Abstract
The United States Department of Agriculture approved an increase to the Cash Value Benefit (CVB) for the purchase of fruits and vegetables issued to participants receiving an eligible Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food package. In order to understand satisfaction, perceptions, and the overall impact of additional benefits for fruits and vegetables at the household level, a qualitative study consisting of structured phone interviews was conducted with families served by WIC in Southern California from November to December 2021 (n = 30). Families were selected from a large longitudinal study sample (N = 2784); the sample was restricted by benefit redemption and stratified by language and race. WIC participants were highly satisfied with the CVB increase, reporting increased purchasing and consumption of a variety of fruits and vegetables. Respondents noted the improved quality and variety of fruits and vegetables purchased due to the increased amount. Findings are expected to inform policy makers to adjust the CVB offered in the WIC food package with the potential to improve participant satisfaction and increase participation and retention of eligible families with benefits from healthy diets supported by WIC.
Keywords:
WIC; diet; fruit and vegetables; diet quality; CVB; satisfaction; WIC foods; WIC benefits; nutrition; food cost 1. Introduction
The economic impacts of the COVID-19 pandemic are continuing to affect families throughout the United States two years after the pandemic’s inception. Access to food was interrupted, food prices increased, and food insecurity for households with children increased from 13.6% in 2019 to 14.8% in 2020 [1]. In response to the pandemic, the United States Department of Agriculture (USDA) allowed several temporary changes to the Special Supplemental Nutrition Program for Women, Infants and Children (WIC). In 2021, the American Rescue Plan Act (ARPA) passed by the United States Congress gave USDA the authority to make temporary changes to assistance programs, such as WIC, during the federally declared COVID-19 public health emergency [2]. WIC provides nutritious foods, nutrition education, breastfeeding support and social service referrals to qualifying women, infants and children up to age 5 years who reside in low-income households. Before the implementation of ARPA changes, WIC families received USD 9 for children ages 1–4 and USD 11 for pregnant and postpartum women to purchase fruits and vegetables with the cash value benefit (CVB) portion of their package [2]. One COVID-related change to WIC brought about by ARPA involved a 4-month increase to the monthly WIC CVB for fruits and vegetables (FV) to USD 35 for all WIC participants during the summer of 2021 [2]. The CVB amount was later modified for one year beginning on 1 October 2021, to USD 24 per month for children (and USD 43 or USD 47 per month for women). These revised amounts are consistent with the recommendations from the National Academies of Science, Engineering and Medicine to support half of the recommended intake of FV for children in the Dietary Guidelines for Americans [3,4,5]. Because WIC benefits are issued to WIC participants in California electronically and the augmented CVB amount was automatically loaded onto the participants’ electronic WIC card, they could begin purchasing FV as soon as the changes were in effect.
While the increased amount for the CVB has been provided, there has also been an increase in prices for all foods due to the pandemic and inflation [1]. According to the Bureau of Labor Statistics, food (at home) prices in the Los Angeles area have increased 9.5% from March 2021 to March 2022, partly driven by an 11.7% price increase for fruits and vegetables [6]. The WIC food packages are considered largely cost insensitive, since most WIC food benefits are redeemable for a specific amount of a food or beverage regardless of food prices. From 1990 to 2016, the average cost of the WIC food package per participant decreased by 23% after adjusting for inflation [7,8]. The USDA permits a 3% buffer for food package expenditures for states to account for food inflation above historical trends or unexpected occurrences such as a pandemic [8]. This allows families to continue buying the same amount of most foods with their WIC package (e.g., 16 oz loaf of bread, 1 gallon of milk) regardless of the retail price [9,10]. However, this is not the case for the CVB portion of the WIC food package, which is the only component of the package that is sensitive to fluctuations in prices because a set dollar amount is allotted per participant, as opposed to a fixed-unit benefit [11].
The CVB is an important component of the WIC food package. Compared to other food package benefits, it provides the most choice because it allows families to choose from a wide range of FV tailored to their own family or cultural preferences. FV is the food group most under consumed in the U.S. relative to recommendations, despite their many health benefits [5]. Because the USDA is considering making the CVB increase a permanent component of the WIC food packages, it is important to understand WIC participants’ views on this change [3]. The purpose of this study is to understand how the satisfaction and use of the CVB changed for WIC participants.
