Caregiver Perspectives on Improving Government Nutrition Benefit Programs

Abstract

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DOI: 10.1542/6361089049112

Video Abstract

OBJECTIVES

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and Supplemental Nutrition Assistance Program (SNAP) provide essential nutrition support for low-income families. However, many eligible families do not receive or fully redeem these benefits. We aimed to understand current and former WIC and SNAP beneficiaries’ perceptions of and suggestions for improving both programs.

METHODS

We conducted semistructured phone interviews with caregivers of pediatric patients who were current or former WIC and SNAP beneficiaries at 2 academic pediatric primary care clinics. Interviews were recorded, transcribed, and coded by 2 independent coders using thematic analysis, resolving discrepancies by consensus. Interviews continued until data saturation was reached.

RESULTS

We interviewed 40 caregivers who were predominantly Black (88%) mothers (90%), with 53% and 83% currently using WIC and SNAP, respectively. We identified 4 themes related to participation barriers: (1) limited product variety available through WIC, (2) inconvenience and stigma associated with purchasing WIC products, (3) SNAP income-based eligibility criteria, and (4) burdensome SNAP enrollment and recertification processes. We identified 3 themes related to suggestions for improvement: (a) decreasing stigma associated with participation, (b) allowing online or phone-based enrollment, and (c) improving coordination with health care systems.

CONCLUSIONS

WIC and SNAP beneficiaries identified several modifiable barriers to enrollment and benefits redemption. Pediatric providers should advocate for programmatic improvements that make it easier for families to access and redeem benefits and should consider implementing innovative cross-sector interventions like medical–financial partnerships, direct WIC and SNAP referrals, and data sharing with government assistance offices.

What’s Known on This Subject:

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and Supplemental Nutrition Assistance Program (SNAP) are government benefit programs that provide nutrition support for low-income families. Previous studies have identified barriers to participation in either WIC or SNAP.

What This Study Adds:

This study explores caregiver perspectives on WIC and SNAP simultaneously. Through qualitative interviews with current and former beneficiaries of both programs, we identify several modifiable barriers to participation and highlight cross-cutting strategies for improving program enrollment and benefit redemption.

Childhood food insecurity is highly prevalent in the United States, affecting 8.8% of households with children in 2022.¹ The American Academy of Pediatrics encourages pediatricians to screen for food insecurity and refer patients to community resources, as highlighted in the 2022 White House Strategy for Hunger, Nutrition, and Health.² One set of resources pediatricians can offer are referrals to government nutrition benefit programs, including the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and the Supplemental Nutrition Assistance Program (SNAP).

WIC participation is associated with improved birth outcomes and decreased infant mortality.³ SNAP participation also has demonstrated health benefits, including decreased food insecurity, improved caregiver-reported child health, and decreased developmental risk.^4,5 However, many eligible families do not participate in these programs. There has been a consistent decline in the national WIC coverage rate since 2016, and in 2021, only 51% of WIC-eligible individuals received benefits.⁶ The national SNAP coverage rate was only 78% in 2020, with wide variation across states.⁷ Some eligible families might choose not to enroll in WIC and SNAP, whereas others may be interested in receiving benefits but have trouble accessing these programs.^8–10

Previous qualitative studies have explored pediatric caregiver perspectives on either WIC or SNAP and barriers to utilizing each of these programs. Barriers to WIC utilization include food package inflexibility, decreased perceived value after children reach age 1, in-store shopping and checkout challenges, difficulty attending appointments, and stigma encountered in the WIC office.^11–16 Recent WIC modernization efforts, including transitioning from paper vouchers to electronic benefits transfer debit cards, providing shopping support via smartphone apps, and initiation of remote certification appointments and remote benefits reloading have been positively received by participants.^11,17–19 SNAP recipients’ perspectives and barriers to participation have also been investigated, although to a lesser extent, revealing dissatisfaction with income limits,²⁰ customer service, and the complex application and benefits determination processes.^8,9

Because low-income caregivers of young children are often eligible for both WIC and SNAP, understanding caregiver perspectives on both programs could help inform improvements in program design and boost participation synergistically. In this study, we aimed to understand perceptions of WIC and SNAP program benefits, participation barriers, and suggestions for improvement among pediatric caregivers who were current or former WIC and SNAP beneficiaries, with the ultimate goal of identifying cross-cutting strategies for improving both programs.

