Empowering PA WIC Families to Form Lifelong Healthy Habits
Client The Pennsylvania Special Supplemental Nutrition Program for Women, Infants and Children (PA WIC)
Project Duration 7 months
Mixed Methods Research
Hi! I’m WICster!
I’m a virtual WIC companion that encourages parents and caregivers to reach their familys' health and nutrition goals by stimulating behavior change towards healthy lifestyles. (What is WIC? Scroll down to the client section to learn more!)
Learn nutritional information with ease.
Caregivers already have enough on their plates and time is an extremely valuable resource for them. With WICster, you don’t have to worry about searching for trustworthy nutritional information. Tips and recipes are sent directly to you through text. You can also control when and how often you receive the texts.
Only receive what’s relevant to you and your family.
WICster only sends you information that is valuable to you and your family. Receive tips on feeding transitions, picky eating, teething, portion size, food and, sleeping safety, and more!
Nutritional tips are based on your preferred topics and the stage your children are in, and recipes are based on your unique PA WIC benefit plan.
Monitor your goals and feel good about your progress.
Enter a goal your family is working on, and WICster will keep you on track! He’ll help you set an achievable, measurable, and attainable goal, send you reminders, and allow you to track your progress.
Raising a family is hard and deserves acknowledgment and celebration. WICster will cheer you on when you’re moving towards reaching your goal and be there to encourage you on rainy days we well!
“How was your week? Were you able to serve a vegetable with every meal?”
“Sending you a high five! You’re doing a great job in reaching your goal.”
Do even more with the WICster mobile app.
Browse tips and recipes using the WICster app. You can search for nutritional tips or recipes by keyword. You can also filter tips or recipes by category or PA WIC member! Save tips or recipes for later use.
Use the app to plan your day. Using the calendar feature, you can plan recipes or nutritional tips that you hope to use for the day. If you plan ahead, WICster will remind you of your plan when the day comes!
WICster promotional video:
Who does PA WIC serve?
WIC serves Pennsylvania residents that meet the income guidelines of 185% of the poverty level or have a nutritional or medical risk that are either pregnant, postpartum breastfeeding or non-breastfeeding, or are infants and children under 5 years of age.
Through our background research, we found that only around half of eligible participants were enrolled in the program. That meant that around 150,000 women, infants, and children in Pennsylvania weren’t taking advantage of these free nutritional foods and resources. Why is participation and retention in the program so low? While 84% of eligible infants are in the program, less than 40% of eligible children are enrolled in PA WIC. Why do so many families drop off the program as their children get older?
The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is an intervention program designed to influence lifetime nutrition and health behaviors in high-risk populations.
PA WIC is under the jurisdiction of the United States Department of Agriculture, and provides healthy foods (in the form of monthly food vouchers), nutrition education, and specialized referrals to other programs. Half of all infants born in Pennsylvania each year receive benefits from WIC sometime during their first year of life. PA WIC has impacted millions of lives since 1974, but like all great programs, their goal is to do more.
This project took place over the span of 7 months in which we engaged in the following research and design processes.
01 UNDERSTANDING THE PA WIC EXPERIENCE
Listening to PA WIC participants
In order to understand the experiences of participants in PA WIC, we conducted semi-structured interviews with 29 PA WIC participants, 5 of them being Spanish-speaking individuals to understand the experience of individuals who do not speak English or speak English as a second language. These interviews were extremely open-ended; however our team had the overarching goals to learn more about if and how they prioritize being in PA WIC, their usage of the benefits the program provides, their relationship with and perception of the staff in the program and with the program overall, their clinic visit experience, and their experience accessing and utilizing PA WIC resources. We centered our questions around these probes, but ended up learning so much more.
What did we learn?
01 WIC participants don’t prioritize being in the program and actually view it as a lot of effort and work.
02 Participants value the tangible benefits such as the financial benefits from the program much more than the nutritional education or resources the program hopes to provide.
03 Resources are non-accessible and non-integrable into PA WIC participants’ lives.
Being in the physical space
Because the clinic experience is such a large part of the PW WIC journey and is the only place participants interact with nutritionists and other PA WIC staff, our team visited 2 clinics and received images from over 10 clinics to better understand the physical experience of a WIC appointment.
