Racial/Ethnic Differences in the Effectiveness of a Multisector Childhood Obesity Prevention Intervention.

OBJECTIVES: To investigate racial/ethnic and language differences in the effectiveness of the Massachusetts Childhood Obesity Research Demonstration (MA-CORD) study among children aged 2 to 4 years enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). METHODS: We performed a multisector quasiexperimental study in 2 MA-CORD intervention communities and 1 comparison community. Using WIC data from 2010 to 2015, we examined intervention effect on child weight and behavior outcomes by child race/ethnicity and parental primary language using multilevel linear regression models with an interaction term. RESULTS: Non-Hispanic Black children exposed to the intervention demonstrated a greater decrease in body mass index (BMI) than did other children (P < .05). Racial/ethnic minority children in the comparison site had greater increases in BMI than did their White counterparts (P < .05). There were no differences in intervention effectiveness by race/ethnicity or language for health behaviors. CONCLUSIONS: White children demonstrated decreased BMI in both the intervention and control groups. However, intervention minority children demonstrated greater improvements in BMI than did control minority children. Public Health Implications. To reduce racial/ethnic disparities, we need to disseminate effective obesity prevention interventions during early childhood in low-income settings.

A Descriptive Analysis of Redemption Patterns by Vendor Type Among: WIC Participants in Massachusetts.

BACKGROUND: The retail environment is an important determinant of food package redemption in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). OBJECTIVE: The objectives of this study were to describe where Massachusetts WIC households redeemed their food benefits each month and monthly variations in benefit redemption depending on a household's most frequently used vendor type each month. DESIGN: These were cross-sectional and longitudinal analyses of administrative data provided by Massachusetts WIC. PARTICIPANTS/SETTING: Monthly redemption data for 209,973 households shopping at approximately 1,000 unique vendors between January 2015 and August 2019 were analyzed. MAIN OUTCOME MEASURES: Outcomes were mean monthly percentage of households that relied on each vendor type when redeeming benefits and mean monthly percent redemption for each benefit category. STATISTICAL ANALYSES PERFORMED: For each month, households were classified as using 1 of 8 vendor types. The monthly percentage of households redeeming at each vendor type was calculated, as well as the monthly percent redemption for each benefit category by vendor type. The averages of these monthly percentages were computed for 2015 and 2019. Data from months when households did not redeem any benefits were excluded from primary analyses because it was not possible to determine their vendor type for that month. RESULTS: On average across months in 2019, the majority of Massachusetts WIC households (63%) relied on large vendors only (ie, superstores, supermarkets, and large grocery stores) when redeeming benefits, and 5% relied on small grocery or convenience stores only. Between 2015 and 2019, mean monthly reliance on small grocery and convenience stores decreased by 3.1 and 0.7 percentage points, respectively. Compared with other vendor types, households that redeemed benefits at superstores only had, in an average month, lower redemption levels for most benefit categories. For example, in the 2019 mean across months, percent redemption of breakfast cereal was 53% among households redeeming at superstores only compared with 74% for those redeeming at small grocery stores only. By contrast, households that relied on small grocery stores only had, in an average month, lower redemption levels for yogurt and cash value benefit compared with other vendor types; for example, in the 2019 mean across months, percent redemption of yogurt was 34% among households redeeming at small grocery stores only compared with 62% among those redeeming at supermarkets only. CONCLUSIONS: Results suggest that retail-based efforts to increase redemption should consider vendor-type reliance. Strategies to increase redemption may be especially important for WIC shoppers relying on superstores.

Caregivers' Perceived Impact of WIC's Temporary Cash-Value Benefit (CVB) Increases on Fruit and Vegetable Purchasing, Consumption, and Access in Massachusetts.

Responding to the COVID-19 pandemic, the American Rescue Plan (2021) allowed state agencies of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) the option of temporarily increasing the Cash-Value Benefit (CVB) for fruit and vegetable (FV) purchases. To examine the impact of this enhancement on WIC caregiver experience, the MA WIC State Office invited 4600 randomly selected MA WIC caregivers to complete an online survey (February-March 2022). Eligible adults had at least one child, had been enrolled at least a year, and were aware of the increase. Of those who opened the screener (n = 545), 58.9% completed it (n = 321). We calculated the frequencies of reporting increased FV outcomes and tested whether responses differed by race/ethnicity, market access, and food security. Most caregivers perceived the CVB increase to benefit FV purchasing (amount and quality, 71.0% and 55.5%), FV consumption (offered to children and personally consumed, 70.1% and 63.2%), and satisfaction with the WIC food package (37.1% reported improved satisfaction, pre- vs. post-increase). Probability of reporting improved outcomes was not found to differ by race/ethnicity, market access, or food security. CVB increases may pose important implications for dietary behaviors and satisfaction with WIC. Policymakers should consider making this increase permanent.