Methods

Study Design and Participants

We recruited a convenience sample of parents and caregivers from 2 academic primary care practices within the Children’s Hospital of Philadelphia Pediatric Resource Consortium, a primary care practice-based research network.²¹ Both practices are in West Philadelphia and serve a predominantly Black (81%) and Medicaid-insured (86%) population.

Participants initially completed a survey regarding preferences for clinic-based food resources and participation in nutrition benefit programs.²² Demographic information, including self-reported race and ethnicity, was also collected. At the end of the survey, caregivers indicated whether they were interested in participating in a subsequent phone interview exploring their perceptions of clinic-based food resources and their suggestions for improving government nutrition benefit programs.

Inclusion criteria included being 18 years of age or older, able to communicate in English, and having at least 1 child aged <5 years. We focused on English-speaking caregivers because both study practices serve a predominantly English-speaking population and because our semistructured interview guide was developed and pilot-tested in English. We focused on caregivers of children aged <5 because they would be potentially eligible for both WIC and SNAP.

Of caregivers who indicated interest in an interview, we purposively sampled current or former WIC and SNAP beneficiaries. A study team member contacted caregivers by phone to confirm eligibility and schedule a subsequent phone interview. Caregivers provided verbal informed consent before each interview and received a $25 gift card as compensation.

This study was designed to comply with Consolidated Criteria for Reporting Qualitative Research guidelines²³ and approved after expedited review by our institutional review board.

Data Collection

Through review of the literature and pilot testing with caregivers who were current or former WIC and SNAP beneficiaries, we developed an interview guide (Supplemental Information) that included open-ended questions regarding the WIC and SNAP user experience. We first asked about participants’ general experiences with each program, and then inquired about suggestions for improving both programs. We also asked how clinics could support families in improving enrollment and redemption across both programs. Interviews were conducted in July and August 2022.

Research Team and Reflexivity

Study team members who conducted interviews (D.N., M.Y., and L.B.) included 2 second-year medical students and 1 clinical research assistant, all with bachelor’s degrees and structured training in conducting qualitative research. All interviewers were female; 1 identified as non-Hispanic white, 1 as Hispanic, and 1 as South Asian. The other 3 coinvestigators were pediatricians and health services researchers with masters-level research training and several years of experience caring for food-insecure families in clinical practice. Research team members had no preexisting relationships with participants. Throughout the data collection, analysis, and manuscript preparation process, our team considered how our identities and life experiences may have impacted research conduct and interpretation of findings, consistent with Consolidated Criteria for Reporting Qualitative Research guidelines.^23,24

Data Analysis

Interviews were audio-recorded and professionally transcribed. Transcripts were reviewed, deidentified, and entered into NVivo (QSR International, Burlington, MA) for analysis. We used a thematic analysis approach to code interview transcripts. Three study team members (A.V., D.N., and M.Y.) initially open-coded 5 transcripts to develop a preliminary coding scheme and dictionary. We used a priori topics from the interview guide to inform codebook development deductively, and then added new codes inductively. Codes were evaluated and revised after each coding session, consistent with a constant comparative method.²⁵ All interviews were then coded independently by 2 study team members, and intercoder agreement was measured using the $\kappa$ coefficient, to help ensure a consistent approach to coding across our study team.²⁶ We met after each set of 5 transcripts was coded, identified codes with a $\kappa$ < 0.8, and resolved discrepancies by consensus. Interviews were continued until our team felt we had reached data saturation, meaning we had captured data that were sufficiently rich and complex to address our study objectives.^25,27,28

Results

We attempted to contact 63 caregivers and completed 40 interviews, for a response rate of 63%. The 23 caregivers who did not complete interviews either could not be reached by phone after 3 attempts, or initially agreed to be interviewed but could not be reached on subsequent call attempts.

