Food Assistance: Performance Measures for Assessing Three WIC Services
(Letter Report, 02/28/2001, GAO/GAO-01-339).

GAO examined the performance measures that the Food and Nutrition
Service (FNS) uses to assess the nutrition education, breastfeeding
promotion and support, and health referral services provided to
participants in the Special Supplemental Nutrition Program for Women,
Infants, and Children (WIC) program. GAO found that FNS has an
outcome-based measure for one of the three nutrition
services--breastfeeding promotion and support. However, the measure,
breastfeeding initiation rate, examines only one of several important
aspects of the service's possible impact on WIC participants. In
addition, several obstacles have hindered FNS' efforts to develop and
implement outcome-based measures for nutrition education and health
referral services for the WIC program. These include difficulties in
identifying measures that would allow the agency to appropriately link a
particular service's activity to a desired outcome and resource
constraints affecting FNS' ability to collect data needed to implement a
proposed measure.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  GAO-01-339
     TITLE:  Food Assistance: Performance Measures for Assessing Three
	     WIC Services
      DATE:  02/28/2001
   SUBJECT:  Performance measures
	     Food programs for children
	     Program evaluation
IDENTIFIER:  WIC
	     Special Supplemental Food Program for Women, Infants, and
	     Children

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GAO-01-339

Report to Congressional Committees

February 2001 FOOD ASSISTANCE Performance Measures for Assessing Three WIC
Services

GAO- 01- 339

Lett er

February 28, 2001 The Honorable Richard G. Lugar Chairman The Honorable Tom
Harkin Ranking Member Committee on Agriculture, Nutrition, and Forestry
United States Senate

The Honorable John A. Boehner Chairman The Honorable George Miller Ranking
Minority Member

Committee on Education and the Workforce House of Representatives

The Special Supplemental Nutrition Program for Women, Infants and Children
(WIC) is a federally funded $4.1 billion- a- year nutrition assistance
program administered by the U. S. Department of Agriculture's Food and
Nutrition Service (FNS). During fiscal year 2000, this program provided $3
billion for supplemental foods and $1.1 billion for nutrition services and
administration to assist lower- income pregnant, breastfeeding, and
postpartum women, infants, and children up to age 5 who are at nutritional
risk. FNS provided annual cash grants to support program operations at 88

state- level agencies. 1 These 88 agencies administered the program through
more than 1,800 local WIC agencies.

To help the Congress better understand the costs of delivering nutrition
services and administering WIC, the William F. Goodling Child Nutrition
Reauthorization Act of 1998 (P. L. 105- 336) directed GAO to assess various
aspects of WIC nutrition services and administration. This report, the third
in a series responding to this request, examines the performance measures

that FNS uses to assess the nutrition education, breastfeeding promotion

1 State agencies are located in the 50 states, the District of Columbia,
American Samoa, the Commonwealth of Puerto Rico, Guam, the U. S. Virgin
Islands, and 33 Indian tribal organizations. These agencies typically are
public or private nonprofit health or human services agencies; they can be
an Indian Health Service Unit, a tribe, or an intertribal council.

and support, and health referral services provided to WIC program
participants. 2 We based our evaluation on the performance measurement
framework contained in the Government Performance and Results Act of 1993
(Results Act), which, among other things, encourages agencies to measure
program performance by determining the extent to which intended program
outcomes have been achieved. Program outcomes are the results of delivering
a program's products and services, while program outputs are

the products and services delivered. An example of the distinction between
the two concepts can be seen in the case of a job- training program. In such
a program, an output could be the number or percentage of program
participants who completed the training. A program outcome, on the other
hand, could be the number or percentage of program participants employed 1
year after the training. Outcome measures on which objective

data can be collected at reasonable cost can be difficult to develop,
particularly for programs that are intended to influence the behavior of
individuals. While emphasizing the use of outcome measures, the Results Act
recognized that the output measures traditionally used by agencies for

measuring performance remain critical to program management. Consistent with
the Results Act's approach to performance measurement, this report discusses
FNS' use of both outcome and output performance measures. Specifically, it
provides information on how FNS measures (1) the outcomes of three services
provided by the WIC program- nutrition education, breastfeeding promotion
and support, and health referral services; and (2) program outputs for these
three service areas.

