- Email: [email protected]
Fit WIC: Attitudes, Perceptions and Practices of WIC Staff toward Addressing Childhood Overweight
RESEARCH BRIEF
Fit WIC: Attitudes, Perceptions and Practices of WIC Staff toward Addressing Childhood Overweight Elena Serrano, PhD1; Emily Gresock, MS2; David Suttle, MD3; Adrienne Keller, PhD4; Elizabeth McGarvey, EdD5 ABSTRACT Objective: To assess the attitudes, perceptions, and practices of staff of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in providing nutrition education on childhood overweight topics with WIC participants. Design: Descriptive and correlational study. Setting: WIC clinics in Virginia. Participants: 106 employees working in direct contact with WIC participants. Mean Outcome Measure(s): Demographic information; comfort level and frequency of discussing childhood overweight-related topics with participants; perception of WIC’s ability to prevent and help address overweight among children and adults; body mass index (BMI); and attitudes toward personal weight. Analysis: Descriptive statistics, regression, and analysis of variance. Results: WIC staff in this study reported a lack of comfort, practice, and confidence in addressing and/or preventing childhood overweight with WIC participants, with differences existing based on job title (P ⬍ .05). Barriers to implementing programs included perceived attitudes of participants, transportation, time, cultural issues, and childcare. Staff BMIs were significantly correlated to ethnicity, age, feeling overweight, unhappiness with current weight, and comfort level discussing fruit and vegetable intake and physical activity (P ⬍ .05). Conclusions and Implications: Staff training, health promotion programs, and culturally relevant educational materials are warranted for WIC staff to build a strong knowledge base and promote self-efficacy about childhood overweight-related topics. Key Words: WIC, staff, overweight, attitudes (J Nutr Educ Behav. 2006;38:151-156)
INTRODUCTION As one of the key food and nutrition assistance programs in the United States, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) aims to “safeguard the health of low-income women, infants, and children up to age 5 who are at nutritional risk.”1 Partici1 Extension Specialist, Assistant Professor, Virginia Polytechnic Institute & State University 2 Former Nutrition Liaison, Division of WIC and Community Nutrition Services, Virginia 3 Department of Health Director, Office of Family Health Services, Virginia 4 Department of Health Associate Professor, University of Virginia 5 Associate Professor, Director, Division of Prevention Research, University of Virginia
Address for correspondence: Elena Serrano, PhD, Department of Human Nutrition, Foods, and Exercise, Virginia Polytechnic Institute and State University, Blacksburg, VA 24061-0430; Tel.: (540) 231-3464; Fax: (540) 231-3916; Email: [email protected]
©2006 SOCIETY FOR NUTRITION EDUCATION doi: 10.1016/j.jneb.2005.11.030
pant benefits include supplemental food packages, nutrition education, and referrals. To date, WIC has demonstrated several positive health and nutrition outcomes, including improvements in birth weights and iron-deficiency among infants.2,3 In the past few years, childhood overweight and adult obesity have been growing concerns in the United States.4,5 This trend has also been evident among WIC populations, with the proportion of overweight children participating in WIC increasing dramatically.6 In response, the Food and Nutrition Service (FNS), the agency of the U.S. Department of Agriculture (USDA) that administers WIC, added a new risk for program eligibility for infants and children, at-risk of becoming overweight. This risk criterion was established as a child at least 24 months old between the 85th and 95th percentile of body mass index (BMI) for age and gender, an infant born to a mother who was obese at the time of conception or during the first trimester or, for
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both children and infants, the existence of obesity in one or both parents.7 Additionally, the FNS awarded grants for a multistate project, titled Fit WIC, to identify opportunities for addressing childhood overweight in WIC clinics through a variety of mechanisms.8 The study reported here represents a component of the Fit WIC project that was conducted to assess the perceptions, attitudes, and practices of WIC staff in Virginia toward addressing key issues related to childhood overweight with clients. This study provides insight into the perceived capacity, challenges, and strategies of WIC to address this growing concern, from the perspective of staff. The results will, in turn, guide the development and pilot testing of staff development and wellness programs that include “front-line support staff.”
DESCRIPTION OF THE EVALUATION Subjects Of a total of 147 staff members, who were in attendance at the respective WIC clinics in all 11 health districts on a single day, 106 WIC staff completed and returned a hard copy questionnaire, for a response rate of 72.1%. All staff with direct contact or communication with WIC participants were eligible to complete the questionnaire. The study was reviewed by the Human Investigation Committee at the University of Virginia prior to its initiation and was exempt as an anonymous survey, with results to be used for educational purposes. Participation in the study was completely voluntary. Confidentiality was ensured by not requiring names or any form of personal identification to be included on the survey instrument. Completed questionnaires were returned to independent evaluators of the WIC program by fax or by mail.
Survey instrument A questionnaire, which included a combination of openand closed-ended questions, was developed specifically for this project by WIC staff working on the grant and university evaluators, because no comparable evaluation instrument existed. The questionnaire, which was developed immediately following focus groups with WIC staff, captured and formalized the key items from the focus groups, while taking into account staff perspectives and attitudes toward their jobs and childhood overweight. The questionnaire was found to have an excellent internal consistency of .852 (Cronbach’s alpha). Further, based on factor analyses, the first eigenvalue for the first principal component was 6.329 and described 42.7% of the variability, demonstrating the instrument’s effectiveness in capturing reliable and consistent responses. Questionnaire topics covered: attitudes about the participants’ own weight, such as if they felt they were overweight and if they were happy with their current weight; perceptions toward how comfortable they were in raising
specific topics or issues with parents related to childhood overweight, such as overfeeding; and practices related to actually “talking” to participants about nutrition, parenting, and physical activity. Suggestions for implementing childhood overweight prevention programs in their respective WIC clinics, based on perceived barriers, were elicited. Demographic information was also collected on age, gender, ethnicity, health district (region), job title, years of work experience with WIC, and highest level of education.
