An Assessment of WIC Clinic Environment Related to Obesity Intervention Success
Phase One: WIC Staff Focus Groups
Attitudes & Beliefs Regarding Obesity
A Report for the
Multi-State Obesity Intervention Project
Division of Child and Adolescent Health
Department of Health
Commonwealth of Virgini
Elizabeth L. McGarvey, EdD
Associate Professor
Anne Wolfe, RD, MS
Nutrition Consultant
Faculty Associate
Division of Prevention Research
Department of Psychiatric Medicine
University Of Virginia
April 2000
WIC STAFF BELIEFS & PERCEPTIONS
Key Findings
Overview
Virginia is part of a multi-state Childhood Obesity Prevention Project that includes WIC staff and researchers from Arizona, California, Kentucky and Vermont. The project is funded by the Food and Nutrition Service (FNS) of the USDA. While grant support was provided to each state to conduct state-specific interventions, a number of common activities were identified by the funding agency in collaboration with the states at the first multi-state group meeting. The common activities included the gathering of information from both staff and WIC participants to facilitate a successful parent-focused obesity prevention program operating within WIC clinics. States are conducting interviews, focus groups and surveys according to their individual work plans.
This report presents the results of the first phase of a comprehensive qualitative and quantitative assessment of the WIC clinic environment. Part of the study investigates the environment (i.e., clinic) to identify the possible factors that might influence the outcomes or success of the intervention. Staff attitudes are considered influential as part of the environment.
Phase one of the assessment includes qualitative research that is actualized as focus groups of WIC staff. Focus groups are not designed to be representative of the population of interest or all WIC staff in Virginia. Instead, the focus groups were conducted to obtain information on attitudes and experiences of WIC staff regarding obesity issues related to the project that will be tested with quantitative research methods in phase two of the study.
Phase two of the study includes a questionnaire survey of a sample of WIC staff in clinics across Virginia. The WIC Staff Questionnaire will be the key data collection instrument for the second phase of the study. Approximately 100 staff in a sample of WIC clinics, selected by region of the state, will be surveyed to test the commonality of issues and attitudes among WIC staff regarding childhood obesity prevention issues. Results of phase two of the assessment will be presented in a separate document.
Purpose of the Focus Group Study
Phase one includes two focus group studies of WIC staff at two clinics.
Specifically, the qualitative phase of the study has four objectives:
Methods
Staff focus groups were conducted at two WIC clinics in Northern Virginia by University of Virginia researchers with expertise in this area. These WIC clinics were selected because staff had agreed to participate in the obesity intervention to be implemented in Year 02 of the grant. The Virginia Health Department Nutrition Supervisor for the health district in which both WIC clinics reside conducted recruitment of focus group members. Staff participation was voluntary. Each focus group included at least two nutrition counselors.
Purposeful sampling was used to select the most information-rich cases. Staff recruitment criteria included 1) direct WIC client contact and 2) staff interest in providing input by actively participating in the focus group at the appointed time. The focus groups were held in January and February 2000. Each focus group took about one hour to complete. The Falls Church focus group consisted of six members; the Springfield focus group included all staff members, clerical or nutritionists, who were in the WIC clinic on the day of the focus group.
Open-ended questions on obesity related to WIC clients and children focused on the social ecology of the parent. "Opinion/values questions" were used to explore the interpretive processes of the WIC staff regarding their role in client prevention activities. "Feeling questions" were included to explore the emotional responses of the staff regarding their experiences and beliefs about obese clients. [A copy of sample questions that were used to facilitate the focus groups is shown in the Appendix. However, due to the nature of the small group process, a number of questions not shown on the list were raised during the focus groups which followed the flow of the discussions on various aspects of the issues of interest. ]
Data Analysis
The focus groups were tape recorded and transcribed. Follow-up on-site interviews were conducted. A cross-group analysis was performed as well as a content analysis of the dialogue of the focus group members. Major themes were identified. Comparisons and contrasts between the groups and among cases (i.e., staff) were conducted.
