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pdfWIC Breastfeeding
Peer Counseling Study
Supporting Statement
for Paperwork
Reduction Act
Submission
Cambridge, MA
Bethesda, MD
Chicago, IL
Durham, NC
Hadley, MA
Lexington, MA
GSA MOBIS
Task Order
#AG-3198-D-06-0105
Revised June 26, 2008
Prepared for
Patricia McKinney
U.S. Department of Agriculture
Food and Nutrition Service
3101 Park Center Drive
Alexandria, VA 22302
Abt Associates Inc.
55 Wheeler Street
Cambridge, MA 02138
Prepared by
Abt Associates Inc.
Contents
Part A Justification ............................................................................................................................. 1
A.1 Explanation of Circumstances That Make Collection of Data Necessary......................... 1
A.2 How the Information Will Be Used, By Whom, and For What Purpose .......................... 5
A.3 Use of Improved Information Technology to Reduce Burden ........................................ 13
A.4 Efforts to Identify and Avoid Duplication....................................................................... 13
A.5 Efforts to Minimize Burden on Small Businesses or Other Entities ............................... 14
A.6 Consequences of Less Frequent Data Collection ............................................................ 14
A.7 Special Circumstances Requiring Collection of Information in a Manner Inconsistent
with Section 1320.5(d)(2) of the Code of Federal Regulations....................................... 14
A.8 Federal Register Comments and Efforts to Consult with Persons Outside the Agency .. 14
A.9 Payments to Respondents ................................................................................................ 16
A.10 Assurance of Confidentiality ........................................................................................... 16
A.11 Questions of a Sensitive Nature....................................................................................... 17
A.12 Estimates of Respondent Burden..................................................................................... 18
A.13 Estimates of Other Annual Costs to Respondents ........................................................... 20
A.14 Estimates of Annualized Government Costs ................................................................... 20
A.15 Changes in Hour Burden ................................................................................................. 20
A.16 Time Schedule, Publication, and Analysis Plans............................................................. 20
A.17 Display of Expiration Date for OMB Approval .............................................................. 23
A.18 Exceptions to Certification Statement ............................................................................. 23
References.................................................................................................................................. 24
Part B Statistical Methods..................................................................................................B-1
B.1
Respondent Universe and Sampling Methods ...............................................B-1
B.2
Procedures for the Collection of Information including:...............................B-3
B.3
Methods to Maximize Response Rates and Deal with Non-Response ..........B-5
B.4
Tests of Procedures or Methods to Be Undertaken .......................................B-6
B.5
Individuals Consulted on Statistical Aspects and Individuals Collecting
and/or Analyzing Data ...................................................................................B-7
Addendum: Responses to Questions from OMB, June 11 and 17, 2008
List of Attachments
Appendix A: Recruitment Documents and Data Collection Instruments
Appendix B: Federal Register Notice and Public Comments
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Contents
i
Part A
Justification
Part A provides supporting statements for each of the eighteen points outlined in Part A of the OMB
guidelines, for the collection of information in a study of the Loving Support peer counseling program
in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), called the
WIC Breastfeeding Peer Counseling Study.
A.1
Explanation of Circumstances That Make Collection of Data
Necessary
The U.S. Department of Agriculture’s (USDA) Food and Nutrition Service (FNS) is requesting
approval from the Office of Management and Budget (OMB) to conduct Phase I of the WIC
Breastfeeding Peer Counseling Study. This phase of the study will examine how States and Indian
Tribal Organizations (ITOs) are using peer counseling grants provided to initiate the FNS Loving
Support peer counseling model in local WIC agencies or to expand existing WIC peer counseling
programs to meet the requirements of the Loving Support peer counseling model. Following the
completion of Phase I, FNS will launch Phase II of the study, which will assess the impact on
breastfeeding duration of enhancing the Loving Support model with evidenced-based strategies to
improve peer counseling programs. A separate request for OMB approval will be submitted for
Phase II approval, once the design has been finalized, based on Phase I findings.
This section contains background information on WIC; breastfeeding promotion in WIC, and
specifically the Loving Support initiatives funded by FNS; and the need for the study.
Background
WIC was designed to improve the health of nutritionally at-risk, low-income pregnant, breastfeeding,
and postpartum women; infants; and children up to five years of age. The program provides
supplemental foods that are rich in nutrients known to be lacking in the target population; health and
social service referrals; and nutrition education, including information about breastfeeding. Over 8
million women, infants and children are served by WIC each month (FNS, 2006). Bartlett and her
colleagues (2006) report that in 2004, WIC served about 941,000 pregnant women and about 2.2
million infants, roughly half of all infants born in the United States (Martin et al., 2002).
Current recommendations of the American Academy of Pediatrics, the American Dietetic
Association, the World Health Organization, and the U.S. government’s Healthy People 2010 goals
call for increases in the proportion of U.S. mothers who breastfeed their babies. The goals for
breastfeeding, as outlined in Healthy People 2010, are to (1) increase to 75 percent the proportion of
mothers who breastfeed their babies in the early postpartum period; (2) increase to 50 percent the
proportion of mothers who breastfeed their babies through five to six months of age; (3) increase to
25 percent the proportion of mothers who breastfeed their babies through the end of the first year; and
(4) close the racial and ethnic disparities in breastfeeding. WIC encourages breastfeeding as the best
source of infant nutrition, and is working to meet the 2010 goals and improve the breastfeeding rates
of WIC women relative to non-WIC participants.
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Part A: Justification
A-1
Loving Support
In a series of efforts to promote breastfeeding, FNS implemented the national WIC breastfeeding
promotion program, Loving Support Makes Breastfeeding Work. This program is a comprehensive
social marketing initiative designed to increase the initiation and duration rates of breastfeeding and
to increase community support for WIC breastfeeding participants. The program was launched in
1997, and includes public awareness materials, participant educational materials, staff training
resources, and policy guidance. Loving Support has been implemented in all 50 U.S. States and
nearly all State WIC agencies, and continues to be the WIC “brand” for breastfeeding support. In
2002, USDA funded a training initiative using the Loving Support “model” developed in the States of
Mississippi and Iowa, and provided it in 22 U.S. States and Indian Tribal Organizations.
In 2004 FNS further built upon the Loving Support breastfeeding program by launching the national
peer counseling initiative, Using Loving Support to Implement Best Practices in Peer Counseling.
The Loving Support peer counseling model developed specifically for WIC in this initiative has been
adopted by 86 States and ITOs across the country and provides a framework for State and local WIC
agencies either to develop a successful peer counseling program or to enhance WIC peer counseling
programs that already exist. It uses training curricula also developed under the Best Start cooperative
agreement: Using Loving Support to Manage Peer Counseling Programs, aimed at program managers
and State breastfeeding and nutrition coordinators; and Loving Support through Peer Counseling,
aimed at peer counselor trainers.
Through implementation of the Loving Support peer counseling program, WIC has continued to move
towards its goal of institutionalizing peer counseling as a core service in WIC. The literature suggests
that peer counseling has shown some success in increasing breastfeeding duration rates, a critical
focus for WIC sites across the country (McLaughlin et al., 2003). In addition, peer counseling has
been shown to be associated with positive breastfeeding outcomes in minority groups that have
proven difficult for WIC to support in the initiation and continuation of breastfeeding (McLaughlin et
al., 2003; Centers for Disease Control and Prevention, 2005).
Beginning in Fiscal Year 2004 and continuing through to the present, Congress has appropriated
about $15 million dollars per year for States and ITOs to support breastfeeding peer counseling in
WIC (Public Law 108-99). FNS has awarded funds to States and ITOs for a two-year grant period on
a non-competitive basis. To receive the funds, States must agree to implement a peer counseling
program that is based on the Loving Support model and is consistent with the guidance set forth in the
Loving Support training curricula. As stated above, State agencies with pre-existing peer counseling
programs can use the funds to expand those programs that meet the requirements of the Loving
Support model or enhance current programs to include all model components.
As part of the current study, FNS requested a review of the documents required of State agencies1 that
have accepted peer counseling funds, including (1) peer counseling implementation plans and
accompanying line item budgets; and (2) State agency Fiscal Year (FY) 2006 State Plans. These plans
were related to (a) breastfeeding promotion and support and (b) peer counseling, with accompanying
updated line item budgets demonstrating how FY 2006 peer counseling funds were being used. The
depth and quality of the information obtained from State agencies varied and, for the most part,
1
A-2
In this supporting statement, we use the term “State agencies” to refer to the 86 States and ITOs that receive FNS peer
counseling grant funds.
Part A: Justification
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provided little detail about the specific ways in which Loving Support is being implemented within a
State or ITO. What information was provided suggests that States do implement the components of
the Loving Support model differently, and most States have used the funds in some but not all local
WIC agencies in their State.
Given the variations that are suggested by the State Plans and the differing contexts in which the
Loving Support peer counseling program may be implemented, it is important for FNS to have
systematic and comprehensive information on the program nationwide. FNS also needs information
to guide future policy on whether enhancements to the Loving Support model can improve
breastfeeding outcomes, which will be the focus of Phase II of the study.
