Gaps in Care, and Nutrition
through Digital Tools
Bitler, PhD | Professor of
Economics | University of California, Davis
& Visitor | Federal Reserve
Bank of Minneapolis
Jenna Nobles, PhD | Demographer & Professor | University of Wisconsin-Madison
Shannon Malloy | Lead Research & Data Associate | Ovia Health
National social programs like the Special Supplemental
Nutrition Program for Women, Infants, and Children (WIC)
safeguard the health of low-income women and children by
providing nutritious foods during critical parts of
their lives — pregnancy and early infancy. Research
shows that participating in WIC improves physical and
mental health outcomes for both mom and baby. Although
almost half of all infants in the U.S. are eligible for
WIC, many don’t take advantage due to lack of knowledge
about the program, how to access it, or a stigma against
But, if nutrition is critical to ensuring healthy pregnancies, how can we connect more moms-to-be with the healthy food and resources they need to have a healthy, successful pregnancy? Researchers from Ovia, University of California-Davis and University of Wisconsin-Madison are studying just that. Tune into this episode to hear research experts discuss the first-ever randomized control trial to improve WIC enrollment, using a digital tool like Ovia, and the potential impact on health equity and outcomes.
Check out other research mentioned in this episode
Health Equity, Gaps in Care and Nutrition through
Shannon Malloy [00:00:00] Hello, everyone, and welcome to another episode of the Ovia Asks podcast. I'm Shannon Malloy, one of Ovia Health's lead researchers on our clinical team. I'm honored to be joined by two of the nation's leading experts on health, nutrition, behavior change and food security. First, Dr. Jenna Nobles, a sociology professor at the University of Wisconsin-Madison and the director of Wisconsin's Center for Demography and Ecology. And secondly, Dr. Marianne Bitler, who is a professor of economics at the University of California, Davis, whose research focuses on the effects of government safety net programs such as WIC.
Today, as I'm sure many of you know, payers and organizations are more focused on improving maternal and infant health equity, addressing the social determinants of health and reducing barriers to care for patients. But the drivers impacting outcomes are complicated and often difficult to address. That doesn't mean there aren't things you can do to help.
Which is why I'm so excited to have Jenna and Marianne on today to discuss the first ever randomized controlled trial (the gold standard of research) to improve enrollment among women eligible for WIC, otherwise known as a special supplemental nutrition program for women, infants and children using a digital tool. Data suggests that it's possible for virtual health solutions to address the social determinants of health, drive holiday decisions and improve outcomes, especially for Medicaid eligible populations.
Good afternoon, Maryann and Jenna. Thank you so much for being here. I'm so happy to have you here today to talk about all things nutrition, food security and behavior change to drive healthy decision making. So before we jump in? Tell us a little bit about yourselves and your work.
Marianne Bitler [00:01:49] My name is Marianne Bitler and I'm a professor of economics at UC Davis and a research associate of the NBER. And my research focuses mainly on the effects of the means test and safety net programs like SNAP and WIC on women, children and other disadvantaged populations. And as I am already suggesting, I focus a lot on food assistance programs and also some on fertility behavior. And I'm particularly an expert on the WIC program, having served on a National Academy of Sciences, Engineering and Medicine panel and evaluating the new food package.
Jenna Nobles [00:02:19] Hi, Shannon, I'm Jenna Nobles, I'm a demographer and on the faculty at University of Wisconsin-Madison. I study fertility and pregnancy health with a focus on the features of people's communities—health care availability, environmental hazards, policies and programs—that shape their fertility and their pregnancy health.
Shannon Malloy [00:02:37] Wonderful, thank you, both your backgrounds are just so impressive, and we are so grateful to work with such incredible partners. And that's also why we were thrilled to WIC with you, particularly on the research with WIC and behavior change given both of your skill sets. So speaking of WIC, can you tell us just a little bit about the study? What's the purpose and what's the study design?
Marianne Bitler [00:02:59] So I'm going to start with a little background. In the U.S. we have a what I would call a fractured safety net of means-tested and universal programs. These are programs which either provide cash or in-kind benefits to eligible participants and include programs like WIC and SNAP, as well as the Earned Income Tax Credit and other programs.
Participation in these types of programs, like WIC, is driven by both eligibility, that is a person satisfying the rules the program has to become a participant, and also by whether people apply for the program.
In the case of the WIC program, as with many other programs, participation is well under 100 percent of those people that are eligible and which agencies and USDA would like to increase participation among those eligible because they think that the program has benefits for people who could be getting it and aren't.