2. Materials and Methods
This qualitative study is part of a larger ongoing study to evaluate the expansion of the monthly WIC CVB in children ages 1–4 years. In the larger study, baseline survey data were collected from caregivers with children served by WIC in Southern California in April-May 2021 (N = 2784), prior to the national increase to the value of the WIC CVB, August-September 2021 (N = 1673), following the implementation of the USD 35 monthly CVB for all children, and April-May 2022 (N = 1063), following the implementation of the USD 24 monthly CVB for all children. The larger study included an oversampling of African American (AA) participants as data have shown that WIC food benefit redemption among this population is lower than other racial ethnic groups [12,13]. The focus on the AA population in this qualitative study could help to better understand potential barriers to use of the CVB and other factors affecting satisfaction with the WIC program among AA participants. The qualitative sample (N = 30) for the current study was drawn from the longitudinal sample. All aspects of the study were reviewed and approved by the California Department of Health and Human Services and the University of California, Davis Institutional Review Boards. Participants in the qualitative sample were each mailed a USD 50 gift card after completing the interview.
2.1. Sampling Method
Southern California WIC participants are approximately 80% Hispanic and previous research in California WIC populations has shown differences in language preference which led to the sample stratification by language [14,15,16]. This sample was also stratified by race, as the longitudinal study oversampled the AA population to better understand the differences in CVB use among this underrepresented population. Among the sample of caregivers who had completed surveys both before and after the CVB change (N = 1673), respondents were stratified by the primary language of survey (English or Spanish); the English-Speaking sample was further stratified by race (AA and non-AA). The sample was then restricted to high (top 25th percentile) and low (bottom 25th percentile) CVB redeemers and stratified by percent of the augmented CVB redeemed (high: ≥96%; low: <56%). To ensure diverse perspectives, a random sample of participants were selected from the 6 strata: Spanish-speaking, high redemption; Spanish-speaking, low-redemption; English-speaking AA, high redemption; English-speaking AA, low-redemption; English-speaking non-AA, high-redemption; English-speaking non-AA, low redemption. Recruitment by text message continued until 5 interviews were scheduled and completed for each strata. Interviews were scheduled and completed from November to December 2021. Forty participants were recruited to achieve a sample of 30 interviews (75% response rate).
2.2. WIC Participant Surveys and Interviews
Information about the 30 qualitative study participants was collected from three sources. Demographic information about each participant (name, date of birth for each child, household food security) was captured from the longitudinal surveys. Additional demographic information was captured from WIC administrative data (race and ethnicity, maternal education level, household size) and the qualitative interviews.
WIC staff recruited the 30 caregivers for the study and informed study participants that they would be contacted by University of California researchers to complete the interviews. Each structured interview took between 16 and 30 min and was conducted by phone by one of two researchers at the UC Nutrition Policy Institute. A female researcher with a Masters in Public Health and Registered Dietitian Nutritionist credential conducted the English interviews (D.L.L.). A male researcher with a Masters in Science conducted the interviews in Spanish. Only the interviewer and participant were on the call during the interview. Researchers informed participants that they wanted to learn about their experiences with WIC foods with the goal of using their feedback to improve the WIC program. Questions included shopping for WIC-eligible FV, preferences on amount of CVB, satisfaction with the increases to USD 35 and USD 24 per month, how much of the increase was used and whether it was hard to spend the full amount, and perceptions of whether the increase resulted in impacts on child intake of FV (both amount and variety), diet of others in the household, and ability to purchase other foods or household necessities (see Abbreviations for interview guide). The interview questions were programed into Qualtrics (Qualtrics, 2020) and interviews were recorded for transcription and for Spanish interviews, translation, and field notes were documented after the interview. Transcripts were not returned to participants for their review or comment.
Using an immersion/crystallization approach, after reading all interview transcripts, transcriptions were coded into themes using Microsoft Excel version 16.61.1, first by question and then across questions [17]. One researcher (LDR) completed the initial coding to develop the following thematic categories: (A) Experiences with CVB at USD 9 per month, (B) Experiences after CVB increase to USD 35 per month, (C) Other changes on spending outside of WIC benefits with CVB increase to USD 35 per month, (D) Impacts of USD 35 per month CVB increase on dietary intakes and (E) Experiences after CVB change to USD 24 per month. Another researcher (DLL) reviewed the transcripts and coding. Any discrepancies were discussed prior to finalizing the coding and themes. Quotes were then selected to illustrate each theme. SP after a quote indicates it came from an interview conducted in Spanish and EN signifies an interview conducted in English; the subsequent number refers to a unique caregiver. Participants did not provide feedback on the coding.
3. Results
3.1. Participant Characteristics
All respondents were women caregivers with children 1–4 years old on WIC. A majority were Hispanic (n = 20), had experienced household food insecurity in the prior month (n = 17), and had more than one child living in their household (n = 22). Families had been on WIC for an average of nearly 6 years and the average age of their youngest child on WIC was 2.7 years (range 1.3 to 3.7 years) (Table 1).
