The WIC & KAT Intersection: A Community Needs Assessment of Urban Public Transportation Routes to Grocery Stores in Knox County, Tennessee, 2012
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The WIC & KAT Intersection:
A Community Needs Assessment of Urban
Public Transportation Routes to Grocery Stores
in Knox County, Tennessee, 2012
Fall 2012
Nutrition 505
Dr. Marsha Spence, Instructor
M. Goff, V. Keshani, R. Meade, L. Newman, E. Norton, M. Ruppert, K. Shanklin,
A. Sparks, C. Sugimoto, K. Wallour, Y. Zhang, M. Zitt
ii
Table of Contents
Abstract ..................................................................................................................................................... 1
Introduction and Background.............................................................................................................. 3
Purpose, Goal, Objectives ..................................................................................................................... 5
By October 12, 2012: ........................................................................................................................................... 5
By December 12, 2012: ........................................................................................................................................ 5
Assessment Process ................................................................................................................................. 6
Results ........................................................................................................................................................ 8
Table 1: Demographics of the six target zip codes ..................................................................................... 9
Table 2: Comparison of 2012 Annual Averages of Knox County Health-Related Demographics to
U.S. National Benchmarks, ........................................................................................................... 10
Table 3: Target zip codes with bus routes to respective grocery stores.............................................. 11
Table 4: Each Dyads Comments on Simulated Grocery Shopping Experience ............................... 13
Results Analysis ..................................................................................................................................... 18
Priority Needs ................................................................................................................................................... 19
Discussion ................................................................................................................................................ 22
Joint Collaboration: WIC Program, Grocery Stores, and KAT ................................................ 26
Reflection ........................................................................................................................................................... 29
References ............................................................................................................................................... 32
Appendices .............................................................................................................................................. 37
Appendix 1 ......................................................................................................................................................... 38
Appendix 2 ......................................................................................................................................................... 41
Appendix 3 ......................................................................................................................................................... 42
Appendix 6 ......................................................................................................................................................... 46
1 Abstract Introduction: Participants enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in Knox County, Tennessee expressed concerns about the accessibility and convenience of using public transportation when purchasing groceries with WIC vouchers. Purpose: The purpose of this project was to provide demographic information about six designated neighborhoods in Knoxville, Tennessee and to assess the adequacy, accessibility and convenience of public transportation used by WIC participants when purchasing foods delineated on selected WIC vouchers. Assessment Methods: The assessment team began meeting in September and identified demographic information, as well as targeted zip codes, grocery stores, and transportation routes. Thereafter, six dyads conducted simulated WIC shopping experiences documented with video voice. Results: Students analyzed transportation routes and the overall grocery shopping experience, determined barriers and priority needs, and provided recommendations. Priority Needs: Students determined the following priority needs: a more customer-friendly transportation system, increased accessibility of transportation, improved facilitation of WIC voucher use in grocery stores, more thorough education and materials for WIC participants, and a streamlined WIC voucher system. Recommendations: Students suggest improving the usability of the transportation system, facilitating an easier shopping experience for WIC participants, and streamlining the WIC voucher system.
2 Conclusion: The assessment highlighted the barriers and needs of the WIC program and the Knoxville Area Transit (KAT) system.
3
Introduction and Background
The United States Department of Agriculture (USDA) administers the Special
Supplemental Nutrition Program for Women, Infants, and Children (WIC). The mission
statement of WIC is “to safeguard the health of low-income women, infants, and children up to
age five who are at nutrition risk by providing nutritious foods to supplement diets, information
on healthy eating, and referrals to health care” (1). The public transit system has potential to
provide efficient and cost-effective transportation to grocery stores for WIC participants. The
mission of Knoxville Area Transit (KAT) is, “to provide our passengers with a comfortable, safe
and professional transportation experience, as well as clear, timely information and a helpful
attitude” (2). To ensure that WIC participants receive maximum benefits from the federal
program and the public transit system, it is necessary to investigate their access to grocery stores
and the feasibility of transportation to and from these locations. In addition, the participants’
ability to effectively utilize the bus system to purchase groceries must be considered.
WIC participants in the greater Knoxville area who use the KAT system for
transportation to purchase groceries were identified as the population at risk for this assessment.
Participants who qualify for WIC are low-income pregnant and postpartum women, infants
younger than the age of one year, and children up to the age of five years(3). Income
requirements specify that participants must have a family income level at or below 185% of the
United States Department of Health and Human Services Poverty Guidelines (4) or be currently
receiving benefits from Supplemental Nutrition Assistance Program, Medicaid (or certain types
of TennCare). National statistics from the USDA estimate that, on average, most WIC
participants come from diverse cultural backgrounds and have a relatively low education level
(5). The economic challenges that lead to enrollment in government benefit programs may also4
preclude participants from owning vehicles for transportation. Accordingly, many WIC
participants must rely on public transportation for execution of routine tasks.
