The Behavioral Ecological model: a framework for early WIC participation.

Abstract: Based upon the Behavioral Ecological theoretical framework, the purpose of this study was to assess determinates of early WIC participation in a North Carolina textile-manufacturing county. A Likert-type questionnaire was utilized to assess intrapersonal, interpersonal, organizational/ systemic, and community/cultural contingencies. Findings indicate cultural intrapersonal and interpersonal contingencies, and systemic barriers influence WIC participation. Recommendations for increasing early WI C participation are presented within the Behavioral Ecological Model. It is imperative that health programmers and policy initiatives take into account the personal, cultural, and environmental influences that promote the adoption of positive health behaviors among different ethnic groups.

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Now in its thirtieth year, the WIC (Special Supplemental Nutrition Program for Women, Infants and Children) agenda grew since 1973 to include an estimated 7.5 million persons by 2003 (U.S. Department of Agriculture, 2003). Part of a national effort administered by states, this program provides supplemental food, health education, and access to healthcare for pregnant and postpartum women, infants, and children to the age of five. About half of those currently enrolled are children aged one to five from economically needy families. Many of these children face health problems resulting from poor nutrition during the prenatal period and infancy. Influencing birth outcomes is therefore one of the important objectives of the WIC program.

Over the program's tenure, substantive assessments have shown that compared with lower income pregnant women not enrolled in the program, WIC participants have fewer premature births, a lower incidence of low birth weight children, fewer infant deaths, a higher probability of early participation in prenatal care, and savings in healthcare expenditures (United States Department of Agriculture, 2003). Improved diet and diet-related outcomes have also led to health improvements as measured by a number of standard indicators mentioned above. In addition, there are indications that the use of WIC programs has led to a heightened awareness of other public health services such as immunization programs and routine wellness checks.

WIC program assessments since the mid-to-late 1970s have indicated continued success when measured by health indicators. One of the earliest examinations of the health effects of WIC programs was accomplished for a study population in Massachusetts (Kennedy, Gershoff, Reed, & Austin, 1982) for the time period 1973 to 1978. Five years of WIC programming in Massachusetts had clearly led to lower infant mortality, higher birth weights, and generally healthier babies for program participants when compared to circumstances for babies born to lower income mothers prior to the inception of WIC (Collins, DeMellier, Leeper, & Milo, 1985). In a more recent investigation of the first 20 years of the WIC program nationally (Owen & Owen, 1997), similar conclusions were reached based on evaluations of such nutritional risk factors as obesity, stunting, general underweight, and associated metabolic disorders, as well as newborn birth weights and infant mortality. A 1990s meta-analysis by researchers from the General Accounting Office (GAO) offered further proof of substantial long-term healthcare cost savings resulting from the WIC program (Avruch & Puente-Cackley, 1995). In fact, progress demonstrated by the WIC program has been steady; with the inclusion of benefits for children under 5 years of age and postpartum women in 1976, clarification of nutrition risk factors in 1978, the extension of hunger prevention measures to homeless women in 1988, and assistance to migratory women in 1995 (Owen & Owen, 1997).

Assessment of WIC outcomes have typically used trimester of pregnancy to determine effectiveness of programs. First trimester enrollment is considered appropriate particularly because birth weight of infants is directly related to length of program enrollment time. A national assessment of prenatal WIC enrollment with a sample of nearly 1,200 prenatal participants accomplished in the late 1980s showed that almost 32 percent of the women surveyed entered the program during their first trimester (Ku, 1989). Another 52 percent entered during the second trimester, and about 17 percent not participate until the third trimester.

Clearly, the decision to participate in WIC programs is multifaceted and intricately tied to decisions about seeking prenatal care. As demonstrated by Ku (1989), women who have already had one child are more likely to enter the program during the first trimester than new mothers. Conversely, a more recent study conducted in New Mexico showed that women who have been pregnant more than four times delay seeking prenatal care. While no single factor seems to explain delays in seeking prenatal care or applications for WIC programs, there is some evidence that negative attitudes such as denial and ambivalence may be involved (Burks, 1992). These attitudes may be part of a wider problem that might best be explained in the context of a behavioral ecological framework.