Table 1.
Characteristics of caregivers interviewed (n = 30).
3.2. Major Themes
The thematic analysis resulted in five major thematic categories capturing the individuals’ experiences and perceptions that the increased CVB had on their satisfaction, purchasing changes, and diet. Perceptions and satisfaction with CVB were analyzed for each of the USD 9, USD 35 and USD 24 CVB amounts during the participant interview. Within each category, there are overarching themes for English and Spanish participants, which are summarized in Table 2 Thematic analysis was used to group the qualitative data into the five major thematic categories, and emblematic quotations are presented for each theme in Table 2.
Table 2.
Emergent themes for (A) experiences with CVB at USD 9 per month, (B) experiences after CVB increase to USD 35 per month, (C) other changes on spending outside of WIC benefits with CVB increase to USD 35 per month, (D) impacts of USD 35 per month CVB increase on dietary intakes and (E) experiences after CVB change to USD 24 per month 1.
3.3. Theme Category A: Experiences with CVB at USD 9 per Month
3.3.1. Shopping for FV Using WIC Benefits Is Easy
The interviewed caregivers shopped for groceries an average of 1.6 times per week. They typically shopped for WIC foods at large stores and/or WIC-only stores, which are smaller stores that cater to WIC clients by providing only WIC-eligible options. All found it very or somewhat easy to use their WIC benefits to purchase the FV that they wanted for their WIC-participating child (Table 1). Those who shopped at large grocery stores noted that there was a large selection of FV to choose from in the produce section. Several cited using WIC shelf labels, the WIC mobile application, or knowledge from being on WIC in the past to help them know which FV were WIC-eligible. Shoppers at WIC-only stores described how FV access was straightforward because all items in the store are WIC eligible.
3.3.2. CVB at USD 9 per Month Is Inadequate
The majority (n = 28) of caregivers interviewed reported that USD 9/month for FV was not enough; only 2 thought this amount was just right, and none thought it was too much. A common sentiment was that USD 9/month was not enough to buy all the FV that their children aged 1–4 years wanted to eat or should eat to be healthy. Many mentioned that USD 9 was enough only for about one week’s worth of FV each month. Many noted that because of the high cost of FV, they had to use their own limited funds to purchase enough FV for their child when the CVB was USD 9 per month.
3.4. Theme Category B: Experiences after CVB Increase to USD 35 per Month
3.4.1. Satisfaction Increased with CVB Increase to USD 35 per Month
When asked about the CVB increase to USD 35 per month, the majority (n = 25) of caregivers felt it was the right amount, while three said it was not enough, and two thought it was too much for their child. Compared to USD 9, USD 35 per month allowed them to purchase FV for their child for the entire month. Many reported that the CVB increase improved the overall diet quality of their child, as caregivers could afford to be less reliant on inexpensive, more processed foods.
“I thought (the CVB increase) was amazing, because we eat more FV since there’s been an increase. (Before the increase) we were eating more processed food and I don’tthink that my daughter was getting adequate nutrition from eating those types of foods and she’s a picky eater too.”(English speaking participant with 2.5 years of WIC participation—EN4)
The few who thought that USD 35/month was not enough cited the high cost of produce while those who thought USD 35/month was too much worried about food waste.
“By the fourth week of the month, I still had a balance, meaning that I had already gotten what I needed. So I felt like if I was to use it, the fruit would just go to waste.”(English speaking participant with 7 years of WIC participation—EN6)
When asked how easy or hard it was to spend the full USD 35/month, a majority rated it as very (n = 22) or somewhat (n = 6) easy; only two said it was somewhat hard. One of the two who said it was hard found it difficult to spend the entire USD 35 in a month because her child did not eat that much. The other had difficulty getting to the store often enough to spend the USD 35 completely. The majority, however, were grateful to be able to afford more FV. Many cited that having a higher CVB amount allowed caregivers to better plan their shopping and menus.
“It (CVB increase) was easier to choose from the variety that the supermarket had without thinking about what I’m going to spend for a small amount.”(Spanish speaking participant with 13 years of WIC participation—SP31)
“I just didn’t feel pressured to go shopping and if I didn’t spend everything, the next time I went I could buy it and the fruit and everything would not spoil.”(Spanish speaking participant with 4 years of WIC participation—SP28)
“It (CVB increase) gave me more options to buy more and less worry to have... Okay if I needed to get it out of pocket am I going to have enough. So I don’t have to worry about it for the month, so if I didn’t want to spend the entire (USD) 35 in one week or you know in one day it’s like okay... Unlike with the (USD) 9,…I know it’s all going to go today.”(English speaking participant with 8 years of WIC participation—EN19)
When asked how much of the USD 35 each month participants spent on FV, respondents reported using either all (n = 24) or most (n = 6); none reported using only some or none of the increased CVB amount. Those who spent most, but not all, of the USD 35 each month spoke about challenges with getting to the grocery store at the end of the month or with getting FV purchases to add up to USD 35 exactly, resulting in a small balance remaining.