Results in Brief FNS has an outcome- based measure for one of the three
nutrition services- breastfeeding promotion and support. However, the
measure,

breastfeeding initiation rate, examines only one of several important
aspects of the service's possible impact on WIC participants. Other key
aspects, for which FNS has not established outcome measures, include the
length of time that WIC mothers breastfeed their infants and breastfeeding's
contribution to an infant's overall nutritional needs. Several 2 The first
report in the series was Food Assistance: Financial Information on WIC
Nutrition Services and Administrative Costs (GAO/ RCED- 00- 66, Mar. 6,
2000). The second report was Food Assistance: Activities and Use of
Nonprogram Resources at Six WIC Agencies (GAO/ RCED- 00- 202, Sept. 29,
2000).

obstacles have hindered FNS' efforts to develop and implement outcomebased
measures for nutrition education and health referral services for the WIC
program. These include difficulties in identifying measures that would allow
the agency to appropriately link a particular service's activity to a
desired outcome and resource constraints affecting FNS' ability to collect
data needed to implement a proposed measure.

FNS employs a large number of program output measures to gauge performance
of the three WIC services. Generally, these measures are used to examine the
types and quantities of services that state and local agencies provide and
whether the agencies are in compliance with grant expenditure and other
program requirements. FNS has been hindered in measuring

program compliance because of weaknesses in the management evaluation
process used to collect data on these measures. Among other problems,
inconsistencies in procedures used to conduct the evaluations have resulted
in problems in interpreting evaluation results as well as in

comparing and analyzing results across evaluations. FNS is considering
recommendations its special task force made in a January 2001 report to
strengthen its processes for management evaluations.

While we believe that the weaknesses in FNS management evaluations should be
addressed expeditiously, we are not making specific recommendations at this
time because FNS is actively considering

corrective actions. However, we will continue to monitor the agency's
actions on these matters and, if warranted, make recommendations in the
future. In commenting on a draft of this report, FNS officials generally
agreed with the information presented, but cautioned that the report
discussed performance measures only as they pertained to three nutrition
service components of the WIC program and not the program in its entirety.
They believed that when viewed from this broader context, the program has
resulted in a number of desirable health outcomes.

Background As part of its administration of the WIC program, FNS makes
grants to the 88 state agencies that in turn provide program benefits-
supplemental foods and a variety of nutrition services- to participants
through more than 1,800 local WIC agencies. The state agencies develop
guidelines intended to ensure that local agencies effectively deliver WIC
benefits to eligible participants, and monitor local agencies' compliance
with these guidelines. Local agencies serve participants directly or through
one or more service delivery sites or clinics located within their service
areas. Staff at local WIC agencies and clinics approve applicants for
participation;

provide food benefits, typically in the form of vouchers that can be
exchanged for WIC- approved supplemental foods at specified grocers; provide
nutrition education; and make health referrals to eligible

individuals. For fiscal year 2000, grants for this program totaled $4.1
billion-$ 3 billion for supplemental foods and $1.1 billion for nutrition
services and program administration costs. Grants for nutrition services and
administration

(NSA) are typically used to support activities in four broad categories:
participant services, including health care referrals; nutrition education;
breastfeeding promotion and support; and program administration, such as
planning and budgeting. This report focuses on three specific services-
nutrition education, breastfeeding promotion and support, and health
referrals. Table 1 describes some of the specific activities that local WIC

agencies provide as part of these services.

