California WIC Participants' and Local Agency Directors' Experiences during the Coronavirus Disease 2019 Pandemic: A Qualitative Examination.

BACKGROUND: The US Department of Agriculture granted waivers to allow flexibility in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) operations during the coronavirus disease 2019 (COVID-19) pandemic; however, research examining the associations between waiver introduction and changes in perceptions, practices, and challenges of WIC participants' and agency directors' experiences is limited.
OBJECTIVE: The objective of this study was to assess California WIC participants' and agency directors' perceptions and practices of remote WIC services during the COVID-19 pandemic. A secondary aim was to understand other COVID-19 challenges related to maintaining access to healthy foods by WIC participants.
DESIGN: A qualitative study that included semistructured interviews was conducted between June 2020 and March 2021. PARTICIPANTS AND
SETTING: One hundred eighty-two WIC participants with a child aged 0 to 5 years from three regions of California (Southern, Central, and Northern) and 22 local WIC agency directors across the state were interviewed. MAIN OUTCOME MEASURES: WIC participants' and agency directors' perceptions, practices, and other challenges during COVID-19. STATISTICAL ANALYSES PERFORMED: Interviews were recorded, transcribed, and analyzed using a grounded theory approach.
RESULTS: Participants shared that they valued the information received from WIC and were very satisfied with remote WIC services. Participants reported that enrolling in WIC remotely was easier than coming in person. All waivers and changes to WIC operations, namely the physical presence, remote benefit issuance, and separation of duties waivers, and remote work and remote delivery of nutrition education, were largely viewed by WIC agency directors as options that should be continued postpandemic. Further, a majority (63%) of households reported experiencing food insecurity, and half of respondents received food from a food bank or pantry during the pandemic.
CONCLUSIONS: Findings suggest WIC will attract and retain the most families by offering a hybrid model of services, incorporating both onsite services and remote options to work more efficiently and effectively.

The global coronavirus disease 2019 (COVID-19) pandemic has economically impacted many communities in the United States, further negatively influencing health outcomes. , Food insecurity rates among US families with children also increased from 13.6% in 2019 to 14.8% in 2020, emphasizing the need for food and nutrition assistance programs for low-income families. The burden of food insecurity has disproportionately influenced certain populations. For example, food insecurity increased more in low-income minority households of Hispanic individuals (48%) and Black individuals (50%) in comparison to those of White individuals (32%).

Research Question: What were perceptions, practices, and challenges of California Special Supplemental Nutrition Program for Women, Infants, and Children participants and agency directors during the coronavirus disease 2019 pandemic?

Key Findings: Findings suggest the California Special Supplemental Nutrition Program for Women, Infants, and Children will attract and retain the most families by using a more flexible hybrid model, incorporating both onsite services and remote options to work more efficiently and effectively.

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is the third largest US Department of Agriculture (USDA) nutrition assistance program serving approximately 6.2 million participants during fiscal year 2020. According to federal guidelines, WIC supports low-income, nutritionally at-risk pregnant and postpartum women, infants, and children up to age 5 years. Before the COVID-19 pandemic, participants in WIC typically visited a local WIC clinic at least quarterly to receive nutrition education and/or breastfeeding support, referrals to other health and social services, and monthly benefits for healthy foods. Benefits redeemable for supplemental healthy foods with approved vendors are provided to participants on electronic benefits transfer cards (WIC Card) monthly, and a companion telephone app helps participants understand and redeem their benefits. To enroll in WIC, women, infants, and children were required to be physically present at a WIC site to certify eligibility (eg, present identification, proof of address, and income information) and determine nutrition risk (eg, provide blood work, weight and height/length values, and complete a dietary assessment). Annually, eligible participants would be re-evaluated in person to continue on the program.