Study Objectives
Phase I of the study involves the collection of data on the implementation of the FNS Loving Support
peer counseling model in State and local WIC agencies, local WIC clinics, and organizations that
collaborate with local WIC agencies on Loving Support peer counseling. The information will
provide a comprehensive and systematic description of the WIC Loving Support peer counseling
program operations and of FNS peer counseling grant expenditures. It will improve USDA’s
understanding of how the program is being implemented and inform the direction of WIC Loving
Support peer counseling policies and practices in the future.
The data collected will cover the following domains: contextual information, local Loving Support
peer counseling implementation, expenditures for Loving Support peer counseling, data collection and
monitoring practices, and local collaborations. More specifically, the study will address the following
research questions:
Contextual Information
1. What breastfeeding promotion services (besides the Loving Support peer counseling
intervention) are being offered to WIC mothers?
2. What are the characteristics (e.g., geographic location, urbanicity, enrollment size) of
WIC local agencies/sites that have implemented the Loving Support peer counseling
program?
3. For those states that keep account of expenditures from all funding sources, how much
Nutrition Services Administrative (NSA) funding is used to support breastfeeding
promotion activities targeted to WIC participants, other than Loving Support peer
counseling?
Local Loving Support Peer Counseling Implementation
4. How is the Loving Support peer counseling program implemented at participating WIC
agencies and how has it been adapted over time?
5. What activities and services are involved in Loving Support peer counseling?
6. How are the Loving Support peer counselors recruited, trained, assigned to WIC mothers,
and monitored in each site?
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Part A: Justification
A-3
7. What are the prospects for continuing Loving Support peer counseling at the participating
WIC agencies?
Expenditures for Loving Support Peer Counseling
8. For peer counseling programs that began in the last year, what have been their
expenditures?
9. What are the expenditures for Loving Support peer counseling programs?
10. In addition to the Loving Support peer counseling funds, how much regular NSA funding
is used to support Loving Support peer counseling activities that meet the FNS model?
11. Do peer counseling programs supported by regular NSA funds use these funds because
they do not meet the requirements of the Loving Support model? Are NSA funds used
because the Loving Support peer counseling grant does not provide enough funding to
cover expenses of a fully implemented program?
Local Collaborations
12. How do the WIC agencies coordinate their Loving Support peer counseling program with
activities and services at area hospitals and other organizations?
13. What are the responses of collaborating organization staff to the Loving Support peer
counseling program?
WIC Participants
14. To what extent do WIC mothers participate in the Loving Support peer counseling
program?
15. What are the responses of WIC staff and WIC participants to the Loving Support peer
counseling program?
Data Collection and Program Monitoring
16. How does each State track various breastfeeding measures (e.g., ever breastfed, duration,
and exclusivity of breastfeeding)?
17. How does the State use data to evaluate the effectiveness of its Loving Support peer
counseling program and other breastfeeding promotion activities targeted to WIC
participants?
18. Can those sites implementing Loving Support peer counseling programs adequately and
effectively monitor changes in breastfeeding rates for initiation and duration?
A-4
Part A: Justification
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A.2
How the Information Will Be Used, By Whom, and For What
Purpose
This section of the supporting statement provides an overview of the research design and data
collection efforts planned to meet the overall objectives of the WIC Breastfeeding Peer Counseling
Study. The section begins with an overview of the research design, followed by a description of the
data collection activities for which OMB clearance is requested. The final section describes how the
information collected will be used.
Overview of the Research Design
The Phase I implementation study will conduct a national census of the 86 State WIC agencies
receiving Loving Support peer counseling funds. Additional information will be collected from a
nationally representative sample of 40 local WIC agencies with Loving Support peer counseling
programs, and purposive samples of 20 of their local clinics/service delivery sites and 40
organizations collaborating on Loving Support peer counseling with the 40 selected local WIC
agencies. (The sampling plan is described in Part B, Section B.1.)
How the Information Will Be Collected
The study will rely on three main methods of data collection:
1. A web-based survey of key staff from State WIC agencies,
2. On-site interviews with staff from local WIC agencies, local WIC clinics, and
collaborating organizations,
3. Data abstraction from administrative systems of local WIC agencies and from existing
documents, and
4. Use of extant data, including the WIC Participant Characteristics (WIC PC) data set.
No interviews are planned with program recipients or participants for the Phase I implementation
study.
Protocols for each form of data collection are summarized below. Recruitment letters and data
collection instruments are provided in Appendix A to this document.
Web-Based Surveys of State WIC Agencies
An on-line survey will be used to collect uniform data from the 86 State WIC agencies receiving FNS
peer counseling grants on the implementation of the Loving Support peer counseling program. These
agencies will be asked about the variety of responsibilities they are charged with to administer,
support, and monitor Loving Support peer counseling, including designating a Loving Support peer
counseling coordinator at the State level; distributing the FNS peer counseling grant to local agencies;
providing State guidelines on the implementation of Loving Support peer counseling; supporting
Loving Support peer counseling training; and tracking and monitoring the effectiveness of the Loving
Support program. Other types of information to be collected include other State-wide breastfeeding
promotion efforts, how States monitor breastfeeding rates (e.g., the indicators tracked, definitions of
the indicators, methods and frequency of data collection), and State data on those indicators. One or
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Part A: Justification
A-5
more State agency staff will be asked to complete the survey, including the State WIC Director,
budget administrator, breastfeeding coordinator and/or peer counseling coordinator.
Prior to contacting the States and ITOs for this study, FNS will contact the FNS Regions to let them
know about the plan and to provide them with the introductory materials that will be sent to the State
agencies. Two weeks prior to the start of the web-based survey, FNS will contact the 86 States and
ITOs to remind them about the study and to inform them that Abt will be contacting them about the
web-based survey. Abt staff will obtain the contact information from FNS and then send e-mails to
all State Directors with instructions on accessing the on-line survey and the deadline for its
completion. If there are respondents who cannot complete the survey via the Internet, the contractor
will offer them the option to complete a paper survey or respond via a telephone interview.
On-Site Interviews with Local WIC Agency Staff, Local WIC Clinic Staff, and Staff From
Collaborating Organizations
Contractor project staff will conduct in-depth, in-person interviews with representatives of a sample
of local WIC agencies implementing the Loving Support peer counseling program, local WIC clinic
staff, and collaborating organizations
The key objective of these interviews is to produce a systematic description of how the breastfeeding
peer counseling services are implemented in local WIC agencies, clinics, and collaborating
organizations nationally. Interview guide topics include contextual information, such as other
breastfeeding promotion activities; staff designated to Loving Support peer counseling activities; peer
counselor qualifications; compensation; and responsibilities; FNS peer counseling grant expenditures;
peer counselor training and supervision; hospital and community partnerships; and perceptions of the
Loving Support peer counseling model.
The recruitment process for the local WIC sites involves FNS notifying the FNS Regions and State
agencies of the local agencies selected in their Region/State and asking the States to notify the local
agencies and encourage their participation. The local WIC agency will be sent a letter of
introduction, signed by an FNS official, that will provide an overview of the study, a detailed
description of the local WIC agencies’ responsibilities in this study, and a request for their
participation. A copy of the introduction letter will be sent to the State WIC agency for each sampled
local agency. The letter will ask the local WIC director to nominate a collaborating organization. In
addition, the letter will ask the local WIC director if the local WIC agency has a clinic or separate
service delivery site that is implementing Loving Support peer counseling independently from the
local agency. If so, we will ask to include clinic staff in our site visit interviews.2 The local agencies
will also be sent the one-page information sheet about the study.
Each local WIC agency will be contacted by an Abt staff member. The staff member will follow up
with each of the local agencies to clarify any questions about participating in the study, collect contact
information, identify WIC clinics that are operating Loving Support peer counseling independently
from the local WIC agency, and begin the scheduling process for those that agree to participate.
During the call, we will identify the names and positions of key staff with whom we will need to
speak. We will also review the program operations data that the interviewer will ask about while on
2
A-6
Abt will include up to 20 clinics that operate Loving Support peer counseling independently from their local WIC
agency in the study sample. Part B of this package describes the process of sampling local WIC agencies and clinics in
more detail.
Part A: Justification
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site. Two weeks before the visit, we will send the Program Information Form for local WIC staff to
fill out prior to the visit along with a topic guide for the local agency interview. We will ask our
agency contact to distribute the topic guide and information to the staff to be interviewed so that they
can prepare as appropriate prior to the interview.
We will get the names of collaborating organizations, and, where relevant, local WIC clinics, as per
our sampling plan, from the local WIC agency. The procedures for recruiting the clinics and
collaborators are similar to those used for the local WIC agency: the local WIC agency will be asked
to encourage their participation, a letter of introduction and study overview will be sent, and
recruiting calls made.
The site visits will be conducted by trained data collectors. Each site visit will take approximately one
and a half days. Data collectors will prepare a report on each interview conducted, following a
standardized format and coding structure.
Data Abstraction from Existing Program Data
The data collection staff will ask local WIC administrators to extract extant program data on the
Loving Support peer counseling program operations and WIC agency expenditures, including those
from the FNS peer counseling grants. This will be requested in the Program Information Form sent to
the local WIC agencies prior to the site visit, and discussed while the data collector is on site.