A synthesis of related studies (Meilde, Orleans, Left, Shain, & Gibbs, 1995; Pagnini & Reichman, 2000; Rogers & Schiff, 1996) suggests several sets of explanatory factors that include socioeconomic, racial and ethnic, and behavioral elements. Socioeconomic factors include poor housing quality, neighborhood attributes, substance abuse, social pathologies, migration, and homelessness. Attitudinal and behavioral elements consist of lack of psychological support, dislike of physicians and nurses, problems with the father, and recognition of pregnancy. Racial and cultural factors include family belief systems, knowledge and perceptions of health problems, attitudes toward pregnancy, and familiarity with available programs. Structural and system factors include transportation, childcare issues, appointment waiting periods, approval waiting periods, treatment by provider representatives, knowledge of program locations and processes.

In summary, a wide rage of determinants of participation is required to understand trimester entry into WIC. The purpose of this study was to assess and present a behavioral ecological framework of WIC participation. The results can determine leverage points for programmatic changes to increase early entry into WIC.

THEORETICAL FRAMEWORK: BEHAVIORAL ECOLOGICAL MODEL

Given the multiplicity of factors motivating prenatal care and WIC participation, the instrument utilized in this study was developed within the context of the Behavioral Ecological Model (Hovell, Wahlgren, & Gehrman, 2002). At the center of this model is the integration of public health and behavioral science.

The Behavioral Ecology Model is rooted in the early work of McLeroy, BiBeau, Steckler, and Glanz (1988) who proposed an ecological model of health behavior that intervenes on five levels of influence including intrapersonal factors, interpersonal processes and primary groups, institutional factors, community factors and public policy; An ecological model for health promotion focuses on both the individual and environmental factors in order to minimize the likelihood of victim-blaming (McLeroy et al., 1988). In order to bring about population improvements in health an ecological approach must address all levels of change, reach people at all levels of decision making, and encourage feedback and interaction across levels (McLeroy et al., 1988; Sallis & Owen, 2003).

Based upon an ecological framework, the foundation of the Behavioral Ecological Model focuses on the interaction of physical and social contingencies to explain and reinforce health behavior (Hovell et al., 2002). As depicted in Table 1, the hierarchy of contingencies from specific to generic includes individual, local network, community, and society. The Behavioral Ecological Model holds the contingencies at each level as leverage points for program intervention and behavior change. In order to create and sustain behavior change, it is crucial to assess individual level variables such as attitudes, beliefs, perceptions, and skill, in addition to social, systemic, and cultural variables including social networks, culture, and community and systemic reinforcements. To accomplish these ends, the survey instrument for this study and subsequent analysis were developed to assess individual, local network, community and social variables influencing the adoption and maintenance of primary prevention behaviors.

METHODS

PARTICIPANTS

Data were collected from a convenience sample of WIC clients from the Gaston Co., NC Health Department WIC waiting room. Although the major limitation to non-probability sampling is limited participant representation, days and times of data collection were varied as to reduce some bias.

INSTRUMENT

A 42 item Likert-type questionnaire was developed to assess intrapersonal beliefs, perceptions, and knowledge; local network reinforcements; and community and systemic influences regarding WIC participation. A Spanish language version of the survey was developed for WIC participants whose primary language was Spanish.

Part one of the assessment tool included clusters of items representing the levels of influence within the Behavioral Ecological Model. Table 1 depicts the various items assessed within each level. Part two of the survey included socio-demographic factors including race, age, income, education, and marital status, and trimester of entry. Content and content validity was ascertained by having the questions reviewed by experts in the area of behavior change theory, maternal and child health, and epidemiology.

PROCEDURE

WIC participants in the waiting area were asked by the research staff to fill out the assessment tool. In order to reduce bias associated with convenient sampling, the principal investigators varied the time and day of data collection so as to capture a wide representation of WIC participants. Assistance was available from the investigators for those who did not fully understand specific questions. University IRB approval was granted prior to the implementation of the study, and all participants were required to complete the consent form prior to participating in the study.

DATAANALYSIS

Descriptive data were generated to assist in understanding behavioral ecological factors. In addition, Kruskal-Wallis tests compared ethnic subgroups and trimester of entry to determine differences in the behavioral ecological factors influencing WIC participation.

