WarmRegards Blog – 08/2018 Texting for Peer Counseling Programs

Welcome to the WarmRegards Blog. This blog is supplemental to the popular WarmRegards WIC e-newsletter. Our next issue, “Helping WIC Clients Access Fresh Healthy Foods,” will be released on Thursday, August 23.

Pew Research from Feb 2018 reports that 94% of people age 18-29 and 89% age 30-49 own a smartphone. Obviously electronic communication via smartphone is the method of choice by most WIC participants. It’s an effective tool to engage moms with the goal of increasing breastfeeding rates and WIC participation.

In one study, 353 women were tested to see if weekly text intervention, from 24 weeks gestation to 6 months in age, increased the rates of moms exclusively breastfeeding. At 6 months, the intervention group had almost tripled EBF rates (43%) compared to the control group (15%).

USDA data indicates that moms who are exclusively breastfeeding at six months are more likely to remain on WIC once the child turns one.

A study posted by Colorado WIC Texting for Retention shows that using a texting service to reach out to WIC participants on a routine basis improves retention rates. These studies underscore the value of using text messaging to improve breastfeeding rates, client engagement, and overall WIC participation.

Once participants have received your broadcast text messages, which are designed to be informative and generate engagement, what is the safest way to continue the two-way conversation?

Obviously training protocols are put in place so that peer counselors and other WIC staff understand the necessity of safeguarding client privacy at all times. Peer counselors know they cannot give lactation advice by text: “Use text messages only for simple, quick notes to check in with mom. Discuss specific questions or concerns by phone or in person.” (KY State WIC Texting Policy for Peer Counseling)

Why is it important to ensure that peer counselors never give personal advice by text? Discussing anything personal in nature regarding someone’s current health status (PHI: Protected Health Information) by text is a violation of HIPAA and subject to penalties up to $50,000 per violation.

The HIPAA Journal addresses the technical safeguards over texting. (“When is Texting in Violation of HIPAA?”)

• Data transmitted beyond an organization´s internal firewall should be encrypted to make it unusable if it is intercepted in transit.

“Standard ‘Short Message Service’ (SMS) and ‘Instant Messaging’ (IM) text messages often fail on all these counts. Senders of SMS and IM text messages have no control over the final destination of their messages. They could be sent to the wrong number, forwarded by the intended recipient or intercepted while in transit. Copies of SMS and IM messages also remain on service providers´ servers indefinitely.

“There is no message accountability with SMS or IM text messages. For these reasons (and many more) communicating PHI by standard, non-encrypted, non-monitored and non-controlled SMS or IM is texting in violation of HIPAA.” (HIPAA Business Journal, 2018)

When using a standard two-way conversational texting platform, can you be assured, 100%, that your staff and peer counselors will never discuss anything deemed to be PHI?

Will a HIPAA-compliant, two-way text platform prevent that risk?

HIPAA states that a covered entity must take appropriate measures to protect PHI. A company can ensure their systems storing the client conversations are secure, but that security is gone once the message leaves the texting platform. It travels through normal SMS messaging channels through the carrier to the text recipient.

Unless that conversation with PHI is encrypted, there is no way to protect the PHI. Any system stating they have HIPAA-compliant texting is misleading. Only you (not the system) have control over the unencrypted text messages you are sending and if they are violating any rules about protecting PHI.

“The HIPAA encryption requirements for transmission security state that covered entities should ‘implement a mechanism to encrypt PHI whenever deemed appropriate’.” (HIPAA Journal, 2018)

Although WIC is exempt from HIPAA, many agencies operate as a hybrid entity covered by their departments as a covered component. How can WIC agencies ensure they are safeguarding participant data to avoid hefty penalties?

 Carefully assess text messages to ensure they do not contain PHI. Keep messages more informative and educational in nature.

1. Appointment reminders are allowed as long as the message does not state the participant’s health condition. Avoid words like prenatal, diabetic, etc.
2. If your state requires, collect written authorization before sending messages.
3. Advertise a method to opt out of texts.
4. Keep texts 160 characters or less, including spaces, and send no more than 3 per week. (Tcpablog.com)
5. Only use encrypted chat platforms for two-way conversations, which allow for user authentication and secure sign on.

By just implementing a few protections, as identified above, communicating with WIC moms through text and secure chat apps can be an extremely effective method to improve breastfeeding rates and overall WIC retention.

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WARMRegards July 2018 – WIC Services and Infant Feeding Practices

This month, we’d like to look at parallels between WIC services and clients’ feeding practices, as well as what WIC clinics can do to promote healthy infant feeding practices.