WIC Participant and Program Characteristics (WIC PC)
Our final source of data is WIC Participant and Program Characteristics (WIC PC). This study
compiles characteristics of a virtually complete census of WIC participants in April in even-numbered
years. Data from the 2006 study are currently being assembled and will shortly be available for
analysis. Relevant items include State and local agency, certification category (i.e., pregnant,
breastfeeding, other postpartum, infant, or child), date of birth, date of most recent WIC certification,
expected date of delivery (if pregnant), race and ethnicity, migrant status, participation in various
means-tested programs, and family or economic unit income. Additional information is available on
anthropometric measures, blood iron, nutritional risks, and breastfeeding (for infants).
These data will serve two functions in our study. First, the counts of pregnant women served by local
agencies will provide a basis for developing a sampling frame for Phase I sites. Second, the
participant-level data will enable us to characterize the Phase I sites, and all sites with (and without)
peer counseling programs, in terms of pregnant participants’ demographics, geographical region, and
trimester of WIC enrollment.
Exhibit A.1 shows the research question, the key variables, and the source of the information.
Use of the information
Results of this study will be used to: (1) capture and disseminate information on implementing peer
counseling programs using the Loving Support model, including lessons learned and successful
approaches used by State agencies; (2) assess the additional technical assistance and training needs of
State agencies; and (3) provide information to FNS and other stakeholders on how State agencies are
using the peer counseling funding.
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Part A: Justification
A-7
A-8
Exhibit A.1
Phase I Implementation Study: Research Questions, Key Variables, Sources of Data, and Data Collection Methods
Research Questions
Part A: Justification
Contextual Information
1. What breastfeeding promotion services
(besides the Loving Support peer
counseling intervention) are being offered
to WIC mothers?
2. What are the characteristics (e.g.,
geographic location, urbanicity, enrollment
size) of WIC local agencies/sites that have
implemented the Loving Support peer
counseling program?
Variables
Source of Data
Data Collection Method
• Types of breastfeeding promotion services provided
• For each type, the approach, methods used, collaborating organizations, WIC
participants targeted (e.g., pregnant, post-partum)
• Evidence of effectiveness of breastfeeding promotion/support services
• Staff members involved in breastfeeding promotion/support services
• Expenditures for breastfeeding promotion and support services
• Type of agency (health, social service, etc.)
• Number of service delivery sites/clinics
• Number of WIC participants
• Geographical region and urbanicity
• Breastfeeding coordinator or lactation consultant on staff
• Amount of WIC Nutrition Services and Administrative (NSA) funds devoted to
breastfeeding promotion/support
• Types of breastfeeding promotion activities for WIC participants and funding
amounts
• Total amount of NSA funds for breastfeeding promotion activities
• Staff from all State
WIC agencies
• Sampled local WIC
agency and clinic
staff
• State web-based survey
• On-site local WIC
agency and clinic staff
interviews
• Staff from all State
WIC agencies
• Sampled local WIC
agency staff
• WIC PC 2006 data
• Agency administrative
data collection
• On-site local WIC
agency staff interview
•
• Staff from all State
WIC agencies
• State web-based survey
• Sampled local WIC
agency and clinic
staff
• On-site local WIC
agency and clinic staff
interviews
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3. For those States that keep account of
expenditures from all funding sources, how
much NSA funding is used to support
breastfeeding promotion activities targeted
to WIC participants, other than Loving
Support peer counseling?
Local Loving Support Peer Counseling Implementation
4. How is the Loving Support peer counseling
• Staffing patterns, responsibilities of staff, additional staff or reassigned staff for
program implemented at participating WIC
Loving Support program
agencies and how has it been adapted
• WIC staff training to support the peer counseling intervention
over time?
• Ways in which 10 core elements of Loving Support peer counseling are
implemented
• Peer counselor pay, benefits and reimbursed expenses
• Peer counselor work schedule and caseload
• Agency’s administrative record keeping process/system as it relates to Loving
Support peer counseling and breastfeeding promotion
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Exhibit A.1
Phase I Implementation Study: Research Questions, Key Variables, Sources of Data, and Data Collection Methods
Research Questions
Variables
Source of Data
Data Collection Method
5. What activities and services are involved in
Loving Support peer counseling?
• State guidance related to activities and services
• Administrative supports and monitoring provided by States
• Places where peer counseling is conducted (e.g., WIC site, participant home,
hospital)
• Methods of counseling contacts (individual meeting, phone, home visit, group
meeting)
• Variation of methods of contact and reasons for using different methods (e.g.,
transportation issues, liability issues, age of child)
• Professional supports available (e.g., lactation consultant, nurse practitioner) for
peer counselors to refer participants
• Procedures by which peer counselors refer WIC participants to professional
supports
• Policies/guidelines and practices about peer counselor recruitment, training, and
monitoring
• Peer counselor recruitment and selection process
• Qualifications and responsibilities of peer counselors
• Demographic similarities of peer counselors to population served
• Training: content, who does training, who receives training, use of Loving
Support curriculum,
• Process of matching and assigning peer counselor to WIC mothers
• Continuing training and supports provided to peer counselors
• Turnover rate of peer counselors
• Process of training additional peer counselors
• Local WIC agencies’ plans for continuing peer counseling
• Changes and modifications anticipated
• Reasons for discontinuing the intervention
• Plans for funding peer counseling
• Staff from all State
WIC agencies
• Sampled local WIC
agency and clinic
staff
• Web-based State survey
• On-site local WIC
agency and clinic staff
interview
• Staff from all State
WIC agencies
• Sampled local WIC
agency and clinic
staff
• Web-based State survey
• On-site local WIC
agency and clinic staff
interview
• Sampled local WIC
agency staff
• On-site local WIC
agency staff interview
6. How are the Loving Support peer
counselors recruited, trained, assigned to
WIC mothers, and monitored in each site?
Part A: Justification
7. What are the prospects for continuing
Loving Support peer counseling at the
participating WIC agencies?
A-9
A-10
Exhibit A.1
Phase I Implementation Study: Research Questions, Key Variables, Sources of Data, and Data Collection Methods
Research Questions
Variables
Part A: Justification
Expenditures for Loving Support Peer Counseling
8. For peer counseling programs that began
• Program expenditures by local agencies that have been operating for one year
in the last year, what have been their
or less compared with all others
expenditures?
9. What are the expenditures for Loving
• Amount of FNS, NSA, and any other funds spent on program
Support peer counseling programs?
• Expenditures of Loving Support grant funds per WIC participant
• Categories of expenditures of Loving Support Grant funds (e.g., staff salaries,
consultation, indirect expenses)
10. In addition to the Loving Support peer
• Amount and percent of NSA funds allocated to Loving Support breastfeeding
counseling funds, how much regular
peer counseling services
Nutrition Services Administrative (NSA)
funding is used to support Loving Support
peer counseling activities that meet the
FNS model?
11. Do peer counseling programs supported
• Presence of peer counseling programs to support breastfeeding that do not
by regular NSA funds use these funds
follow Loving Support peer counseling model
because they do not meet the
• Percentage of Loving Support peer counseling that is paid for by FNS peer
requirements of the Loving Support
counseling grant funds
model? Are NSA funds used because the
Loving Support peer counseling grant does
not provide enough funding to cover
expenses of a fully implemented program?
Source of Data
Data Collection Method
• Sampled local WIC
agency staff
• Local WIC agency staff
interview
• Staff from all State
WIC agencies
• Sampled local WIC
agency staff
• Sampled local
agency WIC staff
• Web-based State survey
• Staff from all State
WIC agencies
• Local WIC agency staff
interview
• Local WIC agency staff
interview
• Web-based State survey
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Exhibit A.1
Phase I Implementation Study: Research Questions, Key Variables, Sources of Data, and Data Collection Methods
Research Questions
Variables
Source of Data
Data Collection Method
Local Collaborations
12. How do the WIC agencies coordinate their
Loving Support peer counseling program
with activities and services at area
hospitals and other organizations?
•
•
•
•
Number and type of collaborating organizations
Responsibilities and contributions of each organization
Type of coordination made with area hospital
Hospital staff involved in the administrative coordination (type and number of
staff)
• Infant feeding policies and practices of area hospital
• Breastfeeding promotion/support services provided by area hospital (content,
timing)
• Hospital staff involved in hospital’s breastfeeding promotion/support services
(type and number of staff, type of service provided)
• Breastfeeding promotion services provided by other organizations
Views of staff of collaborating organizations on the Loving Support peer counseling
program.
• Sampled local WIC
agency and clinic
staff
• Staff from sampled
local collaborators
• On-site local WIC
agency and clinic staff
interview
• Interview with local
collaborating
organizations
• Staff from sampled
local collaborators
• Interviews with local
collaborating
organizations
• Method for determining who receives the peer counseling services
• Extent of peer counseling services participants receive (prenatal, in hospital,
postpartum)
• Number and type of postpartum peer counseling contacts received by
counseling program participants
• Number of calls peer counselors received from participants and timing of the
calls
• Percentage of those WIC participants who refuse peer counseling when offered
• Views of WIC staff of Loving Support peer counseling program and staff
perceptions of WIC participants response to Loving Support peer counseling
• Sampled local WIC
agency and clinic
staff
• Interviews with local WIC
agency staff
• Sampled local WIC
agency and clinic
staff
• Local WIC agency and
clinic staff interviews
13. What are the responses of collaborating
organization staff to the Loving Support
peer counseling program?
