WISEWOMAN Best Practices Toolkit:
Lessons Learned from Selected Projects
Appendix B: Descriptions of Projects Included in
Data-Collection Project
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The following projects were included in the data-collection project:
Massachusetts
WISEWOMAN Project and Lifestyle Intervention
Project Description
The Massachusetts project is operated by the state department of public
health. The Massachusetts project was one of the initial WISEWOMAN projects
and first received funding in 1995. In 1998, the Massachusetts project
formed the Women’s Health Network to offer comprehensive services to women
participating in BCCEDP and WISEWOMAN by connecting them to primary care
facilities. At the time of data collection (FY 2005), the Massachusetts
project had contracted with 26 providers to deliver BCCEDP services; 7 of
the 26 also provided WISEWOMAN screening and lifestyle intervention
services. The contracted agencies included hospitals, visiting nurses’
associations, and community health centers. Some of the seven local
WISEWOMAN sites also contracted with community providers to offer the
screening services.
Lifestyle Intervention
At the time of data collection, the primary lifestyle intervention used
in Massachusetts was the Patient-Centered Assessment and Counseling for
Exercise and Nutrition (PACE) combined with risk reduction education (RRE).
PACE is based on the Stages of Change model and includes (1) assessments of
nutrition and physical activity behavior and (2) goal setting based on the
results of the assessments. The physical activity assessment identifies the
woman’s current level of activity as well as her ability to engage in
physical activity. The nutrition assessment identifies the woman’s current
nutrition habits in the areas of fruit and vegetable intake, dietary fat
intake, and weight gain control. For each assessment, the woman receives a
PACE score that identifies areas for improvement and her readiness to change
in each area. The lifestyle intervention provides separate physical activity
and nutrition counseling tools that correspond to each level of readiness:
(1) not ready to change, (2) ready to change, and (3) actively changing. RRE
used by the program focuses on educating women about the meaning of their
screening results.
At the time of data collection, the Massachusetts project was in the
process of developing the Healthy Heart Program, which adapted the original
PACE materials to have a lower literacy level and to be culturally
appropriate for the women served. The Healthy Heart Program is available in
Spanish, Portuguese, and Chinese; a low-literacy English version is also
available. The Massachusetts project trained all of its educators in the
Healthy Heart Program in November 2005 and began delivering the new
intervention in January 2006.
Supplemental Lifestyle Interventions. At press time, the local sites also
offer women supplemental lifestyle interventions in the form of additional
educational and experiential opportunities to support the adoption of
heart-healthy behavior changes. The project must approve all supplemental
interventions that local sites offer. Examples include (1) free sessions at
a local gym with a personal trainer who develops a home exercise program for
the woman, (2) free multi-session nutrition classes sponsored by a hospital,
(3) free multi-session diabetes education, and (4) referrals to either a
smoking quitline or a certified tobacco treatment specialist and nicotine
replacement therapy. To offer these supplemental interventions, local sites
must partner with local hospitals and community organizations.
Staff Delivering Interventions at Local Sites
The Massachusetts project specifies the type of staff required to fulfill
each role in the lifestyle intervention. The roles of staff, with their
qualifications, are as follows:
- Clinician. A nurse practitioner or physician who completes the
screening exam with the women.
- Risk reduction educator. A nurse practitioner, registered nurse, or
registered dietitian who discusses screening results with the women and
provides the PACE lifestyle intervention, which includes education on
risk factors, strategies for adopting lifestyle changes, and individual
goal setting.
Lifestyle Intervention Delivery
Program participants are screened in a clinical setting for
cardiovascular disease risk factors and then given RRE. The initial meeting
with the risk reduction educator typically occurs after the clinical risk
factor screening exam. This can be done immediately following the exam (if
the clinician and educator are in the same location) or at a later date
(when screening is done through a subcontractor or the woman does not have
time after the exam). RRE is completed in person or by telephone.
Assessments of physical activity, nutrition, and smoking are either
completed during the RRE visit or mailed to the women in advance and
reviewed during the visit. Scores on assessments are used to identify areas
for improvement, and staff work with the women to identify lifestyle change
goals based on the results of the assessments.
