oversight

Food Assistance: Working Women's Access to WIC Benefits

Published by the Government Accountability Office on 1997-10-16.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                 United States General Accounting Office

GAO              Report to the Chairman, Committee on
                 the Budget, House of Representatives



October 1997
                 FOOD ASSISTANCE
                 Working Women’s
                 Access to WIC Benefits




GAO/RCED-98-19
      United States
GAO   General Accounting Office
      Washington, D.C. 20548

      Resources, Community, and
      Economic Development Division

      B-277788

      October 16, 1997

      The Honorable John R. Kasich
      Chairman, Committee on the Budget
      House of Representatives

      Dear Mr. Chairman:

      The U.S. Department of Agriculture’s (USDA) Special Supplemental
      Nutrition Program for Women, Infants and Children (WIC) is designed to
      improve the health of low-income pregnant, breast-feeding, and
      postpartum women; infants; and children up to age 5, who are at
      nutritional risk. The program provides annual cash grants to the states for
      food, nutrition education, health care referrals, and administrative
      expenses. Food benefits are generally provided to participants in the form
      of vouchers or checks that they can redeem for certain foods at approved
      stores. Within the states, local WIC agencies distribute food vouchers and
      provide nutrition education through the clinics they operate in their
      service areas. In fiscal year 1997, appropriations for WIC totaled $3.7
      billion, and average monthly participation was 7.4 million through
      February 1997.

      This report is the third in the series of reports responding to your request
      for information on certain aspects of WIC.1 In this report, we provide
      information on the extent to which WIC program benefits are accessible to
      eligible working women. Specifically, we (1) identified the actions taken
      by local WIC agencies to increase access to WIC benefits for working
      women; (2) asked the directors of local WIC agencies to rate the
      accessibility of their clinics; and (3) identified factors that limit program
      participation.

      This report is based on the results of our nationwide survey of randomly
      selected local WIC agencies. Officials at these agencies (referred to as
      directors throughout this report) provided us with information on their
      agencies’ operating characteristics. The survey responses from our
      random sample are representative of the entire universe of local WIC
      agencies. (App. I contains a detailed discussion of our scope and
      methodology; app. II discusses the methodologies and analysis used in the
      mail survey; and app. III presents the aggregated responses of our mail
      survey.)

      1
       The other two reports are entitled WIC: States Had a Variety of Reasons for Not Spending Program
      Funds (GAO/RCED 97-166, June 12, 1997); and Food Assistance: A Variety of Practices May Lower the
      Cost of WIC (GAO/RCED-97-225, Sept. 17, 1997).



      Page 1                                                        GAO/RCED-98-19 Food Assistance
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                   The directors of local WIC agencies have taken a variety of steps to improve
Results in Brief   access to WIC benefits for working women. The two most frequently cited
                   strategies are (1) scheduling appointments instead of taking participants
                   on a first-come, first-served basis and (2) allowing a person other than the
                   participant to pick up the food vouchers or checks, as well as nutrition
                   information, and to pass these benefits on to the participant. These
                   strategies focus on reducing the amount of time at, or the number of visits
                   to, the clinic. Although three-fourths of the local WIC agencies offer
                   appointments during the lunch hour, only about one-tenth offer Saturday
                   appointments, about one-fifth offer early morning appointments, and less
                   than half offer evening appointments. Collectively, at least one-fourth of
                   the participants do not have access to any clinic hours outside of the
                   regular work day.

                   Seventy-six percent of the directors of local WIC agencies believed that
                   their clinics are reasonably accessible for working women. In reaching this
                   conclusion, the directors considered their hours of operation, the amount
                   of time that participants wait for service, and the ease with which
                   participants are able to get appointments at the desired time. Although
                   most directors were generally satisfied with their clinics’ accessibility and
                   had made changes to improve access, 9 percent of the directors still rated
                   accessibility as a problem. Fourteen percent of the directors rated
                   accessibility as neither easy nor difficult, and 1 percent responded that
                   they are uncertain.