WIC Loving Support Participants
14. To what extent do WIC mothers participate
in the Loving Support peer counseling
program?
Part A: Justification
15. What are the responses of WIC staff and
WIC participants to the Loving Support
peer counseling program?
A-11
A-12
Exhibit A.1
Phase I Implementation Study: Research Questions, Key Variables, Sources of Data, and Data Collection Methods
Research Questions
Part A: Justification
Data Collection and Program Monitoring
16. How does each State track various
breastfeeding measures (e.g., ever
breastfed, duration, and exclusivity of
breastfeeding)?
17. How do WIC agencies use data to
evaluate the effectiveness of its Loving
Support peer counseling program?
18. Can those sites implementing Loving
Support peer counseling programs
adequately and effectively monitor
changes in breastfeeding rates for initiation
and duration?
Variables
Source of Data
Data Collection Method
• WIC breastfeeding information tracking method used at the State level
• Types of breastfeeding measures tracked
• WIC participant involvement in Loving Support tracked at the State level
• Staff from all State
WIC agencies
• Web-based State survey
• Ways in which State data are used in monitoring and evaluation
• Ways in which local WIC agency uses data in monitoring and evaluation
• Local agency participation in evaluation studies
• Staff from all State
WIC agencies
• Sampled local
agency WIC staff
• Sampled local
agency WIC staff
• Web-Based State survey
• Local WIC agency staff
interview
• Methods being used by sampled local WIC agencies to monitor and track
breastfeeding initiation and duration rates
• Agency staff assessment of the adequacy and effectiveness of monitoring
breastfeeding outcomes
• Local WIC agency staff
interview
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There is currently no other national effort that can address the research objectives of the proposed
study. Extant data from the Peer Counseling Implementation Plans and State Agency FY2006 State
Plans related to (1) breastfeeding promotion and support and (2) peer counseling are the only other
available sources of information on the Loving Support peer counseling program. This information is
highly variable, and information to be generated from this study goes well beyond the data provided
in those plans. In addition, the plans do not provide information on why specific decisions or choices
were made. Without the proposed study, FNS would not obtain a thorough and systematic
description of current Loving Support peer counseling efforts. There would be no information base to
evaluate and plan future FNS guidance and technical assistance.
A.3
Use of Improved Information Technology to Reduce Burden
The study strives to comply with the eGovernment Act of 2002 (Public Law 107-347, 44 U.S.C. Ch
36) by using a web-based survey for WIC State agencies to facilitate convenient, timely, and accurate
collection of information. Respondents will be able to complete and submit the web-based survey online. Features of the web-based survey that are intended to reduce burden and increase item response
include: closed-ended questions with specific answer categories; skip pattern questions that only
some respondents need answer; highlighted “key words” that respondents can click on to see standard
definitions; and a “contact us” icon respondents can use to send an e-mail question to the survey
director. The web-based survey is designed so that respondents can complete part of the survey,
check their records or research answers to questions if they are not sure, and then complete the survey
at a later time. This also allows multiple authorized respondents access to the survey. An agencyspecific username and password will be required each time the survey is accessed. No persons other
than those selected to receive usernames and passwords will have access to the website. The use of
on-line survey technology will allow the study contractor to track completed questionnaires in real
time, and it eliminates the need for data entry. The web-based survey will include no tracking of
respondents’ Internet use of any kind. Upon completion of the surveys by all parties, the website will
be dismantled.
On-site interviews are considered necessary for most of the remaining data collection due to the
varied contexts and implementation strategies for Loving Support peer counseling. Interviewers will
need to tailor questions as they learn about local Loving Support peer counseling implementation
through the interview process conducted with differing local staff. However, data on breastfeeding
rates (e.g., breastfeeding initiation, duration, and exclusivity), Loving Support peer counseling
program operations, and expenditure data will be obtained when possible from extant program data
bases.
A.4
Efforts to Identify and Avoid Duplication
Every effort has been made to avoid duplication of data collection efforts. These efforts include a
review of State plans and extant documents describing the Loving Support peer counseling program
as it is implemented in States and selected communities, and pre-populating the data fields of
individual State web surveys with extant data, most notably existing information about each State’s
local WIC agencies so that information does not need to be entered by State agency staff.
As noted in Section A.2, this is the only federally funded information collection that plans to collect
data on the Loving Support peer counseling program.
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Part A: Justification
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A.5
Efforts to Minimize Burden on Small Businesses or Other
Entities
No small businesses or other entities will be involved as respondents in the proposed data collection
effort.
A.6
Consequences of Less Frequent Data Collection
The data collection for the proposed study will be conducted one time only. Without this effort, FNS
will not have the comprehensive, systematic description of the implementation of the Loving Support
peer counseling program required to inform the future program decisions outlined in section A.2,
including expenditures of peer counseling funds.
A.7
Special Circumstances Requiring Collection of Information in
a Manner Inconsistent with Section 1320.5(d)(2) of the Code of
Federal Regulations
There are no special circumstances for the data collection of the WIC Breastfeeding Peer Counseling
Study.
A.8
Federal Register Comments and Efforts to Consult with
Persons Outside the Agency
Federal Register Announcement
In accordance with the Paperwork Reduction Act of 1995, an announcement of the Food and
Nutrition Service’s intent to seek OMB approval to collect information for the Systems Review
provided an opportunity for public comment. This announcement was published in the Federal
Register on September 21, 2007 (72 FR 53983), and specified a 60-day period for comment ending
November 20, 2007. A copy of the Federal Register Notice is provided in Appendix B.
FNS received seven responses to the Federal Register Notice (included in Appendix B). They were
all from Texas, but represented a wide spectrum of staff associated with WIC, including one on
behalf of the State WIC Director, five from local WIC agency staff from various agencies around the
state, and two from peer counselors. The comments were unanimous in their support of the study.
Many talked about the importance of the peer counseling program in their area, the results that they
have seen in terms of increases in breastfeeding rates that they associate with peer counseling, and the
need for continued support for peer counseling.
Included in the comments submitted were suggestions or recommendations for the current study.
These are presented below, along with our response.
•
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The researchers need to provide advance notice of data collection and be flexible in
scheduling appointment times.
Part A: Justification
Abt Associates Inc.
The data collection plan for this study includes advance notice through FNS Regional and
State WIC offices, and advance materials sent to the States and local WIC agencies.
These will give the agency time think about their schedule and to work out the best times
for their participation within the data collection window. The data collectors will work
with the WIC agencies as much as possible to accommodate their schedule in making
appointments with staff.
•
The researchers need to be aware that local agency personnel may serve in several
capacities (e.g., the local WIC director may also be the database manager).
FNS and the Abt Associates researchers are well aware that WIC staff may serve in
several capacities. When scheduling calls, the site visitors will be sensitive to the
multiple roles of staff, and the data collection instruments enable WIC staff respondents
to identify their roles as necessary.
•
While supporting the sample size and burden estimate, one commenter suggested that the
local agency sample be increased, as she felt the study was weighted toward the Statelevel staff.
Resources for this study allow site visits to 40 local WIC agencies across the country.
These 40 agencies will be selected to be nationally representative of all local WIC
agencies with Loving Support peer counseling programs across the country. While more
local WIC agencies could have been included if we conducted a less intensive mail or
telephone survey, the in-depth information that can be obtained through site visits was
deemed to be critical in fully understanding how Loving Support is implemented in the
variety of WIC settings that exist across the U.S.
We will include the census of all 86 State agencies receiving Loving Support peer
counseling funds because States set the tone for how Loving Support is implemented
within a State, and the questions for States are conducive to a web-based survey, which is
less resource intensive than site visits.
In addition to the comments above, there was one individual who stated that an evaluation of the
efficacy of some aspects of the Loving Support peer counseling program would be welcome. Phase II
of the current effort will be an impact study, although at the present time it is designed to address the
impact of an enhanced version of Loving Support peer counseling (high intensity) relative to Loving
Support peer counseling that meets but does not exceed implementation standards (low intensity).
Consultations Outside the Agency
In addition to the public comments above, consultations with experts in technical and substantive
areas occurred throughout the design, instrument development, and data collection planning, and will
continue to take place throughout the study. These individuals are:
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Part A: Justification
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Abt Associates Inc.:
Nancy Burstein, Ph.D.
Deborah Walker, Ph.D.
Centers for Disease Control and Prevention:
Carol A. MacGowan, MPH, RD, LD
Public Health Nutritionist
North Carolina State Department of Health & Human Services:
Bethany T. Holloway, MEd, RD, LD
North Carolina State WIC Breastfeeding Peer Counseling Coordinator
Every Mother, Inc. (non-profit organization):
Mary Catherine Carothers, IBCLC, RLC
Current trainer and former national coordinator for Loving Support peer counseling
The study plans and data collection instruments have been reviewed and approved by the contractor’s
Institutional Review Board (IRB). The contact for Abt Associates’ IRB is:
Marianne Beauregard
Administrator, Institutional Review Board
Abt Associates Inc.
Cambridge, MA
(617) 492-7100
A.9
Payments to Respondents
Data collection for this study does not involve payments to respondents.