Weight status In order to determine if weight status influenced attitudes toward childhood overweight topics, WIC staff were asked to report weight (in pounds) and height (feet and inches). These data were converted to body mass index (BMI), using the BMI Index Formula.9 Weight status was determined by categories established by the Centers for Disease Control, with underweight defined as a BMI below 18.5, normal 18.5 to 24.9, overweight 25.0 to 29.9, and obese as 30.0 and above.10,11
Data analysis The following job titles were used, based on responsibilities and training: office support staff; nutrition assistants; nutritionists; nurses; and managerial staff. Office support staff determine residential, income, and categorical eligibility, print checks, and make appointments. Nutrition assistants require a high school diploma or equivalent, provide both administrative and technical support by helping with office tasks (similar to office support staff), and assist the nutritionist with nutrition assessment and education. WIC nutritionists have specific training in nutrition, with a minimum of a bachelor’s degree in nutrition or dietetics, and eligibility or current licensure as a registered dietitian. They perform health and nutrition assessments, along with nutrition counseling. As with nutritionists, WIC nurses assess medical and nutrition risk of clients, along with counseling. A bachelor’s degree in nursing is mandatory, along with state licensure. Managerial staff coordinate the operations of the clinic, as well as counsel clients upon demand. Statistical evaluation was performed using SPSS (SPSS, Inc., Chicago, IL). Frequencies and means were calculated for all closed-ended responses based on job title and weight status, with both variables assigned numerical codes. Percentages were also calculated, not including nonresponses. One-way analysis of variance (ANOVA) was used to determine differences between responses based on WIC job title, excluding managerial staff because of small cell sizes. Regression analyses were conducted to assess the significance of BMI with several demographic factors, including ethnicity, age, health district, and responses to questions. Open-ended responses were coded and given numerical responses. Frequencies were then calculated based on the
Journal of Nutrition Education and Behavior ● Volume 38, Number 3, May/June 2006
total number of responses, including multiple responses to each question.
LESSONS LEARNED Demographic information Respondents included nutritionists (30.3%), nutrition assistants (31.5%), office support staff (23.6%), nurses (10.1%), and managerial staff (4.5%). The subjects represented a broad range of work experience with WIC, with nearly one-quarter (22.9%) having less than three years of experience and 28.6% more than 10 years. All respondents were female, with the majority being white (70.7%), followed by African American (19.2%), Hispanic (6.1%), and “other” (4.0%), which included one Asian. Seven individuals did not report their ethnicity. Ages of respondents ranged from 23 to 64, with a mean age of 42.0. The highest percentage of individuals was in the age category of 40 to 49 years old (39.4%). Over half had at least a bachelor’s degree (51.9%). Job title was significantly correlated to level of education (P ⬍ .05), with senior level positions having higher levels of education, based on ANOVA.
Weight categories Of the 88 who provided weight and height information, BMIs ranged from 14.2 to 41.3, with a mean BMI of 24.7. Although over half of respondents, 58.0%, were considered normal weight, 3.4% were considered underweight, 26.1% overweight, and 12.5% obese. Based on Pearson correlations and univariate regression, BMI was positively associated with feeling overweight and being unhappy about their current weight, with 86.4% of staff who felt “somewhat” or “very much” overweight classified as overweight or obese and 78.9% of those unhappy with their current weight. BMI was also correlated (P ⬍ .01) to age and ethnicity. Mean BMI increased with age. Nearly two-thirds (63.6) of all respondents between 50 and 64 were classified as overweight. Significant differences were found between African American and white subjects, when excluding Hispanics and “other” from analyses because of small cell sizes. African American staff had over twice the rate of overweight (66.7%) than white staff (29.5%). When including all ethnic groups, African Americans had the highest mean BMI at 28.0 (SD ⫽ 5.42), followed by Hispanic, 27.0 (SD ⫽ 4.02), then white, 24.1 (SD ⫽ 4.32).
Comfort level in addressing childhood overweight topics Overall, WIC staff felt most comfortable about addressing fruit and vegetable intake and least comfortable about overweight or obesity with their participants, as shown by the mean scores in Table 1. All of the responses for this set of questions were significantly correlated to each other (P
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⬍ .01). Ethnicity, age, and length of experience with WIC did not significantly influence scores. Level of education was positively correlated (P ⬍ .05) to all responses. The effects of job title were also significant (P ⬍ .05). Although not included in the analyses, the managerial staff had the highest scores and the office support staff the lowest. Overall, underweight and normal weight WIC staff reported feeling more comfortable about childhood overweight-related topics. There were significant associations between BMI and comfort level about fruit/vegetable intake and physical activity (P ⬍ .05). Almost two-thirds (66.7%) of staff who reported being uncomfortable about discussing physical activity were overweight, and 54.5% of those respondents were uncomfortable with discussing fruit and vegetable intake. In both cases, there was a decline in mean comfort level with increasing BMI. Although not significant, obese staff had the lowest overall mean related to talking about overweight, 2.55, and underweight the highest, 3.33. Nevertheless, one-half of respondents who indicated they felt “very uncomfortable” or “slightly uncomfortable” were of normal weight.
