Oby: From the campus of Harvard Medical School. This is Think Research, a podcast devoted to the stories behind clinical research. I'm Oby.

Brendan: And I'm Brendan. And we are your hosts. Think Research is brought to you by Harvard Catalyst, Harvard University's Clinical and Translational Science Center.

Oby: And by NCATS, the National Center for Advancing Translational Sciences.

Brendan: The special Supplemental Nutrition program for women, infants, and children or WIC is a federal assistance program that provides nutrition education, benefits for foods, health care referrals, and breastfeeding support to low income families. The program serves over 7.3 million low income women, infants, and children across the country. Despite its many benefits there continue to be a significant number of families that, while likely eligible, are not participating in the program. And among those that participate some families don't use all of the benefits that are available to them. Understanding the factors that drive the low use and early dropout of WIC is critically important for developing effective policy and program interventions.

On this episode of Think Research, Dr. Ruslan Nikitin of Harvard Catalyst welcomes Dr. Eric Rimm, professor in the departments of epidemiology and nutrition at the Harvard T.H. Chan School of Public Health. Rachel Colchamiro, the director of the nutrition division at the Massachusetts Department of Public Health. And Cristina Gago a doctoral candidate at the department of nutrition at the Harvard T.H. Chan School of Public Health to discuss their findings.

DR. RUSLAN NIKITIN: Eric, Rachel, Cris, welcome and thank you so much for joining us today. I'm excited to have you share about your project with our listeners. But before we dive into the research project, let's first talk about the WIC program. Rachel, for those who might be less familiar with the Massachusetts WIC, can you briefly describe this program? How does it work and who are the primary beneficiaries?

Rachel Colchamiro: Sure. So, the WIC program is a federal nutrition program that is available in all United States and territories. And it's a program designed to influence nutrition and eating behaviors for a lifetime by targeting a particular period of time in the life cycle that's really critical for nutrition. So, the WIC program serves pregnant participants, children up to the age of five, which includes infants, and postpartum and breastfeeding participants. And through the program participants receive nutrition education, assessment, counseling, breastfeeding support and education, referrals to other key health and social service agencies or organizations, and benefits to purchase healthy specific foods.

DR. RUSLAN NIKITIN: Now, let's talk about the project. Eric, can you tell us about your project and what inspired you to do it?

DR. ERIC RIMM: Yeah. Thanks, the excitement for us was, here is a federally funded Nutrition Assistance program. Which essentially allows those participants that Rachel noted, to have a food package-- have the ability to make their own decisions and purchase a food package which is deemed as a healthy number of foods every month. And in Massachusetts about 100,000 beneficiaries a month.

So, it's like a great opportunity to come into policy level and to say, are there levers that we can help the WIC office understand about how to have more people redeem their full package every month. And that really was the main impetus, is that, here's a benefit that's given out and not fully used.

I had done a lot of work before this with food stamps, now called SNAP. Where every month almost all of the benefits are used and we wanted to use this opportunity. One is because it's an incredible training opportunity for our doctoral students to be able to work with a state office that has such savvy leaders, who are interested in what we were doing. So, it really was a great opportunity to wrap in some doctoral student work. And to work with a really large data set to look at the beneficiaries and what they were purchasing every month and where they were purchasing it every month.

So, we wanted to use this as a dual opportunity. One is to have one student be on the ground and being actually talking to beneficiaries and trying to understand where the problems were. The WIC office was, as I said, very savvy, knew a lot of the issues already. We wanted to see if we could contribute a bit more. But then we also wanted the opportunity to work with a large data set. All of the sales that were made between 2015 and 2019 that had WIC benefits were used gave us the opportunity to see where people were shopping for these benefits.

DR. RUSLAN NIKITIN: Thank you Eric. Cris, tell us a little about your involvement and why this project was important to you.

Cristina Gago: Yeah. First off thank you.

So, another PhD student and good friend, Kelsey Vercammen, actually invited me to join this project back in the proposal stage three years ago. So, at that point she knew that she wanted to do a mixed methods study just like Eric described. And she had already really defined the issue but she wanted someone to take the lead on a secondary qualitative arm. Which would complement her quantitative work with that huge incredible data set that Eric just talked about. So, she invited me to take the lead on that piece under the mentorship of an expert in our department Professor Erica Kenny. And then from there we took off immediately. So, we drafted the proposal and revised and presented it. And it was a total whirlwind.