WIC participants are given paper food vouchers twice per month, based on the pregnancy
status of the mother and/or the age of their child. The vouchers designate the specific variety of
food that participants can purchase at a WIC authorized store. Fruits and vegetables are separate
from the rest of the voucher items, with a specific amount of money allotted for produce.
Participants are responsible for calculating and weighing items to make sure that the amount of
produced selected falls within the allotted price range.
Some members of the population at risk previously had expressed concerns to Knox
County Health Department (KCHD) WIC office regarding the inaccessibility and inconvenience
of using public transportation when purchasing groceries with WIC vouchers (personal oral
communication, Stephanie Welch, September 10, 2012). Specifically, concerns were voiced
about the difficulty of maneuvering the bus system while carrying groceries and managing
children. As a result of these concerns, a need was identified for an assessment of the adequacy,
accessibility and convenience of public transportation used by WIC participants for purchasing
foods delineated on selected WIC vouchers.
To develop, organize, and execute an assessment, a primary team of students,
stakeholders, and collaborators were assembled. This assessment team included graduate
students in the Department of Nutrition at the University of Tennessee, who were enrolled in the
Nutrition Intervention in the Community course under the direction of Dr. Marsha Spence. Key
stakeholders with vested interest in the project include the KCHD WIC program, WIC
participants, the KAT authority, and Kroger Stores. The primary collaborators involved in the
assessment include: Ms. Michelle Moyers, Program Manager at KCHD; Ms. Lorna Edmond,5
KCHD WIC Director; Mr. Tom Coburn, Kroger Regional Manager; Kroger management team;
and KAT management.
Purpose, Goal, Objectives
The purpose of this project was to provide demographic information about six designated
neighborhoods in Knoxville, Tennessee and to assess the adequacy, accessibility and
convenience of public transportation used by WIC participants when purchasing foods delineated
on selected WIC vouchers. The goal of the assessment was to improve food access and equity to
WIC participants by making recommendations for improvement to the transportation and WIC
voucher systems. The objectives of the assessment were as follows:
By October 12, 2012:
1. Characterize the population served by the KCHD WIC program in six neighborhoods in
Knoxville, Tennessee based on socioeconomic demographics, access to food outlets,
income, gender, crime, race, ethnicity, age, number of children, and number of parents in
the household.
2. Identify urban transportation routes and corresponding grocery stores used most
frequently by WIC participants.
By December 12, 2012:
1. Video record six simulated WIC shopping experiences using KAT.
2. Analyze demographic data and video recordings to determine positive and negative
aspects of the simulated WIC shopping experiences
3. Make recommendations to improve the urban transportation and shopping experience of
WIC participants.6
4. Develop a formal presentation and assessment document for the KCHD and associated
stakeholders.
Assessment Process
The first step in planning this assessment involved gathering relevant data. Ms. Michelle
Moyers and Dr. Marsha Spence introduced the assessment project and presented background
information about the WIC program and the voucher system. See Appendix 1 for types of WIC
vouchers used in this assessment. Ms. Moyers and Ms. Lorna Emond provided the six zip codes
in which the largest population of WIC participants resided in June 2012 as well as the six
grocery stores that received the most WIC vouchers over the past twelve months in Knoxville.
Students used the Google search engine and the Census webpage to determine demographic
information for the zip codes, the proximity of each of the six zip codes to KAT bus routes, and
the stores in each zip code that accept WIC vouchers. The KAT website was accessed to
determine the transportation routes leading to the most-utilized grocery stores within the target
zip codes, as well as protocol for purchasing tickets. See Appendix 2 for a map of KAT routes.
Ms. Moyers and Dr. Spence informed the students that the assessment plan had been
discussed with Kroger administrators, who agreed to allow students to video record a simulated
shopping experience in Kroger stores. The management team requested that the students specify
dates and times that the shopping experiences would occur. Of the six target grocery stores, three
were Kroger, while the other three were Walmart. Due to Walmart policies forbidding video
recording in stores (personal communication with Dr. Marsha Spence, September 17, 2012),
students opted to assess these stores by taking detailed notes rather than filming.
The students divided into six dyads, each of which was assigned one of the six zip codes
for assessment. Each dyad selected a bus stop starting point for the simulated shopping7
experience. Ms. Moyers provided shopping lists that corresponded with three of the food
packages available for WIC participants, and each dyad chose one of these lists to use for the
shopping experience. The provided shopping lists were similar to WIC vouchers for prenatal
mothers, 1 year olds, and 2 year olds. This strategy was selected so that each dyad represented a
different eligibility scenario of WIC participants. KCHD provided each dyad with a Visa gift
card of $80, with which the students purchased bus tickets and groceries. KCHD provided
“Baby-Think-It-Over” dolls for students to carry while shopping and riding the bus to further
simulate a typical WIC shopping experience. The dolls were not activated to minimize
disruptions for other KAT passengers.