In response to the COVID-19 pandemic, the US Families First Coronavirus Response Act gave the USDA authority to grant federal waivers to allow states to implement alternatives to in-person service delivery, which included remote services. , Starting in March 2020, these changes allowed states to waive participant physical presence for certification and recertification. In addition, the separation of duties requirement that at least two WIC employees must work on a single certification appointment was also waived. States were allowed to extend certification periods for children, issue food benefits remotely, and allow substitute food options. Food package substitutions allowed WIC participants to obtain alternatives to WIC-approved foods. Local WIC offices were able to utilize these operational changes to enable staff to work remotely, remotely issue benefits, and provide virtual education on use of the WIC Card and app, nutrition, and breastfeeding support. States took various approaches to adopting these federal waivers, with limited research evaluating the influence of waiver flexibilities on WIC participants and agency directors during COVID-19.8, 9, 10, 11 For example, an evaluation of WIC’s transition to remote services in Washington State revealed that both participants and staff were satisfied with remote services and would prefer a hybrid service postpandemic. In Tennessee, WIC participants reported difficulties with increased food prices and with redeeming benefits due to the lack of WIC foods in grocery stores.

In March 2020, California’s governor issued an order requiring individuals to remain at home as much as possible. As a result, local WIC clinics in California adopted all of the federal waivers and shifted to primarily remote service delivery. Whereas current literature has highlighted the influence of COVID-19 on WIC participants, there remains a dearth of research on WIC households in diverse populations. One study in Los Angeles County found that WIC participants were also satisfied with remote pandemic services; however, agency director perspectives were not evaluated, which is necessary for assessing feasibility of long-term adaption to remote changes.

Thus, understanding California WIC participant experiences is integral to reaching an understanding of the national WIC participant population experience during COVID-19 because California serves more WIC participants than any other state, has among the highest rates of poverty, and includes among the most racially and ethnically diverse populations. Therefore, the objective of this study was to assess California WIC participants’ and agency directors’ perceptions and practices of WIC services during the COVID-19 pandemic. A secondary aim was to understand other COVID-19 challenges related to maintaining access to healthy foods by WIC participants.

Methods

The study was reviewed and approved by the California Health and Human Services Agency and the University of California, Davis Institutional Review Boards. WIC participants and agency directors provided verbal consent to participate in the study.

WIC Participant Interviews

It was decided a priori to interview WIC participants with children, whose program eligibility is defined by federal guidelines, from three regions in California: Southern California, Central Valley, and Northern California (∼60 from each with half English-speaking and half Spanish-speaking). These regions were selected because of variation in urban and rural locations, as well as small and large WIC agencies, which could have contributed to differences in operational challenges during the pandemic. In May 2020, 200 caregivers with a child aged 0 to 5 years participating in WIC were randomly selected from administrative records of families served in Los Angeles County. Inclusion criteria included that participants: were aged 18 years or older, were not a foster child, spoke English or Spanish, had a telephone number in WIC records, and had a child participating in WIC. Caregivers were stratified by primary language (n = 100 English and n = 100 Spanish) and whether or not they had been on WIC before the pandemic or had joined WIC since March 2020. Of 200 participants, the first 110 were invited by text message to participate in an interview until 60 interviews were completed in June and July 2020. A similar protocol was followed with WIC participants from the Central Valley and Northern California. Of 200 WIC participants randomly selected from administrative records in the Central Valley, 148 were invited by text to participate until 60 interviews were completed in September and November 2020. Of 200 WIC participants randomly selected from Northern California, 120 were invited by text to participate until 62 interviews were completed in March 2021 (two additional WIC participants were interviewed because they had been scheduled before the 60 mark was reached). This led to a total of 182 WIC participants.

Interview questions were developed to assess WIC participants’ experience and satisfaction with remote interactions, enrollment, or recertification in WIC, and other potential challenges during COVID-19, such as shopping for WIC foods, including the expanded food options. Food insecurity was assessed using the 2-item screener derived from the USDA 18-item Household Food Security Survey. Demographic information, including race and ethnicity and education level were self-reported by participants. The semistructured interview included a combination of multiple-choice, yes/no, and open-ended questions (see Figure 1, available at www.jandonline.org). The instrument was programed into Qualtrics and pilot-tested by research staff. All interviews were conducted by telephone in Spanish (by one researcher) or English (by three researchers), recorded, transcribed and, if conducted in Spanish, translated into English. Interviewers captured responses to close-ended questions using Qualtrics. Each interview took 20 to 45 minutes to complete. Each respondent received a $25 gift card after completing the interview.