                   The directors of local WIC agencies identified several factors that limit WIC
                   participation by working women. The factors most frequently cited
                   reflected the directors’ perceptions of how women view the program.
                   Specifically, the directors told us that women do not participate because
                   they (1) lose interest in the program as their income increases,
                   (2) perceive a stigma attached to receiving WIC benefits, or (3) see the
                   program as limited to those who do not work. Directors less frequently
                   identified other factors—such as the lack of adequate public
                   transportation and long waits at clinics—as also limiting WIC participation
                   by working women.


                   USDA’s Food and Consumer Service (FCS) administers WIC through federal
Background         grants to states for supplemental foods, health care referrals, and nutrition
                   education. To qualify, WIC applicants must show evidence of health or
                   nutritional risk that is medically verified by a health professional. In
                   addition, participants must have incomes at or below 185 percent of the



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                      B-277788




                      poverty level. In 1997, for example, the WIC’s annual limit on income for a
                      family of four is $29,693 in the 48 contiguous states and the District of
                      Columbia.2

                      WIC operates in the 50 states, at 33 Indian tribal organizations, and in the
                      District of Columbia, Guam, the U.S. Virgin Islands, American Somoa, and
                      the Commonwealth of Puerto Rico. These 88 government entities
                      administer the program through more than 1,800 local WIC agencies. These
                      agencies typically are a public or private nonprofit health or human
                      services agency; they can be an Indian Health Service Unit, a tribe, or an
                      intertribal council. Local WIC agencies serve participants through the
                      clinics located in their service area.

                      Most WIC food benefits are provided to participants through vouchers or
                      checks that can be issued every 1, 2, or 3 months. These vouchers allow
                      participants to purchase a food package designed to supplement their diet.
                      The foods they can purchase through WIC are high in protein, calcium, iron,
                      and vitamins A and C; they include milk, juice, eggs, cereal, and, where
                      appropriate, infant formula. The value of the food package varies by state
                      and by the participants’ nutritional needs. The average value of the
                      monthly food package in 1996 for all participants nationwide, excluding
                      infant formula, was $43.54. Families with infants using formula obtained a
                      package valued at about $82.

                      WIC was established in 1972 by Public Law 92-433, which amended the
                      Child Nutrition Act of 1966. In 1989, the act was amended to require that
                      state agencies improve access to WIC for working women by making
                      changes that minimize the time they must spend away from work when
                      obtaining WIC benefits. The directors of local WIC agencies generally
                      estimated that working women represented between one-tenth and
                      one-half of all those served in their clinics, although few agencies collect
                      data on the number of working women.


                      Nationwide, virtually all local WIC agencies have implemented strategies to
Local WIC Agencies    increase the accessibility of their clinics for working women.3 The most
Have Taken Steps to   frequently cited strategies—used by every agency—are scheduling
Increase Clinic       appointments instead of taking participants on a first-come, first-served
                      basis and allowing a person other than the participant (an alternate) to
Accessibility
                      2
                       Poverty guidelines are established separately for Alaska and Hawaii.
                      3
                       While we found that 100 percent of the local WIC agencies we surveyed have implemented one or
                      more strategies, our results are based on a sample, not the entire universe. Thus, we would estimate
                      that at the 95-percent confidence level our finding applies to at least 99 percent of the entire universe.



                      Page 3                                                              GAO/RCED-98-19 Food Assistance
                                         B-277788




                                         pick up the food vouchers. Other, less frequently cited strategies, which
                                         are still used by more than half of the agencies, are issuing vouchers for
                                         more than 1 month at a time, offering appointments during the lunch hour,
                                         expediting clinic visits, and mailing vouchers to participants. Fewer
                                         directors use strategies that extend clinic hours beyond the typical
                                         workday—Saturday, early morning, or evening hours—or located clinics
                                         at participants’ work or day care sites. Figure 1 illustrates the frequency of
                                         use for 10 strategies.