Every PA WIC clinic seemed like a different world. Operations between clinics, demographic of participants, and look and feel of the spaces varied significantly.
02 UNDERSTANDING WHO WE'RE DESIGNING FOR
User-centered research is more than just talking to participants or visiting the clinic space. We aimed to more fully immerse ourselves into the experience of caregivers who are in the program. We did this by enrolling ourselves in the WIC program and going through mock appointments with nutritionists, simulating parenting by taking care of a realistic baby doll for a few weeks, and went grocery shopping for WIC foods.
01 High uncertainty led to additional effort in the shopping and appointment experiences.
02 Caregivers are extremely busy and stressed. Resources need to be easily accessible and actionable to fit into their lives.
Hearing participants’ stories
Understanding PA WIC participants goes beyond understanding the experience in the program. What are their lives like on a day to day basis? What was it like for them growing up? How did their childhood or previous experiences influence their family’s nutritional benefits today?
Our team conducted narrative interviews in which we listened to 4 participants to learn about their ideals, concepts, and knowledge about nutrition and how their habits have changed throughout their lives. Our goal was to better understand how WIC participants make decisions regarding nutrition and how these decisions manifest in their day-to-day lives.
From this, we learned that:
01 Caregivers often prioritize convenience over nutrition and even cost.
02 Many caregivers used a number of loose guidelines for meals, such as making sure each meal had a protein, a starch, and some vegetables. These clear and actionable tips were what stuck with our participants most.
03 REIMAGINING THE PA WIC EXPERIENCE
Co-designing with participants and staff
Magic PA WIC app
We ran a co-design session with participants to assess how they would prioritize additional resources WIC could offer. We asked them to build a “magic WIC app” that could do anything based on different categories of prelabeled buttons.
We asked participants to drag on the buttons and think-aloud as they made their decisions. We then asked them what they would want each button to do and had them rank their priorities based on the buttons they dragged into the app.
Workshop with PA WIC staff
Our team ran a co-design workshop with 30 PA WIC staff from Allegheny County. Each group of 10 staff participated in an activity where they brainstormed the long-term impact and goals they had for PA WIC. Then, they came up with “shifts” that would need to happen in order to achieve these goals. Lastly, each group picked the shift they thought was the most important and ideated on possible solutions that can be implemented to reach this shift as well as the constraints for these ideas.
After analyzing and reflecting, we learned that:
01 Reducing the effort regarding keeping track of WIC appointments and benefit plans would greatly improve participants’ experience on WIC.
02 Participants wanted better access to nutritional resources that fit into their busy lives.
03 WIC staff feels like many problems WIC faces are outside of their control but are eager to be more involved in the process of improving WIC services.
04 KEEPING USERS AT THE CENTER OF THE DESIGN
Imagining scenarios with WIC participants
We generated solutions that explored different behavioral changing strategies. We then created 7 storyboards, or sketches of scenarios, that illustrated these ideas and conducted a rapid exploration of ideas by engaging in a discussion with 7 participants by showing storyboards.
We found the importance of:
01 Reduce open-ended prompts: Through testing ideas such as 5-minute journaling or progress tracking, we found that participants preferred something that was quicker and had more structure.
02 Provide clear guidance and ample praise: The efforts of caregivers is often unrecognized. They really value guidance and support as they try to do what’s best for their families.
03 Lower barriers to entry: To make it easy for participants to get value out of the service, it would be beneficial to automatically or proactively send them resources. However, it would also be beneficial to provide them with opportunities to take a more active role if they wish to.
Longitudinal study with participants
This study was conducted over the span of 4 weeks. We split 15 participants up into 2 groups, the control group was just emailed a link to pdfs of these pamphlets while the experimental groups were sent texts with daily nutritional tips taken from these same pamphlets. Within the experimental group, we split them up into 2 groups: the more personalized group was asked what health and nutrition goals they had for their children, and were sent tips specific to these goals and health topics of interest. Their messages were also directly addressed to them and their children (by including their names in the messages).
