F
Compilation of Proposed Research Topics and Methodological Issues Covered During the Workshop

This appendix contains two major sections: (1) suggested research topics, and (2) suggested methods. The section on research topics is a compilation and condensation of the research topics that were addressed by presenters, discussants, and moderators during the workshop. The topics are organized under themes that emerged during the workshop, some of which differ from the session titles. Suggested research topics that are similar in subject matter have been grouped together even if the suggestions were made during different sessions. The section on methods covers suggestions made by presenters and discussants during sessions one through eight; it does not cover the methodology presentations made during the closing session.

Suggestions differ in style, reflecting differences in the speakers’ approach to the assignment. The list does not reflect priorities or group consensus.

PROPOSED RESEARCHTOPICS

Overview

  • Additional, more rigorous evaluations of the effectiveness of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) (food package, nutrition education, referrals) in:

    • Improving birth outcomes and reducing health care costs,

    • Improving diet and diet-related outcomes for mothers and children,



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F Compilation of Proposed Research Topics and Methodological Issues Covered During the Workshop This appendix contains two major sections: (1) suggested research topics, and (2) suggested methods. The section on research topics is a compilation and condensation of the research topics that were addressed by presenters, discussants, and moderators during the workshop. The top- ics are organized under themes that emerged during the workshop, some of which differ from the session titles. Suggested research topics that are similar in subject matter have been grouped together even if the suggestions were made during different sessions. The section on methods covers sug- gestions made by presenters and discussants during sessions one through eight; it does not cover the methodology presentations made during the closing session. Suggestions differ in style, reflecting differences in the speakers’ ap- proach to the assignment. The list does not reflect priorities or group consensus. PROPOSED RESEARCH TOPICS Overview • Additional, more rigorous evaluations of the effectiveness of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) (food package, nutrition education, referrals) in: o Improving birth outcomes and reducing health care costs, o Improving diet and diet-related outcomes for mothers and children, 

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0 PLANNING A WIC RESEARCH AGENDA o Improving infant feeding practices, and o Improving inter-natal and prenatal health and nutrition status. • Effects of the WIC food packages on the dietary behaviors of WIC mothers and young children. • The effectiveness of prevention and intervention strategies to re- duce the risk of overweight and obesity. Maternal Health and Behaviors • Observational studies on the effect of interconceptional nutrition on birth outcomes and long-term child health, incorporating bio- markers to identify mechanisms and pathways. • Nutritional intervention studies that begin during interconception and give priority to women with previous adverse outcomes and communities with marked nutritional health disparities. • Nutritional research that focuses on women’s health before, be- tween, and beyond pregnancies. Inputs to consider include precon- ceptional smoking, prenatal weight gain, diet, exercise, and smoking cessation. Outcomes to consider include metabolic allostasis and allostatic load, postpartum weight retention, and breastfeeding. • The impact of coordinated surveillance and communication on the promotion of healthful behaviors during pregnancy and post par- tum, with the goals of preventing childhood obesity and improving maternal health. The coordination would be among obstetricians and WIC providers (at a minimum); and the targets of intervention would be maternal pre-pregnancy body mass index, excessive ges- tational weight gain, maternal smoking, and gestational diabetes. • Interventions associated with the length of gestation. Breastfeeding • How to increase breastfeeding rates in the United States. • Effective strategies for WIC to use to support exclusive breastfeed- ing and to promote the initiation and duration of breastfeeding. Components of support for breastfeeding include: peer counselor training, roles, contacts, and cultural competency; lactation consul- tant roles, sufficiency of numbers, and availability; and relationship of counseling to medical care. • Effects of peer counseling on breastfeeding initiation, exclusivity, and duration; cost-effectiveness. • Core WIC staffing with regard to the numbers and types of staff members, how they are used, and relationships among them.