A.10 Assurance of Confidentiality
The individuals participating in this study will be assured that the information they provide will not
be released in a form that identifies them except as required by law. No identifying information will
be attached to any reports or data supplied to USDA or any other researchers.
Abt Associates Inc. has extensive experience in data collection efforts requiring strict procedures for
maintaining the confidentiality, security, and integrity of data. The following data handling and
reporting procedures will be employed to maintain the privacy of survey participants and composite
electronic files.
•
A-16
All project staff, both permanent and temporary, will be required to sign a confidentiality
and non-disclosure agreement. In this agreement, staff pledge to maintain the
confidentiality of all information collected (including memoranda, manuals and
questionnaires) from the respondents and will not disclose it to anyone other than
authorized representatives of the evaluation. Field data collectors are required to carry
their signed pledge with them at all times while in the field and may be required to show
it to respondents. Issues of confidentiality are also discussed during training sessions
provided to staff working in the project.
Part A: Justification
Abt Associates Inc.
•
While in the field, data collectors are required to store all completed forms, surveys, and
material with identifying information on it in a locked car trunk. If the data collector is in
the field for several days, forms and materials are shipped to the central office by Federal
Express, UPS or other traceable shipping service. Regular mail is not used to ship any
material containing respondent information. Field staff are also instructed to avoid
making photocopies of such material.
•
Once in the central office, documents containing respondent information are kept in
locked files cabinets. At the close of the study, such documents are shredded.
•
Data gathered from the interviews will be combined into master respondent files.
Immediately after the file is created, it will be assigned a unique identification number.
Any identifying information will be removed from the survey data and replaced with the
identification number.
•
Any respondent-identifying information will be contained only in a master list to be
created and protected in secure storage, to which only a limited number of project staff
pledged to maintain confidentiality will have access.
In addition, the evaluation contractor has established a number of procedures to ensure the
confidentiality and security of electronic data in their offices during data collection and processing
period. Standard backup procedures will be implemented for the central office computer system to
protect project data from user error or disk or other system failure. Backups and inactive files will be
maintained on tape or compact disks. The system servers will be maintained inside a secure locked
area accessible only to authorized systems personnel. Files will be accessible only by authorized
personnel who have been provided project logons and passwords. Access to any of the study files
(active, backup, or inactive) on any network multi-user system will be under the central control of the
database manager. The database manager will ensure that the appropriate network partitions used in
the study are appropriately protected (by password access, decryption, or protected or hidden
directory partitioning) from access by unauthorized users. All organizations using data on study
participants will maintain security, virus, and firewall technology to monitor for any unauthorized
access attempts and any other security breaches.
Specific precautions will also be taken for the web-based survey. As discussed in Section A.3, the
web-based survey will use session cookies to allow respondents to move from page to page without
reentering identifying information. The survey will not use persistent cookies to track respondents’
browsing habits. Upon completion of the surveys by all State agencies, the website will be
dismantled.
A.11 Questions of a Sensitive Nature
The data collection instruments for this study do not contain questions of a sensitive nature.
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Part A: Justification
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A.12 Estimates of Respondent Burden
Exhibit A-2 presents our estimates of the annual reporting and cost to respondents for the study
instruments described in Section A.2. Time estimates are based on experience with similar
instruments in similar studies and a pilot test of instruments and procedures conducted in summer
2007. The estimated cost to respondents has been calculated using average hourly rates for
respondents obtained from FNS’ 2006 WIC Staffing Data Collection Project, which provides detailed
wage information for WIC staff, and from the Bureau of Labor Statistics’ estimates for occupational
wages (www.bls.gov/bls/wages.htm).
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Part A: Justification
Abt Associates Inc.
Exhibit A.2.
Abt Associates Inc.
Estimate of Response Burden
Number of
Respondent
s
Respondent by Instrument
State WIC Agency Survey
Number of
Responses per
Respondent
Total
Annual
Responses
Hours per
Response
State WIC Director
State breastfeeding or peer counselor coordinator
State budget officer
82
82
82
1
1
1
82
82
82
Non-responses (5%)
12
1
12
36
36
1
1
36
36
72
1
1
1
36
36
36
36
72
Non-responses (10%)
24
1
24
Local WIC Clinic Interview and Program Information
Form
Local WIC clinic director or supervisor
Local WIC clinic peer counselor coordinator or supervisor
Peer counselors
18
18
36
1
1
1
18
18
36
8
1
8
.08
36
1
36
1
4
1
4
.08
Local WIC Agency Interview and Program Information
a
Form
Local WIC agency director
Local WIC breastfeeding or peer counselor coordinator
Local budget officer
Local WIC agency database manager
Peer counselors
Part A: Justification
Non-response (10%)
Community Collaborator Interview Guide
Liaison/contact person in an organization collaborating
with local WIC agency
Non-response (10%)
Total
a
618
618
Response
Burden in
Hours
Estimated
Cost to
Respondents
1
1
.5
.08
82
82
41
$2,574
2,168
1,287
1
30
1
1.5
36
54
1,012
1,073
.5
.5
.5
.08
18
18
36
506
254
329
2
51
1
1
18
18
357
315
.5
18
165
.64
36
.32
461
10
991
9
$11,131
The burden estimate for local WIC agencies and local WIC clinics is the maximum burden for program staff, and includes the initial phone interview, site visit interview and the
completion of the Program Information Form. In the pilot test, we found that completing the Program Information Form sent prior to the interviews, as opposed to providing this
information during the interview, reduced the overall burden for staff as the time taken to complete the form was less than the time it would take to provide the same information
during the interview. However, as filling out the Program Information Form prior to the interview is voluntary, we believed the safest course was to provide estimates of burden as
if all information was gathered during the interview process.
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A.13 Estimates of Other Annual Costs to Respondents
There are no startup or annualized maintenance costs to respondents.
A.14 Estimates of Annualized Government Costs
The period of performance for this task order is from September 8, 2006 through December 31, 2009.
Phase I data collection will occur between March 2008 and September 2008. The cost to the Federal
government for the design, recruitment of WIC agencies and collaborating organizations, data
collection, analysis of data, report writing, and federal government review and oversight for the Phase
I implementation study is $620,730.
A.15 Changes in Hour Burden
This submission to OMB is a new request for approval. The data collection instruments have not
been previously submitted for approval by OMB. The burden of 495 hours represents a program
increase.
A.16 Time Schedule, Publication, and Analysis Plans
This section describes the schedule for the project, along with plans for tabulation, analysis, and
publication of study results.
Study Schedule
The schedule shown in Exhibit A.3 lists the expected period of performance for data collection and
reporting.
Exhibit A.3
Anticipated Schedule for Data Collection and Reporting
Activity
Collect data (web-based surveys and site-visit interviews)
Time Schedule
March – September 2008
Prepare final report, brochure, and journal article
December 2008 – April 2009
Analysis Plan
The Phase I implementation study will generate qualitative and quantitative data collected from
multiple sources. The quantitative implementation study data (e.g., percent of participants who
receive in-hospital peer contact, percent of participants who initiate breastfeeding, number of peer
counselor contacts participants receive of various types) will be analyzed by univariate descriptive
statistical analysis (e.g., means, frequencies, and percentages). The results will document peer
counseling services conducted at a nationally representative sample of WIC agencies in terms of the
program context, implementation process, implementation outcomes, and expenditures. These
descriptive data, combined with qualitative data from interviews with WIC staff, peer counselors, and
collaborating agency staff, will be used to generate systematic, rich information on how WIC
breastfeeding peer counseling services are implemented nationally.
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Part A: Justification
Abt Associates Inc.
Addressing the research questions listed in Exhibit A.1 will be facilitated by organizing
implementation data and analysis into three components: 1) background contextual factors, 2)
implementation outcomes, and 3) intervention expenditures. The key topics and issues included in
each of these components and their use in analysis are discussed below.
Background Contextual Factors
The contextual factors pertain to the setting and context in which the peer counseling intervention is
implemented, including:
•
WIC program characteristics (e.g., geographic location, urbanicity, enrollment size,
demographic composition of the participants);
•
State breastfeeding rates (initiation, duration, exclusivity)
•
Breastfeeding promotion and support activities (other than peer counseling) provided by
the participating WIC agencies;
•
Breastfeeding promotion services available in the community; and
•
Breastfeeding promotion and support services and infant feeding policies in the area
hospital(s) where WIC participants deliver their babies.
Careful and thorough description of these program contextual factors will be essential in
understanding the nature and extent of peer counseling implemented and the degree of success in
achieving desired outcomes. This information will also be useful in determining the feasibility of
implementing certain types/models of peer counseling in specific program and community contexts.
Implementation Outcomes
Our description of peer counseling programs will include:
•
Changes made to local WIC program staffing and operations to support the program;
•
Process of peer counselor recruitment, selection, training, assignment to WIC mothers,
and supervision;
•
Activities involved in peer counseling and the fidelity of the peer counseling
implementation according to the intended design;
•
Coordination of activities between WIC programs and area hospitals and other
organizations;
•
The extent of participation by WIC mothers in peer counseling; and
•
Reactions of WIC and collaborating organization staff, peer counselors, and WIC
mothers (as reported by the local WIC agency and clinic staff) to the Loving Support peer
counseling approach.