Each dyad took one gift card, one “Baby-Think-It-Over” doll, a predetermined shopping
list based on one of the three WIC vouchers, and set out to complete the assessment on a
predetermined date. One student was designated to film the experience with an iPhone (if
assigned to a Kroger grocery store), while the other student performed the simulated shopping
experience. The shopping student was instructed to treat the doll as if it were a baby, handling it
appropriately during the entire experience. Each dyad boarded a KAT bus at a predetermined bus
stop within their designated zip code, traveled with the doll to the destination grocery store, and
purchased all of the groceries on their WIC food package list. Then the dyads returned to the bus
stop and boarded the bus again to return to the original bus stop.
After all of the students completed the simulated shopping experience, the students
viewed their videos and shared verbal and written feedback about each experience with the entire
group. The shopping and transportation experiences were analyzed based on ease of navigating
bus routes, bus timeliness, ease of finding grocery items in amounts designated by the
corresponding WIC food package, and ability to carry groceries while carrying a “Baby-Think-8
It-Over” doll. Beyond the immediate experience of each dyad, students also considered the
relative difficulty of the simulated shopping experience if the doll had been a real child, if
multiple children had been involved in the shopping excursion, or if a larger amount of groceries
had been purchased.
Nominal group process was used throughout the assessment process. The students made
decisions regarding general distribution of labor and data for inclusion and exclusion in the
assessment document. The assessment document was developed and edited in a shared Google
document, which allowed each student to view progress and make comments or changes to the
document during the writing process. To facilitate the nominal group process, students
communicated via email, commented within the Google document, and used other online
messaging systems to give each student the opportunity to share opinions and contribute to the
process.
Results
The demographic characteristics of each of the six target zip codes are listed in Table 1.
For each target zip code, information was acquired about the median family income, percent of
families below poverty level, percent of females, single-mother households, ethnicity and race
characteristics, average household and family size, and the median age. Analysis of some key
data collected for Knox County indicates a distinct disparity between national benchmarks and
Knox County statistics, as indicated in Table 2. The data shows percentage of unemployment and
children in poverty, as well as number of teen births, is higher in Knox County compared to
national benchmarks. Table 3 lists the six identified zip codes, the grocery stores in the zip
codes, and the bus routes to each grocery store. The grocery stores receiving the highest amount9
Table 1. Demographics of the six target zip codes (8-19)
37921 37918 37917 37914 37912 37920
Median family $31,253 $37,806 $23, 807 $30,453 $30,705 $30,426
income
% Families 25.7% 11.1% 11.4% 14.3% 19.5% 22.1%
below poverty
level
% Families 70.8% 47.7% N/A N/A N/A 62.3%
w/female
householder, w/
related children10
Table 2: Comparison of 2012 Annual Averages of Knox County Health-Related
Demographics to U.S. National Benchmarks, (20)
Knox County National Benchmark
Unemployment Rate 7.6% 5.4% (90th percentile)*
Children in Poverty 17% 13% (90th percentile)
Teen Birth Rate 39/1000 22/1000 (90th percentile)
(15-19 years)
*National Benchmark is a desired unemployment rate, the actual US unemployment rate for November 2012 was 7.4%.11
Table 3: Target zip codes with bus routes to respective grocery stores
Zip Code Grocery Store Bus Route
Walmart * Route 20
6777 Clinton Highway
Kroger Route 20
37921
6702 Clinton Highway
Food City Route 20
5078 Clinton Highway
Kroger * Routes 31, 33, 34
37914
Asheville Highway
Kroger * Route 22
2217 N. Broadway Street
37917
Food City Route 22
4216 N. Broadway Street
Walmart * Routes 23, 33
Kinzel Way
Kroger Route 24
37918
5201 N. Broadway Street
Food City Route 24
4805 N. Broadway Street
Kroger * Routes 40, 41
4409 Chapman Highway
Walmart Route 41
37920 7420 Chapman Highway
Food City No route
7608 Mountain Grove Drive
Kroger * Routes 90, 12
4440 Western Avenue
37921
Food City No route
1950 Western Avenue12
of WIC vouchers in the past twelve months are listed in Table 4. The corresponding comments
contributed by each dyad about their respective simulated shopping experience and use of
transportation are included for each store. Both positive and negative aspects of the experiences
are listed, with some basic suggestions that were noted during each trip.
In addition to the comments from each dyad, video recordings from each simulated
shopping experience were edited into a highlight video
(http://www.youtube.com/watch?v=mbtq41pOEno) . The video was organized into the
following sections: waiting for the bus at the bus stop; riding on the bus to the store; the actual
shopping experience; and then boarding the bus with the groceries while holding the doll and
paying the bus driver.
According to the USDA Economic Research Service (ERS) Food Desert Locator, several
areas in Knox County are considered food deserts. These areas are highlighted in pink on the
map located in Appendix 3. The Healthy Food Financing Initiative working group defines a
food desert as a low-income census tract where a substantial number of residents have low
access to a supermarket or large grocery store. To qualify as a "low-income community," a
census tract must have either a poverty rate of 20% or higher or a median family income at or
below 80% of the area's median family income. A "low-access community" is defined as one
with at least 500 people and/or at least 33% of the census tract's population residing more than
one mile from a supermarket or large grocery store (for rural census tracts, the distance is more
than 10 miles) (6). The USDA ERS Food Environment Atlas indicates that approximately 38%
of the Knox County population has low access and proximity to grocery stores, illustrated in
Appendix 4.13
Table 4: Each Dyads Comments on Simulated Grocery Shopping Experience
Zip Code Grocery Constructive Criticism
Location Store
37920 Kroger The signage at the Walmart where we boarded the bus
Chapman Highway was very small and difficult to see.