Level of reported communication about childhood overweight topics WIC staff reported actually talking or communicating to WIC clients about nutrition the most, and parenting and overweight the least, as shown in Table 1. Over one-third (35.6%) of staff indicated that they spent 20 or more hours per week on nutrition, compared to only 8.0% for parenting and 9.6% for overweight. Conversely, two-thirds (68.0%) reported either never talking about parenting or spending less than 5 hours per week on the topic. The rate was slightly lower for overweight, 62.8%. With the exception of parenting, responses varied by job title at the P ⬍ .01 level, with nutritionists talking to participants the most. Weight status, ethnicity, age, and length of experience with WIC did not significantly influence scores. Level of education was correlated (P ⬍ .05) to all responses. In general, higher educational attainment was associated with more teaching reported.
Confidence in addressing childhood overweight On a scale of “not at all” (1) to “completely” (5), fewer than 30% thought it was “very much” or “completely” possible for WIC staff to prevent children from becoming overweight, to help overweight children reach a healthy weight, or to help overweight adults reach a healthy weight. The highest response for each question was “somewhat” (3) at 49.0%, 53.3%, and 48.1%, respectively. On the other hand, very few thought that it was not possible at all. Responses to all three questions were significantly correlated to each other (P ⬍ .01) . There were significant effects (P ⬍ .05) between African American (mean score of 3.32) and white
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Table. Attitudes, Perceptions, and Practices of WIC Staff Related to Childhood Overweight Topics
Office Support Staff (n ⴝ 21)
Topics Comfort level in discussing†: Mealtime 2.50 Behaviors** Parenting* 2.53 Fruit and 2.42 vegetable intake** Overfeeding** 2.16 Excessive 1.89 weight/ overweight** Physical 2.63 activity** How often staff talk to participants about‡: Nutrition** 1.95 Parenting 1.82 Overweight** 1.41 Physical 1.44 activity** Perception of WIC staff being able to§: 2.84 Prevent children from becoming overweight Help overweight 3.10 children reach a healthy weight Help overweight 3.11 adults reach a healthy weight
Nutrition Assistants (n ⴝ 28)
Nutritionists (n ⴝ 27)
Nurses (n ⴝ 9)
Total
3.39
3.78
3.33
3.33
3.07 3.70
3.15 3.77
3.67 3.22
3.06 3.40
3.44 3.04
3.67 3.26
3.13 3.11
3.21 2.87
3.48
3.74
3.22
3.36
2.89 2.21 2.37 2.44
3.74 2.44 2.80 2.85
2.22 2.11 1.89 1.89
2.89 2.22 2.25 2.31
2.96
3.11
2.56
2.89
2.96
3.07
2.44
3.00
3.14
3.11
2.78
3.09
Mean values are shown. *P ⬍ .05 **P ⬍ .01 † Based on scores of 1 to 4 with 1 being “very uncomfortable” and 4 being “very comfortable” ‡ Based on scores of 1 to 4 with 1 being “never” and 4 being “20 or more hours per week” § Based on scores of 1 to 5 with 1 being “not at all” and 5 being “completely”
staff (2.84). (Hispanic and “other” were excluded because of small sample sizes.)
Recommendations for educational materials and programs Out of 131 responses, WIC staff identified educational materials and teaching aids (27 respondents, 20.6% of responses), educational classes for participants (19, 14.5%), and staff training (18, 13.7%) as the most helpful factors in implementing prevention programs at WIC clinics. Other
responses included additional staff (17, 13.0%) and systemic changes (11, 8.4%), such as more space, incentives, or time for staff to be physically active, and changes in the WIC allowable foods list. Cultural relevance was stressed, with staff requesting bilingual materials and Spanishspeaking staff. To promote participation in childhood overweight prevention programs, respondents recommended: group classes (29, 22.1% of 131 total responses), such as cooking classes and exercise classes; incentives (20, 15.3%) like gift certificates, take-home videos, and food; educational handouts
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(15, 11.5%); convenient scheduling of classes (10, 7.6%); and policy changes (8, 6.1%), including mandatory participation in childhood overweight-related classes, follow-up with children beyond infancy, and vouchers for free fruits and vegetables. A staff member summarized many of the comments with the response, “Make it easy for them to do, not a lot of reading, cooking low fat classes, exercising with them.” Perceived attitudes of participants (33, 22.6% of 146 responses), including defensiveness and helplessness, were mentioned as the biggest perceived barriers to participation in childhood overweight prevention programs. One respondent stated, “People are offended/defensive when told they or their children are overweight—attitude about weight control is poor.” Transportation (31, 21.2%), time (29, 19.9%), cultural issues (14, 9.6%), childcare (7, 4.8%), and difficulty in changing behaviors (5, 3.4%) were also considered challenges. Cultural issues primarily referred to different cultural ideals of size and weight. For example, one staff member responded, “Many of our participants are from other countries/cultures and see weight issues very differently.”