Jenna Nobles [00:03:48] Yes, and during pregnancy, it's actually far under enrolled. So only about half of eligible people are enrolled during pregnancy. Ovia provides an unusual platform where it's possible to engage with people far earlier in pregnancy than it's possible through any kind of clinical setting.
So, for example, Ovia and individuals are learning about pregnancies much, much earlier than, for example, somebody shows up at a clinic. It's a platform that people seek out to learn about the resources available to them in pregnancy. And so our research takes advantage of this to learn whether platforms like Ovia could be a way to reach low income pregnant people and connect them to programs like WIC that support them during pregnancy programs they may not know much about or programs they've had trouble connecting to.
And the value of doing this is really, you know, remember that nearly half of pregnant women are eligible for WIC. That's nearly 1.8 million pregnant people a year who are eligible for nutrition support, and over 800000 people are eligible but not getting these services. From the perspective then of the infants who are born who would benefit improvements in their parents’ nutrition during gestation: it’s about one fourth of U.S. infants whose health we could potentially improve by better connecting their parents to the safety net. And so here we're thinking about whether or not a platform like Ovia can be a mechanism to do that.
Marianne Bitler [00:05:09] And so we're carrying out an experiment to see whether telling women who are likely eligible for WIC and are pregnant early on in their pregnancy makes it more likely that they will participate in WIC and have better health outcomes. And we're going to randomly assign this information about possible eligibility so that we can compare women who would otherwise be the same.
We also leverage our unique data collected during COVID to explore pregnancy experiences during COVID and hopefully understand how, when WIC made some rules not apply during COVID so that people could do things remotely, that improved outcomes.
By randomly assigning pregnant people to get information about WIC or nutrition, we're making sure that differences in WIC take up are driven solely by the information and not by other factors.
We view this very much as a pilot to test the ability to reach people where they are, people who are already on these apps and help people enroll for programs for which they're likely eligible when they participate in an app like Ovia.
So our hope is to enroll 6000 women. This is the first study, that we're aware of, that uses a randomized control designed to attract women to the WIC program. And because we're leveraging a digital tool, we can recruit women on a national scale right away. So women all over the U.S. are signing up every day and we can recruit them immediately.
A lot of the existing WIC research that's been published recently only represents individual states like California, or New York, or Texas. And this might be misleading in terms of the sense it gives you of the program as a whole.
An additional bonus to having a national population is that we can leverage state variation, and that's vital to our understanding of what are the barriers to getting enrolled. And as far as we know, this is the first study to encourage women to participate in WIC and by far, to our knowledge, the largest.
Jenna Nobles [00:06:55] And we're really thankful to both J-PAL—the Jameel Poverty Action Lab in the US—and to the University of Wisconsin-Madison for funding this pilot study. These resources have been essential to get this work off the ground.
Shannon Malloy [00:07:11] Wow, that's fascinating. I can't believe that almost half of all infants in the US are eligible for WIC, yet, only a fraction of them actually enroll and take advantage of these benefits. Could you maybe explore the historical barriers to WIC, enrollment, and even doing research about WIC in general?
Marianne Bitler [00:07:32] Sure, there are a few challenges associated with studying a program like WIC. So first, people make choices about whether they're going to sign up for programs based on:.
1: Their assessment of the trade offs of benefits and costs for them.
2: If they know about them.
3: The barriers that get in the way of applying for them.
4: Also whether they're eligible or not, which is a uniform program across the U.S. for the most part.
And so participation is mainly driven by individual choices, which makes it even harder than in other settings where there's a lot of state choices. So if the state is making it really easy to get on one program in one state, and not in other states, then you can compare otherwise similar people and learn about what the effects of the program are. But because WIC is such a national program, it makes it hard to do that.
An additional challenge aside from this causal challenge, is that many women may not know about WIC unless someone else they know is on it and liked it. There also could be differences that are just based simply on where people live, how close they are to the clinic, where they would sign up, and whether there are a lot of stores in their area that participate in the program.
And then, finally, using WIC at the store may be complicated and it may cause stigma for participants. It may be embarrassing to be visualized as the person using WIC to buy food. OK. And finally, for some immigrant groups, even though in almost every state everybody is eligible for the WIC program, there may be concerns about immigration rules.
WIC research also faces a number of challenges. So the first is that we don't have nationally representative data where we know who's on the program. Nor do we know, in good nationally representative data, all the things you would need to figure out who is eligible. So it makes it hard to use these kinds of cross-state comparisons, even if there were policy differences across places. And this makes it so valuable to be able to use the platform and an experiment.