Table 1: Three Nutrition Services by Activities Type of service Description

Nutrition education Providing individual and/ or group nutrition education
sessions. ? Preparing or obtaining nutrition education materials, such as
brochures and videotapes, and interpreting or translating materials to
facilitate nutrition education of non- English- speaking participants. ?
Providing or receiving training regarding nutrition education promotion, and
evaluating and monitoring

nutrition education. ? Providing information on the benefits of the
supplemental foods provided by WIC and how to exchange WIC food vouchers for
food products at WIC- approved grocers.

Breastfeeding promotion ? Providing individual counseling sessions at WIC
clinics or in hospitals and by telephone to promote and and support support
breastfeeding, and maintaining a clinic environment that encourages
breastfeeding. ? Consulting with medical providers regarding breastfeeding
issues.

? Providing or receiving training regarding breastfeeding promotion and
monitoring and evaluating breastfeeding promotion activities. Health
referrals ? Providing each participant with information on available health
care providers.

? Referring participants to a health practitioner, when appropriate, such as
for immunizations, and to social services such as the Medicaid program.

FNS Has an OutcomeBased FNS established the breastfeeding initiation rate as
an outcome- based

Measure for One measure for the WIC program's breastfeeding promotion and
support activities, but has no outcome measures for its nutrition education
or

of Its Three Nutrition Services

health referral services. 3 While this single measure allows FNS to examine
one aspect of the impact of its services on WIC clients, it does not measure
ther important aspects of this service's impact- such as the length of time
that WIC mothers breastfeed their infants and the percentage of daily

nutrition an infant obtains from breastfeeding. FNS has attempted to develop
outcome- based measures for the WIC program's nutrition education and health
referral services but has not yet been successful in implementing these
measures. FNS has identified a measure for nutrition education but has not
implemented it because of resource constraints. For health referrals, FNS
has been unable to identify a measure that, among other things, would permit
it to appropriately link the service's activities

with a desired outcome. Breastfeeding Initiation

FNS established the breastfeeding initiation rate as its outcome- based Rate
Measures Outcomes of

measure for breastfeeding promotion and support activities as part of its
fiscal year 2000 performance plan. 4 The measure represents the percentage
Breastfeeding Promotion of WIC infants between 7 and 11 months of age who,
at some time, have and Support Activities

been breastfed. FNS first reported the results of this measure in May 2000
as part of its 1998 WIC Participant and Program Characteristics Study
(Characteristics Study), a biennial report on the characteristics of WIC
participants and program activities. The overall rate of 42 percent for 1998
will serve as a baseline against which FNS will gauge future years'
progress. 5 FNS has collected data for fiscal year 2000, which it is in the
process of analyzing and expects to be available in the spring of 2002.

Although FNS established an outcome measure for breastfeeding initiation,
this measure does not assess the full range of potential impacts of
breastfeeding promotion and support activities on WIC participants. The

breastfeeding initiation rate includes only WIC infants who are breastfed at
3 While FNS has no outcome measure specific to the WIC program's nutrition
education service, it has an outcome- focused diet quality measure to
monitor progress in improving the diet quality for demographic groups
generally eligible for participation in FNS' programs. According to agency
officials, data from this measure will be used in the future to target the
Agency's nutrition education efforts through programs such as WIC. 4
Performance plans, developed pursuant to the requirements of the Results
Act, assess progress toward the goals and objectives of an agency's
strategic plan. FNS' performance

plan reflects the agency's priorities for the fiscal year covered by the
plan. 5 This percentage is based on data from 63 of 88 state agencies, which
covered about 80 percent of all WIC infants.

some time. It does not address other aspects of breastfeeding, such as
duration or the percentage of daily nutrition that an infant obtains through
breastfeeding. FNS attempted to collect data on breastfeeding duration as
part of its 1998 Characteristics Study. However, only 40 of the 88 state

agencies were able to provide this information for at least 75 percent of
WIC infants in their states. According to FNS, these state agencies were
unable to provide the data because their automated information systems

did not contain complete data on each participant. FNS anticipates the
number of state agencies reporting sufficient data to increase as states
become accustomed to reporting these data. FNS has not attempted to measure
the percentage of daily nutrition an infant obtains through

breastfeeding. While acknowledging the importance of this measure, FNS has
not yet identified an appropriate means of implementing it.