It turned out to be one of the most formative experiences of my research training because I was involved in every single step, from the proposal to publication. Which I think is pretty unique at this stage in a PhD program. So, it was really a safe space to translate and apply everything I had learned as a student, especially knowing that I had such involved and supportive mentors throughout the entire project. Who were supervising and always providing constructive feedback.

Ultimately, I was really drawn to this project for similar reasons to Eric, because of the real world impact it could have. So we could identify specific facilitators and barriers that caregivers faced in accessing their benefits. Then we can form constructive recommendations for actionable change. And ultimately that could improve access to those who need services the most, which is exactly what we wanted to do.

DR. RUSLAN NIKITIN: That is wonderful. Now Rachel, in your experience, what are the key drivers for sub-optimal utilization of WIC that you may be seeing in Massachusetts and why?

Rachel Colchamiro: So, in terms of program participation, we actually have a really good coverage for infants in the program. And we do an annual needs assessment to take a look at the births that occur and those who are likely eligible due to their MassHealth or Medicaid enrollment and compare them to who's actually participating in the program. And we have really high participation with infants. And historically, it's been a little bit tougher to look at children and women. I think that kids as they get older are participating in different nutrition programs and might have access to resources from multiple places. And the logistics of getting to the WIC program and maintaining certification become a little bit more challenging as children get older. We've actually seen a little bit of improvement in that during the pandemic, which I know we might talk about later. So among pregnant people, I think, understanding that WIC is available to folks as soon as they think they're pregnant and that it's not just for children and babies and we can serve participants during pregnancy is really important. So, I think, awareness is an important factor.

In terms of the food benefits and looking at proportions of food benefits used, it has been a challenge that all WIC programs are facing. And some types of foods are redeemed at higher levels than others. We've had a lot of improvements over the years moving from a paper based food benefit issuance system, where folks had to bring checks to the grocery store. And now we all, for the most part, all states are operating with electronic benefits. And folks have much more flexibility and hopefully more ease and less stigma moving through the transactions. But we are still seeing issues with benefit redemption in certain categories. And it could be because some of the foods might not be valued by families and that's something that we're working on a national level.

A lot of times people forget to use their benefits and WIC benefits, they're meant to be supplementary. So they're a little bit different than SNAP in that way. They're meant to complement a person's nutrition needs and they only are available in the given month and some people sometimes forget to use them. A lot of times the process at the registers is complicated and folks have to use their benefits first in order for them to be utilized for the purchase. And so there's some technical challenges there. But in general we really are working on improving utilization. And one thing that we have hopefully been doing is trying to improve the shopping process. And that has, I think with technology over the years, has been getting better. But I think there's some challenges in the shopping process.

DR. RUSLAN NIKITIN: Now let's talk about Massachusetts WIC during COVID. We know that low income families have been disproportionately affected by the COVID crisis. Eric, from the research perspective, did we see any surprising trends with regard to utilization of the WIC program nationally and in Massachusetts? And how did it inform your own research?

DR. ERIC RIMM: Yeah, it's such a complex question. Since there are many different things that happened during COVID. And it wasn't just one point in time where, oh, now we have COVID and this is what happens. Because as COVID progressed, there were waivers that kicked in that allowed Rachel and her whole team to be more flexible working with beneficiaries. And allowing them, obviously, so they didn't have to come in. They could do everything virtually, made it easier to sign up. I mean, there still are issues of how to use the benefits. And in Massachusetts, there's about 1,000 different eligible places that people can go to use their WIC benefits to purchase food. So you can imagine the complexities of that during COVID. Our main project that used this huge data set actually stopped. We stopped collecting data, I mean, we stopped using data in the middle of 2019. So that part was pre-COVID.