Figure 1

Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participant interview guide. COVID = coronavirus disease 2019.

WIC Local Agency Director Interviews

In October 2020, invitations were emailed to all California WIC agency directors (n = 83) with the goal of interviewing approximately 20 WIC agency directors. Of the 29 directors who volunteered, 22 completed interviews in November and December 2020. Interview questions were developed to assess challenges operating WIC during the COVID-19 pandemic, what was done to overcome those challenges, and which waivers and other adaptations agency directors would like to see continued post-pandemic. Specific topics included how the agencies adapted to the changes associated with the USDA waivers (eg, physical presence, extended certification, remote benefit issuance, food package substitutions, and separation of duties) and other changes that resulted from the pandemic (eg, remote work, auto-issuance of benefits by state, remote education, and breastfeeding support). Race and ethnicity, sex or gender, and age information for WIC agency directors were not collected. The structured interview included a combination of multiple-choice and open-ended questions (see Figure 2 available at www.jandonline.org). The instrument was programed into Qualtrics, checked for appropriate skip patterns, pilot-tested with one WIC agency director, and then language was modified for clarity as needed. One researcher conducted all local agency director interviews by videoconference in English. Each interview took 1 to 1.5 hours to complete and was recorded. Responses to open-ended questions were transcribed.

Figure 2

Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) agency interview guide. COVID-19 = coronavirus disease 2019.

Data Analysis

WIC participant responses to close-ended questions were summarized with descriptive statistics (SAS version 9.4). Responses to open-ended questions from WIC participants and agency directors were transcribed to capture quotes and coded using Dedoose (version 9.0.17). The research team determined that the themes arising in WIC participant responses were repeated in the agency director interviews, and deemed saturation was met. Interviews were transcribed by either the interviewer or one of three other researchers. Consistent with grounded theory, the data were used to develop codes rather than the codes being identified a priori. The steps of analysis were based on Braun and colleagues as follows: became familiar with the data by reviewing collectively, generated initial codes and applied them to recorded interview transcripts for each topic area, examined all quotes associated with each code and organized codes into themes, refined themes by having both the initial and second coder independently examine all initial codes and quotes associated with a theme and revise as needed to reach consensus, and selected quotes to exemplify each theme. One researcher, who did not conduct interviews, reviewed the written transcripts to identify preliminary themes within each topic area and then identified quotes to illustrate each theme. All transcripts were coded sequentially by type (WIC participant or WIC agency director). Each statement, which could include multiple sentences, was coded individually. The researchers deemed that saturation had been reached and that no further interviews were needed when no new themes emerged when coding the final interviews within each group.

During May 2021, 30 agency directors invited from the study were sent the draft report and invited to attend a 2-hour virtual meeting and provide written feedback. Themes from the WIC agency director input on the USDA waivers and other changes were then summarized and feedback on the research findings was obtained from 20 WIC stakeholders, including four agency directors, two WIC participants, and 14 WIC researchers and advocates. Stakeholders were asked to reflect upon the findings and revise, clarify, and/or confirm the researchers’ interpretation.

Results

WIC Participant Demographic Characteristics

Of the 182 total respondents, half completed the interview in English and half in Spanish (Table 1 ). Most respondents were on WIC before the pandemic (n = 126; 69%); 56 had enrolled in WIC in March 2020 or later. The majority (85%) were Hispanic, had a high school education (41%) or higher (32%), and had a median of 2.0 children (median on WIC = 1.0). One-quarter (26%) currently participated in the Supplemental Nutrition Assistance Program and three-quarters (75%) participated in Medicaid. Relatively few received Temporary Assistance for Needy Families (4%) and 11% applied for Pandemic-Electronic Benefit Transfer (P-EBT) and 44% received P-EBT due to automatic enrollment.