The bus did not run on schedule, and was an hour
behind schedule when we were ready to leave Kroger.
It was difficult to track our progress on the bus route;
there was no map inside of the bus and we missed our
bus stop as a result, requiring us to walk a few blocks
to the store.
There was no crosswalk present near the Kroger,
making it difficult to cross the street to board the bus, if
necessary.
The grocery cart returns were close to the store rather
than near the back of the parking lot, preventing a bus-
riding shopper from pushing a cart close to the bus
stop.
The bus stop in front of Kroger was difficult to find
due to the small sign, and was just a grassy area next to
a light pole. There was no seating or shade available.
The WIC signage in the grocery store was not
immediately obvious.
The scale in the produce section was in need of
calibration.14
Zip Code Grocery Constructive Criticism
Location Store
37918 Walmart The bus was early.
Kinzel Way WIC eligible items were not marked in the store. The
only items that were marked were a couple loaves of
bread.
WIC labels were orange writing on white labels and
not very noticeable at all.
It was difficult to figure out how much money we had
left for produce (because of adding tax).
There were too many grocery bags when trying to get
on and off the bus with the baby. If it had been a real
baby it would have been dead.
In addition to attempting to maneuver groceries and the
baby onto the bus, it became even more complicated
because of trying to pay and figure that out with an
unfriendly bus driver.
Our eggs broke as we tried to get onto bus.
We were unsure of where to put all of the groceries
when we were on the bus?
The bags take up a lot of space and if there were more
people on it, there wouldn’t have been space.
We didn’t know that we had to pull the cord to request
a stop. It was hard to maneuver the baby, pulling cord,
making sure groceries didn’t go everywhere. We ended
up riding it all the way back around, which took an
additional hour.15
Zip Code Grocery Constructive Criticism
Location Store
37914 Kroger It was a really good experience.
Asheville Highway The grocery bags broke several times-- they needed to
be double bagged or maybe WIC participants could be
provided with reusable or insulated shopping bags.
WIC approved tags were really easy to identify, but we
were unsure (according the WIC guidelines on our
“vouchers”) whether the foods we purchased HAD to
be labeled with the tag. The cashier cleared this up for
us, but she then proceeded to bag two gallons of milk
in a single plastic bag, which increased likelihood of
bag breaking.
The bus was on time and purchasing tickets was easy.
We could have easily passed Kroger because the sign is
very hard to see while on the bus, luckily another bus
rider helped us get off in time. Perhaps the bus stop
could be better labeled on the map or announced by the
bus driver as it is approaching Kroger.
Would have been nice if the grocery store offered carts
with the infant carrier on top.
Perhaps a cart that we could take from the store to the
bus stop.16
Zip Code Grocery Constructive Criticism
Location Store
37921 Kroger The bus was early.
Western Avenue WIC eligible items were not marked in the store. The
only items that were marked were a couple loaves of
bread.
WIC labels were orange writing on white labels and
not very noticeable at all.
It was difficult to figure out how much money we had
left for produce (because of adding tax).
There were too many grocery bags when trying to get
on and off the bus with the baby. If it had been a real
baby it would have been dead.
In addition to attempting to maneuver groceries and the
baby onto the bus, it became even more complicated
because of trying to pay and figure that out with an
unfriendly bus driver.
Our eggs broke as we tried to get onto bus.
Unsure of where to put all of the groceries when on the
bus? The bags take up a lot of space and if there were
more people on it, there wouldn’t have been space.
We didn’t know that we had to pull the cord to request
a stop. It was hard to maneuver the baby, pulling cord,
making sure groceries didn’t go everywhere. We ended
up riding it all the way back around, which took an
additional hour.
37918 Kroger The bus stop signs were small and hard to see.
North Broadway The bus was 5 minutes late.
Crossing a four lane highway to get to the bus stop was
inconvenient and potentially dangerous.
It was hard carrying all the groceries with a baby and
the groceries were heavy.
Calculating the correct amounts of fruits and
vegetables was challenging; weighing fruits and
vegetables was challenging because some scales were
not calibrated.
The layout in Kroger was good and produce was
nice/organized.
Labeling of WIC foods was recognizable.17
Zip Code Grocery Constructive Criticism
Location Store
37912 Walmart The bus was 10-15 minutes early (we missed it the first
Clinton Highway time by 2 minutes).
WIC labels were not clearly displayed in Walmart -
hard to tell which items they are referring to and
sometimes no items labeled (condensed milk).
No sidewalks were near the destination.
The groceries were heavy and challenging to carry to
bus stop.