A careful examination of these factors will provide valuable guidance to WIC program administrators
in the process of adapting peer counseling programs. Our approaches will include (a) narratives to
categorize and describe different approaches to specific implementation issues; (b) tables to indicate
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Part A: Justification
A-21
the distribution of these approaches across the sampled local agencies and to illustrate other
quantifiable variables; and (c) graphic displays.
Expenditures for Loving Support Peer Counseling Analysis of Implementation
Another component of the implementation study is to determine expenditures for the Loving Support
peer counseling program, in the aggregate and per WIC participant. For this purpose we will collect
the following data from State and local WIC agencies:
•
•
•
•
Total fiscal year expenditures on Loving Support peer counseling;
Sources of funds for Loving Support peer counseling (e.g., FNS Loving Support
funds, NSA funds, State funds);
Fiscal year expenditures by purpose (e.g. salaries, travel, indirect costs); and
Number of women served in WIC.
Analysis of these amounts and counts will provide information about both the aggregate and the perparticipant resources required to support these programs. Expenditures per WIC participant will be
compared between newly established programs and ongoing programs, classified according to
whether they have been in operation for at least one year.
Analysis of Implementation Process and Outcomes by Site Characteristics
A final question that can be addressed in Phase I is: How do the peer counseling process and
outcomes vary depending on local WIC agency characteristics, e.g., the number and demographic
characteristics of WIC participants, staff and other program resources, availability of baby-friendly
hospitals in the community, and urban vs. rural community setting? We will examine variations in
implementation and participant outcomes by site characteristics. Such analyses may provide policy
makers and program administrators additional information regarding the feasibility of implementing,
expanding, and refining the peer counseling services in particular types of WIC agencies.
Integrative Analysis of Quantitative and Qualitative Data
While the differences in the types of data and the level of analysis call for the use of different analytic
methods, the ultimate purpose of the Phase I implementation study is to address its objectives by
integrating the results of all analyses. The discussion of how peer counseling is implemented will
weave together the quantitative data analysis results on the number of peer counselors recruited and
trained, types of training received, and types of supervision provided for peer counselors, coupled
with qualitative descriptions of the types of changes programs made in staffing and program
procedures and the types of arrangements WIC agencies make with area hospitals and other
collaborating organizations. Similarly, a discussion of the feasibility of implementing similar peer
counseling services in additional WIC agencies would clearly involve integrating quantitative
findings about the intervention expenditures, comparisons of program and local agency participant
characteristics between the study sites and WIC national data, and assessments of the benefits and
challenges of peer counseling strategy as reported by WIC staff, peer counselors, and WIC
participants.
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Part A: Justification
Abt Associates Inc.
Case Studies
The analytic approaches described above are designed to produce a national picture of the
implementation of WIC breastfeeding peer counseling services. In addition to these descriptions that
aim to paint the aggregate national profile of the FNS peer counseling services, we will prepare case
study descriptions of the 20 WIC agencies where we will collect data at the State, local WIC agency,
and clinic levels.
For each of the 20 clinics included in the Phase I study, we will develop detailed case studies of how
State- and agency-level policies and procedures actually are implemented at the service-delivery
level. The case studies will be largely descriptive, but will also allow for an assessment of whether
peer counseling programs are implemented according to established policies or if there are variations
between clinic practices and documented policies and procedures.
Publication of Study Results
The study’s findings will be presented in a final report for the project. FNS will make the final report
and executive summary available on its web site. In addition to the final report, a brochure and
journal article will be prepared. The brochure will be targeted to non-technical audiences, and the
journal article will be prepared for a peer-reviewed journal.
A.17 Display of Expiration Date for OMB Approval
All data collection instruments for the WIC Breastfeeding Peer Counseling Study will display the
OMB approval number and expiration date.
A.18 Exceptions to Certification Statement
There are no exceptions to the Certification for Paperwork Reduction Act (5 CFR 1320.9) for this
study.
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Part A: Justification
A-23
References
Centers for Disease Control and Prevention (2005). The CDC guide to breastfeeding interventions.
http://www.cdc.gov/breastfeeding.
Martin, J.A., Hamilton, B.E., Ventura, S.J., Menacker, F., and Park, M.M. (2002). Births: Final data
for 2000. National Vital Statistics Reports, 50(5). Hyattsville, MD: National Center for Health
Statistics.
U.S. Department of Agriculture, Food and Nutrition Service (2006a). Nutrition program facts: WIC.
http://www.fns.usda.gov/wic/WIC-Fact-Sheet.pdf. August 8, 2007.
U.S. Department of Agriculture, Food and Nutrition Service, Office of Analysis, Nutrition and
Evaluation, WIC participant and program characteristics 2004, WIC-04-PC, by Susan Bartlett, Ellen
Brobonnikov, Nicole Pacheco, et al. Project Officer, Fred Lesnett. Alexandria, VA: March 2006.
U.S. Department of Agriculture, Food and Nutrition Service, Office of Analysis, Nutrition and
Evaluation, Breastfeeding Intervention Design Study: Review of the literature on breastfeeding
promotion and support interventions. Joan McLaughlin, Nancy Cole, Mary Kay Crepinsek, Mary
Kay Fox, Anne Robertson. Project Officer, Patricia McKinney. Alexandria, VA: 2003.
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Part A: Justification
Abt Associates Inc.
Addendum to the OMB Supporting Statement
WIC Breastfeeding Peer Counseling Study
Food and Nutrition Service, USDA
Responses to Questions from OMB
June 11, 2008
1. Please provide more detailed information regarding the Phase II study, especially the key
research questions and how they relate to the data being collected in the Phase I survey
sample.
Response: Phase II is planned as an impact study. The key question for this part of the study is
whether enhancing the peer counseling offered to WIC mothers in local WIC agencies with Loving
Support peer counseling programs results in longer durations of breastfeeding.
The Loving Support peer counseling program provides a lot of local flexibility on key aspects of the
program model. There is currently not enough known about how States and local WIC agencies are
implementing Loving Support to know what are “standard” and common practices and what are
potential enhancements that could be integrated to increase breastfeeding duration rates. Once we
have the results of the Phase I implementation study, FNS will be in a better position to proceed to
Phase II. A separate OMB package will be prepared for Phase II.
2. Please clarify why the state portion of this “study” is preferred over adding detail to the
current state reporting requirements. It appears as though some portion of Phase I is
designed to compensate for inadequate detail collected in mandatory program reporting
(so the proposed study may not actually be a “study”). Three factors contribute to this
impression. First, the proposal itself states, “The depth and quality of the information
obtained from State agencies varied and, for the most part, provided little detail about the
specific ways in which Loving Support is being implemented . . .” (pp. A2 – A3). Second,
Phase I would begin with a “national census of the 86 State WIC agencies receiving Loving
Support peer counseling funds.” Third, the content of the 18 “research questions” and
much of the proposed survey questions seem to be operationally oriented. Thus, the very
broadest question arises of whether some of the information sought by could be obtained
through refined administrative reporting rather than a study format.
Response: Congress specifically appropriated the funds for the Loving Support peer counseling
program and designated that these funds not be counted against the one-sixth of NSA funds that are
targeted to breastfeeding promotion. As such, FNS is working to obtain a level of detail on the
spending of these peer counseling grant funds that goes beyond what could be expected of States to
report on each year, and can be separated from the reporting on the breastfeeding promotion
expenditures typically documented in the State plans. In addition, FNS needs information that
consistently reports on the more detailed aspects of the Loving Support peer counseling on a one-time
basis for this study, so it would not be appropriate to ask states to report on this information annually.
This type of research is not uncommon for FNS. FNS conducts studies of program operations on a
fairly regular basis, as staff need systematic and consistent information that cannot easily and
efficiently be obtained through mandated reporting in State Plans.
Responses to OMB Questions
1
3. Please clarify the primary research goals and questions overriding the list of 18 largely
operational questions characterized as research questions.
Response: The primary research objective for the Phase I study is to obtain a comprehensive and
systematic picture of the implementation of the Loving Support peer counseling program.
4. Please provide a narrative that identifies and explains the components of the Loving
Support model, considers which components are mandatory vs. optional, which are
subject to interpretation and whether that interpretation is at the State or clinic level, etc.
Such a narrative could help in the assessment of how well the proposed survey is tied
with study objectives.
Response: The FNS guidance for the ten components of the Loving Support model is presented in
the table below, which we think more easily captures the information OMB is asking for in this
question. The left column identifies the mandatory components of the model, while the right column
describes the practices that are not mandatory but are recommended by research. Note that even
within the mandatory components outlined in the left column, much is left to the discretion of the
State and/or local agency, based on its WIC population, experience with peer counseling in the past,
local contexts, etc.
Ten Components of Loving Support:
Required Components of a Peer Counseling Program
I.
Appropriate Definition of Peer Counselor.
• Paraprofessional
• Recruited and hired from target population
• Available to WIC clients outside usual clinic hours and
outside the WIC clinic environment.
II.
III.
Designated breastfeeding peer counseling program
managers/coordinators at State and/or local level.
Defined job parameters and job descriptions for peer
counselors.
IV. Adequate compensation and reimbursement of peer
counselors.
