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INCREASING UPTAKE AND IMPROVING HEALTH: EXPERIMENTAL EVIDENCE ON TAKE-UP OF THE WIC PROGRAM INCREASING UPTAKE AND IMPROVING HEALTH: EXPERIMENTAL EVIDENCE ON TAKE-UP OF THE WIC PROGRAM

Last registered on January 04, 2021

Pre-Trial

General Information

Title

RCT ID

AEARCTR-0006985

Initial registration date

December 31, 2020

Initial registration date is when the trial was registered.

It corresponds to when the registration was submitted to the Registry to be reviewed for publication.

First published

January 04, 2021, 9:09 AM EST

First published corresponds to when the trial was first made public on the Registry after being reviewed.

Locations

Country

United States of America

Region

Primary Investigator

Name

Marianne Bitler

Affiliation

UC Davis

Contact Primary Investigator

Other Primary Investigator(s)

PI Name

Jenna Nobles

PI Affiliation

University of Wisconsin, Madison

Contact Investigator

Additional Trial Information

Status

In development

Start date

2021-01-04

End date

2023-03-01

Keywords

Health, Welfare

Additional Keywords

WIC, take-up, COVID-19, pregnancy outcomes, stigma, information, telehealth

JEL code(s)

H5, I38

Secondary IDs

Abstract

The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) is an important part of the safety net for pregnant women. WIC is a large program, covering about half of infants, and WIC participation has multiple health impacts in pregnancy. Despite this, the program is significantly under-enrolled. Only 63% of eligible pregnant women participate and participation has declined since 2010. Our research pilots a new approach to connect women to WIC. More than 90% of reproductive-age women have smartphones, and more than half use applications to track menstruation and pregnancy. Because prenatal care is underused, apps may provide a uniquely low-cost, scalable way to reach women in early pregnancy. We have partnered with the designers of an app used by several million WIC-eligible women. We pilot a randomized controlled trial that experimentally tests approaches to encourage WIC take-up. Because the app tracks pregnancy health, the experiment also (a) provides the first randomly-assigned variation in WIC with which to evaluate WIC health impacts and (b) allows us to test how well-targeted benefits to the marginal WIC participants are.

External Link(s)

Registration Citation

Citation

Bitler, Marianne and Jenna Nobles. 2021. " INCREASING UPTAKE AND IMPROVING HEALTH: EXPERIMENTAL EVIDENCE ON TAKE-UP OF THE WIC PROGRAM INCREASING UPTAKE AND IMPROVING HEALTH: EXPERIMENTAL EVIDENCE ON TAKE-UP OF THE WIC PROGRAM ." AEA RCT Registry. January 04. https://doi.org/10.1257/rct.6985-1.0

Sponsors & Partners

Interventions

Intervention(s)

We experimentally test an approach to encourage WIC take-up for women using a pregnancy tracking app. We provide women in the treatment arm with a combined information, anti-stigma, and reduced administrative burden intervention. Women in the control arm are instead provided with information from ACOG.

Intervention (Hidden)

1. Treatment arm (Information + Anti-Stigma + Reduced Administrative Burden) gives women information about the foods and other benefits WIC provides and points out that the survey participants are likely eligible for WIC (due to income/participation in other programs). The treatment also attempts to decrease stigma by pointing out that all types of people are on WIC and that participation is widespread. It also aims to inform respondents about how it might even be easier than usual to sign up during COVID-19, as states have waived many in-person requirements. With the goal of cutting the administrative burden for sign-up, respondents are also given the opportunity to click a link connecting them to their nearest WIC clinic.

2. In the control arm, recruited women complete the screener, are consented, and complete the same pre-treatment survey as the control group, are directed to a page with general information about nutrition during pregnancy from the American College of Obstetricians and Gynecologists (ACOG), and then are given the chance to click on a link to learn more about nutrition during pregnancy from ACOG.

Intervention Start Date

2021-01-15

Intervention End Date

2022-12-31

Primary Outcomes

Primary Outcomes (end points)

RCT:
At the time of the initial survey:
Did women in the treatment group click on the link to find out about the nearest WIC clinic? Did women click on any link?

At the time of the follow on survey, we consider:
Self-reported pregnancy outcome was a live birth or not?

Woman has heard of WIC?

Is the woman enrolled in WIC now?

Birthweight

Premature/early birth

Breastfeeding initiated?