But I'm going to pass it over to Cris. Because we had hoped to do these focus groups and had planned these focus groups where you would have 10 people in a room discussing the issues related to shopping, but then COVID happened. So, it really transformed what Cris was able to do. And as she said, what she did and what she was able to do with the team of people that she put together was amazing. So, let me pass it to you Cris. And Rachel can speak to exactly beneficiary trends because there was some drops and some increases, as you would expect. As unemployment rates went up and down and as needs change, there were some big changes. The last numbers that Rachel did show suggesting that there really is fantastic-- they're doing a fantastic job of reaching out to vulnerable populations. But Cris, maybe you can speak to exactly how you had to transform what you did and what you heard. Because I think it was a really important part of your findings from your paper on what happened during COVID.

Cristina Gago: Yeah, that. We had actually received funding months earlier and then in preparing everything, which obviously takes time. By the time that we were into-- suppose it was like the beginning of the year, right before COVID hit. We had just gotten IRB approval for our focus groups and everything was developed and ready. And then everything went online which has presented a lot of methods issues, as you can all imagine. With, how do we collect data? How do we recruit participants? How do we ask questions that are relevant to today's world but reflective of the broader world beyond COVID? Which in all honesty, at that point, I thought was not going to last that long.

So, in translating, yeah, we had to move from in-person focus groups to phone interviews. And so, as an individual, they weren't able to interact with other parents, which is obviously a negative. And then we ended up recruiting mostly online. And I also visited every Market Basket in Massachusetts. Which was, like, the only grocery store that would let me post flyers and I'm really appreciative of them. And ultimately we also ask questions about their experience during COVID. But we try to focus everything on the past with how their experiences were in the longer term before this pandemic. And, so now, I think, I'm going to pass it over to Rachel, because she can speak much more to the experience of beneficiaries. But that was our experience with the research at least.

Rachel Colchamiro: Well, first of all, everyone knows that food insecurity grew tremendously during the pandemic. And we worked really hard with our partner agencies with all types of programs that provide food assistance to folks and we all saw similar trends. But we did see about a 10% to 12% in our caseload from the beginning of the pandemic until today. And we did have a little bit of a dip over the summer time. I think there were a lot of food resources available to families. But that's actually reversed itself and now we're still seeing some climbing numbers.

So, I think, what allowed us to maintain that momentum and really be able to serve families, is the fact that we had electronic benefits for shopping and that we could load those benefits remotely. Which is not necessarily the case in all states. It depends the kind of system they have. But we could make changes to prescriptions and issue folks benefits remotely without them being in-person at clinic.

We also have extremely amazing 90 something percent. 90 plus percent utilization of our app, for our-- it's called WICShopper, and it allows folks to see the benefits they can purchase, where they can buy their food, when their next appointment is, and then allows them to scan food items in the supermarket to see if they're eligible for the program and available to them in their benefits. So that's been extremely amazing. And the other thing that it allows us to do is communicate with families. Because we can post banners and information about how to access WIC during the pandemic. And that was really an important tool.

And from the USDA side, which is the agency that provides funding to the WIC program and oversees it. We got several waivers that allowed us for flexibilities to do all our services remotely, to issue benefits remotely. So I really have a lot of flexibility in how to provide services on the staffing end on our side.

And, so, it became much more accessible to families and that is part of the reason why our child participation rate has really increased over the past two years. Because in traditional WIC service delivery you have to have physical presence, come into the clinic, for kids at least twice a year and that wasn't possible during the pandemic. And so our phone counseling and services was still in place and we were still talking to families every three months, but the access was just so much greater. So, we definitely saw some shifts in how the program operated and in turn shifts and how people interacted with it.

DR. ERIC RIMM: I think, one thing, just to add quickly, that came out of Cris's work was the fact that people were seeing food insecurity when they were watching the news and they were seeing people line up at food pantries. And in Cris, in interviewing people during her focus conversations, was that some people felt that they didn't want to redeem some of their benefits because they felt that they were taking benefits away from others. Which really surprised me initially. There's people who qualified because of income reasons and because they had an infant, which may represent about half of the children born in Massachusetts. But still they felt like somewhere deep down they were better off than others and felt like they were taking the benefits away from someone else. So some of that is just-- I mean, first of all, that's not true. People are issued their benefits every month and if you get a benefit, it doesn't mean that someone else is not going to get a benefit. So, it was really striking to me how caring individuals were. Not only about their own monthly allotment and how important it was for their child or for their unborn child, but also that they were caring about other people that were in the program.