Figure 1: Strategies Used by Local WIC
Agencies to Increase Accessibility for   Percent of agencies
Working Women                                        100            100
                                         100

                                                                                  89
                                          90

                                          80
                                                                                                      75

                                          70                                                                      67

                                                                                                                                  60
                                          60

                                                                                                                                             49
                                          50

                                          40

                                          30
                                                                                                                                                           21
                                          20
                                                                                                                                                                      11         10
                                          10

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                                         Strategies




                                         As shown in figure 1, each of the six strategies—scheduling appointments,
                                         using alternates, issuing multiple vouchers, offering lunch hour
                                         appointments, expediting clinic visits, and mailing vouchers to
                                         participants, are used by more than half of the local WIC agencies. More
                                         specifically:




                                         Page 4                                                                                              GAO/RCED-98-19 Food Assistance
    B-277788




•   Scheduling appointments. All local WIC agencies offer participants the
    convenience of scheduling their appointments. Scheduling appointments
    reduces a participant’s waiting time at the clinic. Furthermore, Kansas
    state officials told us that they recommend that local WIC agencies
    schedule appointments for participants in order to make more efficient
    use of the agency staff’s time.
•   Using alternates. All local WIC agencies allow a person designated as an
    alternate to pick up food vouchers and nutrition information for the
    participant, thus reducing the number of visits to the clinic by working
    women. California state officials told us that they allow the use of
    alternates statewide and that many participants designate a relative or
    baby-sitter as an alternate. At one local WIC agency we visited in
    Pennsylvania, officials told us that alternates, such as grandmothers who
    provide care during the day, can benefit from the nutrition education
    because they may be more familiar with the children’s eating habits than
    the parents.
•   Issuing vouchers for multiple months. Almost 90 percent of local WIC
    agencies issue food vouchers for 2 or 3 months. California state officials
    said that issuing vouchers every 2 months to participants who are not at
    medical risk reduces the number of visits to the clinic.
•   Offering lunch hour appointments. Three-fourths of local WIC agencies had
    some provision for lunch hour appointments. All of the local agencies we
    visited in California operate at least one clinic in their service area during
    the lunch hour, which allows some working women to take care of their
    WIC visit during their lunch break.
•   Expediting clinic visits. Two-thirds of local WIC agencies took some action
    to expedite clinic visits for working women to minimize the time they must
    spend away from work. For example, a local agency official in New York
    State stated that the agency allows women who must return to work to go
    ahead of others in the clinic. The director of a local agency in
    Pennsylvania told us the agency allows working women to send in
    required paperwork before they visit, thereby reducing the time spent at
    the clinic. The Kansas state WIC agency generally requires women to
    participate in the program in the county where they live, but it will allow
    working women to participate in the county where they work when it is
    more convenient for them. Finally, one local agency in Texas remodeled
    its facilities to include play areas where children could be entertained
    during appointments. Not having to spend time minding their children
    decreases the amount of time that women need for visits.
•   Mailing vouchers. About 60 percent of the local WIC agencies, under special
    circumstances, mail food vouchers to participants. Mailing vouchers
    eliminates the need for a visit to the clinic. Officials at all of the state



    Page 5                                           GAO/RCED-98-19 Food Assistance
    B-277788




    agencies we visited allow vouchers to be mailed but are generally very
    cautious in using this strategy. Both state and local agency directors told
    us that mailing vouchers eliminates the personal contact and nutrition
    information components of the program. One local agency director in
    Pennsylvania told us that she mailed vouchers to rural participants during
    a snowstorm when the agency van could not get to scheduled locations.