The USDA’s WIC Infant and Toddler Feeding Practices Study compiles years of data to shed light on the association between WIC enrollment and breastfeeding, infant nutrition, and weight status of children up to two years of age. The second study, reported in April 2018, lists several findings:

• WIC mothers return to work or school by about seven months postpartum, at which point fully employed mothers breastfeed significantly less than part-time or unemployed mothers.
• WIC children develop self-feeding skills at the expected rates for infants.
• WIC children receive a varied diet consisting of fruits, vegetables, meats, and dairy, but also consume more candy and sweets.
• With the exception of Vitamin D, nutrient levels in WIC children meet or exceed recommendations.
• WIC children exhibit a concerningly high weight-for-length status consistent with low-income children.

Overall, these findings show that WIC is working. WIC mothers are balancing work and breastfeeding and WIC children are receiving the nutrition they need to make developmental progress. However, there is still work to be done. The study shows that WIC children consume high levels of overly sweetened or salty foods, something that could be attributed to low-income lifestyles and the accessibility and affordability of these snacks. WIC children are also falling short on their Vitamin D intake. The high weight-for-length ratio seen in WIC children suggests a higher susceptibility to overweight or obese status later in life.

WIC agencies can implement responsive feeding programs to help mothers and children maintain healthy lifestyles and avoid the pitfalls of low-income eating habits.

Encouraging Responsive Feeding

The most important thing a WIC agency can do for child nutrition is keep mothers informed. A responsive feeding program, consisting of short educational videos and information mothers can watch and access on their devices at home, can teach mothers how to respond to their child’s hunger in a healthy way.

Responsive feeding is demand-based feeding. A good responsive feeding program should clue mothers in to the cues they should look out for that their child is actually hungry, not just distressed or wanting attention. Once the child is being fed, mothers should engage with their child during feeding and pace feeding according to signals given by the child, stopping when the child is full, not when the food runs out.

At the 2018 California WIC Association Conference, Dr. Alison Ventura discussed the implications of feeding children in the absence of hunger. When children are fed for reasons other than hunger (child is fussy, food is available, etc.), children are more likely to be at risk for obesity later in life. It is during this important developmental time that children establish self-regulation skills and learn how to recognize that they’re full. Difficulties recognizing satiety often lead to overeating in later childhood and adulthood.

Make sure that your clinic is providing mothers with information and support about breastfeeding and bottle feeding, as well as responsive feeding techniques. For breastfeeders, information should include:

• Latching and positioning
• Recognizing hunger and fullness cues
• Common breastfeeding problems

Formula feeders should be provided with information on:

• Positioning
• Recognizing hunger and fullness cues
• Common signs of overfeeding
• Paced bottle feeding

Benefits to Breastfeeding

The American Academy of Pediatrics states that breastfeeding is unequivocally better for babies than bottle feeding. Breastfed infants tend to:

• Consume lower volumes than bottle-fed infants
• Gain weight less rapidly
• Gain less weight in the first two years of life
• Get sick less often

This is because breastfeeding promotes responsive feeding. With breastfeeding, there is no visible amount of food, so mothers feed until the child begins to resist feeding, indicating they’re full. There is also valuable skin-to-skin contact and eye contact that engages the mother and keeps her from distractedly overfeeding.

Complications with Breastfeeding

Women who do not breastfed may make that choice based on a variety of reasons, though a common factor is prenatal obesity. Women with obese BMIs are more at-risk for a variety of pregnancy-related concerns and are less likely to breastfeed (2018 California WIC Conference).

You can provide valuable nutrition counseling to obese mothers to help them maintain a healthy weight and a healthy pregnancy. Be sure to focus on the prevention of risks, not on the prevention of weight gain and size. You can work with the mothers to focus on nutritious food choices based on cultural foods and favorite foods, while reducing non-nutritious snacks and oversized portions. Review food labels with mothers to discuss serving sizes and reasonable calorie intakes.

Nutrition counseling can be provided to mothers right at your clinic. However, some mothers may not have the time to attend nutrition counseling or may not be able to get to a clinic regularly. In these instances, a secure chat app may be a great way to communicate with mothers one-on-one in a safe environment, allowing you to respond to questions and provide information. You can also provide short, informative videos on your website that mothers can access from their devices at home.

A healthy mother is more likely to breastfeed, resulting in a healthier child. While WIC mothers are breastfeeding at a good rate, there is always room for improvement. Be sure to discuss breastfeeding often with your clients and provide them with easy-to-understand resources.