Results
There were no notable differences between WIC staff at the two WIC clinics in themes and issues that emerged from the focus groups. As such, presented below are the themes that emerged from sessions and representative comments from WIC staff related to each content area.
Following this section, other comments and suggestions from the WIC staff regarding the implementation of an obesity intervention are outlined.
WIC PARENT EDUCATION ON CHILDHOOD OBESITY
Overall, WIC staff support the view that educating the WIC parent about childhood obesity should begin prior to the birth of the child. WIC mothers were considered to be more receptive to input on nutrition, physical activity and weight control issues when they were pregnant. There was a sense that WIC mothers might take more care with health and fitness for their babies even if they themselves were unable or unwilling to make and/or maintain health lifestyles that included obesity control. Several comments from WIC staff below illustrate these sentiments:
When should education about obesity begin with the parents?
In the beginning…with prenatal care… because I think children learn so much by example so you are actually working with the parent's eating habits first because I think that is going to be the biggest influence…You have got to work together.
Perhaps with the pregnant women [an obesity intervention would work]; a pregnant woman is more sensitive to any indication related to her pregnancy
[What] we are not doing is prevention. We do more of the treatment … a very good example … the teenage alternative schools where the teenagers [are] best found [who are] pregnant. They learn more and they practice … because they got pregnant to begin with. They say something is going to be mine and they want to protect what’s mine. So, they will do everything under the sun. This is very clear in teenage pregnancy.
In addition, WIC staff expressed the belief that childhood obesity education should be widespread, not restricted to just the WIC clinic or organizations. The influence of culture was noted on numerous occasions throughout the focus groups.
Everywhere, clinics, bus stops, anywhere you can deal with the culture,
the Hispanic population doesn’t think that being fat is ugly. They think that it is beauty and it is wealth. If you are overweight, it means you’ve got beaucoup money. So you’ve got to think about that also.
ROLES AND RESPONSIBILITIES FOR PROVIDING OBESITY PREVENTION EDUCATION
The responsibility to educate parents about obesity prevention in childhood should be shared by 1) WIC staff, 2) physicians and 3) most of the organizations that provide education and services to the WIC population, according the majority of WIC staff. While one WIC staff person mentioned lack of time to direct toward prevention activities due to heavy paperwork loads, others were more definite about a professional responsibility.
Whose role and responsibility is it to educate parents about prevention of obesity in childhood? Other key people who should be educating parents?
I think we [WIC nutrition counselors] have to speak about prevention.
… We [WIC nutrition counselor] just have to finish our paperwork and we cannot think about she’s [WIC client] overweight…
It starts with the doctor I would think…
The doctor, yeah.
… They, of course, go to the doctor, and then they come to… [the WIC clinic], they see the nutritionist, they come back every six months and we constantly reinforce it…
Well, the schools…
Child care provider…Preschool even…that childcare provider is putting the bottle in their mouth, you know… she might have three or four kids and in order to keep them all quiet she’s going to put that in…and that leads to overweight…
Of interest is a belief shared by a number of staff that even if the education of parents should be with professionals or organizations, parents of WIC parents (grandparents) often have more influence over the eating practices than any other party. This was noted particularly among minority WIC clients as illustrated in the comment below:
For my baby, my mother was here. She was taking care of my kids. And I went with her to the doctor. And the doctor told me that he [the baby] was a little heavy and my mother said "What!?" and she started fighting with the doctor. And I said Mom, "Here it is different." Yet, she was feeding the baby soup when my baby was four months. She did not like to give him cereal because she thinks it is not sweet, not salt, nothing. So, she said, "How's he going to eat this? It is terrible, when you could give him something with sugar, something with salt." And that is the problem we have with our community [Hispanic]. They feed the baby, like tortillas, at six months. Even if he don’t eat, they give him what is sweet and what is salt. They know, at six months, they know.