RESULTS

DEMOGRAPHICS

The mean age of participants was 26.90 (+ or - 5.89), with the majority of participants (75.2%) between the ages of 20 and 29 (see Table 2). About half of the participants reported being white (51.4%), with a majority of the remainder reporting themselves as African-American (27.0%) and Latino (20.7%). About 65% of respondents reported having a 9-12 grade education, while 30% reported last year's income between $5,001 and $15,000. More than half of our sample recipients have a family income similar to the national average for WIC enrollees half of the study participants reported being single, while about 42% reported being married.

Demographic data indicate that about 35% of our sample have been pregnant once, 28% twice, and another 29% three or more times. About 80% of our study participants entered the WIC program while pregnant; of those, 19% entered during the first trimester, 49% the second, and 12% the third trimester.

BEHAVIORAL ECOLOGICAL VARIABLES

While socioeconomic factors have a strong influence on WIC program enrollment, individual, social, cultural, community and system variables also provide reinforcements and or barriers. The following results are presented based upon the constructs of the Behavioral Ecological Model.

Individual Contingencies. Perceived threat of illness to child and/or self was assessed to gather perceptions of the participants as to whether they perceive themselves or their child susceptible to illness if they/ their child do not eat nutritiously during pregnancy and after the birth of their child.

As depicted in Table 3, it is evident from our findings that participants in the WIC program do perceive that either they or their baby may be susceptible to illness if they and/or their baby do not eat nutritiously. In other words, overall, the participants do believe the importance of eating nutritiously during and after pregnancy in addition to having their child eat nutritiously.

When data were assessed according to ethnicity, significant differences were found for the following questions: "I believe it is important for infants and children to eat right in order to be healthy" (p<.001), and "I believe a newborn baby could get sick if it is not properly fed" (p=.038). Our findings indicate that for both statements, Latino WIC participants agreed less often than their white and African-American counterparts. When data were assessed according to trimester entering the WIC program, no significant differences were observed between 1st, 2nd, 3rd trimesters and after the baby was born.

Overall, the majority of participants are aware of and believe in the benefits of utilizing WIC during and after pregnancy; However, only 52.7% of participants agreed that "I am healthier because I eat WIC foods," only 61.8% of participants agreed with the statement, "I believe my children are healthier because they eat WIC foods," only 37.3% of participants agreed with the statement "I have improved my diet because of WIC," 49.1% of participants agreed with the statement "I have improved my children's diet because of WIC," and 52.7% of participants agreed with the statement "Because of WIC, I am trying to improve my family's diet."

When perceived benefits of utilizing WIC were analyzed according to ethnicity, significant differences were noted for the statement, "I believe I am healthier because I eat WIC foods" (p=.030). Our data indicate that more Latinos agreed with this statement than white and African-American participants.

When assessed according to trimester of entry, statistically significant differences were revealed for the statement, "I have improved my diet because of WIC" (p=.027). Our findings indicate that relatively more participants who entered the WIC program in their 2nd trimester agreed with this statement followed by those who entered in their 3rd trimester followed by individuals entering after the baby was born. The least percentage of participants who agreed with this statement where those who entered in their 1st trimester.

Organizational/Systemic Contingencies. As noted in Table 3, two systemic barriers that were noted among participants included, "After I made my first contact with WIC, I had to wait at least 3 weeks before my first appointment" (24.5% in agreement), and "I have to wait too long at my WIC appointments before I am seen" (50.9% in agreement).

When analyzed by ethnicity, significant differences were observed for 4 questions. A higher percentage of Latino than white or African-American WIC participants agreed to the statement, "It was hard to get on WIC" (p=.007), and "WIC is closed during the hours that are best for me to make an appointment" (p=.019). In addition, relatively fewer Latino participants agreed to the statement, "The people on the WIC staff are helpful" (p<.001).

African-American participants were more likely to agree with the statement, "There was too much paperwork to get on WIC" (p=.014). When analyzed by trimester entered into the WIC program, there were no statistically significant differences revealed between 1st, 2nd, 3rd trimester of entry, and entry after the baby was born.

Local Network/Community Contingencies. Researchers also revealed that participants in the WIC program found out about the program from the local health department staff, followed by a friend and then family member. In addition, the majority of participants noted having either a friend or family member who have utilized WIC services in the past.

