activity diaries (99%). Other popular formats included one-on-one nutrition education counseling sessions (97%), as well as bulletin boards and other educational displays in the waiting room (89%). In addition, 82 percent of WIC State Agencies and ITOs reported showing nutrition education videos in clinic waiting rooms. More states are using web-based systems as a tool for WIC nutrition education: 26 percent have webbased interactive nutrition education, 26 percent have web-based nutrition materials, and 15 percent having web-based nutrition education in the waiting room. Access to Health Care and Social Services One of the WIC program’s essential functions is referring participants to other health care and social services. Survey results show that 97 percent of WIC State Agencies and ITOs required clinics to make specific health care referrals, including immunizations (94%); Medicaid (88%); prenatal, maternal, and pediatric care (82%); and dental care (48%).Similarly, 91 percent of State Agencies and ITOs required WIC clinics to make social services referrals, including Child Abuse and Neglect services (86%); the Supplemental Nutrition Assistance Program (formerly known as the Food Stamp program) (79%); TANF (68%); domestic violence programs (62%); and emergency food providers such as food pantries, food banks, churches, and other faith-based organizations (55%).


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Resources


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Outreach The Sustainable Outreach Toolkit, developed by the Oregon WIC State Agency, presents outreach strategies for local agencies to use. www.nal.usda.gov/wicworks/Sharing_Center/Sustainable_Outreach_Tool_Kit_OR.pdf. The North Carolina WIC program developed the “WIC Outreach: Guidelines for Building Media Relations” guide to help local agencies seize media opportunities. www.nal.usda.gov/wicworks/Sharing_Center/NCmediaguidelines.pdf. “Outreach Campaign: Checklist for Local WIC Agencies,” also developed by North Carolina WIC, provides local agencies with outreach strategies, including information on reaching various racial, ethnic, and cultural communities. www.nal.usda.gov/wicworks/Sharing_Center/NCoutreachandreferralchecklist.pdf. The Office of Minority Health at the United States Department of Health and Human Services has a factsheet that helps outreach workers connect communities of color to health services. www.omhrc.gov/assets/pdf/checked/Linking%20Minorities%20to%20Health%20ServicesSuccessful%20Strategies%20for%20Outreach%20Workers.pdf. The WIC Works Resource System provides information about WIC and service tools for nutrition professionals. www.nal.usda.gov/wicworks. The Institute for Social Research identified strategies for the California WIC program on how to reach underserved populations, including diverse racial/ethnic communities. Their findings are presented in “Reaching the Underserved and Improving WIC Services,” 2001. www.wicworks.ca.gov/research/ExecutiveSummary2001.pdf.

Nutrition Education The Food and Nutrition Information Center at the National Agriculture Library developed a “cultural and ethnic food and nutrition education materials” resource list for educators. www.nal.usda.gov/fnic/pubs/bibs/gen/ethnic.html. The National Heart, Lung, and Blood Institute at the National Institutes of Health provides healthy recipes for African Americans and Latinos. “Heart-Healthy Home Cooking, African American Style” http://rover.nhlbi.nih.gov/health/public/heart/other/chdblack/cooking.pdf “Delicious Heart Healthy Latino Recipes” (English and Spanish) http://www.nhlbi.nih.gov/health/public/heart/other/sp_recip.pdf The Center for Weight and Health at the University of California, Berkeley produced two brochures providing information about healthy Korean and Vietnamese food options. “Vietnamese Foods, Healthy Food Options: What to Eat More of and What to Eat Less of.” (English and Vietnamese) http://nature.berkeley.edu/cwh/PDFs/CWH_English_vietfood.pdf “Korean Foods, Healthy Food Options: What to Eat More of and What to Eat Less of.” (English and Korean) http://nature.berkeley.edu/cwh/PDFs/CWH_English_koreanfood.pdf


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The Office of Minority Health at the United States Department of Health and Human Services developed a guide to help health organizations decrease language barriers and improve access to services for persons of limited-English-proficiency. www.omhrc.gov/Assets/pdf/Checked/HCLSIG.pdf. More Than Words Toolkit Series, a resource developed by Hablamos Juntos with support from the Robert Wood Johnson Foundation, clarifies the translation process and provides a roadmap to help health care organizations improve the quality of their translated materials in order to get better results. http://www.rwjf.org/pr/product.jsp?id=39591 U.S. Department of Health and Human Services Guide to Health Literacy offers helpful information on cultural competency for service providers. http://www.health.gov/communication/literacy/quickguide/Quickguide.pdf

The WIC Program The Food Research and Action Center has WIC advocacy and program information, as well as WIC contact lists. www.frac.org. The United States Department of Agriculture, Food and Nutrition Service provides detailed information on WIC. www.fns.usda.gov. The National WIC Association offers WIC information, a calendar of WIC events, and services for members throughout the United States. www.nwica.org.