Shannon Malloy [00:09:28] Yeah, that makes sense. And, you know, given the challenges that you laid out with differences across states, it seems like using a digital solution and enrolling women remotely, if possible, would rapidly increase uptake. So that's a really interesting angle. I know you mentioned before that participation in WIC can actually result in some benefits. So I'd like you to tell us a little bit more about that. What impact can participating in WIC have on maternal health?
Marianne Bitler [00:09:59] So this is a program which provides nutritious foods, but it's smaller than programs like SNAP, and it has been shown to have large and positive effects for infant health. We know a little bit less about maternal health, but it is hard to imagine that having healthier infants isn't better for moms. We think that being able to understand how to nudge women onto WIC who wouldn't otherwise participate might be really valuable for being able to detect any kinds of effects. And so we're going to do this by nudging women, and by nudge I mean an intervention that gently leads individuals towards a desired outcome.
So here, the desired outcome is signing up for WIC if you're eligible. The nudge is that we're going to tell you that you are eligible and also give you a link to an app that'll take you to the nearest clinic to you.
Shannon Malloy [00:10:54] Wow, so it sounds like this study is an opportunity to not only continue to research the impact on infant health, but also potentially study the impact on maternal health because we're enrolling women while they're already pregnant. Can you tell us exactly which outcomes the study will be measuring besides what enrollment?
Jenna Nobles [00:11:14] Yes, so we'll be measuring, you know, really a battery of things. This is a pilot study, so we're studying the things that people tell us about their health and well-being, as well as the behavior that we can measure.
So we're primarily interested in if they will enroll in WIC, if they enroll their infants in WIC.
If so, why? If not, why not?
There is this battery of things that tell us about their health and well-being. So if we're able to move the needle on enrollment with this particular nudge and reduce the burden of getting enrolled, it opens up the door for studies that involve an Ovia/WIC partnership. Those studies could use administrative data to examine whether platforms like Ovia can increase enrollment levels that we see in the administrative data versus what people tell us they did. That kind of partnership would also allow an even richer study of maternal health outcomes as well.
And so when we think about this research, to the extent that we're able to demonstrate a proof of concept of using a platform like review to connect people to the safety net, it would be really exciting for us to have a partnership both with a state agency within WIC. And so we're actively looking for partners for the next stage of this research right now and be really excited to hear from anyone who is excited about this work as well.
Marianne Bitler [00:12:34] And something else that Jenna didn't mention is that it would also be super useful for agencies like Medicaid and various states to be able to track the effects of inducing women to participate in WIC. And so there might be room for partnerships between expanding on partnerships that already exist.
We're going to study intended and self-reported participation in WIC after we figure out who's likely eligible for the program and see how it's affected by this nudge to participate in it. We're also going to ask some questions that, as far as we know, haven't really been explored about why people who are eligible for programs but don't sign up for them don't do so. The goal of this is to understand what drives their non participation and how this information nudge can affect us.
So to give you an example, if it's all about not knowing about programs, it seems like there could be a really big role for information. But if the lack of participation is all driven by stigma, then it would take a different kind of an intervention to affect participation.
And we're going to also look at pregnancy outcomes, according to the randomly assigned nudge.
And finally, we're going to learn about experiences during COVID because like many other programs, the WIC program put in a lot of optional waivers for states to take from their usual rules in order to make it easier for people to keep participating in this program during COVID. And the outcomes that we're going to look at are going to include food insecurity as well as maternal and pregnancy health.
Shannon Malloy [00:14:02] Food insecurity makes me think about health equity and maybe social determinants of health. So what impact or potential impact does this study have on health equity outcomes?
Marianne Bitler [00:14:15] Well, it's going to be a first step in trying to see how apps like Ovia can help reach women where they are and try to encourage women to participate in programs in which they're eligible.
Almost no social safety net program has 100 percent participation among eligible people, even programs which are seen as having very little stigma associated with them and are perceived as being nice programs. And this could easily go beyond WIC to other programs, and it can also tell us more about how COVID affected pregnancy differently for different groups.
Jenna Nobles [00:14:46] This provides potentially the first random variation to test WIC use. If we are able to detect health effects of WIC on maternal and child health, this provides important information for policymakers about maintaining support for programs that reduce income associated with disadvantages in child health, like WIC, right.
Shannon Malloy [00:15:05] And I remember Marianne, you mentioned at the beginning that you've been working on some policy implications of these types of programs. So why is that so important for us to do?
