To gather information on the problem, focus groups were completed with WIC staff, WIC participants, and WIC vendors. WIC staff gathered from the three counties for one focus group. Each county completed a workflow process, writing out each step from the time a participant comes into the WIC clinic until the time he or she leaves. The three counties then came together and began an affinity diagram answering the question: "Why are participants not using the full amount of their fruit and vegetable vouchers?" This question provided a few headings for the affinity diagram, but the team decided that it needed to complete the rest of the focus groups to complete the diagram.
Five focus groups were held for WIC participants—one in each of the four communities in which WIC is held and one additional Spanish-speaking group in Sibley County, where the Hispanic population is higher. The team asked questions to understand participants’ experiences with using the vouchers and asked participants if they were able to use the full amount and what problems they encountered during use. The team also asked what makes it hard to use the voucher, what WIC staff and vendors could do to make it easier, and what participants' single best idea would be for improving the process. The team then held three focus groups for vendors, one in each county. The team used the information collected from participant focus groups to help plan the vendor focus groups, then asked questions to understand what types of experiences vendors are having with the fruit and vegetable vouchers and what their perspective is on what may be preventing participants from using the full amount. The team also used the ideas that it collected for improvement from the participant focus groups and presented these at the end of the vendor focus groups to collect thoughts on feasibility and willingness of stores to help. The final question asked vendors what they thought the most important action for improving use of the vouchers would be.
Participant focus groups were kept to 10 or fewer participants, and vendor focus groups were kept to fewer than 5; there are not many vendors in the communities. The team tried to keep focus groups short (around 30 minutes), but some groups were talkative, so the meetings lasted longer. A $10 gift card was given as an incentive for participation. Meeker and Sibley Counties offered child care for their participant focus group, and refreshments were offered at all focus groups.
Focus group results were compiled and used to complete the affinity diagram, answering the question of why vouchers were not being redeemed at full value. The team then created a fishbone diagram that included four headings: state, WIC staff, vendors, and participants. The affinity diagram topic headings were placed under the appropriate fishbone headings. The team then used the 5-Whys on each of the fishbone entries to dig deeper to identify root causes. Each root cause was then explored to determine which were most feasible (i.e., which ones the team had the most control and influence over). The root cause that came up repeatedly throughout the 5-Whys and was most feasible to work on was the lack of a fruit and vegetable culture in WIC participants' homes. The QI team then used the 5-Hows to identify potential solutions to the root cause that would be feasible for CHS and influential on the problem. Each of the brainstormed ideas was written on a sticky note and placed on the wall. The three main project leaders then combined the ideas into "like" groups. Finally, the team used the multi-voting technique to narrow down the interventions. Each WIC staff member present at the meeting was given three sticker dots and was asked to vote on the interventions, keeping in mind feasibility and influence. Through voting, the team found that WIC staff thought that offering tastes of fruits and vegetables and simple one-page information sheets on that fruit or vegetable that provide information on nutrition, storage, and preparation would familiarize families with new fruits and vegetables and increase use of fruits and vegetable vouchers. The QI team and WIC staff also thought that it may help ease some of the fear WIC participants have about trying new things if they had information to guide them on how to use the fruits and vegetables. The team also hoped that through exposure at the WIC office, children would get excited to have more fruits and vegetables so parents would use their WIC vouchers more often and subsequently bring more fruits and vegetables into the home.
The intervention was implemented during WIC clinic days at all locations for 3 months: May, June, and July 2013. WIC operates on a 3-month schedule, and families are given anywhere from 1 to 3 months of vouchers at a time. Because the intervention was implemented for 3 full months, most of the families on WIC should have been exposed to the tasting events. For the tastings, each WIC certifier offered WIC participants and families the opportunity to participate in the tasting and provided the fruits and vegetables for them to taste. Signs in the clinic announced that fruit and vegetable tastings were being offered. The initial month was a kickoff event and included six different fruits and vegetables for families to try. After the initial month, the following 2 months included just one or two fruits or vegetables; the team realized that when children were offered the choice between something unfamiliar and something familiar, they most often chose the familiar, "safe" option. Therefore, many children were not trying anything new because there was more than likely one "safe" option among the six offered. Staffing limitation was another reason for the decrease in the amount of tasting options. Public health staff already have full schedules, and finding time to purchase and prepare the fruits and vegetables for serving was difficult during the first month.