Food insecurity is a serious issue in the US today. Despite social programs like the Supplemental Nutrition Program for Women, Infants, and Children (WIC), more than 13.1 million children are experiencing food insecurity, and an estimated 19 million live in food deserts. That’s 6.1% of the population.
Lack of access to nourishing, and nutritious foods can have a lasting impact on longitudinal health and success. Hungry children are less likely to participate in social and physical activity and have a harder time focusing in school. Plus, undernutrition in early life is linked to many adverse outcomes, like poorer cognitive skills, reduced healing, stunted growth, lower earnings and a higher likelihood of living in poverty. This makes insufficient nutrition a major social determinant of health (SDoH), especially for pregnant people and infants.
There are programs that exist to help women and children access healthy, affordable food. The Supplemental Nutrition Assistance Program (SNAP) and the Supplemental Nutrition Program for Women, Infants, and Children (WIC) are two such programs that assist low-income families and their children in purchasing healthy foods. WIC, in particular, targets pregnant and postpartum women and, infants and children under 5 with benefits for specific foods rich in nutrients these groups are lacking.
But, many people don’t leverage the benefits they’re eligible for, and many children and pregnant women aren’t getting the nutrition they need to stay healthy. Cultural taboos about federal assistance programs, fear of child welfare involvement, shame, and a lack of awareness of the program and understanding of it may play roles in this chronic underutilization. These barriers and misconceptions have such an impact that it’s estimated only half of eligible persons were participating in WIC in 2023.
To dispel myths about WIC and help connect pregnant women and children to the resources available to them, Ovia partnered with University of California-Davis and University of Wisconsin-Madison to run a first-of-its-kind study. In the following Q&A, researchers explain the findings of the first-ever randomized control trial to improve WIC enrollment, using a digital tool like Ovia, and the potential impact on SDoH, health equity, and outcomes.
Q: Tell us a bit about yourselves as researchers. Why was it important for you to study WIC, food insecurity and nutrition’s impact on maternal health?
We are an interdisciplinary group of researchers from economics, sociology, and public health. This work was led by Dr. Marianne Bitler, a nationally recognized expert in social safety programs like WIC, and Dr. Jenna Nobles, a distinguished demographer with expertise in fertility and immigration. Fiona Weeks is a PhD candidate who supported the implementation of the project.
We chose to study WIC because of the profound impact it can have — and is having — on lives. Approximately half of infants in the U.S. are eligible for WIC, and participation has multiple positive impacts on pregnancy, like improved birth outcomes, improved diet, improved infant feeding practices, improved childhood immunization, and more. However, the program is significantly under-enrolled.
We know that income inequality is growing in the U.S., and social determinants of health like food insecurity play a significant role in health outcomes, so it’s more important than ever to connect people with government-provided benefits that can help them have healthier pregnancies and families.
Q: Tell us about the study, what were you trying to learn?
Because millions of eligible people aren’t taking advantage of WIC benefits, we wanted to pursue a creative way to educate people about WIC and increase WIC program enrollment by promoting WIC through a digital health solution that millions of pregnant people in the United States already use.
To do so, we invited Ovia Pregnancy users between five and 35 weeks pregnant to complete a short prenatal survey about their eligibility for WIC. If they were deemed likely eligible for WIC based upon their self-reported household income or participation in SNAP or Medicaid in their state, we randomized them into either a treatment or control group. Treatment users were educated about the benefits of WIC and given information about their local clinic for enrollment. Control users were presented with information about nutrition during pregnancy from the American Council of Obstetricians and Gynecologists.
After the participants gave birth, we asked them to take another postpartum survey to share with us their knowledge about WIC, whether they ever enrolled in WIC, and why or why not to better understand barriers to enrollment. We also collected information about delivery and infant health outcomes for both groups.
Q: What’s unique about this study compared with other research done on the benefits of WIC? How many people participated? What’s the sample size?
