Journal of Women's Health

: The Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) program aims to remove racial and ethnic disparities in health by addressing the screening and intervention needs of midlife uninsured women. This paper describes the WISEWOMAN program requirements, the design of the 12 projects funded in 2002, the use of a standardized data reporting and analysis system, risk factors among participants, effective behavioral strategies, and plans for the future.

: The WISEWOMAN demonstration projects are examining the feasibility and effectiveness of adding a cardiovascular disease (CVD) prevention component to the early detection of breast and cervical cancer. Women aged 40–64 are eligible if they are enrolled in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) in selected U. S. states and are financially disadvantaged and lack health insurance. The primary outcome measures are blood pressure, lipid levels, and tobacco use. Intermediate measures include self-reported diet and physical activity, measures of readiness for change, and barriers to behavior change.

: During 2002, the 10 projects that were fully operational screened 8164 financially disadvantaged women and developed culturally and regionally appropriate nutrition and physical activity interventions for a variety of racial and ethnic backgrounds. Twenty-three percent of the women screened had high total cholesterol, with 48% of these being newly diagnosed. Thirty-eight percent of the women had high blood pressure, with 24% being newly diagnosed. Approximately, 75% of participants were either overweight or obese, and in some sites up to 42% were smokers.

: The WISEWOMAN demonstration projects have been successful at reaching financially disadvantaged and minority women who are at high risk for chronic diseases. These projects face challenges because they are generally implemented by safety net providers who have limited resources and staff to conduct research and evaluation. On the other hand, the findings from these projects will be especially informative in reducing health disparities because they are conducted in those settings where the most socially and medically vulnerable women receive care.

: The WISEWOMAN program focuses on reducing cardiovascular disease (CVD) risk factors by providing screening and lifestyle interventions for many low-income and uninsured women. To provide the most effective interventions possible, it is important to understand the characteristics of WISEWOMAN participants and their communities.

: We used baseline data collected for WISEWOMAN participants from five states (Connecticut, Michigan, Nebraska, North Carolina, and South Dakota) who had enrolled in WISEWOMAN between January 2001 and December 2002 in order to examine body mass index (BMI) and smoking behavior for evidence of spatial clustering. We then examined whether neighborhood characteristics in clusters of high-risk factors differed from neighborhood characteristics in other locations.

: Six percent of the WISEWOMAN participants lived in ZIP codes with high-BMI clusters, and 4% lived in ZIP codes with high-smoking clusters. High-BMI and high-smoking clusters occurred, however, in different locations from each other. The high-BMI-clustered ZIP codes were, on average, located in more disadvantaged areas. Most of the differences between the high-smoking-clustered ZIP codes and the remaining ZIP codes were not statistically significant.

: Our analysis revealed spatial clustering in CVD risk factors among WISEWOMAN participants. We also found evidence of a correlation between high-BMI clusters and low socioeconomic status of the surrounding community. A more in-depth analysis of the relationship between risk factors (e. g., BMI) and community characteristics in clustered locations will provide further information concerning the role of the community in affecting individual behavior and should allow for tailoring interventions to reduce these risk factors more effectively.

: The WISEWOMAN program provides chronic disease risk factor screening, lifestyle interventions, and referrals to financially disadvantaged women who participate in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). Three states (Arizona, Massachusetts, and North Carolina) participated in Phase One (1995–1998).

: Using a case study approach, we reviewed documents and conducted telephone interviews to compare the three projects' design and execution. The interviews, carried out in mid-2002, involved a convenience sample of project coordinators, project directors, researchers, and one CDC project officer (n = 9).

: Many providers were overwhelmed by WISEWOMAN's research component and disliked its lack of flexibility. Researchers emphasized that high-quality evaluation requires resources and attention. Informants described the challenges of integrating WISEWOMAN with state BCCEDP programs that are in varying development stages and recommended changes in organizational culture and provider practices. Regarding implementation, informants emphasized the need for adequate and appropriate planning, buy-in, training, professional support, and outreach. Our sample also noted that WISEWOMAN projects tend to be labor intensive.

: WISEWOMAN projects face challenges of integrating clinical and lifestyle interventions, reaching beyond a focus on individuals, marshaling substantial resources, and introducing complex interventions into stretched healthcare environments. The three Phase One projects were deemed successful in reaching underserved women, developing a more comprehensive women's health model, strengthening linkages to primary healthcare, experimenting with innovative behavioral interventions, and tapping into women's roles as social support providers and family/community gatekeepers.