Caregivers’ mean age was 32.3 years and the mean age of their youngest child was 1.5 years (Table 1). Caregivers were predominantly Black (88%) and 5% were Hispanic or Latine, similar to the overall population served by the study clinics. All caregivers had experience using both WIC and SNAP, with 52% and 85% currently receiving WIC and SNAP, respectively.

TABLE 1.

Demographic Characteristics

	Caregivers (n = 40)
Caregiver age, mean	32.3 y
Child age, mean	1.5 y
Relationship to child
Mother	36 (90%)
Grandmother	3 (8%)
Other relative or legal guardian	1 (2%)
Caregiver race
Black or African American	35 (88%)
Asian American	1 (2%)
White	1 (2%)
Native American or Alaskan Native	2 (5%)
Other	2 (5%)
Caregiver ethnicity
Hispanic or Latino/Latinx	2 (5%)
Non-Hispanic or Latino/Latinx	38 (95%)
Caregivers’ highest level of education completed
Some high school	4 (10%)
Graduated high school or received GED	18 (45%)
Some college or associate’s degree	14 (35%)
Bachelor’s degree	4 (10%)
Current benefit program use
SNAP and WIC	20 (50%)
SNAP only	14 (35%)
WIC only	1 (2%)
Neither WIC nor SNAP	5 (13%)
Low Income Home Energy Assistance Program	4 (10%)
Temporary Assistance for Needy Families	3 (8%)
Supplemental Security Income	4 (10%)
Previous benefit program use
SNAP	40 (100%)
WIC	40 (100%)
LIHEAP	13 (33%)
TANF	12 (30%)
SSI	6 (15%)

GED, General Education Development; LIHEAP, Low Income Home Energy Assistance Program; SSI, Supplemental Security Income; TANF, Temporary Assistance for Needy Families.

We identified 2 themes related to benefits of participation (Table 2), 4 themes related to barriers to participation (Table 3), and 3 themes related to suggestions for improvement (Table 4).

TABLE 2.

Benefits of WIC and SNAP Participation: Themes and Representative Quotes

WIC Theme	Quotes
1. Caregivers appreciate WIC’s provision of infant formula, nutritious food, and nutrition and breastfeeding education.	“I like that [WIC] gives you the option to get nutritional food, because sometimes the nutritional food costs more than the fast food. I like that I'm able to get fresh vegetables and not just fresh vegetables, but [also] canned fruit, fruit cups, and things like that for the kids.” Participant 10 (current WIC and SNAP participant)
	“The WIC program actually offered more than just food. I remember when I first had my 3-year-old, and I was trying to breastfeed but he really wouldn’t latch on or he would and he would only drink for 2 minutes and then stop, and I was just frustrated, not knowing what was going on. They also offered breastfeeding classes and stuff like that. So, I’m not going to lie, they actually did help me get better at breastfeeding and understanding the infant’s emotion and stuff like that during breastfeeding. So, I like that it’s just not food, but it’s also, they offer other services. Because the lady that I was speaking to, she actually helped me understand how to breastfeed better.” Participant 30 (former WIC participant, current SNAP participant)
SNAP Theme	Quotes
2. Caregivers appreciate being able to use SNAP benefits to purchase a variety of food items.	“I like SNAP because we can get whatever we want. I can go full grocery shopping and get meals that’ll last for weeks, and not have to pick and choose, or try to figure out how many ounces is this meat, or if I can get this meat because of the ounce size or the quantity. And I can just buy whatever I want...As long as it’s cold, and as long as it's approved by EBT, I can get it. I can get my kids whatever milk I want them to drink. It doesn’t have to be cow’s milk. I get them oat milk. I can get them whatever juice, and it doesn’t have to be a sugary beverage. It can be whatever beverage I want my kids to drink.” Participant 7 (former WIC participant, current SNAP participant)
	“If you need [SNAP], it’s great because it can literally fill your house with food… You can go to the store, you can go to literally a corner store, if your child is hungry, and buy them a sandwich.” Participant 20 (former WIC participant, current SNAP participant)
	“[Using SNAP benefits has] been great. No problems because with SNAP, as long as it’s anything foodwise you purchase, as long as it’s not anything that’s already cooked or anything like that. So, it’s plenty of things that you could buy as long as it’s food items.” Participant 39 (former WIC participant, current SNAP participant)