DR. RUSLAN NIKITIN: Rachel, I also wonder, are there any new policies being currently proposed? Or what type of action is needed from local, state, or federal leaders that can protect food insecure families during public health crises and in general?

Rachel Colchamiro: Well, I can speak more specifically to the WIC program. But we are authorized under the Child Nutrition Reauthorization in Congress, along with other child nutrition programs, and we are overdue for reauthorization. And there are proposals in Congress related to maintaining some of the flexibilities that we did put into play during the pandemic. That would theoretically allow better access, less strict time frames for certain types of documentation submission but still allow for nutrition counseling to happen in WIC, which is a critical component.

And what makes the program so unique is that we are providing services really tailored to individual nutrition needs. So I do think there's a chance that what we learn from the pandemic will be carried forward into future policy. And it's been a great live learning experience to figure out what works and what doesn't and we'll be prepared for that. But even if we don't have regulation shift, we have some flexibility in what we're currently allowed to do that will allow us to take the lessons of the pandemic and move forward.

The other piece of legislation, or policy related documents that we should be seeing pretty soon, are some proposed rules from USDA related to both the food package itself, what's in there and how much of it and also vendor regulations.

And one thing that WIC currently cannot do under current regulation is to allow for online purchasing and online ordering of WIC foods. However, some of us did receive some waivers during the pandemic and we actually are one of three projects that has been funded by USDA to pilot online ordering in the WIC program. And we are doing that in conjunction with Walmart and FISCDP, which are our EBT processors.

So we're really excited about that. And we think that there could be movement on the national level for proposed rule changes that would allow transactions to not be in front of a cashier for the WIC program, which would be tremendous in terms of accessibility for food.

DR. RUSLAN NIKITIN: Thank you, Rachel. I now want to move on to the research findings. Eric and Cris, what were the key findings of your research? What surprised you the most? And what are the implications of these findings on the WIC policy in practice?

DR. ERIC RIMM: I think that's a big question. I think some of it was the challenges of working with the state obviously. Rachel, as the director of the WIC program, can't hand over this highly secured data to us and say, here's everything we know about our beneficiaries. So, some of the challenges we had were, how can we package the data and look at it and still ask useful questions. And one of the questions that Kelsey and I were interested in was, where are people redeeming their benefits and does the location of where they usually shop and redeem their benefits impact on how much of their benefits they redeem?

And I think that finding was surprising to me. Maybe it wasn't surprising to Rachel, but the fact that people who redeemed most of their benefits at superstores were less likely to redeem their full food package. And superstores and the use of superstores has been growing over the last four years of the data that we had in Massachusetts. So, as I said, there's 1,000 different places you can purchase things and everything from the small supermarket to a convenience store, all the way up to these huge superstores. And it does-- maybe we need to do better education. Maybe there needs to be a better education of superstores. Of how to mark what foods are eligible. We maybe do better at training of cashiers at superstores, so there isn't the stigma of someone shopping at a superstore going in to check out something and the cashier saying, this is not eligible, run way back to aisle 27 and get the right version of this. So that was-- I think that was surprising.

And maybe less surprising was that beneficiaries who shopped mostly at small grocery stores or convenience stores, redeemed the lowest amount of their cash value benefit for buying fresh fruits and vegetables. So every month an individual is allotted $8 to $11-- pre-COVID was allotted $8 to $11 of essentially dollars they could buy on fruits and vegetables. And those were-- they were redeemed but at a lower rate if someone only shopped at small grocery and convenience stores. And that it's likely just availability of is there enough fresh fruits and vegetables there that the shopper liked for themselves or for their infant. So those are the two main findings. And again I'll pass it off to Cris for some of her interesting findings from the focus groups and the qualitative aspects of this research.

Cristina Gago: Yes, so Kelsey and Eric looked at the large scale patterns of redemption from hundreds of thousands of families across the state of Massachusetts. We looked at individual level experiences, which may be generalizable to larger groups. I should say, there were a couple of unique aspects about our study.

The first, is that we documented both current and early leaving caregiver experiences. Which is pretty unique in the literature. Just because, as you can imagine, it's pretty hard to reach folks who chose to leave the program early. But actually like one unexpected consequence of having everything remote is that we were able to reach a lot of people across the state regardless. Not just those in cities but those in rural-- more rural areas and also across three different languages, which was which was pretty incredible.