There was no shelter over bus stop, in case of
inclement weather.
It was hard to cross the road with groceries without a
sidewalk or crosswalk and with lots of traffic and cars
going 45-50 mph.
The bus stop is not very close to Walmart. There are 3
-4 around but it is still a 3-5 minute walk from stop to
Walmart.18
Results Analysis
Analysis of the assessment results and relevant data indicate that WIC participants face a
number of barriers, in addition to fiscal challenges, that make grocery shopping via public
transportation a challenge. Based on the demographic data gathered, much of Knox County is
considered a food desert, and about 38% of the Knox County population has low access and
proximity to grocery stores (21,22). The amount of food deserts in Knox County greatly affects
the population’s access to food. This lack of access is a barrier for WIC participants who rely on
public transportation to travel to grocery stores. Food deserts can be addressed through a variety
of policy initiatives, including economic incentives to attract grocery stores to these areas,
promotion of farmer’s markets in low-income neighborhoods, and economic incentives and/or
grants for healthier corner stores. These measures have the potential to increase availability and
access of healthier foods for low access areas, which subsequently could decrease a proportion of
the burden placed on the public transit system.
As shown in Table 2, there are distinct disparities between national benchmarks and
Knox County statistics. Knox County has a higher percentage of unemployment and children in
poverty, as well as a greater rate of teen births when compared to the national benchmarks, all of
which could increase the number of individuals eligible for WIC in Knox County. Due to the
financial status of WIC participants, they may be less likely to have access to reliable
transportation. A recent national survey of WIC participants found that location, specialization
in WIC items, store hours and convenience were considered to be high priorities for these
women when procuring WIC supplemental foods (23). These survey results indicate that
accessibility is a high priority for all WIC participants; therefore, Knox County participants may
face greater barriers based on the disparities represented in Table 2.19
In addition to the demographic data collected, the simulated shopping experience
illuminated barriers faced specifically by Knox County WIC participants who use public
transportation. Comments made by dyads in Table 4 indicate challenges in utilizing
transportation, WIC vouchers, and grocery store navigation. These comments were analyzed,
and the recurring themes formed the basis for identifying the following priority needs.
Priority Needs
1. KAT: Need for a more customer-friendly transportation system.
Analysis of the assessment results indicates barriers to efficient use of the public
transportation system. The ease of use of the KAT bus system is crucial for many WIC
participants in Knox County. The first barrier that was evident to the team was the lack of
seating, shade, or shelter at a majority of bus stops. Lack of shelter may prevent some
participants from using the bus system on exceptionally hot or rainy days, as it may be
uncomfortable, or even unhealthy, for them and their children to be exposed to the elements
while waiting for the bus. Secondly, bus timelines on some routes were problematic and
indicated low consistency, with buses running either early or extremely late. This may make it
difficult for participants to plan their day and to depend on the transportation system to get them
to their destination on time. Lastly, many bus interiors that the team observed lacked visible
maps and an announcement system for major stops, making it difficult for unfamiliar passengers
to easily navigate the routes. This may cause riders to feel frustrated or embarrassed because they
missed their intended stops or needed to ask for help. Navigational aids in the buses may
promote a positive experience when traveling to and from grocery stores or any other locations
on the bus routes.
2. KAT: The transportation system accessibility could be improved.20
During the assessment, several dyads noted that bus stop signage was small and difficult
to see. See photograph in Appendix. Bus stops were often located immediately adjacent to
heavily traveled roads that lacked crosswalks, potentially endangering passengers. This would
likely be a major concern for WIC participants with small children. Some dyads had to cross
four-lane highways, such as North Broadway and Chapman Highway, to access the bus stop and
grocery stores. Chapman Highway, in particular, has been the scene of several pedestrian deaths
in recent years. For example, in 2011, a woman crossing the four-lane highway was struck by a
fast-moving vehicle (24). The lack of safe crossing features on roads like these may pose serious
risks to people trying to get to and from the grocery stores, possibly with young children and
heavy bags in hand.
3. Grocery stores: Improved WIC signage and amenities in grocery stores.
Results of the assessment indicated that effective use of WIC vouchers in grocery stores
may be another challenging for participants. While some grocery stores have adequate WIC
signage near WIC approved food items, many lack sufficient or visible signage. Lack of obvious
WIC signage may make it difficult for participants to locate WIC approved foods and
subsequently may be a barrier for participants when using WIC vouchers. See Appendix 5 for an
example of clearly marked WIC eligible items.