Caregiver Perspectives on Underutilization of WIC: A Qualitative Study.

OBJECTIVES: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is a federal program that improves the health of low-income women (pregnant and postpartum) and children up to 5 years of age in the United States. However, participation is suboptimal. We explored reasons for incomplete redemption of benefits and early dropout from WIC. METHODS: In 2020-2021, we conducted semistructured interviews to explore factors that influenced WIC program utilization among current WIC caregivers (n = 20) and caregivers choosing to leave while still eligible (n = 17) in Massachusetts. By using a deductive analytic approach, we developed a codebook grounded in the Consolidated Framework for Implementation Research. RESULTS: Themes across both current and early-leaving participants included positive feelings about social support from the WIC clinic staff and savings offered through the food package. Participants described reduced satisfaction related to insufficient funds for fruits and vegetables, food benefits inflexibility, concerns about in-clinic health tests, and in-store item mislabeling. Participants described how electronic benefit transfer cards and smartphone apps eased the use of benefits and reduced stigma during shopping. Some participants attributed leaving early to a belief that they were taking benefits from others. CONCLUSIONS: Current and early-leaving participants shared positive WIC experiences, but barriers to full participation exist. Food package modification may lead to improved redemption and retention, including increasing the cash value benefit for fruits and vegetables and diversifying food options. Research is needed regarding the misperception that participation means "taking" benefits away from someone else in need.

Nutrition provider confidence in the Massachusetts Childhood Obesity Research Demonstration (MA-CORD) study.

OBJECTIVE: The multi-sector, multi-level Massachusetts Childhood Obesity Research Demonstration (MA-CORD) study resulted in improvements in obesity risk factors among children age 2-4 years enrolled in the Special Supplemental Nutrition program for Women, Infants, and Children (WIC). The goal of this study was to examine whether the MA-CORD intervention increased WIC provider confidence in their ability to identify childhood obesity and obesity-related behaviors. METHODS: As part of the MA-CORD intervention conducted from 2012 to 2015, we implemented WIC practice changes focused on childhood obesity prevention within two Massachusetts communities. We examined changes in provider confidence to assess childhood obesity risk factors and practice frequency among WIC practices located in MA-CORD intervention communities over a 3-year period, compared to non-intervention sites. We measured provider confidence on a continuous scale using questions previously developed to assess provider and parent confidence to make weight-related behavior change (range 0 to 24). RESULTS: There were 205 providers at baseline and 165 at follow-up. WIC providers at intervention sites reported greater confidence in their ability to identify childhood obesity and obesity-related behaviors compared to the usual care sites (ß = 1.01, standard error = 0.13). These findings persisted after adjusting for provider gender, years in practice, highest education level, and WIC position. CONCLUSIONS: The MA-CORD intervention was associated with increased WIC provider confidence to assess children's obesity risk. Interventions that increase confidence in assessing obesity-related behaviors may have salutary effects within WIC programs that serve low-income families.

Childhood obesity prevention in the women, infants, and children program: Outcomes of the MA-CORD study.

OBJECTIVE: To examine the extent to which a Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) intervention improved BMI z scores and obesity-related behaviors among children age 2 to 4 years. METHODS: In two Massachusetts communities, practice changes in WIC were implemented as part of the Massachusetts Childhood Obesity Research Demonstration (MA-CORD) initiative to prevent obesity among low-income children. One WIC program was the comparison. Changes in BMI z scores pre and post intervention and prevalence of obesity-related behaviors of WIC participants were assessed. Linear mixed models were used to examine BMI z score change, and logistic regression models were used to examine changes in obesity-related behaviors in each intervention site versus comparison over 2 years. RESULTS: WIC-enrolled children in both intervention sites (vs. comparison) had improved sugar-sweetened beverage consumption and sleep duration. Compared to the comparison WIC program (n = 626), no differences were observed in BMI z score among children in Intervention Site #1 (n = 198) or #2 (n = 637). In sensitivity analyses excluding Asian children, a small decline was observed in BMI z score (-0.08 units/y [95% confidence interval: -0.14 to -0.02], P = 0.01) in Intervention Site #2 versus comparison. CONCLUSIONS: Among children enrolled in WIC, the MA-CORD intervention was associated with reduced prevalence of obesity risk factors in both intervention communities and a small improvement in BMI z scores in one of two intervention communities in non-Asian children.