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 APPENDIX F • Components of peer counseling implemented by WIC agencies with high-performing programs, prioritizing exclusive breastfeeding and giving attention to ethnic background, race, and acculturation. Infant and Childhood New WIC Food Package and Infant Feeding • New WIC food package for exclusively breastfeeding women: con- tent, presentation, promotion, and implementation. • The impact of new WIC food packages with regard to breastfeed- ing initiation, exclusivity, and duration; formula use by partially breastfed infants; and formula feeding. • The effect of the new infant and child food packages on diet quality and nutritional status, examining the association of meat intake at 6 months with iron status in breastfed infants, and both immediate and longer-term effects of the revised food package. • The effect of formula feeding on health. Obesity Preention • The effect of WIC participation on growth outcomes using the World Health Organization growth standards (0–24 months), de- termining outcomes such as the percentages of overweight and underweight infants and effects of the rate of weight gain early in the period on later weight outcomes. • The effect of coordinated surveillance and communication strate- gies among WIC providers, home visitation programs, childcare providers, and pediatricians on changing behaviors to help prevent excess weight gain among infants from birth to 12 months. The targets of intervention during infancy would include excess infant weight gain; breastfeeding initiation, continuation, and exclusiv- ity; responsive feeding; portion sizes of bottles and solid food containers; outdoor physical activity; limiting television viewing and televisions in bedrooms; improving sleep quality and du - ration; coordinated referrals and communication strategies; im- provements in parents’ ability to handle infant feeding, sleep, and media exposure; and the identification of children at high risk of rapid growth. • The effects of a coordinated communication strategy among WIC, Head Start, and pediatricians on changing behaviors that help pre- vent obesity among children 12 to 60 months of age.

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 PLANNING A WIC RESEARCH AGENDA • Prospective study of WIC versus non-WIC children, for which out- comes would include body mass index, diet and physical activity, television viewing, and health care utilization. Co-variates to be tracked longitudinally would include the child’s family situation, maternal behaviors, Head Start or parenting programs, continuity of care, and neighborhood factors that may contribute to obesity. Relationships of Food Insecurity with WIC Participation • Effects of WIC on food insecurity and diet and health outcomes. • Benefits of different WIC components relative to participants’ food security status. • Relationships of food insecurity with the effectiveness of WIC ser- vices in promoting behavior change. • How WIC can best help families reduce demands and increase capabilities. • Interactions of WIC with other programs, including the Supple- mental Nutrition Assistance Program (SNAP) and Medicaid. • Program responsiveness to the economic situation. • Interventions affecting WIC participation, ways to reduce barriers to WIC participation. Linkages, Collaborative Efforts • Linkages with other providers (e.g., home visitation, childcare providers, obstetricians/gynecologists, pediatricians). • Linkages between WIC interventions and health care utilization and outcomes. • The inclusion of oral health screening, fluoride treatment, dental sealant application, and other basic oral-health activities and refer- rals as part of WIC services. • The use of WIC to help establish pediatric medical homes for infant and child participants. Nutrition Education • Can WIC nutrition education reduce the risk of obesity? • Experimental (randomized) trials to compare one method of nutri- tion education with another (see following section on methods). • The effectiveness of various modes of delivering nutrition educa- tion and the identification of those modes that could be easily ad- opted at other WIC sites.

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 APPENDIX F • Interventions that increase the consumption of WIC foods by participants. • Ways in which factors that contribute to health disparities are re- lated to nutrition education. • WIC’s role in providing nutrition education services to postpartum women and to fathers or other caregivers, and to others who influ- ence care. • The potential applicability of interventions that have been effective in achieving behavior change in settings outside of WIC. • The durability of the behavioral, consumption, and weight changes achieved among WIC participants with the new WIC package of foods and counseling. • Methods to make more effective use of technology in WIC’s nutri- tion education activities. Food Package and Redemption • Interventions associated with voucher redemption. • Comparison of food purchases by households that receive WIC vouchers, cash, or SNAP benefits. • WIC participant purchasing choices and behaviors and factors af- fecting them, including the accessibility of stores that carry WIC foods and the availability, quality, variety, and cost of WIC foods in those stores. • Factors affecting the inventories and participation of small stores acting as WIC vendors. • Ways to make more effective use of technology in WIC, e.g., elec- tric benefit transfer (EBT) machines. • Ways to further improve the quality of food purchased with WIC vouchers, especially in small urban food stores. • The use of WIC benefits in farmers markets, community-supported agriculture, and other local and urban food production venues. Miscellaneous • Assessment of manufacturer-added functional ingredients as part of the larger process of determining which foods will be allowed in WIC food packages. • Ways to maintain or increase funds available to WIC.