Table 1

Characteristics of California Special Supplemental Nutrition Program for Women, Infants and Children (WIC) participants by language

Characteristic	Total (N = 182)	English speaking (n = 91)	Spanish speaking (n = 91)
	←n (%)→
Race/ethnicitya
Asian	7 (3.9)	7 (7.7)	0 (0.0)
Black	3 (1.7)	3 (3.3)	0 (0.0)
Hispanic/Latino	153 (85.5)	65 (71.4)	88 (100.0)
White	13 (7.3)	13 (14.3)	0 (0.0)
Otherb	3 (1.7)	3 (3.3)	0 (0.0)
Education
Eighth grade or less	23 (12.6)	2 (2.2)	21 (23.1)
Some high school	26 (14.3)	8 (8.8)	32 (35.2)
High school graduate/GED	74 (40.7)	32 (35.2)	42 (46.2)
Some college/trade school/associate degree	41 (22.5)	37 (40.7)	4 (4.4)
Four-year college graduate	15 (8.2)	10 (11.0)	5 (5.5)
Postgraduate/professional degree	3 (1.7)	7 (2.2)	1 (1.1)
	←mean (SD)→
No. in household
Children	2.3 (1.1)	2.2 (1.1)	2.4 (1.1)
Adults	2.6 (1.4)	2.4 (1.3)	2.8 (1.5)
Children in household on WIC	1.3 (0.5)	1.3 (0.6)	1.2 (0.5)
Woman in household on WICc (n = 73)	1.0 (0.1)	1.0 (0.2)	1.0 (0.0)
	←n (%)→
Supplemental Nutrition Assistance Program participationd
Before COVID-19e pandemic	47 (25.8)	28 (90.3)	19 (86.4)
Newly applied since COVID-19 pandemic	31 (17.0)	14 (66.7)	17 (56.7)
Temporary Assistance for Needy Families participationd
Before COVID-19 pandemic	8 (4.4)	8 (72.7)	0 (0.0)
Newly applied since COVID-19 pandemic	9 (5.0)	4 (16.7)	5 (15.2)
Medicaid participationd
Before COVID-19 pandemic	136 (74.7)	64 (95.5)	72 (98.6)
Newly applied since COVID-19 pandemic	15 (8.2)	6 (66.7)	9 (69.2)
Other programs applied for since start of COVID-19 pandemicd
Pandemic-EBTf	20 (11.0)	8 (32.0)	12 (36.4)
Free or reduced price school mealsg	12 (6.6)	4 (16.0)	8 (24.2)

The following race and ethnicity options were offered: American Indian or Alaskan native, Asian, Black or African American, Hispanic or Latino, Pacific Islander, White, or Other, with the option for the respondent to self-specify. Respondents could select all that applied.

‘Other’ includes Pacific Islander, American Indian/Alaska Native, or other ethnicities not specified.

Reflects Central and Northern California only; data not available for Southern California participants.

The coronavirus disease 2019 pandemic was declared a national emergency in the United States on March 13, 2020. At the time of writing, the national emergency declaration has not expired.

COVID-19 = coronavirus disease 2020.

Refers to federal food program enacted in response to the COVID-19 pandemic, providing temporary emergency nutrition benefits to select groups of families with children. More information is available at https://www.cdss.ca.gov/home/pandemic-ebt.

Refers to federally assisted meal programs providing nutritionally balanced, low-cost or free breakfast and/or lunch to children each school day. More information is available at https://www.fns.usda.gov/programs.

Satisfaction with Remote Enrollment and Appointments

Among the new enrollees, about half joined WIC for the first time during the pandemic; the other half returned to WIC after a gap in participation:

(We enrolled in WIC) because we needed the help. It was getting very expensive to buy milk and just everything because the kids were not in school anymore. So having them at home 24/7 was increasing my expense for goods like milk and everything they would get at school. –English-speaking participant (P030)

When asked how hard or easy it was to apply to WIC, respondents brought up how easy and quick the enrollment process was. Most participants reported being comfortable (88%) providing proof of income, a requirement for WIC enrollment, remotely:

“This time it was the easiest. It was excellent. It was easier [compared with enrolling in other programs].”–Spanish-speaking participant (P173)

Respondents also talked about how helpful WIC staff members were during enrollment. Several respondents brought up the convenience of remote enrollment compared to in person because of transportation, scheduling, or child care constraints:

I actually found it (WIC appointments) much…easier (than in the past) because I didn't have to go into the office…especially if you can't find a babysitter. So I found it more convenient for me, because I have such a busy schedule because of school. It works perfectly for me. –English-speaking participant (P017)

For all participants in the study, the most helpful ways that participants received information during the pandemic were by telephone call (selected by 87% of respondents), and text (75%). Several indicated that they preferred remote over in-person interactions. However, some participants acknowledged challenges with only interacting remotely, including missing weight checks or blood work used for assessing nutritional risk and other interactions with WIC staff.