STAFF PERCEPTIONS OF OBESITY AMONG WIC MOTHERS
Most WIC staff expressed compassion for the obese WIC mother. They also tended to express some sense of hopelessness in effecting a change in the client's health status due to their inability to effectively have an impact such as weight reduction in the client.
Staff noted personal feelings and thoughts about an obese woman associated with 1) the client's eating habits, 2) her apparent lack of activity, 3) her possible depression, 4) her probable ill health caused by obesity, 5) other stressful personal problems. The comments below indicate the context of these observations.
If you see an obese woman walk into the WIC office with her infant or child, what are your first thoughts?
You make a judgment on their eating habits. Maybe they don’t have the best eating habits and maybe [it's] their activity, I mean maybe they’re sedentary.
My perception would be that they [WIC clients] are out of control…And there may be some things going on in their life. They may be depressed, stressed, it can go either way, They could be too thin or too fat because of those reasons - emotional.
I had a woman once that came in … many years ago for a postpartum weight check-up. She burst out in tears and she said …my husband tells me I’m fat. And she was so depressed …
…The lady, she came here yesterday… when I saw her I was like "Oh my gosh, she is very young, 25 years old, and she is very, very, very fat". And, uh, because of the way she acted with us, she was in a lot of stress. Maybe she was a single mother, I don’t know. Maybe that is the reason she didn’t, uh, something was wrong with her because she was very upset with everybody.
I feel like the clients here, they live a harder life. I feel, you know, they don’t have the luxury of joining a gym…
Some WIC staff tended to have little hope of making a change in the lives of the obese parent, choosing instead to focus directly on the child in the hopes of making a difference.
I focus on the patient. If the patient is a child and I know that, then I instruct the parent. But, see, that’s my personal feeling. I feel like in the past, I haven’t had an impact on adults but I have had an impact on children. …If the child is coming in because he is under five for the WIC program, then that is my patient, not the mother. So then I’m addressing the child’s problem. Probably, the mom is going to take some of the dietary changes I make to the child to heart [for] herself. I mean if I’m telling her use low percent, low-fat milk for her child then I’m sure she’s not going to buy whole milk for herself and low-fat milk for the kid; they probably drink the same milk.
Staff also acknowledged the importance of the health belief model of behavior change regarding the "readiness to change" as an essential element in obesity prevention.
You have to come to a readiness point. There are folks that aren’t ready. They’ve got to figure out what to put on the table the next day. They’ve to get a job; losing weight isn’t a priority at that point.
INFLUENCE OF THE MOTHER'S EATING HABITS ON THE CHILD
Most all WIC staff noted that parent overeating is a significant problem when treating or preventing childhood obesity because they are the most significant role models for their children. As such, a childhood obesity intervention must somehow include the parents unless a program could be implemented in a school setting. With infants, the parent needs to be involved directly.
How does the mother's relationship with food and dieting relate to how this mom feeds her child?
I think children learn so much by example so you are actually working with the parenting eating habits first because…
Like parents say, "I can’t really control my eating," if they are aware of it, "but I’m going to make sure my child is healthy."
…The mother usually completely likes what we are saying because of the implications of the child’s diet. There are portion types that children need to be fed ... the child is too little to force feed… this is one thing that I would be able to put on the table. The next day mom would think I am forcing the child to eat to make them healthy. And I said, "Well, here have this" and most of the time they would choose the portions that are healthy. I'll say this from the point of view of my house, if I invite you to my place and I serve you a [very large] portion like that, you'll feel discouraged and you’ll force yourself to eat it and that is the way the child feels.
WIC FOOD PACKAGES
Do you think the foods that WIC offers in its food packages encourages or discourages high calorie intake among this population?
I mean we can alter the food packages a little bit but they’re all good foods. It’s up to them how they use them, you know. I mean they can buy skim milk. They can buy low fat cheese… Beans are good protein. Eggs are a good protein… I think we could focus on that, but that’s all part of preventing obesity.
What foods would you like to see offered in the WIC food packages? What foods would you like to see taken off the WIC food packages?