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 PLANNING A WIC RESEARCH AGENDA PROPOSED METHODS Data • Link up with surveillance data from the Centers for Disease Con- trol and Prevention (CDC) and make WIC data more publicly available. • Collect more types of data—not just WIC participation and timing of entry into WIC. • Use standardized breastfeeding definitions; consider definitions from the Infant Feeding Practices Study II. • Reduce recall periods to obtain accurate information on the inten- sity of breastfeeding. • Collect data on relevant covariates; include prenatal breastfeeding intentions, past breastfeeding history and experience, early hospital experience, reasons for the feeding choice, and the WIC food pack- age chosen. • Improve the surveillance of obesity-related risk factors. • Improve the surveillance of infant weight gain using the CDC growth charts. • Consider ways to improve the accuracy of self-reporting by clients. • Use focus groups to distinguish characteristics of WIC participants and eligible non-participants. Selection of Outcomes, Target Behaviors, and Interventions • Use a logic model to identify appropriate outcomes, target behav- iors, and interventions (see Chapter 8). Examples of Criteria for Target Behaiors • The behavior has an impact on energy balance or weight, is un- likely to do harm, and has a favorable impact on non-obesity outcomes, such as improving social well-being. • Consider behaviors that have the highest impacts on obesity pre- vention, that WIC is in a good position to address, and that are or should be integral to the mission of WIC. • Target behaviors must matter to partners and caregivers and extend beyond weight and obesity. Examples of Criteria for Interentions • Select interventions that are feasible, replicable in many settings, and affordable.

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 APPENDIX F Possible Research Designs Obserations • Analyze data from the National Health and Nutrition Examination Survey before and after implementation of revised food packages, possibly controlling for characteristics of states’ food lists. • Analyze administrative data from a sample of states. • Conduct periodic national WIC evaluations to track attitudes and behaviors, food purchasing patterns, the use of vouchers, and the mother–child dyad; allow comparisons across the larger states; track changes in the health of selected WIC women and children over time and compare with changes in a control group. • Conduct a long-term prospective study of children with differing exposures to WIC (see Chapter 8). • Compare the dietary intake of those who leave the program with the intake of those who stay, or compare the dietary intakes of early versus late entrants, or both. • Analyze changes between certification and recertification in such measures as weight status, iron status, and dietary patterns. Qualitatie • Include a qualitative component to assess participant experiences, identify helpful aspects of the intervention, and mold future pro- cesses and policies. Combine qualitative and quantitative formative processes and impact evaluation to assess the effectiveness of new measures. • Use a multi-stage research design that involves the development and testing of a communication strategy (see Chapter 3). Experimental • Compare WIC to an enhanced form of WIC. • Randomization by unit, for example, by WIC site or by state Use an intraclass correlation coefficient to adjust for this type of randomization. • Staggered interention with each unit as its own control Use an interrupted time series. • Delayed treatment design Start the intervention at one site, com- pare to another site that does not have the intervention, and then eventually provide it to that site as well. • Within the WIC population, compare the effects of three deliv- ery approaches: (1) learner-centered (group at clinic), (2) online

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 PLANNING A WIC RESEARCH AGENDA learn-at-home (individual), and (3) one-on-one counseling model (control). In each of four to six states with different demograph- ics, select eight clinics: four for approach 1, four for approach 3 (above). Online clients (approach 2) would need to be volunteers recruited from all the study clinics. • Randomized controlled trial design: 1. Identify the approaches with which WIC appears to produce an effect (e.g., nutritional advice, smoking cessation). 2. Offer competitive grants to clinics to improve results along one of the dimensions. 3. Choose clinics that qualify, and randomly assign some of them to be awarded money and some of them not. Reporting • Adopt the Transparent Reporting of Evaluations with Non- randomized Designs (TREND) statement to allow for a more systematic review of the WIC interventions and possibly for the merging of small datasets, • Include a strategy statement, which is a description of procedures used in the intervention that is detailed enough that another inves- tigator could replicate the intervention, and • As part of the research agenda, develop a process for synthesizing and disseminating the WIC research findings.