By Shela Ward

WARMRegards 06/2018 – Keep WIC Clients with Older Children

Welcome back to WARMRegards! We’re restarting our popular e-newsletter for WIC agencies and Nutrition Ed programs so we can once again bring you the latest developments in technology, applications, and tips-of-the-trade to support you in reaching and retaining more WIC clients.

We’d like to start with an exploration of a topic that has been extremely popular amongst our readers: retaining WIC clients after the child turns one. The Food and Nutrition Service of the USDA reports that 85% of eligible children under the age of one participate in WIC. This results in about half of all US-born infants benefiting from WIC services. From ages one to four, however, the percentage of participants drops to just 53%. With children being eligible to receive WIC benefits up to year five, that’s a lot of children missing out on nutrition services they need to grow up healthy and strong.

Barriers to Retention

What is it that’s stopping families from remaining in the WIC program as their child ages? We’ll look at several factors that could explain this decline, as well as ways to overcome these barriers and increase retention rates.

The National WIC Association cites socioeconomic status as a possible reason for client drop-off. Higher income families or families where the parents have received a higher education are less likely to remain with WIC after their child turns one. In many cases, these families relied on WIC for help with formula but left the program as their children were weaned. Additionally, as children get older, many families return to a dual-income household and feel they no longer need the extra support provided by WIC, though they may still be eligible.

Another major reason for low retention rates mentioned by the National WIC Association is that parents lose track of appointments or are unable to find appointment times that work with their schedules. With busy lives, these parents might opt for food stamps, which are easier to apply for and retain.

The Center on Budget and Policy Priorities reports that in-person visits to WIC agencies can be extremely difficult for many families, particularly those without adequate public transportation. Of course, WIC policies require in-person visits every six months, making this a difficult issue to overcome.

Retention rates also may remain low because families don’t realize they’re still eligible for WIC. Clients may have difficulty finding WIC policies and determining their eligibility as their child ages. In households with multiple children, each member of the family may have a different certification period with different end-dates. The confusion this creates may prompt parents to give up and forfeit WIC benefits, whether intentionally or by accidentally missing their certification appointments.

Keeping Clients Well-Informed to Keep Them Coming Back

The barriers to WIC client retention include higher income levels, difficulty getting to appointments, confusion about eligibility, and cumbersome certification processes. The most important thing you can do to retain WIC clients facing these issues is to keep them informed – about everything from policies to appointments.

WIC clients who move up to a higher income level may not realize they’re still eligible for benefits. Or, like one parent in a study conducted by the National WIC Association, they may want to leave those benefits for “someone else who could use it more.” Letting them know that every WIC clinic’s caseload is different, and checking eligibility for them, might encourage them to remain with the program as their children age.

Even low-income families may not realize they’re eligible for WIC benefits. The Center on Budget and Policy Priorities explains that recent declines in WIC caseloads certainly raise the question about whether the policies are difficult to understand or the administrative practices are too cumbersome. The best way to reach and retain these families is by providing them with clear, easy-to-understand outlines of the policies and simple steps to follow to apply.

A collaboration of Central New York WIC agencies have developed an online eligibility screening tool that will allow potential applicants to check their eligibility quickly and easily. For busy, young mothers who prefer electronic communication over face-to-face, programs like this can be the push they need to join WIC and begin receiving benefits.

To retain these on-the-go families, consider utilizing a two-way chat app that allows you to reach out to clients in a safe, secure way that doesn’t violate any confidentiality laws. This would enable you to both send out important information and respond to any questions the client might have. A simple texting program, like Colorado’s Texting for Retention Program, makes scheduling and appointment reminders easy and allows WIC clinics to deliver links and information relevant to mothers of young children.

Streamlining the certification process can encourage families to remain with WIC as their children grow older. Look for ways you can ease the process and get the most out of those in-person appointments. Young mothers in particular prefer to handle as many interactions as possible electronically. Requiring only the two mandated in-person visits yearly and providing these mothers with valuable electronic assets (such as videos on topics of interest like breastfeeding and nutrition) may keep these clients from dropping out of WIC.

Remember that every WIC client is different, so their needs won’t be one-size-fits-all. WIC clinics that offer flexibility are more likely to retain clients. Offer things like online appointment requests, video chats, and web counseling to aid busy mothers who want the information and services WIC provides, but may not have the time to make multiple clinic visits. The most important thing you can do to retain WIC clients after the child turns one is to make information and certification requirements easy to access.

By Shela Ward

For past issues of WARMRegards, as well as other valuable WIC assets, visit digiconow.com.

Important Considerations for your Mobile Health Program

Retaining WIC Clients After the Child Turns One