Appendix A3 WIC NATS Objectives and Research Questions

Appendix A3. WIC NATS Objectives and Research Questions

Objective 1. Provide in-depth descriptive information on how a large, diverse sample of local WIC agencies perform the WIC nutrition risk assessment. Describe the nutrition risk assessment process (e.g., participant completes a nutrition/health assessment questionnaire, blood and anthropometric measurements are taken, etc.) as carried out in practice in a variety of WIC clinics. Gather detailed information on staff and client experiences associated with nutrition risk assessment.

Processes, Protocols, and Staff Training

1. What are the local agency nutrition risk assessment protocols? Describe the standard protocols as delineated in documentation and as observed in practice.

2. Which staff members typically perform nutrition risk assessment in local agencies? Does this vary by local agency characteristics?

3. How do staff determine and document applicable nutrition risk criteria?

1. Are all allowable nutrition risk criteria considered during the nutrition assessment?

2. How do staff ensure a comprehensive assessment is completed?

3. During the nutrition assessment, how do staff clarify when relevant information from the participant is not clear?

4. To what extent is referral information from health care providers used in determining nutrition risk? What type of referral information is used?

5. What training do staff receive related to carrying out the nutrition assessment, and how often is this training delivered (i.e., are there refresher trainings)?

6. Prior to the certification visit, what forms or information (e.g., nutrition assessment questionnaires, diet histories, etc.) does the participant provide to inform the nutrition assessment? What, if any, information does the site staff access prior to the certification visit? Prior to conducting the certification, if WIC staff provide participants with forms or surveys to complete at home or while in the participant waiting area, how long does it take for the participant and/or staff to complete this pre-visit information?

7. How do local agencies ensure that the nutrition risk assessment is conducted in a culturally appropriate manner (e.g., in the participant’s spoken language, etc.)?

Integration of Technology and Tools

8. What tools (nutrition/health questionnaire, review of medical information, diet history, etc.) are used when performing the nutrition assessment? (The Contractor shall collect and collate tools that are used.)

9. How does the WIC Management Information System (MIS) facilitate nutrition assessment and record or store related information? To what extent does the MIS retain information about identified nutrition risks for participants over time? In what ways does it support tracking changes in nutrition risk?

Assessments of Breastfeeding and High Risk

10. How do staff conduct a breastfeeding assessment? Which staff are responsible for conducting a breastfeeding assessment, and what training do they receive?

11. How do SA or local agencies determine which nutrition risk criteria are considered high risk?

12. How do site staff determine if a participant is high risk?

13. What are the protocols for providing nutrition education to high risk participants (e.g., do staff provide an individual care plan? Are participants referred to professional staff?)?

Research Questions (continued)

Operationalization of VENA

14. How is VENA guidance operationalized in the nutrition assessment process observed at local WIC agencies?

15. In what ways do local agencies differ in their nutrition assessment processes? How does Value Enhanced Nutrition Assessment (VENA) implementation vary between agencies and how does it impact their nutrition assessment processes?

16. Identify and describe aspects of the nutrition assessment process that do not readily align with VENA guidance.

Objective 2. Provide in-depth information to systematically describe how a national sample of diverse local WIC agencies use the collection of nutrition assessment information to tailor Program benefits, including: food packages, nutrition education, breastfeeding promotion and support, and referrals to health and social services.

1. How do local agencies use the information obtained in the nutrition assessment to tailor food packages? How does the specified nutrition risk(s) impact the food packages prescribed to participants?

2. How do local agencies use the information obtained in the nutrition assessment to tailor nutrition education? What elements (content, counseling method, delivery medium, etc.¹) of nutrition education are modified based on findings from the nutrition risk assessment?

1. How are nutrition education topics informed by the nutrition assessment for each participant?

2. When a participant has multiple nutrition risks, how are nutrition education topics prioritized?

3. How many nutrition risks are typically discussed with a participant?

4. How often are identified nutrition risks addressed or directly discussed during nutrition education sessions?

5. How is the nutrition assessment information used to guide participants in establishing nutrition and health goals?

6. Are secondary nutrition education contacts tailored to the participant’s nutrition risk(s)? If so, how?

7. How do local agencies ensure that nutrition education is provided in a culturally appropriate manner (e.g., in the participant’s spoken language, etc.)?