FNS' Efforts to Implement FNS established outcome- based measures for both
the nutrition education

Outcome- Based Measures and health referral services in its fiscal year 2000
performance plan.

for Nutrition Education and However, it was unable to implement these
measures and did not include

Health Referrals Have Been outcome- based measures for the two services in
its 2001 performance plan.

Unsuccessful FNS has identified an outcome measure for WIC nutrition
education

services, but has not implemented it primarily because of resource
constraints. FNS intended to evaluate the impact of its nutrition education
services by assessing the nutritional quality of meals consumed by a sample
of WIC participants. FNS planned to implement this measure by extracting
data from a national dietary survey of the U. S. population. This periodic
survey, the Continuing Survey of Food Intakes of Individuals, includes WIC
participants. However, FNS determined that the survey did not contain a
large enough sample of WIC participants to establish national estimates. FNS
lacked the resources needed to develop another sample with a large enough
number of WIC participants to establish national estimates. FNS

officials said that the agency is exploring ways to overcome the sample size
problem for future implementation of this measure. In addition, FNS has not
established a measure for WIC health referral activities that appropriately
links the service's activities with a desired outcome. Initially, FNS
intended to use the percentage of WIC child participants who were immunized
as the outcome measure for its health referral services. To implement this
measure, FNS planned to use data gathered by the federal Centers for Disease
Control and Prevention (CDC)

from its National Immunization Survey. In its 1999 Survey, the CDC began
reporting immunization data for children participating or not participating

in WIC. However, with its 2001 performance plan, FNS discontinued this
measure. Agency officials gave two reasons for this decision. First, they
noted that FNS is not responsible for ensuring that children participating
in WIC are actually immunized, but rather those children needing
immunizations are referred to doctors as appropriate. Second, they pointed
out that immunization data provided by CDC on WIC participants did not
permit FNS to measure the extent to which WIC health referrals actually
contributed to the immunization of WIC child participants. FNS officials
noted that the problems they faced in finding a measure that appropriately
linked WIC health referral activities to a desired outcome are not unique to
the health referral services. They pointed out that it is difficult to
measure the impact of any of the individual services WIC offers because,
among other things, other variables also influence the behavior these
services are intended to promote. For example, there are several other state
and local programs that, like WIC, are aimed at improving

health through nutrition education. Separating the effects of these efforts
from those of the WIC program is difficult at best.

FNS Relies on a Variety FNS employs a large number of program output
measures to gauge

of Output Measures to performance of the WIC nutritional services it offers.
Generally, these

measures are used to examine the types and quantities of services the state
Monitor Program

agencies provide and whether the agencies are in compliance with grant
Performance expenditure and other program requirements. (A detailed list of
output measures can be found in app. I.) To monitor these measures, FNS
depends

in large part on data provided by state and local agencies through routine
financial reports, its biennial Characteristics Study, and FNS' management
evaluations of state and local agency operations. Of these monitoring
methods, FNS relies heavily on its management evaluations to measure state
and local WIC agency compliance with program requirements.

However, weaknesses in the procedures for conducting evaluations of WIC
agencies reduce its value as a performance oversight tool. FNS recently
completed an examination of its practices for conducting management
evaluations for all FNS programs, including WIC, and made several

recommendations for improvements. FNS uses several financial reports
submitted by state agencies to measure the extent to which state and local
agencies meet expenditure requirements. The principal measure is whether
states are adhering to a legislatively established requirement for spending
on nutrition education

activities and breastfeeding promotion and support activities. Combined

spending for these two activities must equal at least one- sixth of the NSA
expenditures plus a target amount for breastfeeding promotion and support
established by FNS at the beginning of each fiscal year. The Addendum to the
WIC Program Annual Closeout Report, prepared by each