DISCUSSION Each month WIC serves more than 7 million people across the country, with WIC staff supplying a multitude of services to participants.12 In this capacity, the program has the opportunity to impact a large number of families. With childhood overweight being a huge public health concern, this study aimed to determine how WIC staff felt toward addressing this growing issue and their attitudes about WIC’s capacity to do so. The main findings from this study were that weight status and job title were significant factors in feeling comfortable about addressing critical weight-related issues with WIC participants. In some ways, these findings are not surprising. First, nearly 40% of respondents were considered overweight. It is possible that the overweight staff felt uncomfortable about talking about behaviors that they may not be engaging in, such as eating a diet rich in fruits and vegetables and/or being physically active. Without further research, however, we cannot make a firm conclusion. Second, clear distinctions exist in training and responsibilities, particularly between office support staff and nutritionists and nurses. Still, office support staff were included in the study, because focus group discussions indicated that regardless of title, assigned duties, expectations, or support from supervisors, they provided advice in the areas of nutrition, weight, pregnancy, and child-rearing issues, particularly while clients are waiting for their appointments. Staff development and wellness programs were identified as top priorities for WIC to implement childhood overweight programs, along with additional staff, space, and time. These options may offer opportunities for staff to improve their self-efficacy about certain topics, improve
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their body image, and even increase access to educational opportunities to prevent childhood overweight. In Iowa, researchers examined staff perspectives on providing smoking cessation interventions and found that training was one of the main factors influencing the availability of programs.13 Although substantial resources are required to do this, a recent study assessed the impact of a breastfeeding promotion program on staff and found that a comprehensive intervention, including clinic environment projects, was successful in impacting their overall knowledge, skills, attitudes, and practices.14 Additionally, a walking program designed to improve the self-efficacy of WIC staff found that intervention site staff were more likely to report a “supportive” workplace environment related to making healthy food choices and being physically active, not to mention feeling more comfortable encouraging WIC clients to engage in physical activity with their children.15 Cultural issues were also identified as growing challenges among our study participants, with numerous requests for bilingual materials and staff. Several studies have found that using culturally relevant materials and staff can improve knowledge and dietary quality of limited resources and WIC audiences.16,17 Several limitations existed with this study. First, the sample was not a randomly selected, population-based survey of all health districts in the state, but rather a convenience sample that included all regions of the state. Although the response rate was 72.1%, the findings are not necessarily representative of all WIC staff in Virginia or elsewhere. There were also limitations with the questionnaire itself. First, it was not tested for concurrent validity, although the questions were formed based on focus group findings with the target audience and found to be reliable. There were no questions included to investigate knowledge about childhood overweight or personal dietary and physical activity behaviors that might influence their teaching practices. In a clinic setting, given the actual time a staff member is able to spend with each participant, 20 hours may be difficult to achieve. Finally, BMIs were calculated based on self-reported weight and height data, possibly leading to underestimation of weight and overestimation of height.18
IMPLICATIONS FOR RESEARCH AND PRACTICE The results of this study provide valuable feedback about current perceptions and practices of WIC staff on parenting, nutrition, and physical activity, as well as insights into the staff’s self-assessment on the ability of WIC offices to address childhood or adult overweight. The findings of this study suggest the need for health promotion programs and training among WIC personnel, built upon successful, research-based models, in order to provide educational opportunities to ensure a strong knowledge base and promote self-efficacy about childhood overweight-related topics.
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Given the disconnect between perceived and expected roles, special attention should be given to “front-line” office support staff in order to build upon their strengths, contact time, and rapport with clients, yet ensure the dissemination of reliable information. For example, sensitive training topics could include: boosting clients’ self-esteem and selfefficacy through positive reinforcement and role-modeling (which does not require content expertise); responding to clients’ questions (with referrals to WIC printed and/or on-line information and WIC nutritionists and/or nurses); and working effectively as a team (including the delineation of job responsibilities). The results also point to the need for the development (or adaptation) of culturally appropriate educational materials, teaching aids, and handouts for WIC staff and participants. Implementation should take into account logistical issues of participants and staff. Finally, successful strategies, including systemic and policy changes, for promoting positive, healthy behaviors and healthy weights among WIC staff, and, in turn, among WIC participants should be further explored and researched.
ACKNOWLEDGMENTS This project was funded primarily with federal funds from the U.S. Department of Agriculture (USDA), Food and Nutrition Service, under a 1999-2001 grant to the Virginia Department of Health, Richmond, Virginia. The contents of this publication do not necessarily reflect the views or policies of USDA, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. government.
REFERENCES 1. Oliveira V, Racine E, Olmsted J, Ghelfi LM. The WIC program: background, trends, and issues. Washington, DC: US Department of Agriculture; 2002. Food Assistance and Nutrition Research Report Number 27. 2. Fox MK, Hamilton W, Lin B-H. Effects of Food Assistance and Nutrition Programs on Nutrition and Health: Volume 4, Executive Summary of the Literature. Food Assistance and Nutrition Research Report No. (FANRR19-4). 2004. Available at: http://www.