The assessment found that the scales in the produce section of one of the stores was
inaccurate, which may complicate the purchase of fresh produce by WIC participants. WIC
vouchers allocate a specific dollar amount for the purchase of fruits and vegetables; thus,
shoppers rely on scales to calculate produce price based on weight. Uncalibrated scales could
easily cause WIC participants to miscalculate the cost of fruits and vegetables, leading to over or
under spending.21
The team found that grocery carts did not have appropriate seating for infant
accommodations, only seating appropriate for small children. This too may be a challenge for
WIC participants because pushing a grocery cart and making food selections while carrying a
child is difficult and inconvenient. Grocery carts with infant carriers would allow WIC
participants with infants to grocery shop more efficiently. In addition, the team found that
grocery cart corrals were largely absent from bus stops along the main transportation routes,
except those bus located at the entrance of grocery stores. Therefore, the assessment team
members, all of which had numerous bags were not able to push the cart to the bus stop; rather,
they had to leave the cart closer to the store and carry their bags. Grocery cart returns near bus
stop would most likely reduce the amount of time WIC participants would need to carry heavy
groceries and could reduce the number of stray carts near the bus stop.
During the assessment, a few assessment team members had trouble carrying the
groceries in the plastic bags provided by the grocery store. Two grocery bags broke and the
groceries fell to the ground on the way to and from the bus stop for one group of students. One
dyad used reusable grocery bags, which helped with carrying heavy groceries such as gallons of
milk. While reusable bags are relatively inexpensive and are for sale at most grocery stores, the
added expense may be prohibitive for some WIC participants who are on a tight budget.
4. WIC: WIC staff could provide education materials for WIC participants about how to use WIC
vouchers and public transportation via websites.
Because the assessment team did not attend any WIC education sessions about how to
use WIC vouchers or public transportation when shopping for WIC supplemental foods, they
relied heavily on the internet and USDA WIC and Knox County WIC websites for information.
It was clear from the assessment that both websites lack step by step instructions for use of WIC22
vouchers at grocery stores or how to access public transportation when procuring supplemental
WIC foods. This information would be useful in addition to WIC educational sessions at the
health department. Convenient web-based information about voucher use and how to use public
transportation may be effective by clarifying specific concerns and questions.
5. WIC: Need for a streamlined WIC voucher system.
The assessment results illuminated the difficulty of purchasing a predetermined and
inflexible amount of groceries with each WIC voucher. Each food package is divided among two
vouchers per month. WIC participants must purchase the entire allocation for each voucher,
rather than purchasing specific items during each shopping trip. This requires carrying large
amounts of groceries home after each shopping trip, even when participants may not need the
entire amount of food items at one particular time. Besides the inflexibility of the voucher
system, keeping track of slips of paper may be more difficult than securing an Electronic Benefit
Transfer (EBT) card in a wallet or purse due to their small size and durability.
Discussion
KCHD is traditionally considerate of health disparities in Knox County, especially
health-related issues in low-income communities (25,26). WIC aims to improve “the dietary
intake of pregnant and postpartum women” and “the growth of nutritionally at-risk infants and
children” (27). WIC has made great strides to enhance participants’ nutritional quality of diet in
the past decade. Although the program has reached several achievements, there are still some
areas that could be modified. For example, to ensure overall easy and convenient food
procurement, the national and local WIC websites could provide participants with step-by-step
instructions about how to use WIC vouchers in grocery stores. Further, information on
navigating the public transit system would be helpful for WIC participants who lack private23
transportation. In addition, transition to electronic vouchers has the potential to simplify the
process for both participants and the WIC program.
The public transit system is a significant source of transportation for WIC participants who
lack private transportation. KAT’s mission is to provide all passengers with a safe, secure and
comfortable journey. Indeed, KAT has taken steps in the past to improve its service (28) by
redesigning the route system, building a new transit station, and updating the buses. However,
there is still potential for improvement in KAT services in order to deliver the best shopping
experience to WIC participants and others who rely on public transportation for grocery
shopping. For example, there are a substantial number of bus stops without shelter or seating.
This could complicate the shopping experience during adverse weather. The lack of bus stop
seating forces people to stand on the side of the road while waiting for the bus.With heavy
traffic, safety issues are a great concern. In addition, bus stop signs are not easily noticeable on
the side of the roads, illustrated in Appendix 6.
Grocery stores play a crucial role in WIC participants’ overall shopping experience.
Kroger, Walmart, and other participating stores display “WIC Approved” tags on the shelves for
patrons to identify the supplemental food items. However, there are some areas that can be
improved. First, grocery carts available in stores are inappropriate for infants. This may force
WIC participants to carry their infants or children during their entire shopping experience. Some
other barriers include inadequate placement of grocery cart returns and store staff failing to
double bag heavy items. Therefore, it is essential for the WIC program, KAT, and grocery stores
to work together to facilitate an easy, safe and convenient shopping experience for the WIC
participants.24
Recommendations
KAT Authority
Following the simulated shopping experience, several recommendations can be made to
enhance the utilization of public transportation for WIC participants. First, it would be helpful
for each bus to feature a route map with bus stops displayed in a visible location. In addition, a
system for announcing each stop on the route prior to arrival could be implemented. Bus stops
could be announced either from the bus driver over the speaker system or via pre-recorded
announcements. Certain websites and smartphone applications exist that track the progress of
buses on routes via global positioning systems. These internet-based resources allow potential
passengers to look up bus routes and to identify where the bus is located on the route in real time
(29). Many large cities and university towns already implement these programs and utilize them
for issuing emergency alerts and re-routes (30-33). Punctuality is an aspect of public
transportation that is difficult to improve due to unpredictable traffic patterns, construction
projects, and accidents. While these factors cannot be controlled or changed, the use of a tracking
system with digital readers at each major bus stop, an internet-based system, or even a text-based
system could improve passenger perception of timeliness. With an alert system, passengers can
plan around buses expected arrival time instead of facing the unpleasant surprise of a late or
early bus. These alterations would better facilitate the effective use of the bus routes, especially
by passengers unfamiliar with the system.
