Because of the compounding effects of discrimination in our medical, legal, and social services infrastructures, Black mothers and infants in the United States face worse health outcomes than other groups. The Supplemental Nutrition Program for Women, Infants, and Children (WIC) – which offers stipends for healthy foods and nutrition education – reduces racial disparities in infant mortality, and improves other key health outcomes for Black families living in the context of poverty. While the benefits are clear, WIC has an opportunity to close these racial disparities even further. By more effectively engaging Black families, WIC administrators can help more families access life-saving programs.
WIC’s potential reach is wide. Nearly half of all infants born in the United States are eligible for the program. However, of the 2.4 million Black individuals eligible for WIC, 41% of them are not participating. Some families make an active choice not to participate in WIC, some face structural hurdles like irregular work schedules that make WIC appointment attendance difficult, and others are deterred by administrative or psychological barriers, like remembering to prepare the many documents needed for appointments, or uncertainty about if they’re eligible to participate in the first place.
We’ve learned in previous research that behavioral design can help potential and current WIC participants overcome the administrative and psychological barriers to program participation and access beneficial nutritional support for their families. For instance, WIC appointment attendance increases for a significant number of families when text message-based appointment reminders are delivered with more advanced notice, giving them adequate time to plan or reschedule when unexpected obstacles arise, like last-minute changes in work schedules or delays in obtaining the paperwork necessary for their appointment.
Given the historical and institutional racism faced by Black families accessing public benefit programs, we approached our latest work with WIC through an equity lens. We designed a suite of WIC appointment reminders to specifically address administrative and psychological barriers for Black families. While there are many principles to consider when doing equity-centered design work, three principles were important to this engagement:
- Design for the context by focusing on structures, processes, and barriers.
- Promote dignity, autonomy, and justice throughout the engagement and after.
- Listen to people with lived experience and prioritize those conversations in the design process.
Here’s how we intentionally implemented these principles. Our hope is that this example of equity-centered design in action may be helpful to others who want to center their work around designing for equity but are unsure how to start.
1) Design for the Context
There are many harmful and false narratives about poverty that proliferate in the United States, including that people who are experiencing it have no one to blame but themselves for their trouble. This narrative runs counter to what we know from behavioral science. Studies have shown that improving the lives of people experiencing poverty requires shifting structures and processes, removing barriers – not changing people. When we “design for context,” we focus on how behavioral design can remove barriers to access and participation in programs, like WIC, that have been shown to improve outcomes for families.
Our previous research on barriers to WIC participation provided a useful starting place for this work. We then went deeper into psychology literature and that of related fields to understand how contexts faced by Black families might exacerbate these barriers and create additional ones. For instance, Black workers are not only overrepresented in the service and hospitality sector – an industry known for high volatility in work schedules – but they also experience higher rates of irregular work hours even within that industry compared to white peers. Given that their work schedules may be harder to predict and subject to more change, Black WIC participants may find it especially difficult to keep their WIC appointment times, which are scheduled months in advance. This could contribute to fewer families staying in the program even when they’re eligible and intend to continue participating.
It is also well-documented that Black individuals often distrust medical providers and government institutions, an unsurprising fact given that Black individuals have historically experienced inequitable access to social services and racial discrimination when seeking medical care in the United States. The impact of racial inequities in care on infant and maternal health in particular – which is a primary focus of WIC – is staggering. Infant mortality rates for Black babies are more than twice that of white babies, and U.S. maternal mortality rates for Black women are three to four times higher than for white women.
Given that WIC is a public health program focused on pregnant women, infants, and children, we anticipated that Black families may have reservations about participating. This insight aligns with the findings of a task force assembled by the California WIC Association, which found that Black WIC participants feel underrepresented in the WIC program.
While research from behavioral science and related fields helped us start to understand how navigating the WIC experience may be different for Black families, we centered the perspectives and expertise of people with lived experience in WIC as our most valuable source of insight.
2) Promote dignity, autonomy, and justice
Our goal for this work was to challenge our own assumptions and instead focus on the amount there was to learn from the lived experience of participants in order to design meaningful solutions for Black families in WIC. To keep the needs of Black families at the center of our process, we structured our work around three core values: dignity, autonomy, and justice.
As a team of behavioral scientists, we started the project by recruiting a team of experts in Black infant and maternal health – including local WIC staff, health equity strategists, and facilitators in Black infant and maternal health programs – to provide feedback on our research and designs at various points in our process. This team of experts not only shared valuable insights from their experience in the field, but also helped prepare us for thoughtful, compassionate, and well-informed conversations with participants.
When talking with both community experts and WIC participants, we created space for autonomy in how they engaged with us. We did this by both asking direct questions that helped fill in specific gaps in our own knowledge, and also inviting people to share their broad ideas, ask us questions, challenge us, and bring up what they thought we might be missing. As we expected, this pushed us to explore new directions for the appointment reminders we might not have otherwise considered, and ultimately, made our collective work stronger.
3) Listen to people
After identifying potential behavioral barriers using our previous research and work with WIC, we sought out the real experts – WIC participants. Because this work focused on designing specifically for barriers faced by Black families, we spoke with Black participants. Knowing that participants have valuable insights to share and have busy schedules to manage, we compensated them fairly for their time spent talking with us. When the pandemic forced us to conduct our conversations virtually rather than meet with participants at the WIC agency, we increased the stipend paid for interviews to cover the costs of scheduling a less convenient time to meet, as well as cover the costs of using data to connect from their personal electronic devices.
Truly listening to participants means giving them an equal seat at the design table and acting on what we hear from them. In conversations with WIC participants, we learned that some of our own favorite appointment reminder designs did not resonate as well as we imagined they would. For instance, we shared designs with participants that centered on two key goals: instilling a sense of belonging with WIC, and making it easier to reschedule appointments. Although participants appreciated the efforts of WIC staff to make them feel like they belong when they are at the WIC agency, they felt strongly that text messages weren’t the right tool for addressing issues of belonging.
“We wouldn’t take that seriously. Even though it’s nice, it’s just like, whatever, if I can come, I can.”
– WIC Participant, West Oakland
Instead, what was most important to participants were messages that included a phone number in the message so they could more easily reschedule on the spot when necessary.
“When we need to reschedule, and we don’t see someone telling us we can, we just don’t want to deal with it. So, we just don’t do it. This [message] is calming. Even with this not being a real scenario, just seeing this, it made me feel better.”
– WIC participant, San Bernadino
After receiving this feedback from participants, we discarded messages aimed at fostering belonging, and advised our WIC partners to instead use appointment reminders addressing administrative hassles, like rescheduling appointments.
A continuous process
Going forward, we plan to draw out more insights from this work and our other public benefits work to help generate more transformative change through policy design with our forthcoming policy lab, and plan to continue working toward safety net improvements that will help programs like WIC better serve all families with an equity-focused approach.
These three principles and our experience implementing them in California are by no means an exhaustive guide for integrating a focus on designing for equity into behavioral design work. Instead, we hope to be a resource and ongoing partner in refining approaches to designing for equity.
You can read more about these text message designs, or if you want to partner with us or talk more about equity design in your own work, reach out to firstname.lastname@example.org.