When assessed according to ethnicity, fewer Latino participants heard about the WIC program from the local health department staff as compared to white and African-American participants, and relatively more Latino than white or African-American WIC participants heard about the WIC program from friends (p=.009). In addition, a lower percentage of Latino WIC participants than whites and African-Americans in this study indicated that they have friends or family that have utilized WIC services (p=.011).

When analyzed according to trimester entered into the WIC program, our study reveals that a higher percentage of participants who entered into the WIC program in their first trimester heard about the program primarily from health department staff (p=.009) than those who entered later in their pregnancy. The majority of those who entered WIC in the 2nd and 3rd trimester heard about the WIC from family and or friends. Additionally, relatively fewer people who entered the WIC program after their baby was born had friends and or family who previously utilized WIC services (p=.011).

DISCUSSION

Gaston County, NC, with 175,000 inhabitants, is an archetypal Southeastern textile manufacturing area with all of the associated historical and economic circumstances of low wage-rate employment when the mills are producing. In terms of ethnicity, about 16% of the county is African-American, and 4 percent are Latinos, whites represent the majority of inhabitants. In addition, a recent federal report (USDA, 2001) profiling the U.S. WIC population reports that most WIC-participant women are between 18 and 34 years of age, and only 7 percent of WIC women are over 35 years old. Somewhat less than 10 percent of WIC women are less than 18 years old. About 30 percent of WIC women have education beyond high school, and the average monthly family income for WIC recipients is $1400. Less than a third of WIC women are employed, and the average family size for WIC participants is four persons. In addition, Latinos are the fastest growing group of WIC recipients. As reflected by the demographic profile of participants in this study, this sample of convenience may be viewed as reasonably representative of local demographics and the national WIC population.

As indicated by findings from this study, intrapersonal, interpersonal, community, and organizational/systemic contingencies vary by ethnicity and may influence trimester of entry. Our findings indicate that the Latino participants tend to perceive less threat of illness, greater perceived benefits, and more barriers to program entry: They also had different cues to enter the WIC program than white and African-American participants. According to our findings, Latino WIC participants did not have high perceptions of illness for themselves or their children if they did not eat healthfully. In addition, Latino WIC participants were less likely to perceive benefits from participating in the WIC program. Barriers to entering and continuing on the WIC program are also noted among the Latino participants. Latino participants in this study were more likely to express lack of helpfulness of WIC staff, difficulty getting on WIC, and the lack of hours open to service Spanish speaking participants. Latino respondents differed from the white and African-American respondents on interpersonal contingencies, as most Latino WIC participants heard about WIC from family and friends rather than through the health care system, and relatively fewer Latino participants indicated that friends or family have used WIC services.

The findings of this study also suggest that behavioral ecological contingencies may influence trimester of entry into the WIC program. Interpersonal and systemic cues to action may influence early entry into WIC. The participants who entered the WIC system before their baby was born were cued to enter the WIC system primarily from the health care system as opposed to those who entered after their baby was born (primarily heard of WIC from family and friends). In addition, relatively fewer women who entered the WIC program after their baby was born received information about WIC through contact with friends or family who had previously used WIC services.

IMPLICATIONS

Based upon the results of this study, recommendations for leverage points in program planning to increase early entry into WIC are presented within the context of the Behavioral Ecological Model. Utilization of this framework increases the likelihood of targeting multiple factors that influence behavior change while reducing the risk of victim blaming.

Table 4 depicts recommendations for leverage points upon which programming should be developed for increasing first trimester WIC enrollment. Due to the reciprocal causation between the sample population and their environment (both physical and social), it is imperative to structure programs and social marketing plans that target all levels of influence (personal beliefs, attitudes, knowledge; social networks and norms; institutional/organizational policies, norms, beliefs and cultural sensitivity; community and policy changes).

Since one goal of the WIC program is to increase first trimester enrollment, our findings suggest that a plan should be developed which emphasizes the positive benefits of WIC among women of child-bearing age. This plan should be culturally competent because our assessment indicates that beliefs and expectations of WIC services differ among ethnic groups. Also, since many women in their first trimester were referred to WIC services by either local health department staff, and/or friends who utilized WIC services in the past, incentives should be provided for all health service practitioners, including physicians, in addition to all past and present WIC service participants who refer participants to WIC.