WIC Local Agency Director and Site Characteristics

The agency directors interviewed had worked at WIC for an average of 18 years. Agency sizes ranged from small (serving under 500 WIC participants per month) to very large (more than 60,000 per month) mirroring the distribution of agency caseloads statewide. Many WIC agencies (n = 13) responded by offering only virtual services. Of the nine agencies that continued some in-person visits, most were for an occasional walk-in visit (a participant presenting unscheduled with a question or problem), breast pump pick up (WIC provides electronic pumps to breastfeeding women), or breastfeeding support for new mothers. In terms of staffing, more than half of the agencies (n = 12) used a hybrid model where some WIC staff worked onsite, whereas other worked remotely, which allowed staff more flexibility in caring for their children while schools and child care were closed. Six agencies continued to have all staff work onsite, whereas four agencies transitioned to having all staff work at home.

WIC Certification and Recertification during COVID-19

A summary of the themes from the WIC agency director input on the USDA waivers and other changes is summarized in Table 2 . During the pandemic, WIC participants in California were primarily certified or recertified over the telephone. Agencies mainly used e-mail with participants to send or sign documents; other electronic methods included text and fax. About half of the agencies also had participants come in-person to WIC clinics for certification appointments and half allowed participants to drop off documents curbside. Remote certification was viewed as the WIC service during COVID-19 hardest to implement compared with other changes, with only one director saying that nothing was hard about remote certification. Despite the initial challenges of remote certification, all but one agency director wanted to continue to have the option to certify participants remotely, even after it would be safe to reopen WIC clinics fully:

Table 2

California Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) agency director input on US Department of Agriculture waivers and other remote operation changes during coronavirus disease 2019 (COVID-19) (N = 22)

Change	Advantages	Considerations	Future needs if continued
Federal waivers
Physical presence for enrollment/ recertification	• Participant convenience • Better access to some participants • Operational efficiency	• Difficult to get height/weight, bloodwork	• Videoconferencing option added to telephone and other remote and in-person methods • Share data across social services
Extended certification for children	• Flexibility in face of extenuating circumstances	• Participant confusion when family members on different schedules • Additional staff tracking	• State guidance on when to use
Remote benefit issuance	• Participant convenience and retention • Frees staff time for other needs	• Postal delays in new WIC cards • Benefit errors not noticed by participants • Participants unaware of foods allowed and not yet purchased	• WIC app improvements for participant benefit trackinga
Food package substitutions	• Participant flexibility • More cultural options	• Confusing to participants and vendors early on	• Clear communication to participants and vendors
Separation of duties	• Customer service, less participant wait times • Operational efficiency	• Possibly less quality assurance	• Use of new WIC Management Information System reports for fraud monitoring
Other remote operational changes
Remote staff work	• Staff flexibility, productivity, and job satisfaction • Reduced space costs	• Supplies/equipment needed	• State guidance on how to operationalize remote staff work (eg, when, who, how) • Technology upgrades
State auto-issuance of benefits	• Ensures participants get benefits • Frees staff time for other needs	• Package errors • Less participant engagement • Lower redemption by some participants	• WIC app notification when benefits are issued • More staff training and communication to participants • Families issued together
Remote education on use of WIC card/app	• Participant convenience	• Easier to demonstrate in-person to participants who are not as tech savvy	• Videoconferencing option added to other methods • Improved state telephone center that participants can contact with issues
Remote nutrition education	• More engagement of some participants • Participant convenience • Better access to educational materials	• Less engagement for some participants • More staff time with loss of group classes	• Videoconferencing option added to other remote and in-person education
Remote breastfeeding support	• Participant convenience, particularly for mothers of newborns	• Less suitable for some breastfeeding issues	• Videoconferencing option added to other remote and in-person individual and group support

Implemented by the state after this study was conducted.