Recommendations from the Research
Ideal Peer Counselor:
• Enthusiasm for breastfeeding
• Basic communication skills
• Previous breastfeeding experience (6 months)
• Similarities with WIC participants served
• Current or previous WIC participant
• Similar ethnic background
• Similar age
• Same language spoken.
Use sample job description provided in the Using Loving Support to
Manage Peer Counseling Programs Training Manual.
Job parameters:
• Settings for peer counselors should include telephone contacts
from home; and clinic, home and hospital visits
• Frequency of contacts with pregnant. and breastfeeding women
is important. Refer to Section 6 (Scope of Practice for Peer
Counselors) of “Using Loving Support to Manage Peer
Counseling Programs” Training Manual for recommended
contact frequency during the prenatal and postpartum period.
Job descriptions:
Use sample job descriptions provided in the Using Loving Support
to Manage Peer Counseling Programs Training Manual.
Many current peer counseling programs report paying peer
counselors the same general hourly part-time rate typical of other
entry level positions such as WIC clerical position. This is often
around $5.50 to $7 per hour. However, nearly all programs share
the belief that peer counselors should be paid more.
Other recommendations:
• Provide travel allowance for home/hospital visits/meetings
• Cover training expenses
• Provide benefits if possible
• Reimburse for telephone and other expenses.
Responses to OMB Questions
2
Required Components of a Peer Counseling Program
V. Training of appropriate WIC State/local peer counseling
management and clinic staff.
Recommendations from the Research
Cross-train so that peer counselors are familiar with WIC services
and WIC staff are trained in breastfeeding support.
• State and local program managers receive training in how to
manage peer counseling programs through “Using Loving
Support to Manage Peer Counseling Programs” training
curriculum.
• WIC clinic staff receive training about the role of the WIC
peer counselor through “Peer Counseling: Making a
Difference for WIC Families,” a PowerPoint presentation
included in the “Using Loving Support to Manage Peer
Counseling Programs” training curriculum.
• State and local staff involved in the training of peer
counselors attend the 2005 Regional train the trainer session
“Loving Support through Peer Counseling.”
• WIC clinic staff are trained in basic breastfeeding support
and receive the training “Loving Support through Peer
Counseling.”
VI. Establishment of standardized breastfeeding peer
counseling program policies and procedures at the State
and local level as part of Agency nutrition education plan.
Involve both State and local stakeholders in developing policies and
procedures for a peer counseling program.
VII. Adequate supervision and monitoring of peer counselors
The mentor/supervisor transition has been reported to be effective
for many successful programs. Refer to Section 8 (Supervision and
Monitoring) of “Using Loving Support to Manage Peer Counseling
Programs” Training Manual.
Conduct weekly phone contacts; regular review of contact logs; and
spot checks.
VIII. Establishment of community partnerships to enhance the
effectiveness of a WIC peer counseling program.
(Use sample Peer Counselor Contact Log and sample Weekly
Activity Report Form provided in the “Using Loving Support to
Manage Peer Counseling Programs” Training Manual).
Potential partnerships to consider:
Breastfeeding coalitions; businesses, community organizations;
cooperative extension program; international board certified
lactation consultants; La Leche League; home visiting programs;
private clinics; hospitals
IX.
Provision of the following to peer counselors:
• Timely access to breastfeeding coordinators and other
lactation experts for assistance with problems outside of
peer counselor scope of practice
• Regular, systematic contact with supervisor
• Participation in clinic staff meetings and breastfeeding inservices as part of the WIC team
• Opportunities to meet regularly with other peer counselors.
X.
Provision of training and continuing education of peer
counselors:
•
Peer counselors receive standardized training using “Loving
Support through Peer Counseling” training curriculum.
•
Peer counselors receive ongoing training at regularly
scheduled meetings.
Responses to OMB Questions
Provide formal instruction in addition to home study.
Provide opportunities to “shadow” or observe other peer counselors
and lactation experts.
Provide career path options (e.g., training/experience to become
senior level peer counselors; training to become IBCLC).
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5. Please identify breastfeeding promotion activities that would be outside of the Loving
Support model. Would a listing of those activities in the survey be helpful for
respondents?
Response: State Survey question #3 lists breastfeeding promotion activities outside of the Loving
Support model, and provides an “other” option if they are doing something not included in the list:
State question 3. Please indicate the breastfeeding promotion activities that your State agency funds
for WIC participants. (Select all that apply)
Media campaigns
Educational materials
Breastfeeding promotion training (other than Loving Support peer counseling training)
Make lactation consultants available to WIC participants
Sponsor certified lactation counselor training (or similar certification training)
Equipment (e.g., breast pumps)
Peer counseling or other counseling by clinic staff to WIC participants that is different
than Loving Support peer counseling
Warmline or hotline
Classes or support group meetings for WIC participants
Other (Specify:)
The local WIC agency interview guide also contains a listing that can be used to prompt staff during
the interview:
Local Agency Question 5. Does your agency provide other breastfeeding promotion services or
programs (e.g., support groups, classes, educational materials) for WIC participants in addition to
Loving Support peer counseling?
No
Yes
**If yes, Please indicate the breastfeeding promotion activities available to WIC participants
in your local agency. (Prompt for funding amt and source, if known, collaborators, and major
activities.)
Media campaigns and/or posting materials in public places, such as WIC clinics.
Making lactation consultants and other trained specialists available to WIC participants
Support groups or classes for WIC participants
Equipment (e.g., breast pumps)
Peer counseling or other counseling to WIC participants that is different than Loving
Support peer counseling
Warmline or hotline
Other (Describe:)
Responses to OMB Questions
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6. Unless there is a statutory basis for assuring confidentiality, please change the supporting
statement and the instructions on the questionnaire more along the lines of FNS’s intent,
e.g., FNS does not plan to release identifiable data except as required by law.
Response: Based on our discussion with Stephanie on Tuesday, June 10th, we will add to Section
A10 and in our confidentiality section of the questionnaires that we will protect respondent
confidentiality to the extent allowable by law.
7. What is the meaning of the numbers (e.g., 12, 24, 8, and 4 in the “number of respondents”
column) in each “non-responses” row of the burden table? Also, note that there seems to
be an error in the State WIC agency, Total Annual Responses column of the burden table.
Response: The number in the “number of respondents” column in the burden table (attached to the
end of this document) in each non-response row represents the individuals that may refuse
participation in the survey. The number is calculated based on our estimated response rates. For
example, we estimate that 95 percent of the State agencies will respond. Thus, 4 of each of the 86
State level respondents listed (State WIC Director, State Breastfeeding or Peer Counselor
Coordinator, or State Budget Officer) are estimated to minimally respond, spending a burden of about
5 minutes on this study (4 State WIC Directors + 2 State Breastfeeding or Peer Counselor
Coordinator + 4 State Budget Officers = 12 respondents). The numbers for the Local WIC agencies,
clinics, and collaborating organizations are calculated similarly, with the estimated 10 percent nonresponse for each entity.
There is an error in the State WIC Agency, Total Annual Responses column that we have corrected in
the table.
8. What are the key estimates that the study will produce? Please explain how the sample
sizes were derived and how they release to precision requirements for key estimates.
Response: The key estimates that the study will produce are proportions of State agencies and local
WIC agencies whose Loving Support Breastfeeding peer counseling programs have particular
characteristics.
An example of State agency level characteristics is the proportion of State agencies that fund
particular breastfeeding promotion activities:
•
•
•
•
•
•
•
Media campaigns
Educational materials
Breastfeeding promotion training (other than Loving Support training)
Making lactation consultants available to WIC participants
Equipment (e.g., breast pumps)
Peer counseling or other counseling to WIC participants that is different than Loving
Support
Warmline or hotline
Responses to OMB Questions
5
An example of local WIC agency characteristics is the proportion of local WIC agencies in which the
service delivery site for WIC peer counseling is:
•
•
•
the local WIC agency
local WIC clinics
other
For characteristics of State agencies FNS desires a full census of agencies receiving Loving Support
funds (n=86). For characteristics of local WIC agencies, FNS seeks an estimate with a confidence
interval of +/- 15 percentage points. For characteristics with a mean proportion of 50 percent, this can
be accomplished with a PPS (probability proportional to size) sample of 40 local agencies.
9. Please explain the proposed procedure for replacing “local WIC agencies that refuse to
participate” and how this will can be done while preserving the probability nature of the
sampling.
Response: The contractor for this study, Abt Associates, will generate a list of 40 local WIC
agencies through the process described in Part B of the Supporting Statement (section B1, Stage 2).
These are the local WIC agencies that will be recruited first. Abt will also develop a backup list of the
remaining agencies using the same procedure, so that if one of the original 40 local WIC agencies
refuses to participate, then recruiters will go to the first local WIC agency on the backup list, then the
second if another refuses, and so on, thus still retaining the probability nature of the sampling.
10. Why are the collaborative organizations to be purposively sampled? What is the proposed
procedure? How will this purposive sampling limit generalizability of the key estimates?
Response: FNS encourages the establishment of community partnerships, but it leaves it to the
discretion of the States and local WIC agencies to determine which organizations are the most
appropriate for their local peer counseling programs. Once we have sampled the local WIC agencies,
and they have agreed to participate, we will ask them which organizations they collaborate with on
the Loving Support peer counseling program. Our experience in the pilot is that it is typically one
other organization or hospital. If there is more than one, we will ask the local WIC agency to identify
the organization that plays the most significant role in their Loving Support peer counseling program.