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ers.usda.gov/publications/fanrr19-4/fanrr19-4b.pdf. Accessed April 21, 2005. Kowaleski-Jones L, Duncan GJ. Effects of participation in the WIC program on birthweight: evidence from the National Longitudinal Survey of Youth. Am J Public Health. 2002;92:799-804. Flegal K, Carroll M, Ogden C, Johnson C. Prevalence and trends in overweight among US adults, 1999-2000. J Am Med Assoc. 2002;288: 1723-1727. Ogden C, Flegal K, Carroll M, Johnson C. Prevalence and trends in overweight among US children and adolescents, 1999-2000. J Am Med Assoc. 2003;288:1728-1732. Dietz WH. Health consequences of overweight in youth: childhood predictors of adult disease. Pediatrics. 1998;101:518-525. US Department of Agriculture, Food and Nutrition Service, Supplemental Foods Program. WIC Policy Memorandum 98-9, Revision 5, Nutrition Risk Criteria; 2003. US Department of Agriculture, Food and Nutrition Service. WIC Works Sharing Center: Fit WIC. Available at: http:// www.nal.usda.gov/wicworks/Sharing_Center/statedev_FIT.html. Accessed April 21, 2005. Centers for Disease Control and Prevention. BMI for adults: body mass index formula. 2003. Available at: http://www.cdc.gov/nccdphp/ dnpa/bmi/bmi-adult-formula.htm. Accessed December 1, 2003. National Institutes of Health. Clinical guidelines on the identification, evaluation, and treatment of overweight and overweight in adults. Bethesda, MD: National Institutes of Health; 1998. NIH Publication No. 98-4083. Centers for Disease Control and Prevention. BMI—Body Mass Index: BMI for Adults. 2003. Available at: http://www.cdc.gov/nccdphp/ dnpa/bmi/bmi-adult.htm. Accessed December 1, 2003. Food and Nutrition Service. Women, Infants, and Children: frequently asked questions about WIC. 2003. Available at: http:// www.fns.usda.gov/wic/FAQs/FAQ.HTM#3. Accessed April 21, 2005. Aquilino ML, Goody CM, Lowe JB. WIC providers’ perspectives on offering smoking cessation interventions. MCN Am J Matern Child Nurs. 2003;28:326-332. Khoury AJ, Hinton A, Mitra AK, Carothers C, Foretich C. Improving breastfeeding knowledge, attitudes, and practices of WIC clinic staff. Public Health Rep. 2002;117:453-462. Crawford PB, Gosliner W, Strode P, et al. Walking the talk: Fit WIC wellness programs improve self-efficacy in pediatric obesity prevention counseling. Am J Pub Health. 2004;94:1480-1485. Ikeda JP, Pham L, Nguyen KP, Mitchell RA. Culturally relevant nutrition education improves dietary quality among WIC-eligible Vietnamese immigrants. J Nutr Educ Behav. 2002;34:151-158. Taylor T, Serrano E, Anderson J, Kendall P. Knowledge, skills, and behavior improvements of peer educators and low income Hispanic participants after a Stage of Change-based bilingual nutrition education program. J Commun Health. 2000;25:241-262. Nawaz H, Chan W, Abdulrahman M, Larson D, Katz DL. Selfreported weight and height: implications for obesity research. Am J Prev Med. 2001;20:294-298.
Fit WIC: Attitudes, Perceptions and Practices of WIC Staff toward Addressing Childhood Overweight Elena Serrano, PhD1; Emily Gresock, MS2; David Suttle, MD3; Adrienne Keller, PhD4; Elizabeth McGarvey, EdD5 ABSTRACT Objective: To assess the attitudes, perceptions, and practices of staff of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in providing nutrition education on childhood overweight topics with WIC participants. Design: Descriptive and correlational study. Setting: WIC clinics in Virginia. Participants: 106 employees working in direct contact with WIC participants. Mean Outcome Measure(s): Demographic information; comfort level and frequency of discussing childhood overweight-related topics with participants; perception of WIC’s ability to prevent and help address overweight among children and adults; body mass index (BMI); and attitudes toward personal weight. Analysis: Descriptive statistics, regression, and analysis of variance. Results: WIC staff in this study reported a lack of comfort, practice, and confidence in addressing and/or preventing childhood overweight with WIC participants, with differences existing based on job title (P ⬍ .05). Barriers to implementing programs included perceived attitudes of participants, transportation, time, cultural issues, and childcare. Staff BMIs were significantly correlated to ethnicity, age, feeling overweight, unhappiness with current weight, and comfort level discussing fruit and vegetable intake and physical activity (P ⬍ .05). Conclusions and Implications: Staff training, health promotion programs, and culturally relevant educational materials are warranted for WIC staff to build a strong knowledge base and promote self-efficacy about childhood overweight-related topics. Key Words: WIC, staff, overweight, attitudes (J Nutr Educ Behav. 2006;38:151-156)
INTRODUCTION As one of the key food and nutrition assistance programs in the United States, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) aims to “safeguard the health of low-income women, infants, and children up to age 5 who are at nutritional risk.”1 Partici1 Extension Specialist, Assistant Professor, Virginia Polytechnic Institute & State University 2 Former Nutrition Liaison, Division of WIC and Community Nutrition Services, Virginia 3 Department of Health Director, Office of Family Health Services, Virginia 4 Department of Health Associate Professor, University of Virginia 5 Associate Professor, Director, Division of Prevention Research, University of Virginia
Address for correspondence: Elena Serrano, PhD, Department of Human Nutrition, Foods, and Exercise, Virginia Polytechnic Institute and State University, Blacksburg, VA 24061-0430; Tel.: (540) 231-3464; Fax: (540) 231-3916; Email: [email protected]
©2006 SOCIETY FOR NUTRITION EDUCATION doi: 10.1016/j.jneb.2005.11.030
pant benefits include supplemental food packages, nutrition education, and referrals. To date, WIC has demonstrated several positive health and nutrition outcomes, including improvements in birth weights and iron-deficiency among infants.2,3 In the past few years, childhood overweight and adult obesity have been growing concerns in the United States.4,5 This trend has also been evident among WIC populations, with the proportion of overweight children participating in WIC increasing dramatically.6 In response, the Food and Nutrition Service (FNS), the agency of the U.S. Department of Agriculture (USDA) that administers WIC, added a new risk for program eligibility for infants and children, at-risk of becoming overweight. This risk criterion was established as a child at least 24 months old between the 85th and 95th percentile of body mass index (BMI) for age and gender, an infant born to a mother who was obese at the time of conception or during the first trimester or, for
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both children and infants, the existence of obesity in one or both parents.7 Additionally, the FNS awarded grants for a multistate project, titled Fit WIC, to identify opportunities for addressing childhood overweight in WIC clinics through a variety of mechanisms.8 The study reported here represents a component of the Fit WIC project that was conducted to assess the perceptions, attitudes, and practices of WIC staff in Virginia toward addressing key issues related to childhood overweight with clients. This study provides insight into the perceived capacity, challenges, and strategies of WIC to address this growing concern, from the perspective of staff. The results will, in turn, guide the development and pilot testing of staff development and wellness programs that include “front-line support staff.”