Marianne Bitler [00:15:15] Well, if you are going to have programs, it seems natural you would want to have everybody participating in them who is eligible if you think the programs are beneficial. So figuring out why people don't participate in them is a first step towards figuring out how to change it so that people participate in them.
And it's also important to understand where COVID pregnancy experiences were different for various reasons. Some people might have really suffered and others might not have. And it seems going forward it would be useful to know more about that as well.
Jenna Nobles [00:15:49] Generally, federal funding for these programs is something that's decided year to year. It has declined in some administrations and increased in others. Providing ongoing evidence for whether, why and how to fund WIC is important for encouraging safety net support in pregnancy and early childhood.
More generally, leveraging the platforms like Ovia to close health disparities in the U.S. is potentially powerful. It's largely unexplored and underexploited. It's definitely an area where a private or public partnership could be really powerful, and we need to at least explore whether it's possible.
Shannon Malloy [00:16:25] Absolutely, unless, you know, millions of Americans use Ovia every single day, it seems like such a natural organic partnership.
So, you know, given the policy implications and how much is really at stake here for millions of women who are eligible for these incredible, life changing programs, but they don't take advantage of them. How do you see a digital tool like Ovia playing out in this scenario?
Marianne Bitler [00:16:49] So there's a little literature about how reaching people where they are is important.
Many social scientists and some economists are engaged in debates about whether this incomplete participation among eligibles is sufficient (which is sort of a neoclassical economics view) or whether it mostly reflects administrative burden and the associated inability to make optimal choices. The latter is more the view of other economists and most other social sciences.
Any program like WIC is going to have some degree of administrative burden. You have to go somewhere, you have to fill out some form. You had to know that you had to go somewhere. You have to fill out some forms, you have to bring a bunch of stuff. You have to follow the rules of the program and then you get this food benefit later.
Learning more about who's not participating will tell us whether these programs are being well targeted and which would suggest that incomplete participation. You know, you might not want to drive the program all the way to 100 percent if people don’t need the benefit. Or, is it the administrative burden and other explanations are more important, in which case it's the most needy people who are participating.
Also, we just don't know very much about how big the role of information is and use of programs like this. So we're getting some information about whether people haven't heard of this program when they're already pregnant, and that, to my knowledge, is fairly unique.
Jenna Nobles [00:18:03] And by gathering information about why people are choosing to enroll after having this information or choosing not to. It's really helpful for us to think about when, whether or how a platform like Ovia could be used to reduce forms of administrative burden, reduce information gaps.
We realize that they're still going to be barriers to signing up, some of which are that people don't want to. And that's obviously, you know, is just fine. It's more that, for everyone who wants to, how can we make it possible for them to be able to?
Marianne Bitler [00:18:35] And I will just give you a little anecdote that we came across in trying to create our survey.
So in our survey, we asked about two other programs (the Medicaid program in the SNAP program) which I have worked on for a good chunk of the last 20 years. And I had to go look up the state names for the kind of Medicaid most people are on when they're pregnant. And also what the state calls SNAP. And SNAP was fairly straightforward. But for Medicaid, even knowing a lot about the program, it was very hard to figure out what the name was in every state of the program that you would be on that would make you eligible for WIC without having to do anything else.
Jenna Nobles [00:19:09] We're trying to link people to information to get signed up at the clinic nearest to them. It is actually fascinating. We uncovered remarkable state to state variation in how many clicks between finding the site and finding the clinic. And so there are tremendous differences in how hard it is to find your way to enrollment. And if we can learn more about that and try to reduce how hard that is, that definitely lends a great role for a platform like Ovia to connect people.
Shannon Malloy [00:19:42] Definitely. That makes sense to try to make it the easiest route possible in order to get the benefits that these women are interested in and need. So thank you so much for that. That great summary. My question is: we've discussed the study from a public health perspective. We've talked about maternal health and infant health outcomes. We've talked about the policy perspective of proving that a program like this is worth continuing to fund year to year. But my question is why is this important for organizations, especially for payers with commercial and Medicaid populations? And to understand what value does this study bring to them?
Marianne Bitler [00:20:23] Well, I think one important value is that, you know, given this evidence about we're improving birth outcomes, if more women are using WIC it might improve their outcomes and reduce costs for payers, and that holds for commercial payers because there's plenty of people on WIC who aren't on Medicaid, as well as people who are participating in the Medicaid program, so it will have savings in terms of avoided health costs for these groups.
