WISEWOMAN Best Practices Toolkit:
Lessons Learned from Selected Projects

Identifying the priority population(s) guides how projects should culturally adapt materials. For example, if a project identifies the priority population as relatively homogeneous, the cultural adaptation should be specific to a single population. However, if the project anticipates serving a variety of cultural populations, its staff need to assess whether one adaptation is sufficient or if the materials need adapting for several populations.

Unlike the Massachusetts project, SEARHC serves a relatively homogeneous population that primarily consists of Alaska Natives. Non-Native women served by the project typically possess an interest in and respect for Native culture and value the opportunity to engage in traditional Native events. The SEARHC project adapted the A New Leaf materials to reflect more typical food and activity choices for women in the region.

SEARHC WISEWOMAN Project
Phone: 907-966-8710 (ask for WISEWOMAN Project Director)

The Nebraska project encouraged local sites to solicit success stories from women to better understand their overall satisfaction with WISEWOMAN. Staff at some local sites promoted the writing of success stories by distributing return-addressed, stamped envelopes to women. In Kearney, Nebraska, the program coordinator estimated that the site received success stories from about 90 percent of program participants. In Wisner, Nebraska, the program coordinator received success stories on a weekly basis from women.

Every Woman Matters,
Nebraska WISEWOMAN Project
Phone: 1-800-532-2227

Both projects and local sites can establish opportunities for experiential engagement. Projects can assist local sites by developing partnerships with organizations that offer opportunities for experiential encounters. If projects do not offer assistance, local sites can develop their own programs for women or establish partnerships with local organizations that offer services to women. High-performing local sites that offered women experiential opportunities developed and conducted multiples types of activities.

A woman in a focus group explained the value of incorporating hands-on opportunities into the lifestyle intervention. She stated, “[I liked] getting to try hummus at an event. It’s amazing when you try something new; when you get a taste, your whole world opens up.”

At Public Health Delta and Menominee Counties in Escanaba, Michigan, the program coordinator organized a walking club for program participants. The club met weekly for 8 weeks. During each meeting, program staff presented brief information on a relevant topic and women walked a set course with program staff. The walking club promoted physical activity, offered women social support while engaging in physical activity, and allowed program staff to develop relationships with the women.

Michigan WISEWOMAN Project
Phone: 517-335-1178

5A. Train local staff on behavior change theories that guide the lifestyle intervention (Project, Local)

5B. Reinforce training on a regular basis and build on staff knowledge of the behavior change theory (Project, Local)

[Practice #5B also applies to the dimension of Implementation, Chapter V.]

Training on behavior change theory requires initial introduction and continual reinforcement. After staff develop an initial understanding of the theory, future training sessions provide the opportunity to deepen staff knowledge related to the theory and its application to the lifestyle intervention.

High-performing local sites deliberately hired staff who already possessed a basic understanding of behavior change theories and arranged training by project or local site staff as well staff outside the project. These training sessions focused on understanding the theory and how to apply it when delivering lifestyle interventions.

To develop staff proficiency in applying motivational interviewing techniques to the Traditions of the Heart lifestyle intervention, SEARHC provided multiple training sessions on the topic. Initially, the training focused on teaching staff skills to understand the behavior change theory and conducting motivational interviews. Subsequent training sessions provided refresher courses to staff and focused more on how to combine the motivational interview and the Traditions of the Heart counseling technique.

SEARHC’s WISEWOMAN Brief Negotiation Roadmap is included in the appendix on page A.6 as a tool to illustrate the process for conducting a motivation-enhancing interview.

The University of North Carolina at Chapel Hill developed the A New Leaf lifestyle intervention and accompanying materials for the North Carolina WISEWOMAN project. The materials include a participant binder with assessment forms and related information. The material draws on multiple behavior change theories and translates the theoretical concepts so that participants can readily understand the material.

  Nebraska’s Intervention Management Log and Master Key are included in the appendix on page A.8

North Carolina WISEWOMAN Project
Phone: 919-707-5301

  This chart is included in the appendix on page A.13.

9. Offer flexibility in staff work schedules to reach women at different times of day (Local)

Michigan WISEWOMAN Project
Phone: 517-335-1178

When combining the screening with education, high-performing sites discussed individual screening results prior to discussing behavior changes because the screening results established a foundation for discussing subsequent behavior changes.

12A. Incorporate multiple learning styles in lessons (Local)

12B. Offer opportunities for experiential learning (Local)

A woman in a focus group discussed the benefit of experiential learning during the lifestyle intervention. She described her experience learning to read nutrition labels, especially for fat contents, on snack foods as follows: “[It] was really effective to actually see [the label] and realize that’s what [I’ve] been eating and putting in [my] body for all these years.”

One woman described the benefit of participating in a class and receiving supportive telephone calls as part of the lifestyle intervention: “When the class came along, I was just on the verge of not taking care of myself and it reminded me to take care of myself and that there are all these people out there who care about me. The telephone calls showed me this was true.”

Another woman described her appreciation for receiving mail associated with the lifestyle intervention. She stated, “I just like getting mail because, to me, it’s like Christmas when you get these booklets that you can look through.”

During focus groups, women described how the lifestyle intervention addressed their individual needs. One woman said, “I eat more fruits and vegetables than before. Conversation helped me. I had a 7-year diet and I lost 70 pounds. Then I was at a standstill. The interventionist helped me to figure out that I need more exercise.” Another women stated, “I have cut back on red meat and fat and I have increased my exercise.”