state, serves as the primary source of data on the state's compliance with
this expenditure requirement. For fiscal year 1999, the most recent year for
which complete data were available, FNS reported that two states and four
Indian tribal organizations did not meet this minimum spending requirement.
In addition, the WIC Program Annual Closeout Report each state prepares
provides data on the final status of the state's grant and costs for the
report year. To measure the nature and amount of program services WIC
agencies

provide, FNS primarily uses data obtained from state and local agencies and
reported in FNS' Characteristics Study. 6 As noted earlier, the
Characteristics Study provides information on a variety of program
activities. Table 2 lists some of the key program activities in the three
areas

of service included in the Characteristics Study as well as information on
the percentage of local WIC agencies offering the activity.

Table 2: Selected Program Activities Used by Local Agencies Percentage of
local Program activity a agencies b

Nutrition education

Nutrition education sessions for pregnant participants provided during
Certification

96. 8 Food benefit issuance

65. 8 Dedicated nutrition education sessions

44. 7 Other health care appointments

20. 2 Nutrition education offered in a language other than English

Spanish 50. 0

French 5.7

Vietnamese 5.3

Laotian 4.6

Various Native American languages 3.9

Hmong 3.8

6 FNS also utilizes special reports to measure the nature and amount of
program services provided to participants. For example, FNS uses such
reports to evaluate the success of state adoption of FNS' national
breastfeeding promotion campaign, Loving Support.

(Continued From Previous Page)

Percentage of local Program activity a agencies b

Nutrition education topics especially for pregnant women Importance of folic
acid

81. 0 Using WIC foods for a healthy diet

82. 9 Strategies to prevent or manage overweight

47. 6 Methods or materials always used in providing nutrition education

Counseling/ discussion 90. 7

Food models 25. 5

Videos, films, slides 7.4

Testing participant's knowledge 4.1

Average length of group nutrition education sessions for non highrisk
participants, in minutes Less than 10

18. 1 10- 19

28. 8 20- 29

21. 2 30- 39

5.1 40- 49

2.1 50 and longer

3.1

Breastfeeding promotion and support

Group education sessions devoted solely to breastfeeding 97. 4

Breastfeeding support groups 80. 7 Provision of breast pumps

43. 6 Individual counseling

31. 4 Home/ hospital visit

30. 9 Peer counseling 16. 7

Health referrals c

Type of referral or service provided Well- baby care and immunizations,
referral for all participants

22. 6 Well- baby care and immunizations, referral as needed

60. 6 Immunizations only, referral for all participants

10. 6 Immunizations only, referral as needed

48. 1 a A total of 460 local WIC agencies responded to the survey. Responses
were weighted to reflect the

universe of 2,203 local agencies, the estimated universe of 8,932 service
delivery sites, and the universe of 8,042,758 enrollees. b Figures may not
sum to 100 percent because respondents could provide multiple responses.

c Responses for these services are by percentage of WIC service delivery
sites providing the service.

According to FNS officials, survey data from local agencies, of the sort
seen in table 2, may no longer be collected for the Characteristics Study
for 2002 and beyond because research funds are unavailable for that purpose.
These officials explained that the Agriculture, Rural Development, Food and
Drug Administration, and Related Agencies Appropriations Act of 1998 (P. L.
105-

86) effectively transferred primary responsibility for research on food
assistance and nutrition programs from FNS to the Department's Economic
Research Service, which has not subsequently funded the collection of the
local WIC agency data. FNS officials believe that these data are important

for monitoring the nature and level of services being delivered by local
agencies. To address this and other research concerns, FNS has attempted to
regain direct responsibility over research funding for food assistance and
nutrition programs.