DESCRIPTION OF THE EVALUATION Subjects Of a total of 147 staff members, who were in attendance at the respective WIC clinics in all 11 health districts on a single day, 106 WIC staff completed and returned a hard copy questionnaire, for a response rate of 72.1%. All staff with direct contact or communication with WIC participants were eligible to complete the questionnaire. The study was reviewed by the Human Investigation Committee at the University of Virginia prior to its initiation and was exempt as an anonymous survey, with results to be used for educational purposes. Participation in the study was completely voluntary. Confidentiality was ensured by not requiring names or any form of personal identification to be included on the survey instrument. Completed questionnaires were returned to independent evaluators of the WIC program by fax or by mail.
Survey instrument A questionnaire, which included a combination of openand closed-ended questions, was developed specifically for this project by WIC staff working on the grant and university evaluators, because no comparable evaluation instrument existed. The questionnaire, which was developed immediately following focus groups with WIC staff, captured and formalized the key items from the focus groups, while taking into account staff perspectives and attitudes toward their jobs and childhood overweight. The questionnaire was found to have an excellent internal consistency of .852 (Cronbach’s alpha). Further, based on factor analyses, the first eigenvalue for the first principal component was 6.329 and described 42.7% of the variability, demonstrating the instrument’s effectiveness in capturing reliable and consistent responses. Questionnaire topics covered: attitudes about the participants’ own weight, such as if they felt they were overweight and if they were happy with their current weight; perceptions toward how comfortable they were in raising
specific topics or issues with parents related to childhood overweight, such as overfeeding; and practices related to actually “talking” to participants about nutrition, parenting, and physical activity. Suggestions for implementing childhood overweight prevention programs in their respective WIC clinics, based on perceived barriers, were elicited. Demographic information was also collected on age, gender, ethnicity, health district (region), job title, years of work experience with WIC, and highest level of education.
Weight status In order to determine if weight status influenced attitudes toward childhood overweight topics, WIC staff were asked to report weight (in pounds) and height (feet and inches). These data were converted to body mass index (BMI), using the BMI Index Formula.9 Weight status was determined by categories established by the Centers for Disease Control, with underweight defined as a BMI below 18.5, normal 18.5 to 24.9, overweight 25.0 to 29.9, and obese as 30.0 and above.10,11
Data analysis The following job titles were used, based on responsibilities and training: office support staff; nutrition assistants; nutritionists; nurses; and managerial staff. Office support staff determine residential, income, and categorical eligibility, print checks, and make appointments. Nutrition assistants require a high school diploma or equivalent, provide both administrative and technical support by helping with office tasks (similar to office support staff), and assist the nutritionist with nutrition assessment and education. WIC nutritionists have specific training in nutrition, with a minimum of a bachelor’s degree in nutrition or dietetics, and eligibility or current licensure as a registered dietitian. They perform health and nutrition assessments, along with nutrition counseling. As with nutritionists, WIC nurses assess medical and nutrition risk of clients, along with counseling. A bachelor’s degree in nursing is mandatory, along with state licensure. Managerial staff coordinate the operations of the clinic, as well as counsel clients upon demand. Statistical evaluation was performed using SPSS (SPSS, Inc., Chicago, IL). Frequencies and means were calculated for all closed-ended responses based on job title and weight status, with both variables assigned numerical codes. Percentages were also calculated, not including nonresponses. One-way analysis of variance (ANOVA) was used to determine differences between responses based on WIC job title, excluding managerial staff because of small cell sizes. Regression analyses were conducted to assess the significance of BMI with several demographic factors, including ethnicity, age, health district, and responses to questions. Open-ended responses were coded and given numerical responses. Frequencies were then calculated based on the
Journal of Nutrition Education and Behavior ● Volume 38, Number 3, May/June 2006
total number of responses, including multiple responses to each question.
LESSONS LEARNED Demographic information Respondents included nutritionists (30.3%), nutrition assistants (31.5%), office support staff (23.6%), nurses (10.1%), and managerial staff (4.5%). The subjects represented a broad range of work experience with WIC, with nearly one-quarter (22.9%) having less than three years of experience and 28.6% more than 10 years. All respondents were female, with the majority being white (70.7%), followed by African American (19.2%), Hispanic (6.1%), and “other” (4.0%), which included one Asian. Seven individuals did not report their ethnicity. Ages of respondents ranged from 23 to 64, with a mean age of 42.0. The highest percentage of individuals was in the age category of 40 to 49 years old (39.4%). Over half had at least a bachelor’s degree (51.9%). Job title was significantly correlated to level of education (P ⬍ .05), with senior level positions having higher levels of education, based on ANOVA.
Weight categories Of the 88 who provided weight and height information, BMIs ranged from 14.2 to 41.3, with a mean BMI of 24.7. Although over half of respondents, 58.0%, were considered normal weight, 3.4% were considered underweight, 26.1% overweight, and 12.5% obese. Based on Pearson correlations and univariate regression, BMI was positively associated with feeling overweight and being unhappy about their current weight, with 86.4% of staff who felt “somewhat” or “very much” overweight classified as overweight or obese and 78.9% of those unhappy with their current weight. BMI was also correlated (P ⬍ .01) to age and ethnicity. Mean BMI increased with age. Nearly two-thirds (63.6) of all respondents between 50 and 64 were classified as overweight. Significant differences were found between African American and white subjects, when excluding Hispanics and “other” from analyses because of small cell sizes. African American staff had over twice the rate of overweight (66.7%) than white staff (29.5%). When including all ethnic groups, African Americans had the highest mean BMI at 28.0 (SD ⫽ 5.42), followed by Hispanic, 27.0 (SD ⫽ 4.02), then white, 24.1 (SD ⫽ 4.32).