This study is unique because to our knowledge, it is the only randomized controlled trial (RCT) to experimentally test whether promoting WIC through a digital means can influence understanding of WIC and WIC enrollment.
The study is still ongoing, but to date, we have screened over 27,000 Ovia Pregnancy users for the study. Of those, over 7,000 completed the prenatal survey. We are still collecting postpartum surveys and outcomes from many participants.
Q: Why did you collaborate with a digital health solution for this project? How is this different from other research approaches?
Increasing program enrollment in WIC requires a multidisciplinary approach; some people will enroll based upon word-of-mouth, and others might see a bus or train advertisement. One thing we noted was that no one was really promoting WIC digitally.
Research suggests smartphone apps are an increasingly popular way to track one’s health, especially before, during, and after pregnancy. More than 95% of reproductive-age women in the U.S. have smartphones, and 83% of U.S. adults with a median household income of less than $50,000 have smartphones.
Considering these data, and the common knowledge that most people are attached to their phones and the digital world more than ever, we wanted to modernize the approach to WIC awareness and enrollment. So, we created an easier, digital way for people to learn about the benefits of WIC, and tested it using an experiment.
Ovia Health’s mobile solutions are free to the end-users, so it attracts a wide and diverse user base, which was attractive from a recruitment perspective for our study. Enrolling participants digitally also made it possible for us to reach many more participants than if we had enrolled participants in-person.
Q: What did you find? What were the preliminary results about WIC enrollment?
Our preliminary results, which were presented for the first time at the 2023 CityMatCH conference, suggest that participants in the treatment group were slightly more likely to have enrolled themselves ( 46.6% versus 42.5%, p=.14) or their child (37.5% versus 34.3%, p=.19) in WIC postpartum, and were significantly more likely to report that they were likely to enroll their child in the future (57.6% compared with 51.3%, p=0.034).
When asked about the services that WIC provides, participants in the treatment group were more likely to know that WIC provides breastfeeding support (65.1% versus 59/0%, p=0.023).
Q: What do we know about people who did enroll? Any trends in geography, race, socioeconomic status, insurance status?
Among those who completed the first survey and received either the intervention or control condition, about 20% of participants identify as Black, 4% identify as American Indian or Alaska Native. This is important because of health disparities that disproportionately impact women and babies of color.
40% of participants were only “somewhat” or “not at all” confident that they would have enough to eat in the next month. We have participants in all fifty states, and several territories!
Q: For those who chose not to enroll, was there a reason? Why ignore benefits available?
That’s a great question. There are many reasons why someone wouldn’t enroll in WIC, but the most commonly reported reason for not enrolling in our study was that they didn’t believe they were eligible, despite meeting the income threshold for enrollment according to their intake survey. There were also respondents who said they had never heard of WIC before or they didn’t know much about it.
This finding suggests that there is still some education and promotion to do in the community about who is eligible for WIC and how to see if you are eligible.
State partners have also noted that people may not enroll because they don’t want to “take away” a spot from someone or because they are afraid it will affect their immigration status.
Q: What impact could this have on WIC enrollment, future research or outcomes? What are you looking to study next?
At the CityMatCH conference, many state WIC staff (WIC programs are directed by individual states) were excited about these preliminary results and were interested in replicating this education strategy for their communities. These results suggest that promoting WIC in a variety of modes, including digitally, may be key to reaching more eligible people and enrolling them in WIC benefits.
The next steps in addressing health equity and food insecurity
The study itself is ongoing, and researchers plan to continue surveying women about their postpartum experiences and outcomes. But early results are clear, there is an opportunity to improve SDoH in a tangible way using digital health solutions like Ovia.
These data should hopefully spark hope and interest for other population health projects. For organizations working to address health equity, trusted digital health solutions can be a viable option. Considering the maternal mortality crisis the U.S. is facing, new innovative strategies are needed to improve maternal outcomes. The methodologies of this survey, and others, could be repurposed and leveraged to tackle a number of challenges in the maternal health space. To learn more, or explore potential partnerships, reach out to the Ovia Health team.