EBT, electronic benefits transfer.

TABLE 3.

Barriers to WIC and SNAP Participation: Themes and Representative Quotes

WIC Themes	Quotes
1. WIC product restrictions can make it challenging to use these benefits.	“If they actually surveyed more people in the community who used WIC, then they would know what [products] to give us. Because they’re just going off a broad list. Not what’s in our community. If you base stuff off of people in the suburbs or in the outskirts that don’t live in our neighborhood, you’re not giving [us] exactly what we need. Or when they do cover [products], they give us more of what we don’t need and less of what we could use.” Participant 3 (current WIC and SNAP Participant)
	“Like right now, because we’re in the shortage of formula, it’s very, very hard for me as a grandparent with looking for formula, and because of the WIC guidelines, they limit the amount and the allotted form of the formula when you do find it. So, if you find it, right? In a store that may have it, you’re still limited to that [amount] because of the guidelines that WIC has on certain formulas... the limitations. So, it makes it harder for us.” Participant 4 (current WIC and SNAP participant)
	“So, WIC has been an up-and-down experience, because, for my child…he has a lot of food allergies. And WIC is very black and white. So like, the things like the fish and the eggs and the milk and things that my son is allergic to, they will not give me alternatives...he can’t get the tuna, so why we can't make that instead money for fruits and vegetables? …They don't really consider the children with food allergies, and that’s kind of like a hindrance to me.” Participant 13 (current WIC and SNAP participant)
2. Families commonly encounter challenges when redeeming WIC, including absent product labels and stigmatizing checkout experiences.	“Finding [WIC products] in stores has been a struggle. Even just for instance, for cereal…I really feel like it if there was a WIC section [in stores], it would be easier. Because sometimes, you get to the register and they’re like, ‘Well, this is not a part of our WIC program at this location.’ And it’s just like, ‘Well, this is difficult, because I just stood and looked at these aisles for 45 min just looking at cereal to make sure that I’m getting the cereal that fits in the criteria of what I need.’” Participant 22 (current WIC and SNAP participant)
	“[Finding WIC products] was a little difficult because certain stores doesn't have, ‘Oh, this is a WIC product.’ And then some stores does have WIC products labeled in bright yellow, which was very convenient and very much easier, instead of me assuming that 1 product is a WIC product and then going up to the register and then it ends up being not, and then you hold up a whole line. So, it would be very much more helpful and convenient if all stores would just label their product as a WIC product.” Participant 28 (former WIC and SNAP participant)
	“The checkout process can be, No. 1, embarrassing for the person getting these products because maybe they don’t want everyone to know that they’re getting these benefits. And No. 2, frustrating for the cashier as well, because now they have a line for the people and they have to stop what they’re doing to go find the proper qualifying items for the customer that’s in line. So, it’s just the convenience of it all and the privacy of it all, too. Like, I don't want everybody to know that I am receiving these benefits, because it’s honestly nobody’s business.” Participant 18 (former WIC participant, current SNAP participant)
SNAP Themes	Quotes
3. SNAP’s income-based eligibility criteria can be a barrier to participation for working families.	“The [SNAP] income limits are just too low. They’re just entirely too low. There’s an entire population of people that are struggling paycheck to paycheck…trying to figure out how to feed their kids based off of working with minimum-wage jobs or maybe getting paid a little bit more than minimum wage, but still income ineligible. You’re still in that grocery store trying to make $20 into $100, but you’re just not eligible.” – Participant 16 (current WIC participant, former SNAP participant)
	“If you’re working, and I go apply for SNAP, and I can’t get it... I think some of the parents out here that’s working should be able to get SNAP to help feed their children. Because you’ve got bills to pay. And then, you’ve got to think about, ‘Wow, now, I have to go shopping for food and I really don’t have that money.’ But you spend it. Because you have to eat to survive.” Participant 23 (former WIC participant, current SNAP participant)
	“They sit there and be like, ‘Oh, because I make $14.50 [an hour], that my food stamps should go down a bit because I can technically financially afford it. I’m like, ‘No. Just because I’m making this amount of money, that’s literally providing rent, bills, car [insurance], all that for my kids. That has nothing to do with food.’ If I then have to kick out money for food, I’m really struggling. My food stamps should not go lower just because I’m making a little bit more money.” Participant 36 (current WIC and SNAP participant)
4. SNAP enrollment and recertification processes can be burdensome and lead to unexpected loss of benefits.	“So, my main issue with SNAP is, I was on the program, and I guess it’s because I didn’t submit something or something, and then they automatically...They just stop your benefit, especially in times when you really need them.” Participant 12 (former WIC participant, current SNAP participant)
	“It’s just, recently, my [SNAP] benefits were cut off and I didn’t get a notification or nobody called me. Nobody sent me a letter. They just cut them off because they said that I needed to send them some type of paper, but I didn’t get a notification of it that they were getting cut off... I didn’t have a job and we didn’t have any money, so we were trying to scramble around to find ways to get for food for my daughter.” Participant 27 (current WIC and SNAP participant)
	“It is a headache with the food stamps, the caseworkers, they don’t always put everything in the computer right. And so then sometimes, they cut your food stamp and stuff like that, and then you don’t know why and have to try to figure it out… Sometimes, you send the information in wrong and then it’s confusing. And then, they’re also just constantly switching off working without calling you or letting you know.” Participant 29 (current WIC and SNAP participant)