Household Food Security Status Is Associated with Anemia Risk at Age 18 Months among Low-Income Infants in Massachusetts.

BACKGROUND: Food insecurity and anemia are prevalent among low-income families and infants. Anemia may reflect iron deficiency anemia (IDA) risk. IDA in infancy and early childhood may have long-lasting developmental effects. Few studies have examined food security status (FSS) as a risk factor for anemia. OBJECTIVE: To examine the association between household FSS, sociodemographic and health-related variables, and anemia incidence at age 18 months among low-income infants in the Massachusetts Special Supplemental Nutrition Program for Women, Infants, and Children (MA/WIC). STUDY DESIGN: This was a longitudinal study using data from MA/WIC (August 2001 to November 2009) to assess the relationship between household FSS during the 12 months preceding the 1-year visit (age 9 to 15 months) and anemia at age 18 months. PARTICIPANTS/SETTINGS: Infants included were not anemic at age 12 months and had complete data on household FSS and the following covariates (N=17,831): race/Hispanic ethnicity, maternal education, breastfeeding duration, household size, and child age. STATISTICAL ANALYSES PERFORMED: Multiple logistic regression was used to examine the association between household FSS during the prior 12 months and anemia at 18 months, controlling for infant age, sex, and race/Hispanic ethnicity, breastfeeding, maternal education, and household size. RESULTS: A majority of infants (56%) were nonwhite, and 19.9% lived in food-insecure households (4.8% in very-low food security). Of the infants who were not anemic at age 12 months, 11.7% became anemic by age 18 months. Infants living in low-food-secure households were 42% more likely (adjusted odds ratio 1.42, 95% CI, 1.27-1.60) to develop anemia at age 18 months than were their food-secure counterparts. Nonwhite race, higher household size, and lower maternal education were also associated with an elevated risk of anemia at age 18 months. CONCLUSIONS: Low food security appears to be associated with a significant increased risk of anemia, as do nonwhite ethnicity, lower maternal education, and larger household size. Knowledge of these risk factors can be used to design IDA-prevention interventions in this vulnerable population.

Mobilizing Community Resources to Enhance Postdischarge Support for Breastfeeding in Massachusetts (USA): Results of a Catalyst Grant Approach.

BACKGROUND: The Massachusetts Department of Public Health's (MDPH) Mass in Motion Program (MiM) facilitates the adoption of community-level strategies that promote healthy weight in 52 municipalities. MiM provided the platform for enhancing postdischarge continuity of care for breastfeeding. OBJECTIVE: This study aimed to improve the continuity of breastfeeding care and support for mothers by enhancing postdischarge care infrastructure and supportive contacts for women and families. METHODS: The MDPH awarded catalyst grants to community-based organizations (CBOs) that facilitated the formation of teams for improving breastfeeding support. The effort focused on populations that often experience disparities in breastfeeding outcomes such as minority women and women receiving Medicaid. The Added Value Model of Community Coalitions was used to qualitatively assess effect across multiple levels of the socioecological model of influence. RESULTS: Six communities were awarded grants to enhance or convene Breastfeeding Continuity-of-Care Teams consisting of at least 3 CBOs, including 1 maternity hospital, the local Special Supplemental Nutrition Program for Women, Infants, and Children, and the local MiM representative. Teams implemented customized plans with performance indicators to create and strengthen infrastructure for supportive contacts with breastfeeding mothers. The project included Baby Café pilots in 3 additional MiM communities. Across all grantee communities, there was an average total increase of 491 contacts with mothers per month, an improvement of 8.5% over baseline. The project created 153 added value outcomes of community collaboration at 5 levels in the socioecological framework. CONCLUSION: The project demonstrated how cross-sector, coordinated efforts focused on vulnerable populations can leverage local strengths to establish/enhance breastfeeding support services customized to local needs.

Breastfeeding Resources in Maternity Hospitals and Birth Centers in the Commonwealth of Massachusetts (USA): A Content Analysis of Discharge Packets.