Michigan WISEWOMAN Project
and Lifestyle Intervention
Project Description
The Michigan Department of Community Health received funding for its
WISEWOMAN project in 2000, and the project began delivering services in
2001. At the time of data collection (FY 2005), the Michigan project
contracted with 21 local coordinating agencies (LCAs) to offer BCCEDP in 82
of 83 counties in the state. All but one LCA was a health department.
Several of the LCAs managed sites in multiple counties, depending on the
region’s arrangement. Nine of the 21 LCAs also offered WISEWOMAN services.
To provide WISEWOMAN services, the LCA must be able to deliver screening and
lifestyle intervention services as well as ensure that women receive
follow-up medical care either at the health department or in the community.
Lifestyle Intervention
The intervention consists of individual lifestyle counseling contacts for
all WISEWOMAN program participants. The Michigan project’s philosophy in
delivering the lifestyle intervention is that ongoing support provided by a
lifestyle counselor, rather than extensive educational information,
encourages women to adopt heart-healthy lifestyle changes. Lifestyle
counselors assist women in understanding the connection between their
behaviors and cardiovascular risk factors and target their delivery of
educational information to the interests of the women. The women are the
decision makers and select their personal behavior changes. The state
encourages all lifestyle counselors to use an “ask, don’t tell” approach and
to provide positive reinforcement that facilitates the achievement of
lifestyle goals.
At the first lifestyle counseling meeting, a lifestyle counselor reviews
the screening results with each woman, explains the meaning of the results,
and describes lifestyle behaviors that can affect these results. The woman
is encouraged to develop a lifestyle contract that includes goal setting
related to nutrition, physical activity, or tobacco cessation. Nutrition
goals reflect the dietary guidelines for Americans and U.S. Department of
Agriculture food guide pyramid. Many forms of physical activity are
encouraged (walking, exercise videos, etc.), and counseling on tobacco
cessation includes a referral to a quit hotline. During lifestyle counseling
follow-up contacts, the woman discusses her progress toward the goals, and
the counselor documents her progress, offers encouragement, and makes
referrals to community resources. The project recently revised the name of
the lifestyle contract form to “Healthy Lifestyle Goals” because local sites
reported that women reacted adversely to the word “contract.”
Staff Delivering Interventions at Local Sites
Lifestyle counselors have at least a bachelor’s degree and represent a
variety of disciplines, including nursing, dietetics, and health education.
All staff members possess an understanding of cardiovascular disease risk
factors and knowledge of how to counsel women on behavior change.
Lifestyle Intervention Delivery
At the time of data collection, women were eligible to receive a varied
number of contacts with the lifestyle counselor, depending on their
screening results. In most cases, if a woman’s results were normal, she
received only one lifestyle counseling contact, a face-to-face meeting that
lasted up to 60 minutes. However, women with normal results who used tobacco
and expressed an interest in quitting could receive two additional 15-minute
follow-up lifestyle contacts by telephone to support their tobacco cessation
efforts. If a woman’s screening results were abnormal, the lifestyle
counselor encouraged her to participate in five telephone or face-to-face
counseling sessions, each lasting between 15 and 60 minutes.
In July 2005, the project implemented a revised lifestyle intervention
protocol that provided all women, regardless of screening results, with
three to six lifestyle counseling contacts. The aim of the revised protocol
was to simplify the program flow and to allow women with few or no risk
factors to benefit from the lifestyle intervention.
Nebraska WISEWOMAN Project
and Lifestyle Intervention
Project Description
The Nebraska project is operated by the state department of health and
human services. Nebraska first received funding in 2000 to provide WISEWOMAN
services. To promote comprehensive care for women, the state unified
WISEWOMAN and the BCCEDP into the Every Woman Matters program. At the time
of data collection (FY 2005), services were available statewide through
contracts with more than 600 providers who conducted BCCEDP and WISEWOMAN
screening. Women are recruited to the program by outreach workers at eight
contracted agencies throughout the state. These workers also connect with
previously enrolled women to encourage re-enrollment and make informational
and supportive telephone calls to deliver the WISEWOMAN lifestyle
intervention, which is administered by trained educators at the University
of Nebraska’s cooperative extension services.
Lifestyle Intervention
The Nebraska project uses two versions of its lifestyle intervention; one
is taught in a classroom setting, and the other is a self-study course.