And from our 37 interviews there were five key themes that emerged. And we wanted to look from the individual experience to the in-store shopping experience to kind of broader policy level factors that impact redemption and retention in the program.

So, the first theme was that the fruit and vegetable benefits are too small. Parents want fruits and vegetables. One mom said, who just enrolled early said, "They give you $11, but that was all that I was using and I didn't think it was worth it." end quote. And following this research we were actually really excited to hear that as part of President Biden's American Rescue Plan Act that amount increase temporarily and we can speak more to this later but we're currently investigating that through a secondary study.

The second theme that we found is that food benefit inflexibility oftentimes prevents full redemption. So there were a lot of positive remarks about the food package and what's included. But kind of the most common criticism is just the inflexibility related to allergies or preferences or culture. Folks wanted more freedom in choosing foods or brands that fit their household preferences.

The third theme was around electronic tools and how exceptional they are in relation to the shopping experience. So as Rachel mentioned-- and I also want to give full credit Massachusetts is kind of a leader and a pioneer in this area. They have implemented so many really valuable reforms. Parents specifically talked about the electronic benefit transfer card which is like a debit card that you can use at grocery stores. And parents also love the WIC shopper app. Like one mom said specifically, "The app was the best thing ever. " end quote. Because it helped them to identify specific products that are eligible. It left less ambiguity. And it also helped to tell them what benefits were remaining and it served as kind of a cue to action or a reminder, you should go to the grocery store today and purchase what's left over.

The fourth theme is that both current and early leaving participants reported positive clinical experiences. So across the board both current and early leaving participants reported good experiences. One mom said, "I didn't have any bad experiences and only had really good ones. I feel like it really helps me." end quote. But more barriers to care were reported, unsurprisingly, among early leaving participants. So for example wait times, ability or inability to reschedule, and also recertification procedures.

And then the fifth theme is that caregivers will disenroll early if they're not in need. And that's exactly what Eric was talking about earlier. And this was not a surprise at all. We know that parents are going to only take what they need. But I think what surprised us is that there were parents that disenrolled early because they thought that they were taking benefits from somebody else who may need it more. And so that's something that we know needs to be tackled. That parents need to understand that they're not taking it from somebody else by taking something that they are eligible for and using it.

DR. RUSLAN NIKITIN: Rachel, how can these findings inform your work going forward? And also, what other topics would be particularly helpful for us to understand in order to develop stronger food and nutrition programs and policy?

Rachel Colchamiro: We did think about how we could move forward based on the initial findings from Cris's project. And one thing is about the messaging of the program and it's actually not the first time we've heard about people not wanting to take it because they think it should go to somebody else. But I think it's really changing our messaging around what participation in the program means and really focusing on the full benefits of the program. And even if folks are feeling like they have enough money for food this program provides very specific nutrient dense foods that are tailored to the family's nutritional needs at the time that they are in their lifespan. So it is like giving a prescription for nutrition that folks need. And so that's a benefit. But also all the nutrition counseling and referrals that go along with that and support. So I think we need to think about our messaging.

Also, the same thing that we need to do with providers, as Cris mentioned. And we actually have had some conversations about how to improve referral networks between providers and the program. And really thinking about WIC as a prevention strategy and getting more provider buy-in to support families to maintain their certification. I think that's really important.

We also can address some barriers that have come up in Cris's research around the certification process. Because of where we are in the pandemic, and with waivers and not really knowing exactly what our regulations will look like, I can't specifically say what we'll definitely need to do. But certainly there are things that we can do, even within our current regulations, that would allow us to provide a little bit more flexibility. And we've learned how to do that during COVID.

In terms of the relationships between the staff and the participants. I think we have a full range. And I think we have situations in which staff and participants are very connected. And we have situations in which they're not. And we need to learn from each other. And we do a lot of quality improvement work in the WIC program. And perhaps, this is an area where we can have programs that have really strong relationships and good practices be able to share their strategies with other programs moving forward.