    Three of the four less frequently used strategies shown in figure
    1—Saturday, early morning, and evening hours—increase clinic hours
    beyond the regular workday. The fourth strategy—selecting clinic
    locations because they are at participants’ work sites or day care
    providers—is the strategy least frequently cited. More specifically:

•   Expanding clinic hours—Saturday, early morning, and evening hours.
    Offering extended hours of operation beyond the routine workday is an
    infrequently used strategy. About one-fifth of the local WIC agencies offer
    early morning hours—before 8 a.m.—at least once a week, and about
    one-tenth offer clinic hours on Saturdays at least once a month. Just under
    half of the agencies are open during evening hours—after 6 p.m.—once a
    week. At least one-fourth of the participants do not have access to any
    clinic hours outside the regular workday.

    The directors of local WIC agencies offered a variety of reasons for not
    offering extended hours of operation. For example, about 8 percent of
    these agencies had previously offered Saturday hours. Directors for
    several agencies said that they had discontinued this practice because
    participation was not high enough to warrant remaining open on
    Saturdays. Other reasons cited were an insufficient number of staff to
    allow for expanded clinic hours (79 percent), the staff’s resistance to
    working hours other than the routine workday (67 percent), and a lack of
    security in the area after dark (42 percent). For example, at one agency we
    were told about two recent homicides after dark near one of the clinics.
    This clinic limits evening hours to one evening each month, and at closing
    time, the staff exit together to the parking lot across the street. In addition,
    in two states we visited, the clinic staff do not have access to their
    statewide computer system in the evenings or on Saturdays, which
    reduces efficiency in processing paperwork and discourages operating
    during extended hours.

•   Clinic locations. About 5 percent of local WIC agencies selected a location
    for one or more of their clinics because it is at or near a work site. For
    example, one Texas agency operates a clinic twice a month at a poultry



    Page 6                                            GAO/RCED-98-19 Food Assistance
                        B-277788




                        farm in an area where several such farms employ women who are WIC
                        participants. In California, two local WIC agencies we visited have clinics at
                        nearby military bases. One has a clinic at an Air Force base, and the other
                        has six clinics at various installations—two at Marine bases and four at
                        Navy locations.

                        Similarly, about 5 percent of local WIC agencies selected clinic locations
                        because they are day care sites for participants. For example, according to
                        a director of a local WIC agency in Texas, she operates a clinic once a
                        month at a day care site used by 71 women who participate in WIC.
                        Operating a clinic at this location is a convenience for the participants.


                        About 76 percent of the directors of local WIC agencies believed that
Directors Generally     accessibility to their clinics is at least moderately easy for working
Believe Their Clinics   women, as measured by such factors as convenient hours of operation and
Are Easily Accessible   reasonable waiting time at the clinics. However, about 9 percent of the
                        directors believed that accessibility is still a problem for working women.
                        Figure 2 shows the directors’ rating of their clinics for accessibility.




                        Page 7                                           GAO/RCED-98-19 Food Assistance
                                         B-277788




Figure 2: Directors’ Views of Clinics’
Accessibility
                                                                                    Very easy

                                                                                    0.9%
                                                                                    Uncertain

                                                                                    0.6%
                                                                                    Very difficult


                                                                    •               8.3%
                                                                                    Moderately difficult
                                                  • 22.6%
                                                                    14.3%
                                                                       •




                                                            53.4%
                                                               •



                                                                                    Neither

                                                                                    Moderately easy




                                         Despite the widespread use of strategies to increase accessibility, some
                                         directors reported that accessibility is still problematic for working
                                         women. In our discussions with these directors, the most frequently cited
                                         reason for rating accessibility as moderately difficult or very difficult is the
                                         inability to operate during the evening or on Saturday. As previously
                                         noted, directors provided several reasons for not offering extended hours,
                                         including the lack of staff, staff’s resistance to working schedules beyond
                                         the routine workday, or the perceived lack of safety in the area around the
                                         clinic after dark.