Local WIC programs must also develop programming and systemic initiatives to decrease barriers to entry: We found that many who called the local WIC office had to wait at least 3 weeks before they could be seen for their first appointment. Therefore, even if a woman initiates interest and desire for WIC services in her first trimester, a wait of 3 weeks could and very well may push her into program participation in her second trimester. Failure to address this issue will result in victim blaming and may deter effective social marketing plans.

As part of the social marketing plan, efforts should be made to involve the community in the planning and implementation of any strategies to increase enrollment during the first trimester. Key leaders from the county in addition to African-American and Latino communities should be identified and utilized as gatekeepers to increase knowledge, and provide cues to entry for all women of childbearing age--especially those in their first trimester of pregnancy.

LIMITATIONS

The authors recognize the bias of limited representation associated with non-probability sampling. Since a convenience sample was utilized, the WIC participant in this study may not be representative of the general WIC population. Consequently, the findings may not be generalizable. However, due to the similar representation of WIC participants in this study to the larger population, this study provides a framework of inquiry to be researched on a larger, more controlled scale.

REFERENCES

Avruch, S., & Puente-Cacldey, A. (January-February 1995). Savings Achieved by Giving WIC Benefits to Women Prenatally. Public health reports, 110, 27-34.

Burks, J. A. (April 1992). Factors in the Utilization of Prenatal Services by Low-income Black Women. Nurse Practitioner, 17, 34-49.

Collins, T. R., DeMellier, S., Leeper, J., & Milo, T. (May 1985). Supplemental Food Program: Effects on health and Pregnancy Outcome. Southern Medical Journal, 78, 551-555.

Hovell, M. F., Wahlgren, D. R., & Gehrman, C. A. (2002). The behavioral ecological model: Integrating public health and behavioral science. In DiClemente, R. J., Crosby, R. A., & Kegler, M. C. (Eds). Emerging Theories in Health Promotion Practice and Research (pp.347-385). San Francisco: Jossey-Bass.

Kennedy, E. T., Gershoff, S., Reed, R. &, Austin, J. E. (March 1982). Evaluation of the effect of WIC supplemental feeding on birth weight. Journal of the American Dietetic Association, 80, 220-227.

Ku, L. (May-June, 1989). Factors influencing prenatal enrollment in the WIC program. Public Health Reports, 104 (3), 301-306.

Meikle, S. F., Orleans, M., Left, M., Shain, R., & Gibbs R.S. (June 1995). Women's reasons for not seeking prenatal care: Racial and ethnic factors. Birth, 22, 81-86.

McLeroy, K, BiBeau, D., Stecker, A., & Glanz, K. (1988). An ecological perspective on health promotion programs. Health Education Quarterly, 15 (35), 351-377.

Owen, A. L., & Owen, G. M. (July 1997). Twenty years of WIC: A review of some of the effects of the program. Journal of the American Dietetic Association, 97(7), 777-782.

Pagnini, D., & Reichman, N. E. (2000). Psychosocial factors and the timing of prenatal care among women in New Jersey's HealthyStart program. Family Planning Perspectives. 32, 56-64.

Rogers, C., & Schiff, M. (March 1996). Early verses late prenatal care in New Mexico: Barriers and motivators. Birth, 23, 26-30.

Sallis, J.F., & Owen, N. (2003). Ecology Models of Health Behavior. In Glanz, K., Rimer, B.K., & Lewis, EM. (Eds). Health Behavior and Health Education: Theory Research and Practice (pp.462-484). San Francisco: Jossey-Bass.

United States Department of Agriculture, Food and Nutrition Service. "National Survey of WIC Participants." October, 2001. Nutrition Assistance Program Report Series, Office of Analysis, Nutrition and Evaluation, Special Nutrition Programs, Report No. WIC-01-NSWP. (www.fns.usda.gov/wic).

HEALTH EDUCATION RESPONSIBILITY AND COMPETENCY ADDRESSED

Responsibility I: Assessing Individual and Community Needs for Health Education

Competency B: Distinguish between behaviors that foster and those that hinder well-being

Sub-competency 4: Analyze social, cultural, economic, and political factors that influence health

Rita D. DeBate, Ph.D., MPH, CHES Gerald F. Pyle, Ph.D.

