Understanding WIC Fruits and Vegetables Redemption in Virginia Qi (Harry) Zhang, Ph.D., Chuanyi Tang, Ph.D. Old Dominion University, Norfolk, Virginia For the Committee to Review WIC Food Packages National Academies of Sciences, Engineering and Medicine June 29, 2016
2 Acknowledgment Preliminary results from an ongoing pilot project funded by Duke-UNC USDA Center for Behavioral Economics and Healthy Food Choice Research (BECR) (USDA Grant # 59-5000-4-0062). Views expressed may not be attributed to the BECR Center, the USDA or the Virginia Department of Health
3 Why Fruits and Vegetables (F&V) Redemption? The only cash value voucher (CVV) in WIC Most options to select (least limitation on brand or size) Most number of redemption records (i.e., 2.7 million/yr) Many questions unanswered Q1: WHAT EXACT F&V are redeemed? Q2: How much CVV is redeemed? Q3: If not 100% redeemed, why?
4 Integrated Approach Quantitative Virginia WIC administrative data in 2015 Participant demographics EBT redemption records Qualitative Focus group and in-depth interviews in three cities in Southeastern Virginia Virginia Beach, Portsmouth, and Suffolk
5 Advantages of the Data to Understand F&V Redemption Large number of transaction (2.7 million in 2015) Detailed information on each record Who? (Family ID) When? (Date) How much? (Redeemed amount) Where? (Store ID) What? (Detailed F&V description)
6 Product Codes and Descriptions Universal Product Code (UPC)(bar code) E.g. 036800311534: Food Club Cut Green Beans - 14.5 oz. Price Look-Up (PLU) code 4 or 5 digit codes issued by International Federation for Produce Standards (IFPS) E.g. 31103: Naval Oranges Not all 4 or 5 digits assigned by IFPS A wild card in Virginia WIC: 4469/44691 Good news: Cashiers can use this code to check out any F&V Bad news: Don t know exactly what F&V is redeemed Source: ifpsglobal.com
7 Study Population Table 1. Descriptive Statistics of WIC Households in Virginia in 2015 Number of Households All 157,457 100 Non-Hispanic White 62,277 39.6 Non-Hispanic Black 52,856 33.6 Hispanic 35,448 22.5 # of WIC (=1) 74,489 47.3 # of WIC (=2~3) 78,572 49.9 # of WIC ( 4) 4,396 2.8 SNAP (No) 75,296 47.8 SNAP (Yes) 82,161 52.2 %
8 Q1: What F&V Were Redeemed? Table 2. Average Monthly Transaction Numbers of F&V in Virginia in 2015 WIC Subgroup Total # of Records Fresh F&V (%) Canned F&V (%) Frozen F&V (%) Dried F&V (%) General F&V (%) All 2,664,080 65.1 7.7 4.8 0.1 22.3 White 1,075,879 63.8 9.8 5.2 0.1 21.2 Black 836,460 Hispanic 641,481 # of WIC (=1) 821,283 # of WIC 1,650,669 (=2~3) # of WIC ( 4) 192,128 SNAP (No) 1,237,838 SNAP (Yes) 1,426,242 63.8 10.0 7.2 0.1 18.9 68.5 2.1 1.6 0.1 27.8 64.6 8.0 4.8 0.1 22.6 65.2 7.6 4.8 0.1 22.3 67.0 7.6 4.8 0.1 20.5 65.2 8.1 5.2 0.1 21.4 65.1 7.4 4.5 0.1 23.0
9 Q1: What F&V Were Redeemed? Table 3. Top 5 Redeemed Fruits in Virginia WIC Program in 2015* WIC Subgroups 1 st (%) 2 nd (%) 3 rd (%) 4 th (%) 5 th (%) All Banana(30.3) Apple(14.2) Grapes(12.4) Strawberry(8.5) Pineapple(3.8) White Banana(33.6) Apple(13.2) Grapes(11.8) Strawberry(9.6) Pineapple(3.5) Black Banana(28.6) Grapes(16.2) Apple(11.6) Strawberry(8.2) Pineapple(5.9) Hispanic Banana(27.7) Apple(18.4) Grapes(9.2) Strawberry(7.4) Avocado(5.6) # of WIC (=1) Banana(30.9) Apple(14.4) Grapes(12.7) Strawberry(8.4) Pineapple(3.9) # of WIC (=2~3) Banana(29.9) Apple(14.2) Grapes(12.2) Strawberry(8.5) Pineapple(3.8) # of WIC ( 4) Banana(31.6) Grapes(13.4) Apple(13.3) Strawberry(8.6) Pineapple(3.5) SNAP (No) Banana(30.7) Apple(13.5) Grapes(12.9) Strawberry(8.4) Pineapple(4.0) SNAP (Yes) Banana(30.0) Apple(14.7) Grapes(12.1) Strawberry(8.6) Pineapple(3.7) *By number of redemption records