Comfort level in addressing childhood overweight topics Overall, WIC staff felt most comfortable about addressing fruit and vegetable intake and least comfortable about overweight or obesity with their participants, as shown by the mean scores in Table 1. All of the responses for this set of questions were significantly correlated to each other (P
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⬍ .01). Ethnicity, age, and length of experience with WIC did not significantly influence scores. Level of education was positively correlated (P ⬍ .05) to all responses. The effects of job title were also significant (P ⬍ .05). Although not included in the analyses, the managerial staff had the highest scores and the office support staff the lowest. Overall, underweight and normal weight WIC staff reported feeling more comfortable about childhood overweight-related topics. There were significant associations between BMI and comfort level about fruit/vegetable intake and physical activity (P ⬍ .05). Almost two-thirds (66.7%) of staff who reported being uncomfortable about discussing physical activity were overweight, and 54.5% of those respondents were uncomfortable with discussing fruit and vegetable intake. In both cases, there was a decline in mean comfort level with increasing BMI. Although not significant, obese staff had the lowest overall mean related to talking about overweight, 2.55, and underweight the highest, 3.33. Nevertheless, one-half of respondents who indicated they felt “very uncomfortable” or “slightly uncomfortable” were of normal weight.
Level of reported communication about childhood overweight topics WIC staff reported actually talking or communicating to WIC clients about nutrition the most, and parenting and overweight the least, as shown in Table 1. Over one-third (35.6%) of staff indicated that they spent 20 or more hours per week on nutrition, compared to only 8.0% for parenting and 9.6% for overweight. Conversely, two-thirds (68.0%) reported either never talking about parenting or spending less than 5 hours per week on the topic. The rate was slightly lower for overweight, 62.8%. With the exception of parenting, responses varied by job title at the P ⬍ .01 level, with nutritionists talking to participants the most. Weight status, ethnicity, age, and length of experience with WIC did not significantly influence scores. Level of education was correlated (P ⬍ .05) to all responses. In general, higher educational attainment was associated with more teaching reported.
Confidence in addressing childhood overweight On a scale of “not at all” (1) to “completely” (5), fewer than 30% thought it was “very much” or “completely” possible for WIC staff to prevent children from becoming overweight, to help overweight children reach a healthy weight, or to help overweight adults reach a healthy weight. The highest response for each question was “somewhat” (3) at 49.0%, 53.3%, and 48.1%, respectively. On the other hand, very few thought that it was not possible at all. Responses to all three questions were significantly correlated to each other (P ⬍ .01) . There were significant effects (P ⬍ .05) between African American (mean score of 3.32) and white
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Table. Attitudes, Perceptions, and Practices of WIC Staff Related to Childhood Overweight Topics
Office Support Staff (n ⴝ 21)
Topics Comfort level in discussing†: Mealtime 2.50 Behaviors** Parenting* 2.53 Fruit and 2.42 vegetable intake** Overfeeding** 2.16 Excessive 1.89 weight/ overweight** Physical 2.63 activity** How often staff talk to participants about‡: Nutrition** 1.95 Parenting 1.82 Overweight** 1.41 Physical 1.44 activity** Perception of WIC staff being able to§: 2.84 Prevent children from becoming overweight Help overweight 3.10 children reach a healthy weight Help overweight 3.11 adults reach a healthy weight
Nutrition Assistants (n ⴝ 28)
Nutritionists (n ⴝ 27)
Nurses (n ⴝ 9)
Total
3.39
3.78
3.33
3.33
3.07 3.70
3.15 3.77
3.67 3.22
3.06 3.40
3.44 3.04
3.67 3.26
3.13 3.11
3.21 2.87
3.48
3.74
3.22
3.36
2.89 2.21 2.37 2.44
3.74 2.44 2.80 2.85
2.22 2.11 1.89 1.89
2.89 2.22 2.25 2.31
2.96
3.11
2.56
2.89
2.96
3.07
2.44
3.00
3.14
3.11
2.78
3.09
Mean values are shown. *P ⬍ .05 **P ⬍ .01 † Based on scores of 1 to 4 with 1 being “very uncomfortable” and 4 being “very comfortable” ‡ Based on scores of 1 to 4 with 1 being “never” and 4 being “20 or more hours per week” § Based on scores of 1 to 5 with 1 being “not at all” and 5 being “completely”
staff (2.84). (Hispanic and “other” were excluded because of small sample sizes.)