BACKGROUND: Few studies have analyzed patient education materials provided at discharge. To the best of our knowledge, there are no comprehensive studies analyzing and reporting the content of breastfeeding discharge packets within the United States. OBJECTIVE: This study analyzed the extent to which patient education materials provided at discharge from maternity facilities in Massachusetts cover topics that support successful breastfeeding. METHODS: We collected discharge packets from all 48 maternity hospitals/birth centers. Topics for analysis were based on recommendations associated with the Baby-Friendly Hospital Initiative and content identified for discharge packets generally. Materials were reviewed independently and scored according to 39 criteria that we assembled from various sources for optimal breastfeeding information at discharge. Bivariate and multivariate analyses were used to explore if any hospital characteristics predicted presence of breastfeeding education topics in written information provided at discharge. RESULTS: An average of 25.4 of 39 criteria (65.2%, ranging from 30.7%-97.4%) were included in packets submitted by all 48 facilities. Exploratory multivariate analyses did not show relationships of hospital characteristics to contents of packets. Each facility received a 2-page report noting strengths, suggestions for improvement, and individual scores on all 39 criteria. CONCLUSION: Discharge packet contents varied widely; whereas some institutions' information met and/or exceeded recommended content, others were limited and/or missing information. These analyses provide a thorough review of discharge packet content for all facilities in Massachusetts; however, further study is needed to identify the implications of such variation for breastfeeding outcomes.

Online Continuing Education for Expanding Clinicians' Roles in Breastfeeding Support.

Lack of health professional support is an important variable affecting mothers' achievement of breastfeeding goals. Online continuing education is a recognized pathway for disseminating content for improving clinicians' knowledge and supporting efforts to change practices. At the time we developed our project, free, accredited continuing education for physicians related to breastfeeding management that could be easily accessed using portable devices (via tablets/smartphones) was not available. Such resources were in demand, especially for facilities pursuing designation through the Baby-Friendly Hospital Initiative. We assembled a government, academic, health care provider, and professional society partnership to create such a tutorial that would address the diverse content needed for supporting breastfeeding mothers postdischarge in the United States. Our 1.5-hour-long continuing medical and nursing education was completed by 1606 clinicians (1172 nurses [73%] and 434 physicians [27%]) within 1 year. More than 90% of nurses and over 98% of physicians said the tutorial achieved its 7 learning objectives related to breastfeeding physiology, broader factors in infant feeding decisions and practices, the American Academy of Pediatrics' policy statement, and breastfeeding management/troubleshooting. Feedback received from the tutorial led to the creation of a second tutorial consisting of another 1.5 hours of continuing medical and nursing education related to breast examination and assessment prior to delivery, provision of anticipatory guidance to pregnant women interested in breastfeeding, maternity care practices that influence breastfeeding outcomes, breastfeeding preterm infants, breastfeeding's role in helping address disparities, and dispelling common myths. The tutorials contribute to achievement of 8 Healthy People 2020 Maternal, Infant and Child Health objectives.

Design of the Massachusetts Childhood Obesity Research Demonstration (MA-CORD) study.

BACKGROUND: Childhood obesity is highly prevalent, is associated with both short- and long-term adverse outcomes, disproportionately affects racial/ethnic minority and economically deprived children, and represents a major threat to public health. Among the most promising approaches for its prevention and management are multilevel, multisector strategies. METHODS/DESIGN: The Massachusetts Childhood Obesity Research Demonstration (MA-CORD) Study was a comprehensive, systematic intervention to prevent and reduce childhood obesity among low-income children ages 2-12 years in two selected cities in Massachusetts. Building on the Obesity Chronic Care Model, MA-CORD expanded a state public health department community-level obesity prevention initiative that incorporated evidence-based interventions in primary healthcare, the Women, Infants, and Children program, early care and education, schools/afterschool programs, as well as community-wide programs to improve food, beverage, physical activity (PA), and messaging environments. The study used a combination of pre- and post-time series and quasi-experimental designs to examine the extent to which the intervention resulted in changes in BMI, individual-level lifestyle behaviors, satisfaction with healthcare services, and quality of life among children, as well as changes in health policies, programs, and environments in the two intervention cities, compared to a comparison city. The intervention period was 2 years. CONCLUSIONS: MA-CORD will determine the extent to which a multisetting, multilevel intervention that integrates activities in primary care with broader public health interventions in schools, early care and education, and the community at large can improve children's dietary and PA behaviors and ultimately reduce obesity in low-income children.

Touching Hearts, Touching Minds: using emotion-based messaging to promote healthful behavior in the Massachusetts WIC program.

The Touching Hearts, Touching Minds initiative was funded through a 2003 United States Department of Agriculture Special Projects grant to revitalize nutrition education and services in the Massachusetts Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Program. The 30 nutrition education materials and facilitated group counseling techniques developed through the project use the power of parent-identified emotional "pulse points" to become more influential in guiding WIC participants to practice positive eating and physical activity behaviors that lead to healthier families. Touching Hearts, Touching Minds materials and strategies have been well received and provide opportunities to transform the nutrition counseling relationship between WIC families and WIC staff. Touching Hearts, Touching Minds has changed nutrition education in Massachusetts and is influencing nutrition education across the country and beyond in numerous venues.