TABLE 4.

Suggestions for Improving Both the WIC and SNAP Programs: Themes and Representative Quotes

Cross-Cutting Themes	Quotes
1. Both WIC and SNAP enrollment processes could be improved by decreasing stigma associated with program participation.	“Just to me, a lot of the workers need to be trained better to make people feel [SNAP] is a program that can help you instead of making them feel like they’re less than because they’re on this program.” Participant 25 (former WIC and SNAP participant)
	“[WIC is] okay the way that it is, I would just want better customer service inside the WIC offices, and more people who are inclined to actually help the customers that walk in there... In terms of actually helping people, like the food stamp office, the WIC offices, a lot of those people don’t even really care about the people that come in….And this is why a lot of people find it difficult to even get [applications] done, because you already have a lot of things going on, and the people that you’re going to really don’t want to help you, they’ll literally treat you like trash.” Participant 35 (former WIC participant, current SNAP participant)
2. Online and phone-based benefits enrollment and redemption support could improve the WIC and SNAP user experience.	“They need to continue to push online enrollment. They have been doing that since the pandemic and they need to continue. They need to continue to try to support the online system, that telephone system to help with making that process easier because you get, that attention is different when you get someone over the phone that’s calling just to talk to you and it’s not the chaos of everything going on around you in the [county assistance] office that’s often times like I said, very negative, disheveled, disorganized, dysfunctional, and aggressive.” Participant 16 (current WIC participant, former SNAP participant)
	“I do have the [WIC] app, and I wish they would send me messages like, ‘Okay, it’s in 2 wk that we’re going to reload your card’… I wish they would inform me like, ‘Okay, [this benefit] is about to expire. Use it now or your card will be reloaded again on this date’… It [would] probably be better to give me an estimate time on when things are about to expire, when things are going to reload, and what necessary information that I need to provide them to keep my benefits.” Participant 28 (former WIC and SNAP participant)
	“Rather than getting, having to actually go to the 1 WIC office in your district or in your area, maybe it can be a virtual appointment, some type of virtual checkup, or something of that nature, because everybody can’t get to those offices.” Participant 38 (former WIC participant, current SNAP participant)
3. Improved coordination between health care providers and WIC and SNAP could boost participation.	“If somebody [in clinic] can volunteer and help families with a tablet or a laptop and help them sign up for [benefits], I think that would be great because you feel more connected and safer. And the hospital, the clinic is a little, some people are a little more personable than how the SNAP people are in the office.” Participant 19 (former WIC participant, current SNAP participant)
	“It was a little difficult for me to go back to the [WIC] office and get my WIC loaded back on my card. So, it would be more convenient for me to go to my children’s health care provider and just get it done there all at once.” Participant 28 (former WIC and SNAP participant)
	“I just feel like they just need to make [WIC] more convenient for people, because it’s a mess and it’s all over the place. It’s not structured right. I think it should really go through the doctors. Listen, when I had my son, he got weighed and then I went to WIC a day later or 2, just a couple days after I came from the doctor’s office from getting weighed, getting his measurements and all that. You having to go to the WIC to do the same thing? I feel like that’s silly. I feel like it’s not worth it.” Participant 34 (former WIC participant, current SNAP participant)