In terms of your larger question. What else can we learn? I think we need to learn about how folks are becoming aware of the nutrition programs that are available to them and how they're enrolling. What is the impetus? What makes them want to stay across all programs? And we're working really hard to think about how we can work together with other programs, that serve low-income populations, to increase collaboration and increase enrollment for families.

So, we have implemented this prior to the pandemic but we've now strengthened it. We have a data sharing agreement with both the SNAP program and Medicaid MassHealth. Which allows us to identify families who are not participating in the program, but are likely eligible because of their enrollment in other means tested programs. And we send text messages to families, letting them know about the program. And connecting them to our online free application, which feeds their information directly to local agencies who can reach out to them to make an appointment.

So, we've used our technology and we've used our partnerships. And we hadn't been doing that with Medicaid and MassHealth prior to the pandemic. And we started doing it with SNAP and with the bidirectional share. So, we also let them know who's just in WIC and likely eligible for SNAP, but not participating. So we can ensure that families can maximize their enrollment. But learning a little bit more about motivations for enrollment, or just enrollment in general, I think, is really important. This is a good first step.

DR. RUSLAN NIKITIN: So you talked about collaborations, and we all know that effective collaborations are a key to a successful project. So I'd like to briefly talk about your partnership. Eric, how did you identify your collaborators for this project? And generally, how can researchers best leverage community and other partners perspectives in the research process?

DR. ERIC RIMM: Yeah, I won't go into all the history of it. I had attended a WIC conference several years ago and met the then director of the WIC program in Massachusetts. And it was just a discussion about what we do as researchers. What questions she had at the time. And was there any way that we could work together. I had a history of working with large data sets, working with other supermarkets and SNAP. And so, I think, some of it was just a mutual interest in doing research. But then having the opportunity as Rachael stepped into that position was incredible.

You know, I think, some of it is having someone in Rachel's position, being interested in quality improvement. And having us, hopefully, be able to provide something to them, which is something that maybe they otherwise couldn't do. The true challenge was they have jobs. And, so, we had to find something where we could offer something that didn't take up too much of their time. But allowed us to partnership with the hope that we could, in the end, provide them with something that they otherwise wouldn't be able to fund themselves. Or be able to do themselves.

So, as Cris noted, Massachusetts WIC program is at the cutting edge of states across the country. And they're such a positive force and such a great group of people, that Rachel has working underneath her. That I don't want to say, oh, gee, we were absolutely shocked. But it was such a wonderful opportunity for us that Rachel was so supportive, and so giving of her time and her team's time. So it really was-- I think I've tried this in other places and other times and things kind of crash and burn if both sides aren't working together. And this was a time where it clearly did not crash and burn. It really was such a unique opportunity and I do hope that we can continue this. And the idea of this program was to-- this funding program was to create a pilot study. So that we could build from it. So from that sense it really was just a win-win for everybody involved.

DR. RUSLAN NIKITIN: Thank you. Now from the student's perspective. Cris, what advice would you give to other students who are interested in getting involved in nutrition and policy research? Also, how involvement in this project contributed to your doctoral training and overall educational experience.

Cristina Gago: I think, in terms of advice for other students, I would say, to be very thoughtful about who you choose to work with and learn from. When I was applying to PhD programs, I heard from so many people that, more so than what you're working on, who you're working with is what will determine your ability to finish. And also, your general happiness. And I found that to be really true. I feel really fortunate to have been invited onto this project, in my first year by a peer.

She actually invited me at a PhD student party. We were social and we talked and we thought we would work well together. And from that, we built relationships. And we also built up this team, who we're continuing to work with on other projects. And the exciting thing is that projects snowball from other projects. So, who you work with now will impact who you work with in the future. And then who you connect with.

And so, honestly from this, I feel like most of my other research has really stemmed. And, I mean Kelsey and I, endlessly fan girl over Rachel, if that's appropriate to say. And I'm going to keep on bringing funding to her and ideas and questions, as long as she'll have me. And ultimately the contribution to my doctoral training most directly this research resulted in the first chapter of my dissertation, which was recently published. And, it also introduced me to Professor Erica Kenny, who served as a co-investigator on the study. And I loved working with her and learning from her. And so, I actually invited her to join my dissertation advisory committee, for the past two years. And she's fundamentally shaped the perspective I bring as a researcher in training.