                                         While about 76 percent of the directors of local WIC agencies perceived
                                         that access to their clinics is easy at current participation levels, this
                                         situation could change with increases in WIC participation overall, as well



                                         Page 8                                               GAO/RCED-98-19 Food Assistance
                         B-277788




                         as with increases in participation by working women—a situation
                         anticipated by many directors. About 58 percent of the directors indicated
                         that they expect participation by working women to increase with the
                         implementation of welfare reform. These expectations have already been
                         realized in some states. Directors of local WIC agencies in Tennessee and
                         Indiana reported that their states have already implemented some aspects
                         of welfare reform and that the number of working women participating in
                         WIC has increased.


                         Federal, state, and local WIC officials explained that overall participation in
                         WIC is likely to grow with the implementation of welfare reform because
                         the perceived value of WIC benefits will increase as benefits from other
                         assistance programs are lost. Moreover, the percentage of working women
                         in WIC is likely to increase because welfare initiatives place a premium on
                         moving the beneficiaries of these programs into the workforce.

                         Increases in WIC participation could burden staff and space resources and
                         hinder some agencies’ ability to continue to provide easy access to their
                         clinics. In fact, many directors who rated access to their clinics as
                         generally difficult cited a current lack of resources—staff and space—as
                         the primary reason.

                         Other local WIC agency directors reported similar staff and space
                         constraints, noting that they were already working at full capacity and that
                         one or more of their clinics had no room to accommodate more
                         participants. For example, one director told us that his clinic was “already
                         bulging at the seams” and that increases in participation would leave the
                         clinic critically short of staff and space. Such shortages could limit
                         working women’s access to WIC clinics.


                         Women’s perceptions about WIC—such as the value of the program’s
Directors View           benefits to them as their income rises or the perceived stigma attached to
Women’s Perceptions      obtaining benefits—were the limitations to participation most frequently
as a Major Factor        cited by the directors of local WIC agencies. Another major factor limiting
                         participation is that women may not be aware of their continued eligibility
Limiting Participation   for WIC if they begin working while participating or if they are working and
                         have not participated in WIC. Less frequently cited factors limiting
                         participation in WIC include difficulties in reaching the clinic and long
                         waits at the clinic.




                         Page 9                                            GAO/RCED-98-19 Food Assistance
                             B-277788




Frequently Cited Factors     The directors of the local WIC agencies indicated that working women’s
Limiting WIC Participation   views of the WIC program may limit their participation, despite the agency’s
                             efforts to make the program more accessible to them. Sixty-five percent of
                             the directors considered the fact that working women lose interest in WIC
                             benefits as their income rises as a significant factor limiting participation.
                             For example, one agency director reported that women gain a sense of
                             pride when their income rises and they no longer want to participate in the
                             program. While working women may choose not to participate in WIC as
                             their income increases, one local agency director noted that the eligible
                             working women and their families who drop out of the program lose the
                             benefit of nutrition information.

                             The stigma some women associate with WIC—how they appear to their
                             friends and co-workers as a recipient—is another significant factor
                             limiting participation, according to about 57 percent of the local agency
                             directors. One director said that when women go to work, they tend to
                             change the way they view themselves—from thinking that they need
                             assistance to thinking that they can support themselves. Another director
                             told us that when her clinic was located in the county building, women
                             were reluctant to come in because they were recognized as WIC recipients
                             by county employees working elsewhere in the building.

                             Another aspect of the perceived stigma associated with participating in WIC
                             is sometimes referred to as the “grocery store experience.” The use of WIC
                             vouchers to purchase food in grocery stores can cause confusion and
                             delays for both the participant-shopper and the store clerk at the
                             check-out counter and result in unwanted attention. For example, the
                             directors of two local WIC agencies in Texas said that the state’s policy
                             requiring participants to buy the lowest-priced WIC-approved items in the
                             store contributes to the stigma, which limits participation. In Texas, a
                             participant must compare the cost of WIC-approved items, considering
                             such things as weekly store specials and cost per ounce, in order to
                             purchase the lowest-priced items. Texas state WIC officials told us that this
                             policy maximizes the food dollar, thus allowing benefits for a greater
                             number of participants.