Benefits of WIC Participation

Caregivers expressed appreciation for the range of services provided by WIC. Caregivers liked that WIC encouraged nutritious food choices. One mother shared, “We get to get foods that we don’t normally eat, which is good for us because it’s much healthier. I get to expose my family to wheat bread… more produce, more fruits, and stuff like that” (participant 28, former WIC and SNAP participant). Caregivers also appreciated WIC’s nutrition education and support programs, including breastfeeding support, nutrition brochures, recipes, and Farmers Market Nutrition Program vouchers. One caregiver noted how WIC’s nutrition education had benefited her family, “[WIC] gave me different ideas of different meals to make for the kids to keep them healthy” (participant 12, former WIC participant, current SNAP participant).

Benefits of SNAP Participation

Caregivers valued the autonomy and flexibility provided in making food purchases using SNAP, allowing them to account for their families’ preferences and dietary restrictions. One caregiver noted, “All products are really SNAP products, unless it’s cooked [food]” (participant 10, current WIC and SNAP participant). Caregivers positively contrasted this flexibility with WIC’s product, brand, and size restrictions. Many caregivers shared that the freedom associated with SNAP facilitated an easy shopping experience and convenient redemption of benefits.

Barriers to WIC Participation

WIC Product Restrictions Can Make It Challenging to Use These Benefits

Participants noted numerous ways in which WIC’s strict product restrictions led to underutilization of benefits. Caregivers particularly highlighted limitations related to product size, formulation, and brand restrictions, which were exacerbated during the 2022 formula shortage. Some participants also described difficulty navigating WIC accommodations for their children’s food allergies. One parent shared, “I’m like, ‘my son is allergic to [dairy].’ And [WIC] just took it off, as opposed to giving us more [benefits] in a different area” (Participant 13, current WIC and SNAP participant). Additionally, some caregivers noted that WIC coverage of 100% juice felt inconsistent with their pediatrician’s recommendation to limit juice intake.

Families Commonly Encounter Challenges When Redeeming WIC, Including Absent Product Labels and Stigmatizing Checkout Experiences

Caregivers also shared challenges associated with WIC redemption. Many caregivers reported difficulty identifying WIC products. One caregiver noted, “Finding which products [are covered] takes time… you have to literally look at the weights, look at the actual names, the flavors” (participant 22, current WIC and SNAP participant). Caregivers also described sometimes feeling embarrassed when making purchases using WIC, particularly if they were forced to return or exchange products they had believed were WIC-eligible.