Rita D. DeBate, Ph.D., MPH, CHES is an Associate Professor in the School of Community and Environmental Health at Old Dominion University. Gerlad F. Pyle, Ph.D. is a Professor in the Department of Health Behavior and Administration at The University of North Carolina at Charlotte. Address all correspondence to Rita 19. DeBate, Ph.D., MPH, CHES, Old Dominion University, School of Community and Environmental Health, 104c Spong Hall, Norfolk, VA 23529, Phone: [phone], email: [e-mail].

Table 1. Behavioral Ecological Model *

Level    Contingencies             Assessment Items

Individual
    Perceived threat of illness
         *    I believe a pregnant woman can feel sick if she does not
              eat right
         *    I believe a baby may be born with health problems if its
              mother does not eat well during pregnancy
         *    I believe a newborn baby could get sick if it is not
              properly fed
         *    I believe it is important for infants and children to
              eat right to stay healthy
         *    I believe a newborn baby could get sick if it is not
              properly fed

    Perceived benefits

         *    WIC helps me to eat better
         *    My baby benefits from WIC
         *    I benefit from WIC
         *    WIC helps my children eat better
         *    I believe I am healthier because I eat WIC foods
         *    I believe my children are healthier because they eat WIC
              foods
         *    I like the foods that WIC provides
         *    My children like the foods WIC provides
         *    I believe the first three month is the most important
              time during pregnancy to have good health habits

    Perceived barriers

         *    I don't like to use the food vouchers WIC provides

    Self-efficacy

         *    Changing the foods I eat was hard to do
         *    Changing the foods my children eat was hard to do

    Cues to action

         *    Have you used WIC during previous pregnancies
         *    I heard about WIC through [friend, family member,
              neighbor, church, health department, hospital, my
              doctor]

Local Network

    Family, friends and coworkers

        *     My friends and family have used WIC services
        *     I heard about WIC through [friend, family member,
              neighbor, church, health department, hospital, my doctor]

Community Contingencies

    Policies

    Cultural competency

        *     The people on the WIC staff are helpful
        *     I believe the people at WIC respect me
        *     The people at WIC listen to me
        *     It was hard to get on WIC
        *     WIC is closed during the hours that are best for me to
              make an appointment
        *     I have to wait too long at my WIC appointments before I
              am seen
        *     After I made my first contact with WIC, I had to wait at
              least 3 weeks before my first appointment
        *     When I called to schedule an appointment with WIC I left
              a message and no one called me back.

Society Contingencies

    Normative beliefs

    Laws

    Policies

        *     It is hard to get on WIC because I have transportation
              problems

* Adapted from Hovell, Wahlgren, & Gehrman, 2002

Table 2. Demographic Characteristics of Study Participants (N=113)

Demographic Variable                  N     (%)

Race
    African-American                  30   (27.0)
    Latino                            23   (20.7)
    White                             57   (51.4)
    Native-American                    1   (00.9)
Age
    Through 19 years old               1    (.9)
    20-29 years old                   85   (75.2)
    30-39 years old                   24   (21.2)
    40 years old and older             3    (2.7)
Educational Status
    Less than 9th grade                6    (5.4)
    9-12th grade education            72   (64.9)
    More than 12th grade education    33   (29.7)
Marital Status
    Married                           47   (42.3)
    Single                            54   (48.6)
    Divorced                           9    (8.1)
    Widowed                            1    (0.9)
Income
    0-$5.000                          27   (24.9)
    $5,001-$15,000                    34   (30.1)
    $15,001-$20,000                   16   (14.2)
    $20,001-$30,000                   19   (16.8)
    $30,001 and greater                7   (06.2)
    Missing                           10   (08.8)
Parity
    First Pregnancy                   40   (35.4)
    Second Pregnancy                  32   (28.3)
    Third Pregnancy                   23   (20.4)
    Forth or more Pregnancy           10   (08.8)
    Missing                            8   (07.1)
Trimester of WIC Entry
    First trimester                   21   (18.6)
    Second trimester                  55   (48.7)
    Third trimester                   14   (12.4)
    Entered WIC after birth of baby   23   (20.4)

Table 3. Percentage of WIC Participants Indicating Variables within
the Behavioral Ecological Model (n=110)

Behavioral Ecological Model
    Level of Influence             Variable                  Agree

                                                          N      (%)