                             Another director told us that a pilot project in which WIC-approved foods
                             are purchased using a card that looks like a credit card could help reduce
                             the stigma associated with shopping in the grocery store. The WIC card
                             retains information on unused benefits and can be used at the check-out
                             counter like an ordinary credit card.




                             Page 10                                          GAO/RCED-98-19 Food Assistance
                         B-277788




                         More than half of the directors indicated that a major factor limiting
                         participation is that working women are not aware that they are eligible to
                         participate in WIC. Local agency officials we spoke to in both California
                         and Texas confirmed that many working women do not realize that they
                         can work and still receive WIC benefits. Furthermore, these officials said
                         that WIC participants who were not working when they entered the
                         program but who later go to work often assume that they are no longer
                         eligible for WIC and drop out.


Other Factors Limiting   Other factors limiting WIC participation were difficulty in reaching the
Participation            clinic, long waits at the clinic, or the lack of service during the lunch hour.
                         For example, 41 percent of the directors of local WIC agencies indicated
                         that difficulty in reaching the clinic—the unavailability or inadequacy of
                         public transportation—was a limiting factor. Eighteen percent of the
                         directors reported long waits as a limiting factor. About 7 percent reported
                         that clinics not being open during the lunch hour was a factor limiting
                         participation—not surprising since more than three-fourths of all agencies
                         offer lunch hour appointments in at least one of their clinics.


                         We provided a copy of a draft of this report to the USDA for review and
Agency Comments          comment. We met with Food and Consumer Service officials, including the
                         Acting Director for the Supplemental Food Program Division, Special
                         Nutrition Programs. The Service concurred with the accuracy of the report
                         and provided several minor clarifications, which we incorporated as
                         appropriate.


                         To examine the accessibility of WIC for working women and the factors
Scope and                limiting their participation, we conducted a mail survey of 375 directors of
Methodology              local WIC agencies, visited 18 clinics in four states, and met with USDA
                         headquarters officials and state agency officials responsible for WIC. We
                         conducted our review from March through September 1997 in accordance
                         with generally accepted government auditing standards.


                         We are sending copies of this report to the Chairman, Senate Committee
                         on Agriculture, Nutrition, and Forestry; the Chairman, House Committee
                         on Agriculture; and the Secretary of Agriculture. We will also make copies
                         available to others upon request.




                         Page 11                                           GAO/RCED-98-19 Food Assistance
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If you have any questions about this report, please contact me at
(202) 512-5138. Major contributors to this report are listed in appendix IV.

Sincerely yours,




Robert A. Robinson
Director, Food and
  Agriculture Issues




Page 12                                         GAO/RCED-98-19 Food Assistance
Page 13   GAO/RCED-98-19 Food Assistance
Contents



Letter                                                                                             1


Appendix I                                                                                        16

Objectives, Scope and
Methodology
Appendix II                                                                                       18

Methodology and
Analysis Used in the
Mail Survey
Appendix III                                                                                      20

Aggregated Responses
to the Mail Survey
Appendix IV                                                                                       29

Major Contributors to
This Report
Tables                  Table I.1: Local WIC Agencies Visited                                     17
                        Table II.1: Sampling Errors for Selected Percentages                      19

Figures                 Figure 1: Strategies Used by Local WIC Agencies to Increase                4
                          Accessibility for Working Women
                        Figure 2: Directors’ Views of Clinics’ Accessibility                       8




                        Abbreviations

                        FCS        Food and Consumer Service
                        USDA       U.S. Department of Agriculture
                        WIC        Special Supplemental Nutrition Program for Women, Infants,
                                        and Children


                        Page 14                                        GAO/RCED-98-19 Food Assistance
Page 15   GAO/RCED-98-19 Food Assistance
Appendix I

Objectives, Scope and Methodology


              We conducted our review to obtain information on the extent to which the
              benefits of the Special Supplemental Nutrition Program for Women,
              Infants, and Children (WIC) are accessible for eligible working women and
              their children. Specifically, we (1) identified actions taken by local WIC
              agencies to increase access to WIC benefits for working women;
              (2) obtained agency directors’ assessment of their clinics’ accessibility;
              and (3) identified factors limiting participation in the program.