It's more convenient for the participants. They seem happier when they can do it (certify/recertify) at home. They don't have to grab the kids, travel down to the office, sit in the waiting room. It can be very hectic for them. And we don't really have their attention when we're trying to counsel them. But when it's at home, they're more relaxed and they're just happier. –AD15

The no show rate is definitely lower, doing it remotely. When we had appointments in the clinic every day, the no show rate was so high for certification appointments, mid certification appointments, and now when we're doing services remotely we’re able to get a hold of probably 90% of our appointments. –AD16

With remote certification, agency directors suggested that technology that augments the ability to conduct appointments by videoconference could make the process even easier. Extending the certification period for children was considered relatively easy by the 10 agency directors who implemented it, and six of the 10 directors stated that they would not do anything differently if they could implement extended certification periods in the future. Six of the 10 agencies that implemented the extended certification waiver said that they would like to continue to have it as an option, particularly for children who were not at high risk.

Remote Benefit Issuance and Food Package Substitutions

Remote benefit issuance was viewed as easier to implement during COVID-19 compared with other federal waivers. More than one-third of directors said that nothing was hard about remotely issuing food benefits and more than half said that they would not do anything differently from what they had done during the pandemic. Despite initial difficulties getting WIC cards to participants due to issues with mail, all 22 agency directors wanted to continue to have the option of issuing food benefits remotely. Directors cited the convenience of the process for both WIC participants and WIC staff.

With regard to remote benefit issuance, the most common challenges reported by agency directors involved having to rapidly learn a new process, as well as dealing with food benefit errors that went unnoticed when not having access to information that had previously been printed on the physical checks for WIC foods. Fourteen agencies also reported implementation challenges with the food package substitutions, most notably the challenges faced by participants and vendors in understanding the allowable substitutions and allowing the purchases to go through at the point of sale.

Overall, WIC agency directors reported that clinics were successfully able to pivot to remote operations due to the USDA waivers. The WIC Division was proactive in providing support and guidance to agencies, including weekly statewide calls for all local agency directors, as well as enacting the waivers rapidly, which allowed local agency directors to learn quickly how to deliver WIC services remotely. One agency director stated:

COVID has brought WIC into the modern era. WIC was this antiquated program that was so onerous about coming to the site and then they (participants) had to sit and wait…. So just the flexibility and the ease of participating in WIC that has happened because of remote services is such a gift, and we should never give it up. –AD04

COVID-19 Challenges Related to Maintaining Access to Healthy Foods

More than one-quarter (29%) of WIC participants reported having less income due to reduced wages or work hours or job loss. Fewer than half of those with lost income (43%) applied for paid sick leave, wage replacement, or unemployment benefits. Such income protections were less often available to Spanish-speaking (28%) than English-speaking (59%) respondents. A majority of respondents (63%) reported household food insecurity, and half of all respondents had received food from a food bank or pantry during the pandemic. Among those who had used the emergency food system, most (76%) said the first time doing so was during the pandemic. Pandemic-EBT was described as being extremely helpful during a time of great need:

[Pandemic-EBT] really helped us a lot because it was at the time that we had no money, no job, or unemployment. It still hadn't come. Because what they gave them [children] from school was too difficult for me because I don't have transportation to go daily to pick [it] up. –Spanish-speaking participant (P064)

With children learning from home instead of in person at school, families were often required to provide more meals. More than half of families (53%) had received school meals for their school-age children before the pandemic. Slightly more than one-third (39%) continued to receive school meals. Among those receiving school meals, the majority (93%) were very or somewhat satisfied with the school meal program.