3.4.2. CVB Increase Resulted in Purchasing Greater Amounts and Variety of FV
A majority said that the increase in CVB from USD 9 to USD 35/month changed their fruit (n = 27) and vegetable (n = 25) purchases. The majority said that they bought both a greater amount (n = 27) and a greater variety (n = 25) of FV. The ability to buy a greater variety of FV also enabled caregivers to introduce their child to new FV. Introducing children to new FV was more of a barrier when they received only USD 9/month because they did not want to spend such limited funds on produce that their child might not like. A positive impact reported by caregivers was that children learned to like new FV that they had been unable to try before.
“I started looking up different recipes for different vegetables because I would just buy the basics like carrots, celery, the same old stuff and make the same old soups (before the increase)… and now I buy more cauliflower, squash. We eat a lot of roasted vegetables now and I just want to expose them to a bigger variety.”(English speaking participant with 2.5 years of WIC participation—EN4)
“I thought the change was extremely helpful. Because instead of just grabbing a few breakfast fruits, I was able…to try different fresh vegetables that normally I wouldn’t try. It (CVB increase) made me go more outside my comfort zone. It actually paid off because my son ate more of the newer things than the same old stuff he was used to.”(English speaking participant with 2.5 years of WIC participation—EN13)
In addition to greater amounts and variety of FV, participants reported being able to afford a better quality FV—making eating FV more enjoyable. Participants were especially grateful during the summer when the variety of FV available was more plentiful.
“Because it (CVB increase) was like a kid in the candy store. It’s like, wow, we have this resource now that we can get more and more. They (the children) just love...They were introduced to artichokes, and they wanted dragon fruit and things like that we were not able to do before. So it was it was great.”(English speaking participant with 3 years of WIC participation—EN10)
Finally, the CVB increase to USD 35/month helped offset the cost of the increase in the amount and variety and improved quality of FV purchased for children to eat. It allowed participants the ease of not worrying about the cost of the FV, which unlike other WIC foods, are price-sensitive for WIC participants.
“We didn’t worry about the sale prices at that point… having a little bit more to work with made it where you’re not budgeting as hard for the things that you like.”(English speaking participant with 2 years of WIC participation—EN11)
4. Discussion
Changing the CVB component of the WIC food package provided WIC families with additional resources to reduce the burden of how much they spent for FV and minimize any detrimental impacts on diet quality associated with the COVID-19 pandemic. Prior to the CVB changes, one study in Massachusetts conducted a qualitative analysis on caregiver perspectives of the WIC program and factors that led to underutilization, finding that for many the FV benefit was the main reason for continued enrollment but, the set amount of USD 9/USD 11 per month was insufficient [18]. This study is among the first to evaluate the impact that two changes to the CVB amount (USD 35 in June 2021 and adjustment to USD 24 in October 2021) have had on satisfaction, purchasing habits, and diet quality for WIC families. A qualitative approach for this study allowed the 30 WIC participants interviewed to openly share their perceptions and experiences with the changes to the CVB amount. The restriction by percent of CVB redeemed and stratification by race/ethnicity and language yielded a broad perspective of experiences.
Based on the findings across all groups, satisfaction with the WIC food package increased with both CVB amount changes (USD 35 per month for 4 months and USD 24 per month thereafter). Overall, caregivers felt that they were able to purchase greater quantities and varieties of FV for their children that were more aligned with recommendations for health. Caregivers also noted that this allowed them more opportunities to introduce their children to a greater variety and quality of FV that were out of reach when the CVB monthly amount was set at USD 9. With the increased amount of CVB, the findings also showed that families had the ability to provide healthier options to their children during meals and snack times. With the increased amount, families had more FV access throughout their monthly benefit period instead of only the first week of their benefit period, after which the amount purchased with only USD 9 was consumed.
Results also suggested that the increased CVB leads to healthier options available for the household in general, suggesting that an increase in WIC CVB may have spillover impacts beyond the children on WIC. Pregnant and postpartum mothers eligible for WIC, although not the focus of the study, also reported benefits from an increased CVB amount. These women’s perceptions and experiences about their own CVB amount increase were in line with what was reported about the increase received for their children.