Individual
        I believe a pregnant woman can feel sick if
                she does not eat right                    87    (79.1)
        I believe a baby may be born with health
                problems if its mother does not eat
                well during pregnancy                     88    (80.0)
        I believe it is important for infants and
                children to eat right to stay healthy    106    (96.4)
        I believe a newborn baby could get sick if it
                is not properly fed                      100    (90.9)
        I benefit from WIC                               100    (90.9)
        WIC helps me to eat better                        76    (69.1)
        My baby benefits from WIC                         99    (90.0)
        WIC helps my children eat better                  84   4(76.4)
        I believe I am healthier because I eat WIC
                foods                                     58    (52.7)
        I believe my children are healthier because       68    (61.8)
                they eat WIC foods
        I like the food WIC provides                      88    (80.0)
        My children like the foods WIC provides           83    (75.5)
        I believe the first three months is the most
                important time during pregnancy to
                have good health habits                   90    (81.8)
        I don't like to use the food vouchers WIC
                provides                                  15    (13.6)
        Changing the foods I eat was hard to do           22    (20.0)
        Changing the foods my children eat was hard
                to do                                     14    (12.7)
Community Contingencies
        The people on the WIC staff are helpful           92    (83.6)
        I believe the people at WIC respect me            80    (72.7)
        The people at WIC listen to me                    94    (85.5)
        It was hard to get on WIC                         18    (16.4)
        WIC is closed during the hours that are best
                for me to make an appointment              9    (08.2)
        I have to wait too long at my WIC appointments
                before I am seen                          56    (50.9)
        After I made my first contact with WIC, I had
                to wait at least 3 weeks before my
                first appointment                         27    (24.5)
        There was too much paperwork to get on WIC        17    (15.5)
        When I called to schedule an appointment with
                WIC, I left a message and no one
                called me back                            15    (13.6)
Society Contingencies
        It was hard for me to use WIC because I have
                transportation problems                   14    (12.7)
Behaviors
        I have improved my diet because of WIC            41    (37.3)
        I have improved my children's diet because of
                WIC                                       54    (49.1)
        Because of WIC, I am trying to improve my
                family's diet                             58    (52.7)

Behavioral Ecological Model
    Level of Influence             Variable              Neither Agree
                                                         nor Disagree

                                                          N      (%)

Individual
        I believe a pregnant woman can feel sick if
                she does not eat right                    14    (12.7)
        I believe a baby may be born with health
                problems if its mother does not eat
                well during pregnancy                     15    (13.6)
        I believe it is important for infants and
                children to eat right to stay healthy      3    (02.7)
        I believe a newborn baby could get sick if it
                is not properly fed                        8    (07.3)
        I benefit from WIC                                10    (09.1)
        WIC helps me to eat better                        31    (28.2)
        My baby benefits from WIC                         11    (10.0)
        WIC helps my children eat better                  23    (20.9)
        I believe I am healthier because I eat WIC
                foods                                     43    (39.1)
        I believe my children are healthier because       35    (31.8)
                they eat WIC foods
        I like the food WIC provides                      21    (19.1)
        My children like the foods WIC provides           25    (22.7)
        I believe the first three months is the most
                important time during pregnancy to
                have good health habits                   12    (10.9)
        I don't like to use the food vouchers WIC
                provides                                  23    (20.9)
        Changing the foods I eat was hard to do           31    (28.2)
        Changing the foods my children eat was hard
                to do                                     39    (35.5)
Community Contingencies
        The people on the WIC staff are helpful           10    (09.1)
        I believe the people at WIC respect me            28    (25.5)
        The people at WIC listen to me                    15    (13.6)
        It was hard to get on WIC                         21    (19.1)
        WIC is closed during the hours that are best
                for me to make an appointment             18    (16.3)
        I have to wait too long at my WIC appointments
                before I am seen                          33    (30.0)
        After I made my first contact with WIC, I had
                to wait at least 3 weeks before my
                first appointment                         25    (22.8)
        There was too much paperwork to get on WIC        28    (25.4)
        When I called to schedule an appointment with
                WIC, I left a message and no one
                called me back                            15    (13.7)
Society Contingencies
        It was hard for me to use WIC because I have
                transportation problems                   11    (10.0)
Behaviors
        I have improved my diet because of WIC            49    (44.5)
        I have improved my children's diet because of
                WIC                                       43    (39.1)
        Because of WIC, I am trying to improve my
                family's diet                             43    (39.1)

Behavioral Ecological Model
    Level of Influence             Variable                Disagree