Shannon Malloy [00:20:50] Right, Marianne? And that's such a great point. And with millions of eligible women not yet enrolled in WIC, that must translate to a tremendous cost savings across the entire payer system that are just, you know, up for grabs.
If we were able to enroll or reach the WIC enrollment goals for those payers or state programs, think of the cost savings, and, more importantly, reaching women who are at highest risk of these adverse outcomes.
We know this is a really big focus for many organizations right now. For example, I know that the Blues Association recently announced their national health equity strategy to confront the nation's crisis and racial health disparities. And they cited a specific interest in maternal and infant health. And there are a number of payers and health systems who are also helping to pilot this new NCQA program, called the Health Equity Accreditation Plus evaluation program.
So it's so good to be topical and relevant right now for all these organizations, and it's really great that you are doing research that's going to inform these programs. And I think that we're able to, you know, more importantly, see a real impact on communities and individuals and families, which is really why we're here.
So speaking of what are the implications on individual women or their communities or their families, you know, for this study, what are the short term and long term payoffs for programs like this?
Marianne Bitler [00:22:21] Well, in the short run, we have evidence from a variety of sources suggesting that WIC use improves pregnancy outcomes such as birth weight and reduces infant mortality. And some of this stems from older work about the rollout of the program.
So the program was rolled out in the 70s, and this work looks at birth outcomes using national birth certificate data and finds they're better after the program existed. But there's also more recent work using administrative and linked data from New York, Texas and South Carolina, where people have tracked the outcomes for kids who use the program when either their mothers used it when they were in utero or they used it at some point in their life.
Now, effects on children are definitely less well studied, but some work on my own, using national data, suggests that eligible families' food insecurity goes up when children lose their eligibility for WIC at age five. Luckily, we didn't find worse nutrition outcomes for the kids, but certainly adult food insecurity increasingly suggests that the program is having an effect even for these kids who are still on it at age five.
Jenna Nobles [00:23:22] We're also learning more and more about the long run effects of having adequate nutrition during gestation and early in childhood. Malnutrition early in life has costs for growth, for cognition, ultimately for education.
This then translates into both wages and health in adulthood. And so though we still have much to learn about the long run returns to programs like WIC, particularly on children who are enrolled early and learning about where they're at much later in life, the evidence is clear that ameliorating hunger early in life matters for people's long-run well-being.
Shannon Malloy [00:23:54] Is there anything else you'd like to leave with the listeners today?
Jenna Nobles [00:23:59] I think that as we think about the maternal health crisis in the US and large disparities, maternal infant health by race. What we're trying to work on here is one piece of a much bigger puzzle.
And so what we can do here is try very hard to help people get services that they need and get people in the door. That's one component of a larger strategy that thinks really carefully about endemic racism and the kind of threats and harmful experiences that people have every day in the U.S..
And so when we think about a comprehensive approach to reducing inequity in the US here, we're working on the nutrition piece and we hope that that can move the needle some and ideally that would be combined with other efforts to tackle the threats that Black, Indigenous and people of color (BIPOC) experience during pregnancy.
Shannon Malloy [00:24:53] Wow. Well, thank you so much, both Jenna, Marianne. You know, I personally feel so strongly that this type of work and research like this truly can have such a positive and broad impact on the American population at large and generations to come.
Like you said, you know, nutrition is so critical to ensuring healthy pregnancies. And if Ovia is able to work with you all to connect more moms-to-be with the healthy food and resources that they need to have a healthy, successful pregnancy, that would just be the most rewarding work. Your work not only nourishes moms, but it teaches an entirely new generation about the importance of food, health, preventative wellness and self-care.
So, it's my hope that Ovia will continue to do more studies like this in collaboration with you, with WIC, or with Medicaid. To see organizations leverage digital platforms like Ovia where millions of parents are on there every single day to help close those gaps in care, reduce inequities and have a true impact on maternal health through digital-first technology.
And I would also call on payers and employers alike to look at this success and see new ways to engage and improve the health of your workforce and populations. There is so much you can do and explore. Ovia is really looking forward to the next few years. It's going to be a really exciting future for us to be able to see which organizations adopt early and make a meaningful impact.
So with that, I want to thank you Jenna and Marianne again. It was such a pleasure to work with you as always, and such a joy to hear your thoughts today. And I'm looking forward to hearing more about the results of this pilot study and hearing from you both soon.
Jenna Nobles [00:26:42] Thank you so much, Shannon.
Marianne Bitler [00:26:43] Thanks.
Shannon Malloy [00:26:46] Thank you so much to all of our listeners, and stay tuned for the next episode of Ovia Asks coming soon.