In addition, the findings showed that families were able to offset costs in other areas when the CVB amount was increased. For example, many families noted that they were able to buy more grains and meats for their family since they no longer had to pay out of pocket for more FV. For some households, the CVB increase also helped to alleviate the burden of increasing the cost of housing, transportation and overall food costs. Some families interviewed in this study emphasized they did not redeem the full value of the enhanced CVB because they could not get FV purchases to add precisely to the CVB amount, suggesting they were primarily focused on displacing their personal FV expenditures with the augmented CVB instead of increasing total FV purchases. Future analyses will be needed to explore whether the enhanced CVB was associated with increased FV intakes. Additionally, with the acceleration of inflation, families noted the rising cost of FV but stated the CVB increase allowed them the choice to spend on better quality and more variety while not having to worry so much about their budget.
When the monthly CVB amount was readjusted to USD 24, caregivers remained appreciative of the CVB amount greater than USD 9, but they noted that the previous amount of USD 35 was more consistent with their child’s dietary needs. The ideal mean CVB amount reported by the interviewed group was USD 38.17 [3,5]. While WIC is a food assistance program, the WIC food package was designed to be supplementary, meaning that the foods provided in the food package are only meant to partially meet a child’s dietary needs [19].
This study provides new information on WIC participants’ experiences and perceptions when food package changes occur. Interviews were conducted and analyzed by collaborating researchers not affiliated with WIC to minimize social desirability bias. Although interviews were conducted with a diverse sample based on race and ethnicity, one limitation of the study is that it included only participants from Los Angeles County in California where the cost of living is generally much higher than in other places. California ranks as the 4th most expensive state or federal district in the United States for the composite cost of living in 2021 [20]. Another limitation is that the sample was comprised of respondents to two previous surveys, thus they may be more satisfied with their WIC experience and open to sharing their experiences than non-respondents.
5. Conclusions
This study examined the perceptions and experiences of WIC families on the CVB amount change during the COVID-19 pandemic. Results suggest maintaining the CVB for children 1–4 years of age at the current level (USD 24/month), which is in line with the NASEM food package revision recommendations or increasing the amount further, will benefit WIC families’ ability to purchase and consume greater amounts, varieties and quality of FV. Study results provide timely perspectives to inform policymakers about benefit changes for the WIC food package. Based on the study participants’ positive perceptions of the CVB changes to date, a permanent increase in the CVB would be well-received by WIC participants and would increase access to fruits and vegetables among low-income households with young children in the United States. The permanent augmentation of the WIC CVB amount is also likely to increase WIC program participation and retention of eligible families, thus reducing the burden of access and leading to healthier diets supported by WIC.
Author Contributions
Conceptualization, C.E.M., L.D.R., D.L.L., M.M.T., C.E.A. and S.E.W.; methodology: C.E.M., L.D.R., M.M.T., C.E.A. and S.E.W.; formal analysis, L.D.R. and D.L.L.; investigation, L.D.R. and D.L.L.; data curation, L.D.R. and D.L.L.; writing—original draft preparation, C.E.M., L.D.R. and D.L.L.; writing—review and editing, C.E.M., L.D.R., D.L.L., C.E.A., M.M.T. and S.E.W. visualization, C.E.M.; supervision, L.D.R. and S.E.W.; project administration L.D.R., M.M.T. and S.E.W.; funding acquisition, L.D.R. and S.E.W. All authors have read and agreed to the published version of the manuscript.
Funding
This research was funded by David and Lucile Packard Foundation, grant number 2020-70267 and Healthy Eating Research, a national program of the Robert Wood Johnson Foundation, Round 12, grant number 77239.
Institutional Review Board Statement
The study procedures were approved by the California Department of Health and Human Services (Project number: 2020-048) and University of California, Davis (Project number: 1841932-2) Institutional Review Boards.
Informed Consent Statement
Informed consent was obtained from all subjects involved in the study.
Data Availability Statement
The data include personal identifiable information and will not be publicly posted. Inquiries about the data can be sent to Catherine E. Martinez (catherinem@phfewic.org).
Conflicts of Interest
The authors declare no conflict of interest.
Abbreviations
Definition of abbreviations and acronyms.
| CVB | Cash Value Benefit |
| WIC | Special Supplemental Nutrition Program for Women, Infants, and Children |
| ARPA | American Rescue Plan Act |
| USD | United States dollar |
| USDA | United States Department of Agriculture |
| FV | Fruits and vegetables |
| EN | English-speaking participant, followed by the participant ID number used for coding purposes |
| SP | Spanish-speaking participant, followed by the participant ID number used for coding purposes |
| AA | Black or African American race |
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