Food packages without fresh foods are a problem in effective change of eating patterns according to most of the WIC staff. A contradiction was noted in educating parents to the five fruits or vegetables a day eating guide and the lack of fresh food in the WIC food packages. It was of no concern to WIC staff that the food packages are intended to supplement the available food of clients. The lack of fresh fruit and vegetables was presented as problematic.
Other items that were suggested for inclusion in the food packages were foods that were ethnic-specific, like rice for the Hispanic clients. Also, there was a lively debate about whether or not to include bottled water in the food packages. The WIC staff opinions were mixed on this. Certain minority staff strongly felt that the tap water in the United States was "good water" and that if they themselves drank it, then the WIC clients certainly could as well. Others felt that it was calorie free and would help fight obesity, unlike fruit juice, for example.
…Would be nice to do more fruits and vegetables… In Maryland they are allowed to go to the farmer’s market.
Five- a-day, we are trying to encourage people to eat five a day, but then don’t offer fruit or vegetables okay, it’s low in calories, it’s high in fiber, it is one of the things you should eat for weight reduction.
…getting rice in the package
… They [WIC clients] say, "They give us the beans but they don’t give us the rice," so they eat it with tortilla which is more fattening than the rice…
See taken off the WIC package? Peanut butter, I’m sorry. Peanut butter… is good because it’s an American food.
… They might get one peanut butter because they got kids in school. You know kids… say "Ooh mommy, you know such and such is using peanut butter… I want peanut butter too." So they buy one and the rest is rice, right? … A jar of peanut butter lasts them because it’s 1 ½ lbs. it lasts them a long, long time. So, that’s one of the reasons that they get the peanut butter… the insistence of the child.
It should be offered if you need spring water.
Do you think that juice is contributing at all to the childhood obesity problem?
I think it does.
Because kids love juice and the more they ask for it, the more the mother gives…
And you really have to teach them [about limiting juice intake] because they think because you’re giving it in WIC, then you know, "Give me as much as I want."
OTHER ENVIRONMENT ISSUES POSSIBLY RELATED TO OBESITY
A checklist of issues was reviewed as consideration for placing a child at risk for later obesity. Below are comments related to family meals, television viewing, and lack of outside play related to safety issues.
Family Mealtime
…I am sometimes surprised that few families that have family meals together anymore. …A lot of kids are sitting at the table by themselves. Or, they just open up the refrigerator, pre-access to food. There’s no real family meal anymore.
Some families eat with their children…
But the problem and I have to go back … we have high density of Hispanics. They live … commune type; it’s not an individual type. They live 3 and 4 families in one apartment that has 3 bedrooms and they share. Maybe one of them supervises them [the children] but she has children of her own. We know for sure that she is going to take care of her children first because that is a natural thing. Then the other kids. They [the other children] are not neglected but they get into the refrigerator and they can eat whatever they find over there without supervision. That’s what we encounter.
I’ve run into that too with any nationality really. Middle Easterners, they’ll be living with the grandmother and the grandfather. The grandmother might be doing all the cooking and the grandmother might be giving them candy and the uncles might bring home something…
Many of our clients who come to the clinics… hold onto two jobs. It could be baby-sitting two different places. They really don’t have any time to prepare simple balanced meal. At the max, they will …open up a can of green beans, or open up, you know, a frozen package or something.
The moms come in and feel very guilty about being late to pick up the child-- 6 hours, 10 hours…The child has been there. They [the mothers] take them to McDonald’s to make them happy. So the food habits, changed because of their involvement in … and the kind of job they do.
Television
And a lot of them sit in front of the TV and eat. I just had a little boy this morning. He was on the thin side…Even the parents were aware of the problem. They’ve had the TV on during mealtime and he was distracted. He wouldn’t eat
They watch a lot of TV, computer and games…
Safety Issues
And people are afraid to let their children out because of what, you know, violence, crimes, that sort of thing.