To measure overall compliance with program requirements, including those
related to nutrition education, breastfeeding promotion and support, and
referral services, FNS regional offices conduct management evaluations at
each of the 88 state WIC agencies and at a sample of local agencies. In
general, each of the state agencies and selected local agencies are reviewed
every 3 years. According to FNS, management evaluations are

the primary means of measuring state and local WIC agency compliance with
program requirements. As part of the management evaluations, staff in FNS'
regional offices conduct interviews, review planning documents, observe
interactions, and examine participants' files. Listed below are some of the
types of nutrition education, breastfeeding promotion and support, and
health referral service program requirements that can be assessed during
management evaluations:

? Nutrition education ? State agency WIC plan includes nutrition education
goals and action

strategies, ? Local agencies offer each participant a minimum of two
nutrition

education contacts during each 6- month certification period and documents
the provision of service or the participant's refusal or inability to
participate, ? State agency has developed or identified nutrition education

resources and materials for use by local agencies, and ? Nutrition education
material provided is easily understood by

participants. ? Breastfeeding promotion and support

? State and local agencies have a designated breastfeeding promotion and
support coordinator who provides technical assistance to local agencies,

? State agencies have developed standards for local agencies for use in
providing breastfeeding promotion and support, and ? Local agency staff has
received training on promotion and

management of breastfeeding promotion and support. ? Health referrals

? Local agency staff refers participants, as appropriate, to private or
public health care services.

FNS has not made full use of management evaluations to measure program
performance and provide needed oversight. In large part this is due to
inconsistencies in the procedures used to conduct the evaluations, which
have caused problems in interpreting evaluation results as well as in
comparing and analyzing results across evaluations. FNS recently examined
its practices for conducting management evaluations for all FNS programs,
including WIC. Results of this review were highlighted in a January 2001
report to the Administrator. The report noted that (1) management
evaluations at state and local levels were not being conducted

uniformly across FNS regional offices; (2) standard vocabulary did not exist
for identification of certain concepts; (3) standard definitions were needed
for such key terms as deficiency (a judgment that the agency being reviewed
is not in compliance with program requirements and must take corrective
action); (4) additional staff time needed to be allocated to testing and
training prior to implementation; and (5) a learning, feedback, and
modification period would be needed to support consistent data collection
and the development of reporting methods. The task force recommended a
number of actions aimed at obtaining more consistent information that, if
implemented, could provide FNS with better data for identifying national
trends, quantifying deficiencies, developing policies, and measuring mission
effectiveness. Agency officials told us that a response from the
Administrator is expected by April 2001.

Agency Comments and We provided a draft of this report to USDA's Food and
Nutrition Service for

Our Evaluation review and comment. We met with FNS officials, including the
Director,

Office of Analysis and Nutrition Evaluation; the Director, Supplemental Food
Program Division; and officials in the Grants Management Division. These
officials generally agreed with the information presented in this report.
However, they cautioned that the report addressed performance measures as
they pertained to three nutrition service components of the WIC program and
not the program in its entirety, which includes supplemental foods and other
aspects of nutrition services. FNS officials believed that research on the
effects of the WIC program as a whole indicated that it has contributed to a
number of desirable outcomes including improved diets and infant feeding
practices, reduced incidence of

anemia among children, reduced incidence of infant mortality and low
birthweight infants, and reduced postpartum medical expenses. Also, these
officials provided us with a number of technical comments that we
incorporated into the report, as appropriate.

Scope and In developing information for this report, we spoke with and
obtained data Methodology from officials at FNS' headquarters in Alexandria,
Virginia, and the seven

FNS regional offices- Northeast in Boston, Massachusetts; Mid- Atlantic in
Robbinsville, New Jersey; Southeast in Atlanta, Georgia; Midwest in Chicago,
Illinois; Mountain Plains in Denver, Colorado; Southwest in Dallas, Texas;
and, Western in San Francisco, California. We reviewed legislation,
policies, procedures, and practices; reviewed reports issued by GAO and
others related to WIC; and interviewed various officials responsible for
administering the WIC program. We also reviewed FNS' strategic and annual
performance plans and other documents developed as part of implementing the
Results Act. We conducted our work from

September 2000 through January 2001 in accordance with generally accepted
government auditing standards. We are sending copies of this report to the
appropriate congressional committees; interested members of the Congress;
the Honorable Ann M. Veneman, the Secretary of Agriculture; and other
interested parties. We will also make copies available to others upon
request. If you or your staff have any questions about this report, please
contact me at (202) 512- 7215. Key contributors to this report are listed in
appendix II.