I think it's very convenient that they just have it like a drive-through, you don't have to get out with the kids in the car and honestly I think everything about it is very convenient. –English-speaking participant (P002)

Although many participants experienced limited resources, many stocked up on staples early on in the pandemic (reported by 41% of respondents) due to concerns about shortages and to reduce shopping trips and potential COVID-19 exposure. The respondents who stocked up on food reported purchasing quantities sufficient for up to 2 weeks (41%) or longer (42%) at a time. Others reported that they would have liked to purchase more staples but were unable because of food shortages in stores:

Yes, (we stocked up on food) for fear that there is no longer anything at the market. It has already happened to us. What we looked for we haven’t found. –Spanish-speaking participant (P179)

Compared with before the pandemic, most families purchased either the same amount (48%) or more (47%) shelf-stable foods during the pandemic. For most households, purchase of fresh fruits and vegetables during the pandemic did not change (57%) or increased (38%). About one-third (30%) reported challenges finding WIC foods, more often at grocery stores than at WIC-only stores, but primarily at the start of the pandemic. Among those who reported challenges finding WIC foods, the most common shortages were for cow's milk (64%), eggs (33%), and fresh fruit (33%).

The beginning was really difficult. A lot of the places didn't have all the [WIC] items and I had to just skip out on stuff for the month. –English-speaking participant (P133)

Discussion

When the COVID-19 pandemic was declared a national emergency, WIC operations across the country quickly transitioned to provide remote services as permitted through USDA waivers, in essence allowing the program to test new and innovative approaches. This is the first study to evaluate both California WIC participants’ and agency directors’ perceptions regarding what worked well and what challenges remained during COVID-19 to inform enhancements to the WIC program service model. This study utilized a qualitative approach by interviewing 182 WIC participants and 22 local agency directors, analyzing responses and translating them into themes, then obtaining feedback from participants on the research findings. This approach to share research results with WIC stakeholders was to ensure findings were consistent with the experiences of agency directors and participants, a method that has been shown to be successful in the past for using research findings to inform policy. This also allowed for multiple perspectives to be engaged in the process and yielded recommendations that were both participant- and director-centered. In addition, the study design to evaluate WIC participants and agency directors’ perceptions and practices to changes to WIC services during the COVID-19 pandemic in a time-sensitive manner was only possible because of the longstanding collaborative partnership between a university partner and a WIC local agency.

Based on findings from the agency interviews, all waivers and changes to WIC operations, particularly the physical presence, remote benefit issuance, and separation of duties waivers, and remote staff work and remote delivery of nutrition education, were largely viewed as options that should be continued postpandemic. Overall, agency directors felt that WIC will attract and retain the most families using a more flexible hybrid model. Findings from the participant interviews also indicated comfort with remote enrollment and education processes. These findings that remote services have been well received by WIC participants and would benefit participants to maintain a hybrid model in the future are consistent with two other states, Tennessee and Washington, and Los Angeles County, that evaluated WIC participant experiences throughout the COVID-19 pandemic. , , The Tennessee study evaluated 24 WIC participants’ experiences during the early part of the pandemic and found that the carryover of WIC flexibilities, such as physical presence and food package substitution waiver, would improve WIC program participation. These findings are also consistent with a study of 52 Washington WIC staff and 40 WIC participants that found that both participants and staff were satisfied with remote services during the pandemic. Finally, this study is consistent with a study of 246 Los Angeles County WIC participants that found high levels of satisfaction with remote service delivery, 25% of participants preferring all WIC services remaining remote with 75% desiring some in-person contact with WIC after the pandemic. However in the study by Ventura and colleagues, only Los Angeles WIC participants were interviewed with a child between 1 and 2 years, whereas in the current study, WIC participants and agency directors from three different regions in California provided a more balanced perspective on experiences and challenges utilizing WIC services during the COVID-19 pandemic.

In addition to changes to WIC services during COVID-19, the pandemic presented WIC participants with challenges related to accessing healthy foods. For example, WIC participants reported high rates of food insecurity and many received food from a food bank or pantry during the pandemic, which was also seen in a cross-sectional study of US households that found WIC participants experienced higher rates of food insecurity and food pantry use than non-WIC households. Challenges such as shopping for WIC-approved food items were further exacerbated as California WIC participants reported difficulty finding WIC staples at grocery stores early in the pandemic due to retail shortages. These experiences were consistent with WIC participants in Tennessee and Washington State. Further, government lockdowns and grocery store policies established to reduce the spread of COVID-19 caused unintentional consequences on WIC participants. For example, in Tennessee, WIC participants had trouble shopping with children due to limited patrons allowed in stores, whereas in this study, most California WIC participants were concerned about increased COVID-19 exposure during grocery trips.