ABC Class Lifestyle Intervention. The University of Nebraska’s
cooperative extension services developed the ABCs for Good Health class
curriculum, which emphasizes Aim for Fitness, Build a Healthy Base, and
Choose Sensibly. This curriculum was developed by a health and wellness team
for the University of Nebraska’s cooperative extension services in 1999 for
use with clients taking part in cooperative extension services activities.
The curriculum consists of four sessions that integrate educational
materials, interactive lessons, and goal setting related to increasing
physical activity, making positive nutrition changes, and improving overall
health behaviors. Participants receive a notebook with relevant educational
information and a pedometer. The classes provide an opportunity for women to
prepare and sample heart-healthy foods, as well as an opportunity for weekly
goal setting. At the beginning of each class, the educator reviews each
woman’s progress toward her goal from the previous week. At the end of
class, each woman sets a new goal for the coming week. The class series
begins with physical activity lessons so that the women can monitor their
walking throughout the four sessions and, ideally, continue to walk for
exercise after the class has ended.
To support consistent class attendance, outreach workers make a reminder
telephone call to the women before each class. To promote the women’s
healthy lifestyle changes and offer encouragement, an outreach worker
attempts to contact the women for 6 months while they are still enrolled in
WISEWOMAN but after they have completed the ABC class.
Self-Study Lifestyle Intervention. The self-study materials (Be a
WISEWOMAN – Get Heart Smart!) are offered as an option to participants who
do not want to attend the ABC class. The project’s previous lifestyle
intervention coordinator developed the five informational booklets that
comprise the self-study materials based on the ABCs for Good Health class
curriculum.
The following informational booklets are sent to women on a monthly
basis:
- ABCs of Good Health (emphasizes physical activity)
- Fruits & Vegetables
- Whole Grains
- Straight Facts About Fat
- Maintenance
Along with the first informational booklet, the outreach workers send the
women a notebook, pen, pedometer, and walking log to track their steps. The
self-study information is presented clearly and concisely so that
participants can easily understand each pamphlet. Mailings of materials are
followed up with telephone calls, as described below.
Staff Delivering Interventions at Local Sites
At the time of data collection, a combination of outreach workers and
educators from the University of Nebraska’s cooperative extension services
delivered the lifestyle intervention. The outreach workers made telephone
calls to the women to ensure receipt of self-study materials, discuss goal
setting, and provide support in making behavior changes. These workers did
not require a specific background and they ranged from lay health workers to
nurses. Educators with master’s degrees in education, home economics, or
related disciplines delivered the ABCs for Good Health classes.
Following data collection in 2005, the Nebraska project transitioned
responsibility for intervention management from the outreach workers to a
network of regional lifestyle interventionists and staff from federally
qualified health centers. These people ensure that women complete the
6-month intervention process. A background in health education is required
for regional lifestyle interventionists, and they range from registered
dieticians to community health education specialists.
Lifestyle Intervention Delivery
At the time of data collection, after a woman had been screened for
cardiovascular disease risk factors and agreed to participate in the
lifestyle intervention, an outreach worker was responsible for calling the
woman to offer her the ABC class and self-study options. Each woman selected
an intervention based on her level of interest and availability, but
outreach workers strongly encouraged women to participate in the ABC class.
The ABC class has an in-person didactic format, typically offered in four
weekly sessions. Extension educators from the Nebraska cooperative extension
services deliver the ABC class sessions. These educators, who are based in
county offices throughout the state, are well versed in nutrition and
physical activity, and they provide examples and tools that help the women
assess their ability to make personal changes. Each educator aims to offer
the ABC course series at least twice a year.
The self-study intervention is delivered by mail and telephone. The women
receive five mailings and follow-up telephone calls from outreach workers.
During the calls, the outreach workers ensure that the materials were
received, answer questions, discuss goal setting to achieve a healthy
lifestyle, and support and encourage lifestyle changes as they are made.
North Carolina
WISEWOMAN Project and Lifestyle Intervention
Project Description
The North Carolina project is operated by the state department of health
and human services. North Carolina had one of the original WISEWOMAN
projects and first received funding in 1995. At the time of data collection
(FY 2004), WISEWOMAN services were available in 40 of the 100 counties in
the state. The project contracts primarily with county-level health
departments to provide both screening and lifestyle intervention services.