Robert E. Robertson Director, Education, Workforce and Income Security

Appendi xes Output Measures for Monitoring Program Requirements and
Activities for the Three

Appendi x I

Services Performance measure Description of requirement or activity Source
of data Nutrition education

Amount of Nutrition Services and Requirement that state agencies spend an

Financial report Administration (NSA) funds spent for

amount not less than the sum of one- sixth the nutrition education by state
agency

total amount of its NSA expenditures on nutrition education and
breastfeeding promotion and support plus a breastfeeding promotion and
support target amount established by FNS at the beginning of each fiscal
year

Extent to which participant actually Requirement that each participant will
be provided Management evaluation review of receives nutrition education
with at least two nutrition education contacts

participants' files during each 6- month certification period

Extent to which the nutrition education is Requirement that nutrition
education contact will Management evaluation observations of in individual
or group settings be provided to each participant in individual or staff-
participant interactions, and review group settings of participants' files
and documents Number of state agencies with a nutrition Requirement that
each state WIC agency will Special reports to the agency and coordinator
designate a nutrition coordinator responsible for

management evaluation review of nutrition education

documents Number of state agencies that have

Requirement that state agency will include in its Management evaluation
review of state developed nutrition goals and action plans state plan a
nutrition plan with education goals agency's State Plan of Operations and
action plans, including a description of

education methods Extent to which nutrition education is free, Requirement
that the participant will be provided Management evaluation observations of
easy for participant to understand, and

with free nutrition education that is easily staff- participant
interactions, and review bears a practical relationship to

understood and bears a practical relationship to of participants' files and
documents

participant's needs participant's needs situation and cultural preferences

Number of local agencies offering nutrition Requirement that, in order to
meet the needs of Management evaluation observations education in foreign
languages non- English- speaking participants, WIC agencies and review of
documents; survey of local offer nutrition education in languages other than
agencies through WIC Participant and English, such as Spanish, Laotian, and
French

Program Characteristics Study Extent to which nutrition education

Requirement that state agency will provide Management evaluation
observations of emphasizes the relationship between

nutrition education that emphasizes the staff- participant interactions, and
review proper nutrition and good health

relationship between proper nutrition and good of participants' files and
documents

health Extent to which nutrition education

Requirement that state agencies will assist Management evaluation
observations of reinforces positive changes in food habits nutritionally at-
risk individuals in achieving positive staff- participant interactions, and
review that result in participant's improved changes in food habits,
resulting in improved of participants' files and documents

nutritional status nutritional status and in prevention of nutrition related
problems

Extent to which state agency provides the Requirement that each state agency
will identify

Management evaluation review of state local agency with nutrition education
or develop nutrition education resources and

agency's State Plan of Operations and resources and materials educational
materials for use in local agencies

other state documents; review of resources at local agency

Performance measure Description of requirement or activity Source of data

Number of visits made to FNS' nutrition Measurement of local agency program
activity to Special report education Web site provide nutrition education
strategies to WIC staff and increase staff nutrition education knowledge
through FNS- implemented Web site, WIC Works

Percent of WIC staff who are Registered Measurement of FNS' recruitment and
retention Special report (biennial survey by public Dieticians (or RD-
eligible) or Registered efforts to increase the number of registered

health and nutrition program directors) Dietary Technicians dieticians,
which is critical to the delivery of quality nutrition services, including
nutrition education