In terms of WIC agency directors’ experiences during COVID-19, directors stressed the need for flexibility to reflect their diverse skills and serving different numbers of participants with varied needs. Moving forward, states and local agencies need to be attentive to how alternative methods work for various WIC participants and locations, which could influence WIC participation rates in the future. This includes updating WIC services to address diverse languages, technology access and capabilities, life stage and nutrition risk, and remote and rural locations. For example, in a recent study by Vasan and colleagues comparing how WIC participation differed before and during the pandemic in 40 states that offered in-person or remote benefit issuance, researchers found that remote benefit issuance was associated with increased WIC participation. In the current study, agency directors articulated that care is needed so as not to lose what makes WIC special because WIC provides not only food but also vital services and nutrition information to young families at a critical stage and is foundational to their continued health. Considerations and future needs were identified, such as offering videoconference for remote breastfeeding support and improved communication for WIC participants and vendors in regard to food substitutions, that can be used to ensure that the advantages of each waiver and other changes implemented during the pandemic can be equitable and sustained moving forward as permanent options in WIC. In addition, the findings suggest that many WIC participants may benefit from remote services because of additional barriers (eg, transportation, child care, and work) beyond risk of infection from COVID-19.

In summary, many lessons were learned during the COVID-19 pandemic by WIC agencies and WIC participants through the use of waivers, which were recommended by agency directors as permanent options for regular WIC operations long after the pandemic is no longer a concern. These changes could modernize WIC practices and improve the program moving forward, ensuring greater access and program retention so that low-income women, infants, and young children receive the proven health benefits of the WIC program. Agency directors were universally in favor of a hybrid model in which the waivers become permanently allowed, and utilization of remote services continues, in concert with a return to onsite services because they become safe to provide. They believed these options optimize participant service and equity and best meet the health and nutrition needs of modern-day WIC participants.

Overall, WIC agency directors felt strongly that permanent adoption of flexibilities will provide “more tools in the WIC toolkit,” thus allowing WIC to serve participants more effectively and efficiently. WIC participants, likewise, valued the additional flexibility and convenience of remote services. WIC has long individualized the content of nutrition education to meet the needs of each WIC participant. As such, WIC nutritionists and registered dietitian nutritionists should consider further individualizing WIC nutrition education by providing additional flexibility regarding mode of delivery—virtual or in-person.

Strengths and Limitations

This study adds to the limited literature on WIC participant and agency director experiences during COVID-19, and examined time-sensitive WIC operational changes that may influence the delivery of WIC services in the future. A limitation is that the study sample included a random sample of WIC participants from three regions of the California and all local agency directors in the state were invited to participate in interviews; however, bias may have resulted from differential response rates. Another limitation is that whereas race and ethnicity and education level were self-reported by WIC participants, this study did not collect race and ethnicity, sex or gender, and age information for WIC agency directors, which may contribute to an individual’s attitude, perception, and perspective related to COVID-19. Further, participants who were willing to respond to a text invite to participate in the study and participate in a telephone interview may be more willing to participate in remote services than other participants who prefer in-person services. Interviews were conducted by researchers not affiliated with WIC to minimize social desirability bias; however, some interviewees may have been reluctant to share all of their opinions. Further, qualitative techniques such as reflexivity and confirmability were not used; however, a triangulation approach was used by counting similar responses to corroborate findings and a subset of WIC participants and agency directors provided feedback on the findings to confirm correct interpretation. Finally, food insecurity rates may appear higher compared with other studies since this study captures any food insecurity over the past year and uses the 2-item screener vs the USDA 18-item Household Food Security Survey.

Conclusions

This study examined experiences of WIC families and agency directors during the COVID-19 pandemic in California. Moving forward, a hybrid model pairing remote with onsite services will permit WIC agency directors to work more efficiently and effectively, putting time and attention where most needed. Moreover, providing remote options removes barriers to WIC participation, creating more equitable access by increasing participant-centered, convenient services. Study results provide timely insights to inform lasting improvements to the WIC program that can benefit both agency directors and participants, potentially increase participation in WIC and retention of eligible families, as well as inform preparedness for future crises.