16. Build new skills by teaching about the process of reaching goals (Local)

17. Celebrate when women accomplish the goals they set for themselves (Local)

17A. Identify ways for the program to celebrate goals (Local)

17B. Teach women the importance of goals and how to reward themselves for achieving goals (Local)

Also, staff can discuss the importance of identifying rewards for achieving goals as well as establishing and rewarding interim goals. Rewards that mark goal attainment can be free or low-cost indulgences that the woman enjoys, such as a bubble bath. Local programs can also reward the woman for achieving identified goals by highlighting the woman’s accomplishment as a success story or providing an incentive to recognize goal attainment. High-performing local sites provided women with incentives to celebrate behavior changes, encouraged women to document goal attainment by writing success stories, and taught women how to self-reward behavior change.

The WISEWOMAN program at Jordan Hospital in Plymouth, Massachusetts, also encouraged women to identify goals that support a heart-healthy lifestyle. The project asked women to track their progress toward these goals. To facilitate tracking, staff at the local site developed monitoring forms for the most common goals—increasing physical activity, eating five fruits and vegetables a day, and adopting a low-fat diet. Along with the monitoring forms, staff provided a tip sheet that educates women on a given topic and reinforces the importance of adopting the targeted heart-healthy behavior. Staff asked women to return the completed tracking forms and sent women an incentive to celebrate goal attainment.

  The goal-setting form used in SEARHC and the tracking forms used in Plymouth, Massachusetts, are included in the appendix on page A.14.

Women’s Health Network, Massachusetts WISEWOMAN Project
Phone: 617-624-5434

At the Public Health Delta and Menominee Counties in Escanaba, Michigan, staff offered women the opportunity to participate in heart-healthy activities. Staff coordinated a two-session grocery store tour that included education about heart-healthy food choices and a tour of a local grocery store to help women locate these foods. The site also offered a weekly walking group to interested women.

20. Link women to free or low-cost resources that support behavior change and address common barriers to adopting healthier lifestyles (Local)

21. Identify resources to address access to care barriers (Local)

One woman described the benefit of receiving referrals through WISEWOMAN: “The referrals were the best part for me; without the referrals, I would not have done anything.”

22A. Connect incentives to individual goal setting (Local)

22B. Provide incentives that address women’s barriers to behavior change (Local)

22C. Offer incentives that encourage women to monitor their behavior changes (Local)
[Practice #22C also applies to the dimension of Maintenance, Chapter VI.]

22D. Use incentives to encourage participation in program activities (Local)

22E. Develop incentives that increase program name recognition in the community (Local)

One purpose of incentives is to support the goals that women set during the lifestyle intervention. These incentives are offered to either encourage or reinforce adoption of goals or reward goal achievement. An example is a water bottle or walking reflector to support achievement of physical activity-related goals.

Another purpose of incentives is to help overcome women’s barriers to behavior change. These incentives are offered to reduce common barriers to the adoption of a heart-healthy lifestyle, such as the costs associated with joining a gym.

Programs also use incentives that assist women in monitoring their behavior changes, such as distributing pedometers to women to support their use of the 10,000 Steps program. When providing these incentives, staff at high-performing sites gave one-on-one attention to ensure that the women knew how to use the self-monitoring tools.

Incentives are also distributed to women to encourage participation in program activities. For example, the program might distribute a pin or other piece of jewelry to women during each screening visit. Over time, the women might look forward to receiving the incentives and attending the annual screening appointments. High-performing local sites explained the purpose of these incentives during in-person encounters.

A final reason for distributing incentives is to increase recognition of the program in the community. Incentives developed for this purpose need to display the program name visibly and be something that women will carry with them. Tote bags, jackets, towels, and water bottles with the program name are examples of incentives that increase program visibility.

During focus groups, one woman described an incentive that was connected to her individual goals: “I got vegetarian recipes and a good cookbook …. I like to eat as little meat as I can and the cookbooks were helpful. I also learned ways to get more fiber.”

The SEARHC project also distributed jewelry to women during each screening visit. The project developed several pins, each of which depicts traditional Alaska Native artwork. Each woman received a pin that corresponded to the number of years she participated in WISEWOMAN. Women could anticipate receiving a new piece of jewelry at each annual screening appointment.

In addition to the towel and jewelry, SEARHC distributed other incentives that fulfilled a variety of purposes. The incentives have included tote bags, cutting boards, pedometers, water bottles, and stress-reduction balls.

During focus groups, women described the benefit of social support from other participants and staff members. One woman stated, “When I’m walking with the walking class, I find I must be accountable.” Another woman who received supportive phone calls from WISEWOMAN staff said, “The outreach worker makes me feel like I’ve known her forever, even though I’d never met her [before].”

25A. Assess program satisfaction at the end of education and counseling or support sessions (Project)

25B. Encourage women to write success stories to document their satisfaction (Project)

In many WISEWOMAN programs, the lifestyle intervention concludes before the woman is due for her annual screening appointment. The end of the lifestyle intervention provides an opportunity to assess satisfaction. It is likely that the women have engaged in multiple contacts with the program at this point and have had an opportunity to contemplate its messages and recommendations. The fact that the women are still engaged in program services can increase their likelihood of response.

Success stories provide anecdotal evidence of how the lifestyle intervention has affected the lives of the women. These stories illustrate what the women have valued during their participation and focus on their priorities, challenges, and achievements. Projects can use success stories to understand the types of behavior changes women adopt.

To understand the impact of the program on women’s lives, the Every Woman Matters program in Nebraska encouraged women to submit success stories after completing the lifestyle intervention. For this purpose, local sites provided a structured form and a postage-paid envelope. In addition, cooperative extension educators who delivered the class-format lifestyle intervention assessed satisfaction using an evaluation form distributed at the end of the class.

Every Woman Matters, Nebraska WISEWOMAN Project
Phone: 1-800-532-2227