Barriers to SNAP Participation

SNAP’s Income-Based Eligibility Criteria Can Be a Barrier to Participation for Working Families

Some caregivers described no longer meeting SNAP income eligibility criteria, which are often more stringent than WIC criteria, despite experiencing food insecurity. Caregivers voiced frustration that the program did not consider other essential expenses, like rent, in eligibility determination. One caregiver shared, “They keep going off your income, but they don’t understand that you have bills that you have to pay… People have to put gas in their cars …They don’t calculate none of that” (participant 14, current WIC and SNAP participant). Another caregiver shared her experience just missing the eligibility threshold: “[It feels like] they want me to cut my hours at work to be approved for the program, and I don’t see the benefit in that for my children” (participant 15, former WIC and SNAP participant).

SNAP Enrollment and Recertification Processes Can Be Burdensome and Lead to Unexpected Loss of Benefits

Many caregivers encountered obstacles during SNAP enrollment and recertification, including delays in receiving or renewing benefits. Caregivers also shared experiences of losing benefits, often without previous notification and sometimes because of case worker error. One caregiver said, “It’s the keeping SNAP [benefits] that’s hard. It’s like, as soon as you get a job or you do something and you get a little more money, they cut everything off. Or somebody does something in the system and messes up your entire application, [and then] you have to redo [it]” (participant 3, current WIC and SNAP participant).

Improving WIC and SNAP Enrollment and Redemption

Both WIC and SNAP Enrollment Processes Could Be Improved by Decreasing Stigma Associated With Program Participation

Caregivers described stigma encountered in WIC and county assistance offices, as well as broader societal misconceptions around program participation. One caregiver shared, “It’s not good to already be in a stressful life situation and then have to go into these atmospheres where the workers aren’t friendly, too. So maybe more training for the workers to learn how to deal with people in high-stress situations in a more professional and courteous manner” (participant 18, former WIC participant, current SNAP participant).

Online and Phone-Based Benefits Enrollment and Redemption Support Could Improve the WIC and SNAP User Experience

Many caregivers discussed the convenience of online and phone-based enrollment applications, compared with in-person or mail applications. One caregiver shared, “I feel like more people would enroll [in WIC] if they didn’t have to physically go down there and be interviewed” (participant 21, former WIC participant, current SNAP participant). Another caregiver highlighted the value of the WIC smartphone application for identifying eligible products, “If I’m not sure about something, I can check the WIC app to see what qualifies for it” (participant 10, current WIC and SNAP participant).

Improved Coordination Between Health Care Providers and WIC and SNAP Could Boost Participation

Multiple caregivers suggested improved coordination between WIC, SNAP, and medical offices as a potential strategy for increasing enrollment and retention. One caregiver said, “They should have a WIC department inside of the hospital…so when people have their infants, they can sign up for WIC right then and there” (participant 33, current WIC and SNAP participant). Caregivers also suggested that clinics should provide families with help enrolling in WIC and SNAP, and that sharing children’s measurements and laboratory values with WIC could minimize the need for redundant testing.

Discussion

This study is among the first to simultaneously examine perspectives on WIC and SNAP among a population of low-income caregivers with experience using both programs. Participants valued WIC’s provision of infant formula, breastfeeding support, and subsidies for nutritious food, but disliked stringent product restrictions and associated in-store shopping challenges. These findings are consistent with previous reports on barriers to WIC participation.^11–16 Regarding SNAP, participants valued the flexibility of benefits, but noted the sometimes limiting nature of income-based eligibility criteria and highlighted the need to reduce administrative burdens associated with maintaining benefits. In line with this suggestion, previous research on the SNAP program has shown improved retention in the setting of policies that simplify recertification and reduce the burden of interim eligibility reporting requirements.^29,30

Across both programs, caregivers discussed stigma encountered in program offices and opportunities for technology to improve the user experience. Importantly, improved coordination with clinics and health care providers emerged as a key strategy for improving enrollment and retention. Participants noted that parts of their children’s WIC appointments, like measurements of height, weight, and hemoglobin levels, could feel redundant with well-child visits and viewed this as an opportunity for improved data sharing to reduce redundancy. Participants also supported creating standardized processes for WIC and SNAP enrollment in clinical settings, like having a benefits enrollment navigator available to families during primary care visits.