10 Q1: What F&V Were Redeemed? Table 4. Top 5 Redemption Vegetables in Virginia in 2015* WIC Subgroups 1 st 2 nd 3 rd 4 th 5 th All Salad(9.4) Corn(9.0) Onion(8.0) Tomato(8.0) Pepper(7.5) White Corn(9.4) Tomato(9.1) Salad(8.1) Bean(7.7) Onion(7.5) Black Corn(10.4) Salad(8.9) Pepper(8.0) Onion(8.0) Bean(7.8) Hispanic Salad(13.9) Pepper(9.5) Onion(8.9) Tomato(6.2) Corn(5.7) # of WIC (=1) Salad(9.6) Corn(9.4) Tomato(8.0) Onion(7.5) Bean(7.3) # of WIC (=2~3) Salad(9.2) Corn(8.8) Onion(8.2) Tomato(7.9) Pepper(7.7) # of WIC ( 4) Salad(9.6) Corn(8.9) Pepper(8.4) Onion(8.4) Tomato(8.3) SNAP (No) Salad(9.4) Corn(9.1) Tomato(8.1) Onion(8.1) Pepper(7.5) SNAP (Yes) Salad(9.3) Corn(8.9) Onion(7.9) Tomato(7.9) Pepper(7.5)
11 What Factors Were Associated with Fresh F&V Choices? Table 5. Conditional Logistic Regression Results for Choosing Fresh F&V/ Choosing Fresh Fruit Fresh F&V Fresh Fruit Given Fresh F&V OR 95% CI OR 95% CI White Ref Ref Black 1.006* 1.000 1.012 1.121*** 1.114 1.128 Hispanic 1.245*** 1.237 1.253 1.497*** 1.487 1.507 # of WIC (=1) Ref Ref # of WIC (=2~3) 1.028*** 1.022 1.034 0.936*** 0.931 0.941 # of WIC ( 4) 1.137*** 1.125 1.149 0.993 0.983 1.004 SNAP (No) Ref Ref SNAP (Yes) 0.985*** 0.980 0.990 1.027*** 1.021 1.032 Note: * : P<0.05; **: P<0.01; ***: P<0.001
12 Q2: How much CVV Was Redeemed? Table 6. CVV (F&V benefits) Redemption Patterns in Virginia in 2015 Monthly CVV Redemption Total CVV $ Redemption Rate (%) All 8.49 72.0 White 8.69 71.9 Black 7.92 66.9 Hispanic 8.83 78.1 # of WIC (=1) 6.50 71.4 # of WIC (=2~3) 9.41 72.0 # of WIC ( 4) 17.17 78.4 SNAP (No) 8.72 72.2 SNAP (Yes) 8.29 71.8
13 Q3: If Not Redeemed in Full, why? Table 7. Logistic Regression Results of Whether Redemption Rate is below 100% or 75% Not Full Redemption (Redemption rate < 100%) Under-redemption (Redemption Rate < 75%) OR 95% CI OR 95% CI White Ref Ref Black 1.806*** 1.724 1.892 1.422*** 1.385 1.461 Hispanic 1.059** 1.012 1.108 0.647*** 0.628 0.667 # of WIC (=1) Ref Ref # of WIC (=2~3) 1.129*** 1.087 1.172 0.974* 0.951 0.997 # of WIC ( 4) 0.942 0.853 1.041 0.621*** 0.581 0.664 SNAP (No) Ref Ref SNAP (Yes) 1.198*** 1.155 1.243 1.072*** 1.048 1.096 Note: * : P<0.05; **: P<0.01; ***: P<0.001
14 Summary of Quantitative Results In general, 65% of WIC redemption on fresh F&V Banana/vegetable salad bag: #1 fruit/vegetable Hispanic households and more participants prefer fresh F&V Average F&V redemption rate: 72% Black and SNAP participants with lower redemption rates Limitation of quantitative approach Limited number of explanatory variables in the data Lack of insights into consumer decisions and behaviors
15 Q3: If Not Redeemed in Full, Why? Supplementary qualitative research Research questions What factors influence F&V purchases? Why do not many WIC participants redeem the full F&V benefits? Data collection and analysis Focus group In-depth Interview Data analyzed using NVivo 11
16 Qualitative Study Table 8. Number of Participants and Sites in Qualitative Study Location Date Data Collection Method # of Participants WIC clinic in Virginia Beach, VA 4/7/2016 In-depth interview 3 5/12/2016 In-depth interview 1 WIC clinic in Portsmouth, VA WIC Clinic in Suffolk, VA 4/16/2016 In-depth interview 3 5/6/2016 Focus group 11 4/21/2016 Focus group 7 6/2/2016 Focus group 5
17 What Factors Influenced WIC Participants F&V Purchases? Price and affordability Price has a lot to do with it (F&V purchase). We always get them (i.e., fruits and vegetables). Sometimes might be short of money and we can t buy constantly. Quality and freshness I like to smell my fruits and vegetables. If it does not smell nice, I do not buy them. Nutrition Well my main thing why I switched to frozen because of the process that they do to the food when it is canned and the health of my children. The frozen keeps iron and vitamins in the vegetables and fruit.