Well, I was involved with a school-aged boy that was overweight and the mother where they lived was scared to let him play outside…
[A]dults, you know, are a lot like children in a way. . .Talking about the safety thing and living in an apartment and not getting out. Watching television. They are doing the same thing as the child was… They don’t walk. They don’t exercise.
Cultural Differences
The WIC staff were very aware that cultural issues were important in how effective any nutrition counseling or obesity prevention activities were likely to be. The following comments illustrate the range of impression and opinions shared by the WIC staff in the focus groups.
What I’ve noticed about the population of Ethiopians, we have a number of Ethiopians around this area as our clients, we are told that for them overweight is not obesity. If the child is overweight then the child is okay.
With the Asians, with the Orientals, we have different instructions. The first group of Vietnamese - the mothers are usually underweight. I mean this according to the standards we used to test weight for pregnant women of the past. But the children are fairing rather well, they are okay, I don’t see that many overweight among them. We don’t have that many, we have a few Korean, Korean culture covers them to show weight a little bit about a person.
… The Southeast Asian population… they have a very different perception about the infant health status…They associate the weight of the baby with the money status…[they see] high economic group[s] who can afford to spend money on food…
We have a number of Vietnamese and Koreans; we have a number of Filipinos also. The Filipinos also tend to be all right… it doesn’t seem to be much of a problem among them. However, they worry about the number of children at two months who are being considered overweight, and that frightens you.
…About the African Americans …They eat a lot of greasy foods and I try to stay away from greasy foods.
…I am Hispanic… we don’t like … our parents don’t like skinny babies. They think that it is unhealthy for whatever reason. They think that you are not feeding the baby properly and they make a big issue out of it. So the bigger, the fatter the baby is, the better you look like you are a great mother. Never did I thought that heavy might not be a healthy baby, because I have that and I experienced that my baby was beautiful …I am here in the United States and I have to follow through [on reduced feeding of my child] because he was having lots of problems. And I have that battle with my mom, you know, the Hispanics have that thinking. That is why they come over here [to the WIC clinic] and [WIC nutritionists] say that "Your baby is overweight or heavy," they don’t like to hear that. It is like you are criticizing them…
Hispanic mothers… that is the problem we have with our community. They feed the baby like tortillas at six months even if he don’t eat, they give him what is sweet and what is salt, they know, at six months they know…
STAFF COMFORT IN ADDRESSING OVERWEIGHT/OBESITY ISSUES AMONG CLIENT
Most WIC staff expressed relative comfort discussing weight issues with clients. Having time to do so and materials to hand out upon first meeting were identified as needs. Also, WIC staff reports that the client has to be "ready" to discuss weight issues.
Three key issues related to addressing overweight in this regard were identified as 1) understanding the client's personal and/or cultural perspective, 2) generating staff-client trust and 3) present-focused counseling.
Do you feel comfortable about addressing overweight and obesity in this population? What would make you feel more comfortable to address the issue of obesity, particularly childhood obesity in this population?
I found when I was doing the counseling… I always touched on the subject. I don’t know whether it’s because of me because it’s a big priority in my life… When an overweight, … prenatal woman was coming in, I’d always go over it [overweight issues]. I’d look at the chart and sort of do the whole weight thing… I always mentioned that if they were overweight. I never had a problem doing it and I never felt like I offended anybody.
I think occasionally parents are shocked that their child is overweight because they don’t view it this way. This may be the cultural issue… I think sometimes when you say, "Oh they’re overweight". They're shocked at that. They’re not offended but they’re just surprised.
Weight management [workshops] in childhood and adulthood. It really would help just to have some more handouts on overweight and obesity. It [would] help learning how to talk to patients.