              We conducted a mail survey of 375 randomly selected local WIC agencies
              from a nationwide list of 1,816 local agencies provided to us by the U.S.
              Department of Agriculture’s (USDA) Food and Consumer Service (FCS). The
              survey asked the directors of the local agencies to provide information on
              (1) the strategies they have implemented to increase the accessibility of
              their clinics, (2) their views on the overall accessibility of their clinics for
              working women, and (3) factors that limit participation by working
              women. In addition, we asked directors to provide descriptive information
              on their agency, such as the number of clinics and participants. (See app.
              III for a complete list of questions.)

              We used the survey responses to develop overall results that are
              representative of those that would be obtained from all local agencies
              nationwide. For an explanation of the survey results and how they can be
              used, see appendix II. Appendix III presents the aggregated responses to
              our survey.

              To better understand the problems and limitations affecting working
              women’s access to WIC benefits, we visited local WIC agencies and
              interviewed agency staff in several states. We judgmentally selected the
              sites visited to obtain states and agencies with high levels of participation
              and WIC funding and to provide geographic diversity. In addition, we
              discussed the selection of local WIC agencies with state agency officials,
              who identified unique agency features for consideration in selection, such
              as rapid growth in participation or migrant workers’ participation. Table
              I.1 lists the local WIC agencies that we visited.




              Page 16                                            GAO/RCED-98-19 Food Assistance
                                        Appendix I
                                        Objectives, Scope and Methodology




Table I.1: Local WIC Agencies Visited
                                        Location                      Local WIC agency
                                        California
                                        Healdsburg                    Alliance Medical Center
                                        San Diego                     American Red Cross
                                        Stockton                      Community Medical Centers, Inc.
                                        San Diego                     Mercy Healthcare
                                        Santa Ana                     Planned Parenthood, Orange & San Bernadino Counties
                                        Irwindale                     Public Health Foundation Enterprises, Inc.
                                        Chula Vista                   San Ysidro Health Center
                                        Santa Barbara                 Santa Barbara County Health Care Services
                                        Kansas
                                        Newton                        Harvey County Health Department
                                        Olathe                        Johnson County Health Department
                                        Kansas City                   Wyandotte County Health Department
                                        Pennsylvania
                                        York                          Community Progress Council, Inc.
                                        Camp Hill                     Family Health Council of Central Pennsylvania
                                        Harrisburg                    Hamilton Health Center
                                        Gettysburg                    WIC of Franklin and Adams Counties
                                        Texas
                                        Austin                        Austin Health and Human Services, Travis County Health
                                                                      Department
                                        San Antonio                   San Antonio Metropolitan Health Department
                                        San Antonio                   Santa Rosa Health Care Corporation

                                        In addition, we interviewed state agency officials and FCS headquarters and
                                        regional officials to obtain information on overall program operations,
                                        policies, and guidance.

                                        We provided a draft copy of this report to FCS for review and comment. We
                                        performed our work from March through September 1997 in accordance
                                        with generally accepted government auditing standards.




                                        Page 17                                                  GAO/RCED-98-19 Food Assistance
Appendix II

Methodology and Analysis Used in the Mail
Survey

              In developing the questionnaire for our mail survey, we conducted 12
              pretests with directors of local WIC agencies in four states, the District of
              Columbia, and one Indian tribal organization. Each pretest consisted of a
              visit to a local WIC agency by two GAO staff, except for a pretest by
              telephone with one director. During these visits, we attempted to simulate
              the actual survey experience by asking the local agency director to fill out
              the survey. We interviewed the director to ensure that (1) the questions
              were readable and clear, (2) the terms were precise, (3) the survey did not
              place an undue burden on local agency directors, and (4) the survey
              appeared to be independent and unbiased in its point of view. We also
              obtained reviews of our survey from managers at FCS.