The health departments have the capacity to deliver services either by
embedding WISEWOMAN into a pre-existing general clinic or by developing a
WISEWOMAN-specific clinic at the site.
Lifestyle Intervention
The North Carolina WISEWOMAN project uses A New Leaf: Choices for Healthy
Living (New Leaf), a lifestyle intervention developed by researchers at the
University of North Carolina–Chapel Hill (UNC) specifically to target the
WISEWOMAN population in North Carolina. It emphasizes foods common in the
southeastern United States. New Leaf was adapted from the Food for Heart
nutrition intervention developed by Dr. Alice Ammerman at UNC. Food for
Heart includes nutrition assessments and lifestyle counseling tools for use
by a variety of health care providers. These assessments and counseling
tools are expanded in New Leaf to include physical activity, smoking
cessation, and osteoporosis education.
New Leaf emphasizes individual tailoring, goal setting, and
identification of barriers and perceived benefits of lifestyle changes. A
component of the intervention is a behavior risk assessment with four
sections that gauge (1) diet and barriers to dietary change; (2) physical
activity, barriers to physical activity, and physical limitations; (3)
smoking cessation; and (4) lifestyle risk factors for osteoporosis. Each
risk assessment form uses a structured scoring template that quickly
identifies areas of risk.
The primary educational tools used in New Leaf are a manual or notebook
and a cookbook with regionally appropriate heart-healthy recipes. The manual
is organized by risk factor and includes tips for addressing risk factors
identified in the assessment forms. It also has a section that provides tips
on nutrition and physical activity to prevent and control diabetes. Other
New Leaf materials include a practitioner’s training guide and Thera-Bands®
(latex stretch bands) to facilitate physical activity. As the need arises,
researchers at UNC develop new modules for inclusion in New Leaf. In 2005,
for example, a weight-loss module was pilot tested with a cohort of women.
Future plans include development of a leader’s guide to support
implementation with a broader population of WISEWOMAN participants.
Staff Delivering Interventions at Local Sites
Nurses employed by the health department are the primary providers of
screening and lifestyle intervention services to WISEWOMAN participants.
Some sites also involve other staff at the health department, such as health
educators and nutritionists, in delivering the lifestyle intervention.
Lifestyle Intervention Delivery
The project provides New Leaf intervention materials to all contractors
without charge. Project contractors are encouraged, but not required, to use
New Leaf materials. Counseling sessions can occur individually or in a group
setting, and some sites provide a combination. Contractors deliver
interventions in person as well by telephone and mail. Counseling usually
occurs during one or two sessions with a nurse at the health department.
Although how the local sites deliver the lifestyle intervention varies,
most, including all the sites involved in this study, use New Leaf.
SEARHC WISEWOMAN Project and
Lifestyle Intervention
Project Description
The WISEWOMAN project in Southeast Alaska is managed by the South East
Alaska Regional Health Consortium (SEARHC). SEARHC receives funding from the
Indian Health Service to provide medical services to Alaska Natives in the
region and from the Health Resources and Services Administration (HRSA) to
operate nine sliding-fee-scale community health centers. SEARHC first
received funding for WISEWOMAN in 2000. Local sites operate with
grant-funded staff based in two regional clinics, two sub-regional HRSA-funded
clinics, and several smaller HRSA-funded clinics where staff provide program
services through itinerant visits.
Lifestyle Intervention
Standard Lifestyle Intervention. SEARHC offers what is called a “standard
lifestyle intervention,” as well as a variety of educational and
experiential activities to all participating women. Previously, the standard
lifestyle intervention was individual counseling guided by the Traditions of
the Heart (TOH) tool, but this intervention was recently redefined to
provide staff more flexibility in what constitutes a standard intervention
contact. Now staff can complete TOH with the woman or perform another type
of intervention that meets CDC’s definition of a minimum intervention.
TOH expands on and adapts the counseling tool A New Leaf: Choices for
Healthy Living developed by Dr. Alice Ammerman and colleagues at UNC. TOH
uses language that is culturally sensitive to Alaska Native women, includes
nutrition and activity tips that have regional and cultural significance,
and addresses all forms of tobacco use, among other adaptations. Included
with TOH is a series of nutritional and physical activity assessments that
women complete annually, a workbook that provides nutrition and physical
activity tips and education, and a cookbook with a variety of heart-healthy
recipes. In total, the nutrition assessment uses eight forms:
- Fish, birds, and meat.