01 PA WIC participants resonated heavily with proactively receiving resources. 1 out of 6 participants in the control group clicked on the resources, telling us that it was not enough for users to simply receive trustworthy information. In the 4 weeks of sending participants these tips, not only did all 9 participants implement at least one tip into their lives, on average, they implemented 11 of the 25 tips sent to them.
02 The total tip implementation rate for the more personalized group (51.2%), was about (10.4%) higher than the other (40.9%). There is a high correlation between personalization and implementation.
03 The response rate of those in the highly-personalized group (85.6%) was over 36% more than those in the low (49.5%). This reveals that there was a high correlation between personalization and engagement.
04 BEHAVIORAL CHANGE RESEARCH INFORMING AND INSPIRING OUR DESIGN
Through extensive research, our team found numerous strategies of behavior change that have led to successful outcomes. The following are a few that have been used by a large number of health platforms striving to encourage positive behavior change. These theories inspired our design of WICster.
Nudging: “A nudge...alters people's behavior in a predictable way without forbidding any options or significantly changing their economic incentives. To count as a mere nudge, .. the intervention must be easy and cheap to avoid. Nudges are not mandates" (Thaler and Sunstein, 2008). Source
Our design incorporates nudging through proactively sending users nutritional tips, recipes, and tip reminders through text or app notifications.
Self-monitoring: "Self-monitoring increases awareness, curiosity and consciousness within a user" (Norris, 2018). Research suggests that this awareness often leads to users taking responsibility for and control over their behaviors. With self-monitoring, there exists intrapersonal competition that comes from comparing performance against an individual’s own goal and past performance – striving to break previous records and keep on track. Source
WICster incorporates self-monitoring by asking for users' goals, checking in on how users are doing with their goals, and tracking caregivers' goal progress.
Theory of Planned Behavior: According to TPB, “Intentions to perform behaviors of different kinds can be predicted with high accuracy from attitudes toward the behavior, subjective norms, and perceived behavioral control" (Ajzen, 1991). According to the theory of planned behavior, an individual is more likely to do something they planned to do. Source
Our design incorporates the Theory of Planned Behavior by allowing caregivers to plan their day or week ahead of time by adding recipes to their calendar.
Our solution incorporates proactivenudging, personalization, high-quality content, self-monitoring, and planning. WICster sends notifications to users either through SMS text or through a native mobile app with nutritional tips and recipes, goal reminders/check-ins, allows for users to track their progress towards their goals, and allows them to plan their meals.
DESIGNING WICSTER'S PERSONALITY
The criteria we used when creating “good tips” were to include
What health information is being shared
Why the information is valuable
How to implement the information
We aimed to make the WICster companion supportive and non-judgemental. We want participants to feel empowered and confident in the health choices they make for their families. To ensure that our tone and voice is encouraging, we asked participants about the tone of the daily texts and found that most participants found the tone encouraging and informative, as we had hoped.
“It doesn't belittle you or make you feel stupid like, ‘oh duh, you should know this’... It’s kind of like when you get a Snapple, and you look at the top, there's a Snapple fact. It's like, when you open the text message...there's a Snapple fact inside. You know there's going to be some type of good fact that you could actually use or pass on to somebody that you know...” – PA WIC Participant
WICster also asks for user feedback after each nutritional tip and will take this feedback to heart by further personalizing the tips based on the feedback. Moreover, WICster will supportively check in on caregivers' progress towards their goals weekly and offer encouragement and praise for their hard work.
In order to increase the relevancy of tips, we implemented a feedback system of whether the tip was useful or not, which will allow participants to customize the tips they receive in the future. Participants can also tailor the topics of tips they receive at any time by adjusting the settings. WICster will send tips relevant to the PA WIC member’s stage of life and tips will automatically be updated as the member moves from stage to stage and gets older.
Figure 21. Onboarding process
Figure 22. Tip notification flow
Figure 23. Goal-setting flow
Figure 24. Goal check-in flow
To see the conversational flow designs in more detail or to see more flows, please visit our team's website at https://wickednutrition.webflow.io/ and visit the design process page.
EXPANDING WICSTER INTO A MOBILE APP
Why an app? Every family is different. We want our design to empower all participants and take agency in finding the solutions that work best for their families.