Recommendations for educational materials and programs Out of 131 responses, WIC staff identified educational materials and teaching aids (27 respondents, 20.6% of responses), educational classes for participants (19, 14.5%), and staff training (18, 13.7%) as the most helpful factors in implementing prevention programs at WIC clinics. Other
responses included additional staff (17, 13.0%) and systemic changes (11, 8.4%), such as more space, incentives, or time for staff to be physically active, and changes in the WIC allowable foods list. Cultural relevance was stressed, with staff requesting bilingual materials and Spanishspeaking staff. To promote participation in childhood overweight prevention programs, respondents recommended: group classes (29, 22.1% of 131 total responses), such as cooking classes and exercise classes; incentives (20, 15.3%) like gift certificates, take-home videos, and food; educational handouts
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(15, 11.5%); convenient scheduling of classes (10, 7.6%); and policy changes (8, 6.1%), including mandatory participation in childhood overweight-related classes, follow-up with children beyond infancy, and vouchers for free fruits and vegetables. A staff member summarized many of the comments with the response, “Make it easy for them to do, not a lot of reading, cooking low fat classes, exercising with them.” Perceived attitudes of participants (33, 22.6% of 146 responses), including defensiveness and helplessness, were mentioned as the biggest perceived barriers to participation in childhood overweight prevention programs. One respondent stated, “People are offended/defensive when told they or their children are overweight—attitude about weight control is poor.” Transportation (31, 21.2%), time (29, 19.9%), cultural issues (14, 9.6%), childcare (7, 4.8%), and difficulty in changing behaviors (5, 3.4%) were also considered challenges. Cultural issues primarily referred to different cultural ideals of size and weight. For example, one staff member responded, “Many of our participants are from other countries/cultures and see weight issues very differently.”
DISCUSSION Each month WIC serves more than 7 million people across the country, with WIC staff supplying a multitude of services to participants.12 In this capacity, the program has the opportunity to impact a large number of families. With childhood overweight being a huge public health concern, this study aimed to determine how WIC staff felt toward addressing this growing issue and their attitudes about WIC’s capacity to do so. The main findings from this study were that weight status and job title were significant factors in feeling comfortable about addressing critical weight-related issues with WIC participants. In some ways, these findings are not surprising. First, nearly 40% of respondents were considered overweight. It is possible that the overweight staff felt uncomfortable about talking about behaviors that they may not be engaging in, such as eating a diet rich in fruits and vegetables and/or being physically active. Without further research, however, we cannot make a firm conclusion. Second, clear distinctions exist in training and responsibilities, particularly between office support staff and nutritionists and nurses. Still, office support staff were included in the study, because focus group discussions indicated that regardless of title, assigned duties, expectations, or support from supervisors, they provided advice in the areas of nutrition, weight, pregnancy, and child-rearing issues, particularly while clients are waiting for their appointments. Staff development and wellness programs were identified as top priorities for WIC to implement childhood overweight programs, along with additional staff, space, and time. These options may offer opportunities for staff to improve their self-efficacy about certain topics, improve
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their body image, and even increase access to educational opportunities to prevent childhood overweight. In Iowa, researchers examined staff perspectives on providing smoking cessation interventions and found that training was one of the main factors influencing the availability of programs.13 Although substantial resources are required to do this, a recent study assessed the impact of a breastfeeding promotion program on staff and found that a comprehensive intervention, including clinic environment projects, was successful in impacting their overall knowledge, skills, attitudes, and practices.14 Additionally, a walking program designed to improve the self-efficacy of WIC staff found that intervention site staff were more likely to report a “supportive” workplace environment related to making healthy food choices and being physically active, not to mention feeling more comfortable encouraging WIC clients to engage in physical activity with their children.15 Cultural issues were also identified as growing challenges among our study participants, with numerous requests for bilingual materials and staff. Several studies have found that using culturally relevant materials and staff can improve knowledge and dietary quality of limited resources and WIC audiences.16,17 Several limitations existed with this study. First, the sample was not a randomly selected, population-based survey of all health districts in the state, but rather a convenience sample that included all regions of the state. Although the response rate was 72.1%, the findings are not necessarily representative of all WIC staff in Virginia or elsewhere. There were also limitations with the questionnaire itself. First, it was not tested for concurrent validity, although the questions were formed based on focus group findings with the target audience and found to be reliable. There were no questions included to investigate knowledge about childhood overweight or personal dietary and physical activity behaviors that might influence their teaching practices. In a clinic setting, given the actual time a staff member is able to spend with each participant, 20 hours may be difficult to achieve. Finally, BMIs were calculated based on self-reported weight and height data, possibly leading to underestimation of weight and overestimation of height.18
IMPLICATIONS FOR RESEARCH AND PRACTICE The results of this study provide valuable feedback about current perceptions and practices of WIC staff on parenting, nutrition, and physical activity, as well as insights into the staff’s self-assessment on the ability of WIC offices to address childhood or adult overweight. The findings of this study suggest the need for health promotion programs and training among WIC personnel, built upon successful, research-based models, in order to provide educational opportunities to ensure a strong knowledge base and promote self-efficacy about childhood overweight-related topics.
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Given the disconnect between perceived and expected roles, special attention should be given to “front-line” office support staff in order to build upon their strengths, contact time, and rapport with clients, yet ensure the dissemination of reliable information. For example, sensitive training topics could include: boosting clients’ self-esteem and selfefficacy through positive reinforcement and role-modeling (which does not require content expertise); responding to clients’ questions (with referrals to WIC printed and/or on-line information and WIC nutritionists and/or nurses); and working effectively as a team (including the delineation of job responsibilities). The results also point to the need for the development (or adaptation) of culturally appropriate educational materials, teaching aids, and handouts for WIC staff and participants. Implementation should take into account logistical issues of participants and staff. Finally, successful strategies, including systemic and policy changes, for promoting positive, healthy behaviors and healthy weights among WIC staff, and, in turn, among WIC participants should be further explored and researched.
ACKNOWLEDGMENTS This project was funded primarily with federal funds from the U.S. Department of Agriculture (USDA), Food and Nutrition Service, under a 1999-2001 grant to the Virginia Department of Health, Richmond, Virginia. The contents of this publication do not necessarily reflect the views or policies of USDA, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. government.
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