- Dairy, eggs, cereal, and salt.
- Fruits, vegetables, side dishes, desserts, and snacks.
- Spreads, dressings, and oils.
- How active are you?
- Beverages.
- What makes it hard to eat right?
- What makes it hard to keep active?
Each form is designed so that the most heart-healthy choice is in the
far-left column and the least heart-healthy choice is on the far right. This
design allows quick scoring and identification of areas for improvement.
Staff apply motivational interviewing techniques when counseling women.
This encourages the women to identify goals for lifestyle change instead of
having the educator provide goals. Although the woman does much of the
talking during the encounter, the educator asks for the woman’s permission
to provide education and advice on cardiovascular disease risk factors,
including nutrition, physical activity, tobacco, and stress. If the woman is
ready, the educator and the woman jointly set at least one behavior
modification goal at the end of the intervention session. Women who are not
ready to set a goal during this contact but are interested in making changes
in the future are called within 1 month to assess their readiness to set a
goal. Delivery of the standard lifestyle intervention takes between 40 and
90 minutes, depending on the woman’s situation.
Educational and Experiential Activities. These are a major component of
the lifestyle intervention. They offer women opportunities to participate in
physical activity and to increase their knowledge of heart-healthy
nutrition. In many instances, the opportunities for physical activity are
experiential and occur on a regular basis, such as weekly swimming at the
community pool or ongoing weight-lifting sessions. The educational
activities typically focus on nutrition and are given either as a short
series of classes on one topic or as a one-time event. The sites use
existing curricula and develop original educational classes, often selecting
topics based on participants’ expressed interests. Most sites schedule a
variety of monthly gatherings that target physical activity and nutrition.
Each site’s health educator is responsible for organizing and conducting
these supplemental activities.
When organizing gatherings and experiential activities, the project
director affords significant flexibility to the health educators on the
topics they may address. The primary requirement is that the activities
support one or more of the four targeted cardiovascular disease risk
factors—nutrition, physical activity, tobacco, and stress.
To support the delivery of the lifestyle intervention, local staff build
partnerships in the community with interested organizations. These
partnerships vary across sites and include community pools, other physical
fitness venues (gyms, yoga studios), and community buildings to host
gatherings. Partnerships are viewed as mutually beneficial to the program
and the partnering organization. Some sites also partner with participants
to host gatherings in their homes. SEARHC emphasizes applying the
socio-ecological model in its WISEWOMAN program, and partnerships with
community organizations support the use of this model.
Staff Delivering Interventions at Local Sites
SEARHC’s service delivery model is based on a two-person staff team (one
person with a clinical background and one with a health education or
community health background) at each local site. The staff member with the
clinical background serves in the role of patient educator and has primary
responsibility for enrolling and screening women and delivering the
lifestyle intervention. The staff member with the community health
background serves in the role of health educator or community wellness
advocate, depending on his or her educational training, and has primary
responsibility for coordinating experiential and educational opportunities.
Lifestyle Intervention Delivery
A patient educator completes the standard lifestyle intervention with the
women, typically during the enrollment or annual re-enrollment visit. The
intervention can be completed after enrollment if the woman receives the
WISEWOMAN screening during a visit to the clinic for another purpose. The
standard intervention is provided either in person or by telephone. The
assessments take about 15 minutes to fill out and are typically completed
during the intervention session. However, the assessments can be mailed to
the women in advance, and the women complete them and bring them to the
visit.
A health educator or community wellness advocate organizes the
educational and experiential opportunities that complement the standard
lifestyle intervention. Many of the education opportunities are in a class
format with multiple participants. The experiential opportunities usually
involve multiple participants and entail physical activity. The educational
and experiential activities are typically offered in community sites (versus
the clinic). All educational and experiential opportunities are optional for
the women.
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Page last reviewed: July 10, 2007
Page last modified: July 10, 2007
Content source: Division
for Heart Disease and Stroke Prevention,
National Center for Chronic Disease Prevention and
Health Promotion
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