A mobile app will integrate all of the information participants want into one place and extend beyond the capabilities of SMS to provide participants even greater access and guidance.
With 76% of low-income adults in the US owning smartphones and 35% of them using only their smartphones for accessing the internet, an app is the ideal way to reach participants.
This design makes it easy for participants to see their WIC profile, which includes their children’s goals, benefit balance, and appointment times, all of which participants expressed strong interest in being able to see.
In addition to this, it would give participants complete access to valuable WIC resources as well as allow them to use the proven successful method of Theory of Planned Behavior to plan healthier and more nutritious meals.
The WICster app has a tip and recipe database that allows users to have full control over the nutritional tips and recipes they want to see. It’s convenient and trusthworthy.
Rationale: Interviews with participants and staff have shown that ease of access may be achieved by having all of WIC’s resources in one place. Participants enjoyed seeing a resource library in the prototypes, compared to having to scour the internet for information that may not be trustable. They also enjoyed that the resource library gave them more agency to choose what to search for, instead of only automatically being sent nutritional information.
The Design: The resource library is a database of tips and recipes. Participants can search for tips and recipes by keyword using the search option. They can also filter them by topic (using tags) or by PA WIC member. If filtering by PA WIC member, the information given will depend on the member’s age and preferences, which they can input in onboarding and/or visiting the settings page. Users can also add it to their “liked” list of tips to revisit at a later time.
Planning ahead leads to a much higher chance of engaging in a certain behavior (Ajzen, 1991), so WICster enourages users to plan their days ahead of time and receive reminders on the plan.
Rationale: Planning families’ days needs to be easy: Interventions based on Theory of Planned Behavior (Ajzen, 1991) have recently been shown to produce large effects on behavior in online interventions. However, because caregivers’ schedules are so busy, they need a way to plan that is quick and convenient. 2. Keeping track of families’ food habits is important. Participants enjoyed that the planner was a way to monitor their families’ food habits by being able to go back and see the recipes they used for a certain day.
The Design: We implemented a daily planner in the app to make planning and, ultimately, behavior change easier for families. Users can browse recipes and add them to any day with a click of a button, and receive a reminder for their plan on that day.
Current State & Value of Solution
In order to address the technical feasibility of this solution, we created an automated version of the SMS daily tips and started running it with participants.
We created a database of over 100 tips and used a number of technologies (such as Twilio, Google sheets, and Firebase Cloud Functions) to enable the personalized tips, and goal check-in through SMS. This allowed us to validate that the automated version can be as valuable as manually sending tips, as we did in our longitudinal study.
We allowed participants we interviewed to opt-in to the service and started sending tips in the middle of July. We let them choose the frequency they’d like to receive tips.
Over 3 weeks of running the prototype, we sent 217 tips and none of the 12 users opted out of the service.
Figure 25. The technology powering the automated version of WICster
WIC Nutritionists already help participants set goals and provide participants contextualized pamphlets to help them develop a healthy lifestyle. However, currently, there are only 4 appointments a year with nutritionists and many participants that there is not any additional support between appointments.
With WICster, by allowing users to input their preferences and provide feedback on whether the nutritional resources were helpful or not, WICster can continuously collect data from users and provide it to nutritionists. With that user input, nutritionists will gain insight on what participants find helpful and how to better help participants. They can further improve and develop content that is more customized to the needs of the participants.
We believe that this cycle of receiving user input and feedback and updating content will make a greater impact on PA WIC.
Looking forward, our next suggested steps for PA WIC are to encourage nutritionists to edit and add to the tip database and run a pilot study with a local agency of PA WIC.
1. The best solution is not always the most expensive or "fanciest" one. Sometimes a cheaper or simpler solution fits users' needs even more or allows users to gain more value out of the solution.
2. Mixed methods research is extremely valuable. Our team always prioritized listening to PA WIC participants and taking what they had to say seriously. However, in addition to listening, we observed PA WIC participants' decision-making strategies, conducted surveys, practiced quantitative data analysis, and engaged with them in co-design sessions. These mixed methods allowed our team to uncover a wide range of values our users hold and the challenges they face inside and outside of PA WIC.