Additionally, the individual bus stops can be improved in a number of ways. First,
providing a seating area with shade and shelter at each bus stop would enhance the transportation
experience of all passengers, particularly those with long wait times, disabilities, the elderly, or
children. Larger and more visible bus stop signage would help passengers who are unfamiliar25
with the bus route and may otherwise have difficulty locating the bus stop in adequate time for
boarding. The bus stops could be further improved by featuring a digital display that indicated
projected arrival time for the buses on the route. The location and placement of bus stops is also
an area in need of revision. Bus stops located adjacent to the entrance of grocery stores are ideal
and prevent passengers from walking long distances. Bus stops located close to the stores can
also protect participants from standing in close proximity to busy roads. In the case that bus stops
are located across the road from grocery stores, pedestrian crosswalks are necessary to ensure
passenger safety.
Grocery Stores
Not only can public transportation improve the shopping experience of WIC participants,
but grocery stores can also simplify the grocery shopping process for them. The signage for WIC
approved food items is often missing, ill placed, or difficult to see. Larger WIC signs would help
to facilitate a better shopping experience. All WIC approved items should be labeled and clearly
aligned with their corresponding WIC sign. The scales in the produce section should be
calibrated regularly, so that their weight readings are accurate. This is critical for the WIC
participants strategizing and calculating their produce purchases accurately. Grocery carts
should be available with an infant carrier in addition to those with child seating. Instructing all
cashiers to ask individuals using WIC vouchers or Special Nutrition Assistance Program EBT
cards whether or not they would like their groceries double-bagged, may help alleviate the
frustration of broken bags for those who are using public transportation. Finally, at least one
grocery cart corral in the parking lot of the grocery store should be placed adjacent to the bus
stop. By doing this, shoppers can utilize the cart to transport groceries and children until
boarding the bus.26
WIC Program
In addition to KAT and grocery stores, the WIC program can make administrative
changes to enhance the shopping experience of participants. Although the assessment team
recognizes that the revising the current voucher system in favor of EBT cards is a complex
recommendation and cannot be made at the local level, this would alleviate issues dealing with
lost, damaged, or forgotten vouchers. Use of EBT cards could allow participants to procure
certain WIC supplemental foods that are desired at a specific time, rather than getting all of the
items assigned to the voucher. Participants would have the autonomy to distribute procurement
of designated WIC approved items throughout the month as desired, helping to eliminate food
waste from spoilage. Because the described administrative changes at the federal-level may take
time to implement, switching to the EBT card system is not likely in the immediate future for
Knox County; thus, alternative methods to enhance the shopping experience of WIC participants
are recommended. Vouchers, or attachments provided with the vouchers, could contain all of the
information needed for selecting appropriate items and quantities. In addition to the WIC office
and staff members providing information about how to use vouchers efficiently when taking
public transportation, we recommend that the Knox County and USDA WIC websites feature
step-by-step instructions and advice on this topic. If adopted, the assessment team believes that
these recommendations would have a positive impact on use of WIC vouchers by participants.
Joint Collaboration: WIC Program, Grocery Stores, and KAT
Many of the recommendations listed may entail joint collaboration between the Knox
County WIC Program, area grocery stores, and KAT. However, one initiative that is particularly
well suited for a joint effort to enhance WIC participants’ shopping experiences when using
public transportation is providing WIC participants with durable, reusable shopping bags that27
could prevent loss of groceries from unreliable or damaged plastic bags. Although most grocery
stores offer reusable bags for purchase, they would be an added expense for WIC participants.
Therefore, the assessment team recommends that WIC participants receive reusable bags at no
cost to help ensure convenient access to supplemental foods provided by the WIC program. In
addition, supplying the bags may encourage participants to grocery shop at a particular store,
perhaps increasing customer loyalty in addition to making the shopping trip more efficient.
Further, the WIC program and collaborative partners could provide participants with infant
carriers or slings to free their hands for carrying groceries; thus reducing another barrier in the
procurement process for WIC participants who have infants. Overall, these recommendations, as
well as those previously discussed, may result in higher rates of voucher use among WIC
participants in Knox County due to a more efficient process of procuring supplemental foods
with WIC vouchers, especially when using public transportation.