                                                          N      (%)

Individual
        I believe a pregnant woman can feel sick if
                she does not eat right                     9    (08.2)
        I believe a baby may be born with health
                problems if its mother does not eat
                well during pregnancy                      7    (06.4)
        I believe it is important for infants and
                children to eat right to stay healthy      1    (00.9)
        I believe a newborn baby could get sick if it
                is not properly fed                        2    (01.8)
        I benefit from WIC                                 0
        WIC helps me to eat better                         3    (02.7)
        My baby benefits from WIC                          0
        WIC helps my children eat better                   3    (02.7)
        I believe I am healthier because I eat WIC
                foods                                      9    (08.2)
        I believe my children are healthier because        7    (06.4)
                they eat WIC foods
        I like the food WIC provides                       1    (00.9)
        My children like the foods WIC provides            2    (01.8)
        I believe the first three months is the most
                important time during pregnancy to
                have good health habits                    8    (07.3)
        I don't like to use the food vouchers WIC
                provides                                  72    (64.5)
        Changing the foods I eat was hard to do           57    (51.8)
        Changing the foods my children eat was hard
                to do                                     57    (51.8)
Community Contingencies
        The people on the WIC staff are helpful            8    (07.3)
        I believe the people at WIC respect me             8    (07.3)
        The people at WIC listen to me                     1    (00.9)
        It was hard to get on WIC                         71    (64.5)
        WIC is closed during the hours that are best
                for me to make an appointment             83    (75.5)
        I have to wait too long at my WIC appointments
                before I am seen                          21    (19.1)
        After I made my first contact with WIC, I had
                to wait at least 3 weeks before my
                first appointment                         58    (52.7)
        There was too much paperwork to get on WIC        65    (59.1)
        When I called to schedule an appointment with
                WIC, I left a message and no one
                called me back                            80    (72.7)
Society Contingencies
        It was hard for me to use WIC because I have
                transportation problems                   85    (77.3)
Behaviors
        I have improved my diet because of WIC            20    (18.2)
        I have improved my children's diet because of
                WIC                                       13    (11.8)
        Because of WIC, I am trying to improve my
                family's diet                              9    (08.2)

Table 4. Behavioral Ecological Recommendations for WIC Programming to
Increase Early Trimester Participation

Contingency     Components                   Appropriate Intervention
  Level          of level
Individual
        WIC participant beliefs,
        perceptions, intentions to
        commitment
                       *    Increase positive expectations among
                            pregnant women regarding benefits of
                            entering the WIC program in 1st trimester
                       *    Increase belief among Latino sub-population
                            that WIC participation can improve their
                            health
                       *    Increase belief among Latino sub-population
                            that WIC participation can improve their
                            children's health

Local Network

        Social network of
        WIC participants
                       *    Increase awareness of WIC program among
                            Latino social networks
                       *    Increase awareness of benefits of WIC
                            among Latino social networks
                       *    Provide incentives for referring to WIC
                            among Latino sub-population

Community Contingencies
        WIC program (staff,
        procedures, regulations)

                       *    Increase helpfulness of WIC staff to
                            Latino sub-population
                       *    Increase ease of entering WIC program
                            among all potential participants
                       *    Increase hours of operation which service
                            Latino sub-population
                       *    Decrease length of time between client
                            contact and call back
                       *    Decrease length of time between client
                            contact and first appointment
                       *    Increase cues which will trigger entry
                            into the WIC program among health
                            department staff and other health care
                            service providers who service women in
                            their childbearing years.

Social Contingencies
        Coalitions, health departments,
        neighborhood associations, formal and
        informal community leaders
                       *    Increase awareness of WIC program to all
                            associations, coalitions, formal and
                            informal leaders of Latino sub-population
                       *    Increase awareness of WIC benefits to all
                            associations, coalitions, formal and in
                            formal leaders of Latino sub-population
                       *    Provide incentives to refer target
                            population to WIC among associations,
                            coalitions, formal and informal leaders of
                            Latino sub-population
                       *    Develop a culturally appropriate social
                            marketing plans which markets WIC,
                            benefits of WIC to ethnically diverse
                            sub-populations Implement a culturally
                            appropriate social marketing plans which
                            market WIC, benefits of WIC to ethnically
                            diverse sub-populations