Thus, when we report the results from these collaborative organization interviews, they will pertain to
those organizations that have been the most helpful to the local WIC agencies in carrying out the
program. While they will not be representative of all collaborating organizations across the country,
they will be representative of local WIC agencies’ primary collaborating organizations.
Please reconsider which questions could be re-formatted as “yes/no” questions rather
than “check all that apply” questions. While the number of questions would of course be
longer as a result, the cognitive burden of a yes/no format has been found to be lower than
“check all that apply” questions. For example, the “yes/no” format has been found to
produce higher data quality than a “check all that apply format” when the response
options are lengthy. Further, in a yes/no format, one of each pair of mutually exclusive
response categories can be eliminated altogether (e.g., two pairs of responses in Question
7 on the WIC State Survey).
Response: Following the pilot of the surveys, we asked for general feedback about the survey and
specific questions about the difficulty level of the questions asked. Although you note that a lengthier
Responses to OMB Questions
6
survey with yes/no questions actually decreases burden, the respondents from our pilot test indicated
that they perceived the case to be otherwise. They told us that they wanted us to keep the survey as
short as possible, so we think lengthening the survey would be a problem for State staff. Issues about
the length of the survey are compounded by the fact that it is a web-based survey and more web pages
to scroll through could potentially increase the burden for those who have internet connections that
require more time to load each page. In addition, the pilot test respondents did not indicate that any of
the “check all that apply” questions were confusing or difficult. For these reasons, we would prefer
not to have to change these questions at this point, as we believe that we would need to test the
lengthier yes/no questions in a similar fashion. Given the goal of having some results available to
policy makers in the coming months, we recommend proceeding with the survey as currently
proposed.
11. Please avoid tabular formats where possible, shifting to series of person-specific
questions.
Response: Similar to the issues raised in question 10, our pilot testing revealed no issues associated
with the survey tables. Given the current schedule for the study, we would recommend that we
proceed with the survey as piloted.
12. On State Level Staff portion of WIC State Survey (p. 6), please use first name only as
identifier in person-specific questions. This approach helps keep staff information
organized and requires less personal information from the respondent than a full name for
staff. Consider which types of information are necessary for the study’s goals. For
example, “How long has person been in this position” may be secondary information
unnecessary for study.
Response: We will do as you suggest and use first name only as an identifier.
We have had the survey reviewed by FNS evaluation and WIC program staff, CDC staff involved in
breastfeeding promotion, and WIC state and local agency staff to try to keep the survey focused on
issues that are key to understanding Loving Support peer counseling and the context in which it is
implemented. The question on the length of time in the staff position is relevant for two reasons: (1) it
allows the evaluators to assess the persons knowledge of Loving Support peer counseling (staff that
have been in the position for a relatively short time will not know the program like an experienced
hand); and (2) it allows federal WIC program staff to assess the level of experience of staff
implementing this important breastfeeding promotion effort.
13. Is information available that would suggest that the “typical” level of staff for this table or,
alternatively, how is known that the respondent does not need to provide information on
fifty individuals, which would be very burdensome to complete?
Response: The range of staff for this table is about 2 to 4, including the State Director, Breastfeeding
or Peer Counselor Coordinator, and a budget/finance staff person.
Responses to OMB Questions
7
14. What is to be calculated from the staff information? FTE in all breastfeeding promotion?
FTE supported by Loving Support?
Response: FTE supported by Loving Support peer counseling grants.
15. Would it be possible to restructure the State Written Guidance (p. 12). Specifically, the
section could begin “Does State provide guidance in addition to or instead of the
recommendations found in Using Loving Support to Manage . . .” A “no” response would
result in a skip of several questions. If the response is “yes,” the respondent could
proceed to each component (role, etc., qualification, timing, frequency, etc) and be asked a
sequence of yes/no questions and, if “yes,” be provided the follow-up questions.
Response: The question will be re-worded along these lines.
16. Frequency of Contact information. Instead of providing either a table for completion or a
series of questions, could the contractor glean information if a state agency simply sent
the state’s “Frequency of Contacts Guidelines” to contractor? This approach could both
increase accuracy (enhance data quality) and reduce burden on respondent.
Response: The State guidelines are often provided in different formats (including e-mails) over
months and years. We believe that asking States to provide their written guidance would actually
require them to take them more time to gather and send it to us than if we ask these contact questions
via a survey at one time. Given our experience with asking for Loving Support Implementation plans,
State plan sections, and budgets, we anticipate that we would need one or more follow-up calls to
clarify information and to understand missing information.
17. If the goals of Phase 2 related to breastfeeding outcomes and if locally collected data will
be used, wouldn’t the questions about breastfeeding data (e.g., exclusivity and duration)
be better focused on data quality aspects like consistency of collection methods (e.g., self
reported on a form versus orally to a counselor etc) rather than mode of availability (e.g.,
Excel)?
Response: FNS is interested in gathering a broad array of information on breastfeeding data
collected by the states. As part of this effort, FNS has requested that Abt Associates provide a
separate deliverable on State tracking of breastfeeding data following the completion of the State
Survey. This deliverable will include the States focus (e.g., rates, duration, and frequency of
breastfeeding), various measures used by the State, how the States use the data, and other items that
will help FNS determine the status of data collection on this important topic.
18. Does FNS have the authority to mandate that States collect information on “ever
breastfed” and “duration” that is based on an FNS-provided definition that is common
across States?
Response: FNS does have this authority and has done so. However, this is a fairly new mandate and
FNS will be able to get a sense of how State agencies are doing through the results of this survey.
Responses to OMB Questions
8
WIC Breastfeeding Peer Counseling Study
Food and Nutrition Service, USDA
Responses to Second Set of Questions from OMB
June 17, 2008
1. Please explain why a complete census of the grantees is needed. Wouldn’t a sample of
grantees do in an effort to reduce burden?
The census of grantees serves three purposes. First, it provides us with a complete picture of the
ways in which Loving Support peer counseling funds are implemented. It is clear that State WIC
agencies are using the Loving Support peer counseling funds in a wide variety of ways, and
differently from one another; a sample of States is likely to produce an incomplete picture of Loving
Support peer counseling implementation. Our need to do a census, instead of take a sample, was
confirmed by review of State agencies’ Implementation and State Plans, discussions with individuals
involved in Loving Support peer counseling implementation, and our pilot test in four States.
Secondly, the census will provide FNS with a complete picture of funding for Loving Support peer
counseling; how funds are used varies, sometimes being matched by other State or grant funds;
sometimes distributed across all local WIC agencies and sometimes just to one. FNS needs to report
to Congress on how the funds appropriated for peer counseling have been used, and thus it needs to
make sure all State agencies are included in a census survey. Finally, it is necessary to do a census of
the states in order to select a representative sample of local WIC agencies receiving Loving Support
peer counseling funds. There is no pre-existing list available of the local sites receiving this funding.
2. Please provide a broad overview of how everything fits together. Explain how the
information in Phase I and Phase II will ultimately help FNS reach its end goal.
In Phase I, FNS is interested in learning how Loving Support peer counseling is being implemented
across the country, including the following: fund distribution and use, number and nature of staff on
the State and local level; written guidance provided to local WIC agencies; responsibilities, training,
and supervision of peer counselors, numbers of WIC participants served by peer counselors; types of
data collected by State and local WIC agencies; and whether other community organizations are
involved. Phase I will provide FNS with information on the current status of the program and how it
has evolved and which, if any, aspects of the Loving Support peer counseling model are “standard”
and where there may be important variations. Based on information from Phase I, FNS will identify
key enhancements of the Loving Support peer counseling model. FNS is then interested in knowing
from Phase II whether breastfeeding duration, a key focus of WIC breastfeeding efforts and one that
research suggests is improved through peer counseling, can be improved by enhancing the Loving
Support peer counseling program. Strategies suggested by research and that are not being done
universally will be targeted for the enhancements.
As you can see, before FNS can initiate Phase II, a better understanding of how State and local WIC
agencies are implementing Loving Support peer counseling is necessary. It is only then that the
strategies for enhancing the program can be identified, and the current level of implementation
identified against which the enhanced programs will be compared.
Responses to OMB Questions
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3. How will Abt collect the data for the “separate deliverable on State tracking of breastfeeding
data?” Is FNS submitting an OMB clearance for this collection?
The “separate deliverable” referred to above is a memo that will be submitted to FNS on the results of
the questions asked in the State Survey on data collection (found in the last main section of the State
Survey, “State Data Collection about Breastfeeding and the Loving Support Peer Counseling
Program”). These questions are part of this request for OMB approval. FNS did not want to wait
until the final report was submitted to learn about the State data on breastfeeding, so it requested a
separate memo shortly after the results of the State Survey were obtained.
Responses to OMB Questions
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| File Type | application/pdf |
| File Title | Microsoft Word - Revised Part A WIC PeerCounseling 6.26.08.doc |
| Author | NicholsonJ |
| File Modified | 2008-06-27 |
| File Created | 2008-06-27 |