Conclusion
Strengths and Limitations
Several strengths and limitations were noted throughout this assessment. One strength
was that the students were able to incorporate several different experiences into the assessment,
which provided a variety of perspectives for the overall experience. Documentation through
video recording, photographs, and firsthand experience contributed to formation of a realistic and
detailed account. The final strength is that much of the basis of these recommendations comes
from real experiences, which were designed to simulate WIC participant’s experience as much as
possible. This simulated WIC shopping experience provided greater depth and breadth of
information than that which could be gained by theorizing ideas in a meeting or class room.28
A major limitation of the assessment was that the students were unable to conduct
interviews, focus groups, surveys, or receive first-hand accounts from any WIC participants.
These data collection methods would provide additional information and insight into the
experiences and perceptions of WIC participants. Another limitation was that the “Baby Think it
Over” dolls used for the assessment did not adequately replicate the experience of a WIC
participant with one or more children to manage during a grocery trip. WIC participants may
have multiple children in various states of emotional distress or maturity, and these factors were
not simulated during this assessment. Furthermore, having multiple children enrolled in the WIC
program could require additional grocery store trips. Greater amount of groceries to manage
during each shopping trip could result in an even more complicated experience for WIC
participants. Assessment of these factors would be beneficial to assist in devising potential
solutions to these issues. Use of Visa gift cards rather than WIC vouchers was another limitation
to the assessment process. Gift cards allow for self check-out, flexibility in case of incorrect
purchases, and flexibility regarding price limitations on grocery items, whereas WIC vouchers
place stricter parameters on the procurement of WIC supplemental foods. Use of gift cards in
the simulated shopping experience prevented the students from fully assessing the barriers that
accompany use of vouchers. Regarding transportation, students were not able to begin the
experience from actual residences or neighborhoods, which can further complicate the overall
travel experience by adding travel time to and from bus stops with children and groceries.
Initiating the public transportation simulation from a particular residence may provide
information about travel times, safety concerns, and other barriers specific to certain areas and
neighborhoods.29
Future Assessments
Future assessments may include assessing neighborhoods within the designated zip codes
and the bus routes to particular grocery stores from these locations. It would also be valuable to
assess other grocery stores to see if they are accessible by the bus routes. Another simulated
shopping experience could involve multiple trips to grocery stores to understand the barriers
faced by a mother of two or more children, such as the weight of the groceries and the feasibility
of simultaneously managing multiple grocery lists and children. A future simulated shopping
experience could utilize a voucher instead of a gift-card to assess the constraints of actual
voucher use. Future projects could work with the KAT bus routes to incorporate
accommodations such as shaded areas at bus stops for inclement weather, enhance accuracy of
bus scheduling, and examine feasible assistance for managing groceries and children on a bus.
Overall, future assessments and projects may further enhance the findings of this assessment to
create an intervention and plan to reduce the barriers that were addressed during this
documentation.
Reflection
This assessment project utilized a valuable avenue for evaluating the needs of WIC
participants using public transportation. Through simulation, students were allowed to witness
some of the difficulties faced by this population when trying to procure supplemental WIC foods
for themselves or their toddlers. The transportation and shopping experiences were designed to
be as realistic as possible, and although the “Baby-Think-it-Over” dolls did not present as much
of a challenge as would a real-life infant or toddler, various difficulties faced in the simulated
experience were enough of a hindrance to prove that obvious barriers exist for WIC participants
using public transportation.30
According to the USDA ERS report evaluating the consequences of food deserts,
“limited access to nutritious foods may be linked to obesity and diet-related diseases” (34). The
WIC program helps to offset these issues by supporting women, infants and children who are at
risk of malnourishment for the prevention of illness and disease in critical periods of life
(1,27,35). However, the impact of the program is diminished if women have limited access to the
supplemental foods provided by the program, and these vulnerable populations could continue to
suffer. The recommendations resulting from this assessment aim to improve the community
system affecting the WIC population, including the KAT public transportation system, the WIC
program, as well as the grocery stores in Knox County.
Regardless of the apparent successes of this project, there are multiple barriers to
addressing the problems that exist among this population. One such barrier is funding. Changes
to the public transport system, WIC program, and grocery stores may require large sums of
capital, which may stand in the way of improving some aspects of these systems. They also
require attention and support by the directors of the KAT transit system, the WIC program, and
managers of the various grocery stores. If any one of these stakeholders fails to approach the
proposed changes with seriousness and the propensity to change, improvement is unlikely to
occur.
An additional barrier for assessing WIC participants is the educational background of
people enrolled in the program. If changes are made to the vouchers, the WIC program cannot
simply assume people will adapt; education level of this population must be accounted for. Lack
of education may already account for the failure or inability to use vouchers, so care must be
taken to not exacerbate this problem by inadvertently complicating the system. WIC may need to
provide education on using new vouchers if changes are implemented. Again, this has potential31
to require more money, human resources, and time.
It is difficult to attend to the needs of every at-risk individual, due to the variety of
resources available to people in different areas of the metropolitan area, people with and without
cars, and people with different numbers of children. For these reasons, recommendations may
not be implemented in ways that best serve everyone. Nonetheless, the stakeholders and
collaborators in this project have the responsibility and capability to improve conditions for a
broad positive impact.32
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