: This report presents the effectiveness of the Massachusetts Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) Project (MWWP) in reducing the cardiovascular disease (CVD) risk of uninsured and underinsured women aged ≥50.

: Healthcare sites were randomly assigned to an enhanced intervention (EI) or minimum intervention (MI). Women enrolled at all sites received CVD risk factor screening, onsite counseling, education, referral, and follow-up as needed. Women enrolled at EI sites received additional services and specially designed interventions, including one-on-one nutritional and physical activity counseling and group activities, such as walking groups, nutrition classes, and cultural festivals. We report results for 1443 women who attended the initial screening in 10 study sites. Blood pressure, total cholesterol, number of servings of fruits and vegetables, and level of moderate or vigorous physical activity were assessed at baseline and 12-month follow-up screenings. Baseline data were collected between March and June 1996; follow-up data were collected 12 months later.

: The comprehensive screenings significantly lowered the overall prevalence of hypertension, resulting in a 7% reduction in high blood pressure among women at the EI sites (p = 0.02) and a 9% reduction at MI sites (p = 0.009). A significantly greater percentage of women became physically active at the EI sites (18%) than at the MI sites (6%) (p = 0.04).

: MWWP is a promising model for providing comprehensive preventive healthcare to uninsured and underinsured women.

: The Arizona Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) project used provider counseling, health education, and community health workers (CHWs) to target chronic disease risk factors in uninsured, primarily Hispanic women over age 50.

: Participants were recruited from two Tucson clinics participating in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). Women were randomly assigned into one of three intervention groups: (1) provider counseling, (2) provider counseling and health education, or (3) provider counseling, health education, and CHW support. At baseline and 12 months (1998–2000), participants were measured for height, weight, waist and hip circumference, and blood pressure. Blood tests were conducted to check blood glucose, cholesterol, and triglyceride levels. At each time point, participants also completed 24-hour dietary recalls and questionnaires focusing on their physical activity levels.

: A total of 217 women participated in baseline and 12-month follow-up. Three fourths were Hispanic. All three intervention groups showed an increase in self-reported weekly minutes of moderate-to-vigorous physical activity, with no significant differences between the groups. Significantly more women who received the comprehensive intervention of provider counseling, health education, and CHW support progressed to eating five fruits and vegetables per day, compared with participants who received only provider counseling or provider counseling plus health education.

: All three interventions increased moderate-to-vigorous physical activity but not fruit and vegetable consumption. The intervention group with provider counseling, health education, and CHW support significantly increased the number of women meeting national recommendations for fruit and vegetable consumption.

: The high rates of relapse that tend to occur after short-term behavioral interventions indicate the need for maintenance programs that promote long-term adherence to new behavior patterns. Computer-tailored health messages that are mailed to participants or given in brief telephone calls offer an innovative and time-efficient alternative to ongoing face-to-face contact with healthcare providers.

: Following a 1-year behavior change program, 22 North Carolina health departments were randomly assigned to a follow-up intervention or control condition. Data were collected from 1999 to 2001 by telephone-administered surveys at preintervention and postintervention for 511 low-income, midlife adult women enrolled in the Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) program at local North Carolina health departments. During the year after the behavior change program, intervention participants were mailed six sets of computer-tailored health messages and received two computer-tailored telephone counseling sessions. Main outcomes of dietary and physical activity behaviors, beliefs, and attitudes were measured.

: Intervention participants were more likely to move forward into more advanced stages of physical activity change (p = 0.02); control participants were more likely to increase their level of dietary social support at follow-up (p = 0.05). Both groups maintained low levels of reported saturated fat and cholesterol intake at follow-up. No changes were seen in physical activity in either group.

: Mailed computer-tailored health messages and telephone counseling calls favorably modified forward physical activity stage movement but did not appreciably affect any other psychosocial or behavioral outcomes.

: Although historically Alaska Native women have had a relatively low incidence of cardiovascular disease (CVD), this pattern has changed dramatically in recent years. Alaska Native leaders have identified decreasing cardiovascular risk as an intervention priority.

: From October 2000 to April 2001, Southcentral Foundation, an Alaska Native-owned and managed health corporation in Anchorage, conducted a pilot randomized controlled trial of a heart disease prevention program tailored for Alaska Native women. The aim was to assess feasibility and cultural acceptability and to develop enrollment procedures. Of 76 women who enrolled, 44 were randomized to the intervention group. Thirty-seven of 44 attended at least two intervention sessions, 23 completed prequestionnaires and postquestionnaires, and 27 returned for 12-month follow-up screening. Thirty of 32 control group participants returned for 12-month follow-up screening. The intervention included 12 weekly sessions on lifestyle change and goal setting. At baseline and 12 months, participants' height, weight, resting blood pressure, fasting lipid levels, and blood glucose were measured. At sessions 1 and 12, participants completed assessments regarding diet, physical activity, tobacco use, and psychosocial status.