Woman down/sad/had little pleasure

Not enough food/worried about food

For the descriptive analysis, primary outcomes:
Woman has experienced delay of medical care due to COVID

Woman has experienced loss of employment income or unemployment due to COVID

Woman did not have enough food to eat because she couldn't afford it

Women knows about WIC relative to knowledge about SNAP

Woman plans to enroll in WIC for her baby

Why women did not enroll in WIC and/or SNAP?

How the woman feels her state has done with handling COVID?

Primary Outcomes (explanation)

The woman clicked on a link about WIC. Woman clicked on link to find out about the nearest WIC clinic is set to 0 if the woman is in the control group.

Woman clicked on link for either group is set to 1 if clicked, and 0 if did not.

Secondary Outcomes

Secondary Outcomes (end points)

Does the woman know about services WIC provides and what food you can purchase?

Does the woman know about when women/infants/children can enroll in WIC?

Measures 3 to 8 are taken from the initial and follow up survey, and will also be compared to similar questions about SNAP.
Woman did not enroll because don't know about program (0 if enrolled)

Woman did not enroll because she doesn't think she's eligible

Woman did not enroll because it is too hard to sign up

Woman did not enroll because WIC isn't for people like me

Woman did not enroll for other reasons

Pregnancy complications

Was baby born in hospital?

Did baby go to NICU?

Confident will get food in next 4 weeks

On Medicaid

On SNAP

Engagement with the pregnancy app

Secondary Outcomes (explanation)

Reasons woman did not enroll are not mutually exclusive.

Experimental Design

The app platform can randomize users based on a random numeric seed assigned at sign-up. The two arms of the RCT experiment include a control arm and a treatment arm. Following the report of a pregnancy, women will be recruited over email. They will be consented, complete a screener survey, and if likely eligible for WIC, be randomized into one of the two arms.
A large share of women but not all women found to be already participating in WIC will also be screened out.

Experimental Design Details

The app can randomize users based on a random numeric seed assigned at sign-up. The arms of the RCT experiment include a control arm and a treatment arm. Following the report of a pregnancy, women will be recruited over email. They will be consented, complete a screener survey, and if likely eligible for WIC, be randomized into one of the two arms.
Women will be screened out if their income is likely outside the WIC eligibility range and they are neither participating in SNAP nor in Medicaid.
A large share of women found to be already participating in WIC will also be screened out (we will keep some in so we can compare our non-WIC participants to WIC participants).
The pre-treatment screening survey will ask respondents about pregnancy status; current enrollment in Medicaid, SNAP or the Indian Health Service; and household income level; as well as current WIC participation. Women who are at least 18 years old and meet criteria for WIC enrollment (are currently pregnant and are either enrolled in a means-tested program that makes them automatically eligible for WIC (Medicaid or SNAP) or have a household income less than or equal to 185% of the federal poverty guidelines) will be invited to participate in the study. Minors and women who reside outside the United States will be excluded. Most women who are already enrolled in WIC at the time of the eligibility screening will also be excluded. Women who meet eligibility criteria and agree to participate will be randomized to one of two study arms and asked to respond to some additional pre-treatment survey questions. Women who complete the main survey or the later follow-on survey will receive a $5 Amazon gift card. We may increase the post-incentive amount if recruitment is low.
The main survey asks all women a number of questions about pregnancy history and what factors would influence whether women would enroll in WIC and SNAP. It also asks about intended breastfeeding, effects of COVID on prenatal care use, internet quality, and what the women were doing last week. Finally, it asks about loss of income due to COVID, and food security, as well as chronic health conditions, smoker status, mental health, education, whether the pregnancy was planned, how well they think their state has managed the COVID crisis, and other demographics.

Randomization Method

The women will be randomized according to a random numeric seed assigned at sign-up for the app, based on a digit from 0-9. Half of the digits will be assigned to the treatment arm and half to control arm.

Randomization Unit

Individuals

Was the treatment clustered?

Experiment Characteristics

Sample size: planned number of clusters

6,000 women

Sample size: planned number of observations

6,000 women

Sample size (or number of clusters) by treatment arms

3,000 women in each arm

Minimum detectable effect size for main outcomes (accounting for sample design and clustering)

The MDE for clicking on the link is 7 percentage points (variable is 0 or 1). This is based on assigning women to the treatment and control arms with equal probabilities. The MDE for the outcomes at follow up using the offer as an IV for click through is 0.9 standard deviations. (These are 0/1 units.)

Supporting Documents and Materials

IRB