And beyond that dissertation, Erica and I and Rachel and Eric, are also working on a secondary project, which is specifically looking at that increase in fruits and vegetables benefits. And ultimately, we want to understand how the implementation of that enhanced benefit can impact disparities that already exist. So that's just one example. But I've actually worked with everybody on this project on other things and that's been the best piece I think.

DR. RUSLAN NIKITIN: And finally, Rachel, how can the research community be an effective partner in addressing nutrition and health policies? How can we more effectively and efficiently translate science into evidence based policies and practices?

Rachel Colchamiro: So, I just wanted to reiterate, I think a lot of things that Eric and Cris said. So, having these partnerships really allows us to increase our capacity. We have a dedicated epidemiologist in our staff, but there's only so much that one person can do. And we have a tremendous amount of data, all WIC programs do.

For example, because of electronic benefits we know this data down to the UPC level. What everyone is buying and quantity and where they're buying it, what time of day they're buying it. But we have an immense level of data that we would never be able to really fully utilize. So these partnerships really increase our capacity. They also give us access to funding streams that we wouldn't have been able to tap on our own.

So, together we can find funding to do projects like this that we wouldn't have been able to seek out from the state level. And things that we can't do on the state level. Like some types of advocacy. And being able to use findings to really push for policy change is something that we can't always do in the same way that a partner organization can. And so that's pretty critical. So I think that that's really important for any program is to have your allies and your collaborators. And having Harvard School of Public Health work on this with us has been incredible.

I think, in terms of making sure the science addresses policy is to really have good relationships. And so that the researchers really have a good understanding of how the program works. And what's feasible and what's not feasible. And I found with this team that was really solid. I've worked with other researchers who want to study things, or do things, that we're not allowed to do or really don't have the bandwidth to do. And this was very realistic.

And so the process was really-- made a whole lot of sense because we can investigate what's currently going on. And think about things that we could actually accomplish and change. And so I think, having that good understanding and a really good working relationship is really important.

DR. RUSLAN NIKITIN: Rachel, Eric, Cris, thank you so much for joining us today. Before we end, I'd like to ask you to share one takeaway with our listeners. What is the one thing you would like them to remember?

DR. ERIC RIMM: Well, I think that one is the uniqueness of a partnership between an academic institution and a state and national organization. That it can really-- it can really work and it can be beneficial to research efforts and can be beneficial to policy efforts. So I think, that's the best takeaway, the most important takeaway.

And for me the takeaway was, wow, this is really a complex system. And my vision of what WIC was, was a new mom being able to get benefits to be able to supply food for their infant. But it's so much more complicated than that because there's adopted children, there's foster children, there's the complexities of many children in one household. So I think, what I learned from it is that this is a really complex program that Rachel runs. And hopefully our partnership can continue to help her make it better.

Cristina Gago: I think that you've covered it. I left this experience just thinking-- being absolutely astounded at the work that WIC does. How much they accomplish on such a grand scale and how well they do it. You would think that people who left the program early would report negative experiences. And by and large the folks who left early said, no, it was great. There were just other factors in life that pulled them away from it. So I left with an immense amount of respect for this program. And also a million other questions to ask.

DR. RUSLAN NIKITIN: And Rachel.

Rachel Colchamiro: I've worked in WIC my entire career. And I feel it's a really important program. And I think Eric mentioned about half the babies born in the United States participate. So it's a really impactful program. But we are so caught up in the delivery of the service that we don't have the capacity to really look at the impact. And to really understand the positive outcomes that are associated with participation. Or understand the things that maybe aren't going so well that we need to change. And so we need to have really healthy research collaborations, partnerships with the program to really understand what we're doing and what we should be doing. And so that's just critical and I do hope that we are able to continue our partnership in the years to come.

DR. RUSLAN NIKITIN: Thank you all so much. That's a wrap.

DR. ERIC RIMM: I've always wanted to say that. That's wrap.

Brendan: Thank you for listening. If you've enjoyed this podcast, please rate us on iTunes and help us spread the word about the amazing research taking place across the Harvard community. To learn more about the guests on this episode, visit our website: catalyst.harvard.edu/thinkresearch.