Researcher Profile: Drs. Alice Ammerman & Molly De Marco
Dr. Ammeran began her career as a WIC nutritionist. She is currently a Professor in the Department of Nutrition, Gillings School of Global PublicHealth at UNC–Chapel Hill, and directs the UNC Center for HealthPromotion and Disease Prevention. Her research focuses on the design,implementation, and dissemination of innovative approaches to chronic disease risk reduction (through nutrition and physical activity) in low income and minority populations. Dr. Ammerman co–directs the Center for Training and Research Translation. Dr. Ammerman is a member of the standing NIH study section on dissemination and implementation research and is actively engaged with USDA staff and SNAP–Ed implementers in enhancing their approach to policy and environmental change for obesity prevention, as well as evaluation of program impact.
Dr. De Marco is a Research Scientist at the UNC Center for HealthPromotion and Disease Prevention. She conducts research on determinants of health disparities and food insecurity and focuses on community–based research that engages low–income and historically marginalized populations.For the past four years, she has directed a program, funded through SNAP–Ed, to assist SNAP recipients to make healthy food choices, extend SummerMeals to more SNAP–eligible families in rural communities, and engage SNAP recipients in community gardens to build access to healthy food.
How did you become interested in studying WIC program recipients and retailers?
WIC is one of the nation’s most successful and cost-effective nutrition intervention programs, serving women and children at a critical time for impacting long term health. I (Alice) began my career as a WIC nutritionist at a community health center in Atlanta, Georgia after completing my masters in public health. I (Molly) have a long standing interest in healthy food access and health disparities. WIC is a significant program addressing both of these concerns.
You recently finished a round of listening sessions with WIC users in different states—what would you say are your major impressions from that work? Were there any opinions that appeared close to unanimous, for example?
We conducted listening sessions with women who receive WIC in Texas, Oregon, and North Carolina. One of the key issues we heard was that being able to find the food items that are WIC-allowable was often very difficult. We heard that effective labeling was vital. Retail staff who understood the program well and were efficient as well as patient at check-out were greatly appreciated by WIC participants and this influenced their choice of where to shop.
We also heard that the general approach of shoppers who use WIC is to save money overall. During the listening sessions, there was little suggestion that customers with WIC were selecting more expensive food items unless it related to taste preference particularly for their children
The sessions involve groups of women who use or qualify for WIC—what kind of training does the focus group leader receive to help them make participants feel comfortable?
Experience and sensitivity to different population groups is probably most important. We were both trained in qualitative research methods and have conducted many focus groups over the years with individuals from a wide range of backgrounds and experiences.
What would you say are the biggest challenges for ensuring these sessions are as successful in drawing out useful perceptions and insights as possible from the participants?
It’s important to be welcoming. We make sure we greet everyone when they arrive and provide light, healthy snacks. Everyone is given a table tent to write their name on so participants can become familiar with each other. We also always start with a fun question that everyone can answer like an icebreaker. Some of the listening sessions were held around Thanksgiving so we asked people to talk about their favorite Thanksgiving dish. When conducting focus groups with young mothers, it’s important to be prepared to accommodate their children. In many cases, infants and toddlers stayed with their mother’s during the session, so we provided space for them and quiet toys/distractions such as crayons and paper. Observing the mother child interactions can provide insights as well.
Once you have all the insights from WIC users, how do you go about suggesting changes to retailers in how they handle these customers? What sort of tactics are necessary there, to ensure that your relationship with retailers remains positive?
We are working on a summary of the listening sessions and other white papers that were funded through the BECR Center. Many of these researchers gleaned similar insights from their work regarding what we are calling the “WIC shopping experience.” Because the WIC program provides substantial revenue for participating retailers, it is likely that retailers will be interested in how to improve the WIC shopping experience and maintain store loyalty among WIC participants. We plan to offer retailers recommendations based on the listening sessions and white papers regarding staff training and labeling. This can result in a win-win situation if WIC shoppers bring their business to retailers and if well trained store staff are more efficient at check-out.
Can you give our readers an example of one aspect of the customer service experience to which WIC customers might object, and what discrete thing retailers might do to solve the issue?
In grocery stores there is often quite a bit of clerk turnover as the jobs are fairly low paying. As a result, often the clerks do not understand the WIC program and what items are allowable. This can makes checking out using WIC longer and embarrassing and stigmatize the WIC customer if the clerk doesn’t ring items in correctly. More training for the clerks is one way to solve the issue. Clearly labeling items as WIC allowable will also help reduce the instances of items brought to the clerks not being WIC-eligible.
Can you share with us any next steps for this research? Or, hypothetically, what would be your ideal next steps (if you had access to any data you wanted)? What would be the dream scenario here?
We would like to develop some small scale “experiments” to test customer reaction and perceptions regarding both changes in the store environment and changes in how clerks interact with customers using WIC. It would also be helpful to assess whether these changes have an impact on store sales and customer loyalty. It would be useful to have data to take to retailers demonstrating that an improved WIC shopping experience results in higher revenue and more frequent customers.
In addition to learning about the impressions of store customers, you’ve also spent quite a bit of time on the other side of the equation, with retailers. From the latter’s point of view, what are the major challenges for serving WIC customers?
From what we’ve heard in talking with retail staff and retail association leaders, one of the major challenges of serving customers who have WIC is navigating the WIC system especially when some states are still using paper WIC vouchers and other states have transitioned to an electronic benefits transfer (EBT) mechanism like the SNAP program. In general, WIC retailers using the EBT system find it much easier to comply with WIC regulations and track sales.
Some retailers expressed concern with the multiple transactions required for customers paying for some items with WIC and other items with different forms of tender such as cash or SNAP. These multiple transactions made such check-outs lengthy annoying other customers. We also heard from grocery retail staff that the business often has to “eat” costs if unallowable items are purchased or if there are failures within the reimbursement process.
Grocery retailers also found it hard to keep up with the changes in the WIC-allowable food items. Although many wanted to make more effort to market items directly to WIC customers to facilitate the shopping experience, they were concerned about inducing stigma by making it more obvious which customers were WIC participants.
In addition to WIC participant insights, what other data would be useful in understanding more about WIC purchases and associated costs?
It would be useful to have data to help differentiate what foods are purchased using WIC and SNAP benefits relative to food purchased with non-nutrition-benefit funds. These data are held by different agencies like state departments of social services. This is where we need to work to secure such data. We are in the midst of doing just that.
On the occasion that you gain access to new sales data, what do you look at first? What is the most useful information for you to have, to get an overview of the stores’ customers and their behavior?
We are interested in looking at how purchases differ based on whether cash or WIC or SNAP benefits are being used. We are interested in examining whether purchase behavior changes, for example if healthier food is purchased, once an individual begins to receive WIC benefits. We are interested in learning whether purchase behavior remains the same once WIC benefits are no longer received.
We would also like to learn about how changes within the store environment, say adding more prominent WIC signage, affect purchasing behavior.