Breastfeeding promotion and support

Amount of nutrition services and Requirement that state agencies must spend
a Financial report administration funds spent on target amount of nutrition
services and breastfeeding promotion and support administration funds on
breastfeeding promotion and support Number of state agencies with a

Requirement that the state agency will designate Special report; management
evaluation

breastfeeding coordinator a breastfeeding promotion and support of state
agency's State Plan of

coordinator to provide support and technical Operations and other documents

assistance to local agencies and to develop state agency activities Number
of local agencies that have a

Requirement that every local WIC agency will Special report; management
evaluation breastfeeding coordinator designate a breastfeeding coordinator
responsible of local agency documents

for providing promotion and assistance Number of states that implement all
or Measurement of the success of FNS' campaign-

Special report part of FNS' National Breastfeeding

Loving Support- designed to promote Promotion Campaign

breastfeeding in the WIC program Extent to which state agency provides the

Requirement that state agency will develop Management evaluation review of
state local agency with breastfeeding education

breastfeeding education resources and materials agency's State Plan of
Operations and resources and materials and provide technical assistance to
local agencies

other documents Number of state agencies that have

Requirement that the state agency develop Management evaluation review of
state developed standards for local agency use standards for use by local
agencies for

agency's State Plan of Operations and in providing breastfeeding support

breastfeeding support for prenatal and other documents

postpartum women Number of local agencies offering Measurement of program
activity to encourage

Survey of local agencies through WIC education sessions devoted to pregnant
participants to begin and continue Participant and Program Characteristics
breastfeeding

breastfeeding their infants Study Number of local agencies that have staff

Measurement of local agency activity to Survey of local agencies through WIC
that make home or hospital visits to encourage and support breastfeeding by
mothers Participant and Program Characteristics mothers of newborns

of newborns through home or hospital visits Study Number of local agencies
offering peer

Measurement of local agency activity to Survey of local agencies through WIC
counseling for breastfeeding encourage and support breastfeeding through
Participant and Program Characteristics

peer support and discussion groups Study

Number of local agencies that have Requirement that the state WIC agency
develop Management evaluation review of state

received training on promotion and and provide to local agencies training on
agency's State Plan of Operations and management of breastfeeding promotion
promotion and management of breastfeeding

other documents and support

promotion and support

Performance measure Description of requirement or activity Source of data
Health referrals

Number of participants provided with Requirement that WIC staff provide each
Management evaluation review of information on health care providers
participant with information on available health participant file data and
other documents

care providers Number of participants referred to a

Requirement that WIC staff refer participants to a Management evaluation
review of

health practitioner when appropriate health practitioner when appropriate,
such as participant file data and other documents when a pregnant
participant has not yet received prenatal care or a child participant has
not received age- appropriate immunizations

Number of WIC agencies with on- site Measurement of WIC agencies that are
collocated

Survey of local agencies through the pediatric care with pediatric care
facilities to assist in meeting, in WIC Participant and Program part, the
requirement that WIC staff help Characteristics Study; management
participants obtain and use preventive health care evaluation of local
agency operations services and local agencies serve as a link between
participants and health- care providers

Number of WIC agencies offering wellbaby Measurement of WIC agencies that
offer wellbaby Survey of local agencies through the care and immunizations
care services to assist in meeting, in part, WIC Participant and Program the
requirement that WIC staff assist participants

Characteristics Study; management in obtaining and using preventive health-
care

evaluation of local agency operations services

Appendi x II

GAO Contact and Staff Acknowledgments GAO Contact Robert E. Robertson, (202)
512- 7215 Staff

In addition to the contact named above, Abiud Amaro, Clifford Diehl, Judy
Acknowledgments

Hoovler, Angela Miles, and Ron Wood made key contributions to this report.

(150291) Lett er

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GAO United States General Accounting Office

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Appendix I

Appendix I Output Measures for Monitoring Program Requirements and
Activities for the Three Services

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Appendix I Output Measures for Monitoring Program Requirements and
Activities for the Three Services

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Appendix II

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