The themes identified in this study highlight the need for clinicians and health systems to support families in accessing and using WIC and SNAP. Several pediatric primary care clinics have started working toward improved coordination with WIC through colocation, electronic health record integration, and even coenrollment at concurrent primary care and WIC visits.^31–35 The concurrent care model allows families to complete WIC enrollment and receive WIC nutrition and lactation counseling during primary care visits, resulting in improved convenience, reduced redundancy, and decreased transportation costs.³⁵ Our findings provide support for scaling these approaches, which could mitigate the sometimes duplicative nature of pediatric and WIC office visits. Some clinics have also begun providing colocated benefits enrollment support through medical–financial partnerships, and our findings support this approach to both addressing food insecurity and boosting government nutrition program participation.^36–38

Our findings also highlight potential strategies for federal and state policymakers seeking to improve WIC and SNAP to better meet families’ needs. In April 2024, the USDA’s Food and Nutrition Service announced several changes to the WIC food package, including soy-based substitutions for dairy products and an increased fruit and vegetable allowance.³⁹ Although these changes are promising, our findings suggest that future WIC innovations should also focus on minimizing size and packaging restrictions and ensuring vendor compliance with labeling of WIC-eligible products. In addition, our findings support continued implementation of virtual options for WIC certification, benefits reloading, and nutrition education.⁴⁰ Studies have shown that applications like WIC Shopper are associated with increased benefit redemption, and our findings support broader awareness and adoption of these applications.^41,42 The challenges described by caregivers of children with food allergies also highlight the importance of clear communication of WIC policies to beneficiaries, because WIC does allow some food substitutions with physician attestation of an allergy.

Food and Nutrition Service also published its reevaluation of the Thrifty Food Plan in 2022, resulting in a 21% increase in SNAP benefits.⁴³ Our findings support this expansion, given the many competing expenses faced by working families. Our findings also suggest that modifying SNAP to only cover foods that are deemed nutritious, as has been proposed in Congress,⁴⁴ may have the unintended consequence of reducing the flexibility, autonomy, and ease of redemption that beneficiaries currently value. If policies that restrict SNAP purchases to nutritious products are implemented, our findings suggest that policymakers should focus on ensuring clear labeling requirements that facilitate easy identification of SNAP-eligible products and optimize the in-store experience for beneficiaries. Across both programs, state agencies should ensure staff are trained to minimize stigma associated with receiving benefits and to treat all applicants and beneficiaries with dignity and respect.

Our study has several limitations. As a qualitative study of a low-income English-speaking primary care population in West Philadelphia, we acknowledge that the themes that emerged may not be generalizable to other settings. Although there are national standards for both programs, administration of WIC and SNAP varies widely by state. Health systems and state policymakers should therefore consider conducting similar qualitative studies focused on their own patients and constituents. In addition, future studies should include caregivers who speak languages other than English, because these individuals likely have unique experiences not captured in this study.

Conclusions

Current and former WIC and SNAP participants suggested several improvements to boost program participation, including reducing stigma in the enrollment process, decreasing administrative burdens in the renewal process, and improved coordination with health care providers. To help close the eligibility/enrollment gap, pediatric providers should consider partnering with local assistance offices and federal and state policymakers to provide health system-based benefits enrollment support, improve data sharing to reduce redundancy for participants, and advocate for WIC and SNAP programmatic improvements.

Glossary

SNAP

Supplemental Nutrition Assistance Program

WIC

Special Supplemental Nutrition Program for Women, Infants, and Children