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USDA WIC Nutrition Services Standards: Cultural Competency Components Nutrition Assessment • State agency ensures that standardized dietary assessment procedures are used consistently statewide by all local agencies. These procedures include an assessment of participant diet and feeding practices at time of certification and other requirements. •

State agency ensures that medical/health/economic/social information is collected and assessed at the time of certification ensuring participants’ privacy and confidentiality.

Nutrition Education • Content of nutrition education considers participants’: Nutritional needs/interests, household situation, and cultural preferences Language spoken and literacy level Religious values •

Local agency provides nutrition education that is: Family-centered Responsive to participant needs

Evaluation • State and local agencies use written criteria to evaluate nutrition education and breastfeeding promotion and support materials. The criteria for evaluating these materials should address: Language to ensure its appropriateness for the participant population Literacy level to ensure its appropriateness for the participant population Content to ensure its accuracy and its relevance to participants Graphic design that reflects the participant population (i.e. ethnic/cultural background, developmental stages, etc.) •

Appropriate methods to deliver nutrition education should be evaluated considering participants’: Ages Nutritional needs Preferences Culture Lifestyle

Breastfeeding Promotion and Support • State agency develops guidelines for ongoing training that includes all clinic staff and includes culturally appropriate breastfeeding promotion strategies WIC Supplemental Foods and Food Packages • State agency uses appropriate criteria for selecting and authorizing WIC foods, including cultural or religious considerations whenever possible. Program Outreach and Marketing • State and local agencies should use marketing strategies to promote participation in WIC using materials designed and outreach conducted with consideration for language and cultural needs of participants. FRAC Summary Source: USDA’s Nutrition Services Standards www.fns.usda.gov/wic/benefitsandservices/rqns.htm Making WIC Work for Multicultural Communities: Best Practices in Outreach and Nutrition Education

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USDA WIC Value Enhanced Nutrition Assessment: Cultural Competency Components Key Steps in the Process of WIC Value Enhanced Nutrition Assessment • Collecting the Relevant Information: When selecting methods to collect relevant information, the WIC state agency should consider such factors as: What are the issues/needs of the participant? What method should be used to obtain the information – oral, written, other, and/or some combination of these methods? • Clarify and Synthesize the Information that has been Collected: Critical thinking necessitates the collection of all information prior to deciding upon the best course of action, including social/cultural information. • Identify the Pertinent and Appropriate Risks and Other Related Issues (such as cultural preferences, environmental factors, etc.): This is crucial when planning personalized nutrition interventions that will improve the health status and influence behavior. Dietary Assessment is Essential to a WIC Nutrition Assessment • WIC personnel may ask about appetite, favorite foods, and cultural food preferences, rather than quantify ounces or servings. • Other cultural/personal information that may be collected includes: frequency, amount, and type of feedings offered; food preferences or aversions. • Variables, such as knowledge, attitudes, beliefs, and family and community environment, affect food consumption and should be addressed. • Environmental and family factors to consider include: Migrant status – food preparation and storage equipment Food security – availability of safe and nutritious food Feelings on breastfeeding/breastfeeding support Usual meal pattern Activity level/feelings about the need for physical activity Essential Staff Competencies for WIC Nutrition Assessment • Multicultural awareness is an important component of WIC nutrition assessment: WIC staff are required to understand how sociocultural issues (race, ethnicity, religion, group affiliation, SES, and world view) affect nutrition and health practices and nutrition-related health problems. Factors to consider include: • Cultural groups in the target population including their families and communities, values and beliefs, characteristics, and resources: Respects different belief systems about issues such as blood-work, immunizations, dietary supplements, alternative medicine, and traditional healers Evaluates cultural practices for their potential to harm the client’s health or nutritional status • Cultural eating patterns and family traditions such as core foods, traditional celebrations, and fasting: Assesses eating patterns Evaluates food selection and preparation within a cultural context • Differences in communication styles between groups and how these differences may impact the assessment process: Uses translation services appropriately Uses culturally appropriate strategies to assess breastfeeding practices and beliefs FRAC Summary Source: Value Enhanced Nutrition Assessment (VENA) in WIC www.nal.usda.gov/wicworks Making WIC Work for Multicultural Communities: Best Practices in Outreach and Nutrition Education

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