Food Assistance: Working Women's Access to WIC Benefits (Letter Report,
10/16/97, GAO/RCED-98-19).

Pursuant to a congressional request, GAO provided information on the
extent to which Special Supplemental Nutrition Program for Women,
Infants, and Children (WIC) program benefits are accessible to eligible
working women, focusing on: (1) the actions taken by local WIC agencies
to increase access to WIC benefits for working women; (2) asking the
local WIC agency directors' opinions on the accessibility of their
clinics; and (3) factors that limit program participation.

GAO noted that: (1) the directors of local WIC agencies have taken a
variety of steps to improve access to WIC benefits for working women;
(2) the two most frequently cited strategies are: (a) scheduling
appointments instead of taking participants on a first-come,
first-served basis; and (b) 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; (3) these
strategies focus on reducing the amount of time at, or the number of
visits to, the clinic; (4) 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; (5)
collectively, at least one-fourth of the participants do not have access
to any clinic hours outside of the regular work day; (6) 76 percent of
the directors of local WIC agencies believed that their clinics are
reasonably accessible for working women; (7) 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; (8)
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; (9) 14 percent of the
directors rated accessibility as neither easy nor difficult, and 1
percent responded that they are uncertain; (10) the directors of local
WIC agencies identified several factors that limit WIC participation by
working women; (11) the factors most frequently cited reflected the
directors' perceptions of how women view the program; (12) specifically,
the directors told GAO that women do not participate because they: (a)
lose interest in the program as their income increases; (b) perceive a
stigma attached to receiving WIC benefits; or (c) see the program as
limited to those who do not work; and (13) 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.

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

 REPORTNUM:  RCED-98-19
     TITLE:  Food Assistance: Working Women's Access to WIC Benefits
      DATE:  10/16/97
   SUBJECT:  Food relief programs
             Women
             Children
             Infants
             Eligibility criteria
             Locally administered programs
             Program management
             Disadvantaged persons
IDENTIFIER:  USDA Special Supplemental Nutrition Program for Women, 
             Infants, and Children
             WIC
             
******************************************************************
** This file contains an ASCII representation of the text of a  **
** GAO report.  Delineations within the text indicating chapter **
** titles, headings, and bullets are preserved.  Major          **
** divisions and subdivisions of the text, such as Chapters,    **
** Sections, and Appendixes, are identified by double and       **
** single lines.  The numbers on the right end of these lines   **
** indicate the position of each of the subsections in the      **
** document outline.  These numbers do NOT correspond with the  **
** page numbers of the printed product.                         **
**                                                              **
** No attempt has been made to display graphic images, although **
** figure captions are reproduced.  Tables are included, but    **
** may not resemble those in the printed version.               **
**                                                              **
** Please see the PDF (Portable Document Format) file, when     **
** available, for a complete electronic file of the printed     **
** document's contents.                                         **
**                                                              **
** A printed copy of this report may be obtained from the GAO   **
** Document Distribution Center.  For further details, please   **
** send an e-mail message to:                                   **
**                                                              **
**                                            **
**                                                              **
** with the message 'info' in the body.                         **
******************************************************************


Cover
================================================================ COVER


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

Food Assistance

(150270)


Abbreviations
=============================================================== ABBREV

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

Letter
=============================================================== LETTER


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). 


   RESULTS IN BRIEF
------------------------------------------------------------ Letter :1

The directors of local WIC agencies have taken a variety of steps to
improve 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. 


   BACKGROUND
------------------------------------------------------------ Letter :2

USDA's Food and Consumer Service (FCS) administers WIC through
federal 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 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. 


--------------------
\2 Poverty guidelines are established separately for Alaska and
Hawaii. 


   LOCAL WIC AGENCIES HAVE TAKEN
   STEPS TO INCREASE CLINIC
   ACCESSIBILITY
------------------------------------------------------------ Letter :3

Nationwide, virtually all local WIC agencies have implemented
strategies to increase the accessibility of their clinics for working
women.\3 The most frequently cited strategies--used by every
agency--are scheduling appointments instead of taking participants on
a first-come, first-served basis and allowing a person other than the
participant (an alternate) to 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 Working Women

   (See figure in printed
   edition.)

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: 

  -- 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 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 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. 


--------------------
\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. 


   DIRECTORS GENERALLY BELIEVE
   THEIR CLINICS ARE EASILY
   ACCESSIBLE
------------------------------------------------------------ Letter :4

About 76 percent of the directors of local WIC agencies believed that
accessibility to their clinics is at least moderately easy for
working women, as measured by such factors as convenient hours of
operation and 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. 

   Figure 2:  Directors' Views of
   Clinics' Accessibility

   (See figure in printed
   edition.)

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 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. 


   DIRECTORS VIEW WOMEN'S
   PERCEPTIONS AS A MAJOR FACTOR
   LIMITING PARTICIPATION
------------------------------------------------------------ Letter :5

Women's perceptions about WIC--such as the value of the program's
benefits to them as their income rises or the perceived stigma
attached to obtaining benefits--were the limitations to participation
most frequently cited by the directors of local WIC agencies. 
Another major factor limiting participation is that women may not be
aware of their continued eligibility 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. 


      FREQUENTLY CITED FACTORS
      LIMITING WIC PARTICIPATION
---------------------------------------------------------- Letter :5.1

The directors of the local WIC agencies indicated that working
women's 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. 

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
      PARTICIPATION
---------------------------------------------------------- Letter :5.2

Other factors limiting WIC participation were difficulty in reaching
the 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. 


   AGENCY COMMENTS
------------------------------------------------------------ Letter :6

We provided a copy of a draft of this report to the USDA for review
and 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. 


   SCOPE AND METHODOLOGY
------------------------------------------------------------ Letter :7

To examine the accessibility of WIC for working women and the factors
limiting their participation, we conducted a mail survey of 375
directors of 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. 


---------------------------------------------------------- Letter :7.1

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. 

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


OBJECTIVES, SCOPE AND METHODOLOGY
=========================================================== Appendix I

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. 



                               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. 


METHODOLOGY AND ANALYSIS USED IN
THE MAIL SURVEY
========================================================== Appendix II

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. 



                               Table II.1
                
                Sampling Errors for Selected Percentages

                                                        Sampling error
Percent                                                   (in percent)
----------------------------------------  ----------------------------
5                                                                   ï¿½2
10                                                                  ï¿½3
20                                                                  ï¿½4
30                                                                  ï¿½5
40                                                                  ï¿½5
50                                                                  ï¿½5
60                                                                  ï¿½5
70                                                                  ï¿½5
80                                                                  ï¿½4
90                                                                  ï¿½3
95                                                                  ï¿½2
----------------------------------------------------------------------
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. 




(See figure in printed edition.)Appendix III
AGGREGATED RESPONSES TO THE MAIL
SURVEY
========================================================== Appendix II



(See figure in printed edition.)



(See figure in printed edition.)



(See figure in printed edition.)



(See figure in printed edition.)



(See figure in printed edition.)



(See figure in printed edition.)



(See figure in printed edition.)



(See figure in printed edition.)


MAJOR CONTRIBUTORS TO THIS REPORT
========================================================== Appendix IV

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. 


*** End of document. ***