              In order to maximize the response to our survey, we mailed a
              pre-notification letter to respondents 1 week before we mailed the survey.
              We also sent (1) a reminder postcard 1 week after the survey, (2) a
              reminder letter to nonrespondents 2 weeks after the survey, and (3) a
              replacement survey for those who had not responded 31 days after the
              survey. We received survey responses from 350 of the 375 local agencies in
              our sample. This gave us a response rate of 93 percent. After reviewing
              these survey responses, we contacted agencies by phone to clarify
              answers for selected questions.

              Since we used a sample (called a probability sample) of 375 of the 1,816
              local WIC agencies to develop our estimates, each estimate has a
              measurable precision, or sampling error, which may be expressed as a
              plus/minus figure. A sampling error indicates how closely we can
              reproduce from a sample the results that we would obtain if we were to
              take a complete count of the universe using the same measurement
              methods. By adding the sampling error to and subtracting it from the
              estimate, we can develop upper and lower bounds for each estimate. This
              range is called a confidence interval. Sampling errors and confidence
              intervals are stated at a certain confidence level—in this case, 95 percent.
              For example, a confidence interval, at the 95-percent confidence level,
              means that in 95 out of 100 instances, the sampling procedure we used
              would produce a confidence interval containing the universe value we are
              estimating. Table II.1 lists the sampling errors for selected percentages.




              Page 18                                          GAO/RCED-98-19 Food Assistance
                                  Appendix II
                                  Methodology and Analysis Used in the Mail
                                  Survey




Table II.1: Sampling Errors for
Selected Percentages                                                                                                 Sampling error
                                  Percent                                                                               (in percent)
                                  5                                                                                                  ±2
                                  10                                                                                                 ±3
                                  20                                                                                                 ±4
                                  30                                                                                                 ±5
                                  40                                                                                                 ±5
                                  50                                                                                                 ±5
                                  60                                                                                                 ±5
                                  70                                                                                                 ±5
                                  80                                                                                                 ±4
                                  90                                                                                                 ±3
                                  95                                                                                                 ±2

                                  Note: Sampling errors are calculated for the 95-percent confidence level using the finite population
                                  correction factor and 297 cases, the smallest number of valid cases for questions with finite
                                  categories. Questions with more than 297 valid cases will have slightly smaller errors.


                                  In addition to the sampling errors reported above, one of our analyses
                                  required a ratio estimate in order to calculate sampling errors. We report
                                  that 24 percent of participants nationwide are served by local agencies
                                  that have no regular hours beyond the hours of 8 a.m. to 6 p.m., that is,
                                  participants have no access to Saturday, evening, or early morning hours.
                                  The sampling error associated with this estimate is 8 percent. Therefore,
                                  our estimate of 24 percent ranges between 16 and 32 percent, using a
                                  95-percent confidence level.

                                  In estimating the number of participants without access to hours beyond
                                  the routine workday, we made conservative assumptions that lowered the
                                  estimate. For example, if an agency had five clinics and only one with
                                  extended hours, we assumed that all of the agency’s participants had
                                  access to the extended hours, even though this clinic does not serve all of
                                  the participants. Since we did not collect data on the number of
                                  participants at each clinic, we cannot determine the extent to which our
                                  estimates might be affected by these conservative assumptions.




                                  Page 19                                                         GAO/RCED-98-19 Food Assistance
Appendix III

Aggregated Responses to the Mail Survey




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Aggregated Responses to the Mail Survey




Page 28                                   GAO/RCED-98-19 Food Assistance
Appendix IV

Major Contributors to This Report


               Robert E. Robertson, Associate Director
               Judy K. Hoovler, Evaluator-in-Charge
               D. Patrick Dunphy
               Fran A. Featherston
               Renee McGhee-Lenart
               Carol Herrnstadt Shulman
               Sheldon H. Wood, Jr.




(150270)       Page 29                                   GAO/RCED-98-19 Food Assistance
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