18 What Factors Influenced WIC Participants F&V Purchases? Children s preference My kids like broccoli and cauliflower. No squash or no carrots. The kids really only like broccoli and cauliflower, actually. Time constraints You may do canned because you have less time. You may do fresh because you have more time. Or you may do frozen because it is more convenient. Canned I will get 70-80% of the time, and the rest is fresh
19 What Factors Influenced WIC Participants F&V Purchases? Many participants make unplanned shopping trips and go to store more than once per week Whenever I run out. I guess or when money is available. No particular day. I mean I don t have a particular day I go shopping. It is just me and my kids. I am the only one that be cooking for them so If I do not have something when I am cooking, I will go to the store. I shop when I am available. When I am not busy. I go to the grocery store all the time.
20 Why Were WIC F&V Benefits Underredeemed? Store experience Sometimes when you go to the store there is no WIC sign so you do not know what to buy. I do not use mine because it would not work, and I got frustrated. When changed from under 12 to 1 year old. Tried to get fruits and vegetables and at the store does not work. Store will not allow, I got frustrated, so I quit using the WIC and paid cash. They keep saying not this or that. I got frustrated and paid cash. Stores are not consistent. You can get one thing at one store and not the other. CVV has a very general eligibility e.g. any fresh F&V is eligible. Why did the CVV benefit get denied?
21 A Complicated Daily Information Exchange Process in the WIC Program Has WIC agency added this code to the APL? Depending on Is this F&V UPC/PLU code on the Approved Product List (APL)? Depending on Has the Vendor at the Corporation Level submitted the code? Yes Approved WIC F&V benefits Yes No Does the Cashier know how to override a system denial with the wild card code (e.g., 4469)? No Denied WIC F&V benefits Depending on Figure 1. F&V Code Matching Process in WIC Depending on Has the store manager submitted the code to the Corporation? Does the cashier receive proper WIC Training?
22 Why Were WIC F&V Benefits Underredeemed? Individual factors Forget the benefits Sometimes I do not pay attention to time frame on it. The time may have ran out that month. You can forget that you have got to cash them. Marginal value of WIC benefits I spend some and it is not all of it. You get to the store and do not have enough for this or that so the balance just sits on the card. Most of the time I use the SNAP card, so I really do not have to redeem them on the WIC card.
23 Why Were WIC F&V Benefits Underredeemed? Lack of related knowledge Uh, it was difficult at first because of how it is explained in the pamphlets and programmed on the card and which products and named brands you get. I did not really understand. I was just getting canned at first for fruits and vegetables. I did not know about how to purchase the fresh fruits and vegetables. And sometimes people do not know what to do with fruits and vegetables because they are not used to eating fruits and vegetables. What to cook or what not to cook or how to cook it.
24 Why Were WIC F&V Benefits Underredeemed? Personal preferences or needs No. We do not really eat vegetables. He (her son) does not really eat vegetables or the fruit. He does not really like sweet potatoes and stuff like that. Lack of transportation Some people do not have vehicles. There is no public transportation.
25 Policy Implications and Future Research: How to Improve F&V Redemption? Participants: Timely reminder Text message: Our Just-in-Time Incentive (JITI) Project Smartphone App: e.g. EBTShopper Store: Enhancing F&V redemption experiences Product presentation and labeling Employee training WIC Program + Store Integrating and streamlining the information exchange
26 A Great Team to Work with Virginia Department Health: Michael Welch (WIC Director), Todd Osborne, Melanie Jones, Fleming Kenneth, Brian Tun, Sheila Brewer, Karki Sudeep WIC Clinic Managers and their Staff: Kathleen Walters, Lisa Anderson, Karen Bower Old Dominion University: Junzhou Zhang, Leigh Diggs, Yuzhong Shen, Kayoung Park USDA: Elizabeth Frazao, David Smallwood, Joanne Guthrie, Patrick McLaughlin BECR Center: Alice Ammerman, Matt Harding, Terry Hartman
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