3. Describe the frequency and type of referrals to internal (such as peer counselor or WIC Designated Breastfeeding Expert, or WIC Registered Dietitian) and external health or social services prompted by nutrition risk assessments?

4. In what way does the MIS facilitate the tailoring of program benefits using information from the nutrition risk assessment?

Research Questions (continued)

5. At appointments following the initial assessment:

1. Considering the nutrition goals set or referral services made during the initial nutrition assessment, how do staff follow-up on the identified nutrition risks in follow-up appointments? In what situations do staff routinely follow-up on these goals and/or referrals? In what situations do staff not routinely follow-up on them?

2. Are WIC program benefits adjusted based on changes noted with respect to identified risks?

3. How is the provision of nutrition education or other program benefits adjusted based on nutrition risks (including those that not addressed in prior appointments during the certification period)?

6. How consistent are the tailoring practices within and across sites? Do identified risks consistently result in similarly tailored benefits? If not, what accounts for the variation observed?

Objective 3. Investigate relationships between WIC nutrition services processes (to include the nutrition risk assessment and the associated tailoring of program benefit delivery), and the clinic experience, participant and staff perceptions, and overall clinic flow and efficiency.

1. How long does it take WIC staff to (1) conduct the nutrition assessment, and (2) provide tailored nutrition education and breastfeeding support, (3) food package prescriptions, and (4) referrals, based on the information gathered in the nutrition risk assessment? What is the total time a participant is at the clinic for a WIC visit, and then specifically, the time it takes for the nutrition assessment and providing benefits? In other words, describe the timing of clinic flow of the nutrition services process.

Staff Satisfaction and Suggestions for Improvement

2. How do staff perceive the nutrition assessment process? What are staff suggestions to improve the nutrition assessment process for tailoring program benefits?

3. What resources do staff utilize when conducting a nutrition risk assessment? Are there technical resources/assistance needed for staff to perform a nutrition assessment and tailor benefits beyond what they currently have available?

4. What associations, if any, are identified between nutrition services processes and staff satisfaction? What associations are identified between nutrition services processes and clinic efficiency (as measured by participant time spent directly engaged with staff and participant time spent waiting to engage with staff)?

Participant Satisfaction

5. Are participants satisfied with their nutrition services experience as a whole, and are they satisfied with each of the various components of nutrition services, including but not limited to satisfaction with nutrition risk assessment?

6. How well do participants feel the services they receive reflect their specific needs and/or concerns?

7. In what ways do participants view the nutrition services as valuable? What are their suggestions for improvement?

8. What associations, if any, are identified between how local agencies conduct the nutrition services process and the clinic experience, including clinic flow and participant satisfaction?

Research Questions (continued)

Objective 4. Analyze study findings to identify specific practices or features of nutrition service processes that facilitate the use of nutrition assessment information for providing tailored Program benefits and are associated with participant and staff satisfaction.

1. What practices, when used in the nutrition assessment process, facilitate a timely delivery of tailored Program benefits (including food packages, nutrition education (including breastfeeding promotion and support), referrals, and follow-ups)?

2. What are the benefits of MIS systems in facilitating nutrition assessment? What features of MIS systems are most effective in facilitating a comprehensive assessment and applying the information to tailored benefits?

3. What are promising practices for clinic flow and time savings involved in the nutrition services process?

4. What are staff and participant suggestions to improve clinic flow?

5. What are promising practices for participant experience, satisfaction, and minimizing participant burden involved in the nutrition services process?

6. What are promising practices for staff satisfaction in the nutrition services process? Which of these practices also minimize staff burden?

1 See nutrition education guidance, p.3 https://wicworks.fns.usda.gov/wicworks/Learning_Center/ntredguidance.pdf

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