Or it’s that readiness, I think it’s like…developing that because the first time you see a client, they’re not ready to deal with it. But what you say or what do, you plant in their heads… maybe, eventually moves them that direction…
All of us have belief systems that [represent] the different parts of the United States, different parts of the country, the world, you know. And you need to build up from there. We have to find out the commonality from the differences. And a lot of times the counselors start with the differences, you know. I think we need to start with the commonalities. You eat rice, I eat rice, you eat bread, I eat bread, you know… spend some time and have a relationship…
You have to win their trust and get them to talk a lot because otherwise they won’t come out with anything.
I think a lot depends on the mothers…, whether, how she reacts to you.
I’ve been here quite a while. So, you get to know a lot of these people and you’ll notice that some of these people come back for their second, their third, their fourth child. Every time they come back, they’re a good 10 lbs. heavier and I have even used that. I’ll go back and say, "Well now let’s see what you weighed when you had your first child," you know, and you’ll be surprised at how much they’ve gained over the years.
I tend to focus in on the most immediate, I mean sometimes it’s hard to say, "Well, you know down the road 10 years… this could happen…" But the immediate consequences, like in pregnancy, if you gain too much, your blood pressure could go high, then diabetes…
SUGGESTIONS FOR A CHILDHOOD OBESITY PREVENTION MANUAL
There was not general enthusiasm for a manual for the prevention program. However, the WIC staff seemed resigned to the fact that such a manual would probably be forthcoming. They were willing to use it but reported that in-service training would be vital to fully involving them in the project.
If you received a copy of an implementation manual for designing and implementing WIC Childhood Obesity Prevention Project, what information would you like to see presented in the manual?
I would say that it should go along with an in-service… a manual… it probably would sit on the shelf…
It’s much more beneficial for somebody to meet with a group and do a workshop.
I might like some educational materials…on different levels from basic to more advanced, maybe something that moves you. Kind of an outline…
[A manual that] helps you approach that person, how you get into it with them, you know…open ended questions that get your client to talk.
Other Findings
Opinions and ideas related to the effective implementation of an obesity intervention resulted from comments made in the focus group sessions and in casual conversations with the researchers at site visits. These points included the following:
Must make the obesity intervention personal. The global sense, like you said, it gets a little bit overwhelming because it is. We have actually labeled it an epidemic so that can be a little bit intimidating. Because how is one clinic or one person going to be able to change that in a global sense? But if you look at it as an individual and that there is a possibility that you can make a difference in just that one person, then you could at least make a dent in it.
Belief that child-focused interventions can work but probably not adult obesity interventions. … As one of the nutritionists I think that it is hard to pass on to adults the need to change things. It is like a yo-yo, they are up weight and down weight but when I did weight reduction with children I had a lot more success…
Cultural beliefs of parents are problematic when implementing a child-focused obesity intervention …our clients are not only concerned about weighing too much but more about a large number of criteria that is cultural…
Staff comfort level may be influenced by their own obesity. Maybe the clients are really influenced by the environment. If they came in the clinics and there wasn’t a lot of information on obesity or the staff themselves knew them personally because they lived in a small community. And they knew the staff didn’t work out either, some of the staff had [overweight] children who were friends with their children. Those were big issues. Because they felt that they were being told messages that the staff didn’t really care about except for the nutritionists.
Lack of staff commitment to obesity reduction. I talk to them… I’m not telling them my personal feelings I’m just saying, hey, this is what USDA guidelines suggest and I’m just passing the information along.
Lack of opportunity for outside child play. Parents, they say the places the children are not allowed to play outdoors they are not allowed to do enough physical activities and that may be one of their problems.
SUMMARY
Phase one of the assessment provided information from staff that is consistent with that found in the current literature on client obesity. This information will be incorporated into the WIC staff questionnaire under development for Phase two of the assessment.
Phase two of the project will further investigate the prevalence of the key issues identified in the focus groups and will gather related information from which to consider implementation issues. Overall, WIC staff input from focus groups indicates support for participation in a childhood obesity intervention to the extent that time is available for such participation. Appropriate training and on-going involvement of staff is recommended. Any additional paperwork will require additional personnel since WIC staff report having no time available to perform than their current workload.
WIC Staff Focus Group Questions