: At 12 weeks, significant improvements were noted in moderate walking and physical activity self-efficacy. Also observed was substantial movement from the contemplation and preparation stages to the action stage regarding physical activity and heart-healthy eating.

: Although the small sample size precludes drawing conclusions about the intervention's effect, participants reported lifestyle and psychosocial changes. The pilot study resulted in protocol changes that improved the design and implementation of a subsequent large-scale study.

: To serve the populations targeted by Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) effectively, healthcare providers need educational materials that are evidence based and ethnically relevant and can be easily incorporated into busy clinic settings. We describe a replicable process used to redesign and tailor physical activity and diet education materials for African American women in the southeastern United States.

: The process consists of seven phases. Quantitative and qualitative analyses were used on data gathered in 2000 from two expert panels and eight focus groups.

: Expert panelists preferred materials perceived to be high quality, easy to understand, organized to facilitate use by healthcare providers, and with content relevant to African American women. Focus group participants were mostly concerned with the visual appeal and content of educational materials. They liked high-quality materials that are brief; avoid jargon and use simple language, bright colors, and photographs; and provide useful information that acknowledges the context of their lives, including their family roles.

: The redesign process can produce ethnically and culturally appropriate educational materials for use by WISEWOMAN providers and other healthcare providers in conjunction with cardiovascular (CVD) risk reduction and behavioral counseling. To be effective, materials must address the needs and concerns of both providers and patients.

: Cardiovascular disease (CVD) is a major public health concern in the United States. We developed an annual training course, Nutrition and Public Health, A Course for Community Practitioners (NPH), to address the identified training needs of state staff responsible for designing and implementing the Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) program and to support other health professionals working in programs that address chronic disease prevention and management.

: After conducting a needs assessment with state-level WISEWOMAN staff in 2001 to identify topics of interest, we formed an advisory committee to provide guidance on topics, theoretical frameworks, training concerns, and multilevel intervention approaches. The first week-long training course, which included an intensive field practicum, was implemented in the fall of 2002.

: Participants rated three fourths of the elements listed in a posttraining evaluation as a course strength, giving particularly high ratings to various indicators of course quality (100%) and networking opportunities (95%). Just over half (55%) rated the field practicum as a course strength. Four fifths (83%) of participants responded to a 6-month follow-up evaluation, and most indicated that the course had increased their knowledge and skills and increased their confidence in planning programs.

: Unique features of the course include its suitability for public health practitioners not previously trained in nutrition, its promotion of multilevel interventions, and its focus on CVD risk reduction and nutrition interventions for underinsured and uninsured populations.

: Although most health departments recognize the need for programs to reduce the risk of cardiovascular disease (CVD) among older, low-income women, they face numerous barriers to successfully implementing such programs. This paper explores counselors' attitudes and beliefs about patients and perceived barriers to implementing the North Carolina Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) program.

: Health departments were assigned to provide patients with either an enhanced intervention (EI) or a minimum intervention (MI). Cross-sectional baseline and 12-month follow-up surveys were completed by health department counselors designated to deliver the MI or EI. Both surveys addressed counselors' beliefs about patients' motivation and attitudes, their counseling practices, and their personal diet and physical activity behaviors and attitudes. The follow-up survey also addressed opinions about the feasibility of long-term WISEWOMAN implementation.

: Counselors were skeptical about patients' motivation to improve their lifestyle, citing high perceived cost and burden. At follow-up, EI counselors reported having higher self-efficacy for counseling, incorporating more behavioral change strategies, and spending more time counseling than did counselors at MI sites. They were also more likely to report making healthful personal lifestyle choices. All counselors identified lack of time as a major barrier to counseling, and most cited obtaining low-cost medications for patients, ensuring that patients made follow-up visits, and implementing the program with existing staff as key challenges to the long-term sustainability of WISEWOMAN.

: Our findings provide insight into the organizational challenges of implementing a CVD risk-reduction program for low-income women. We discuss ways in which intervention and training programs can be improved.

: Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) provides low-income, underserved women ages 40–64 with risk factor screening and lifestyle intervention and referral services to prevent cardiovascular disease (CVD). Integrating WISEWOMAN's services with the culturally appropriate medical care and support services offered by community health centers may improve the program's ability to reduce CVD burden among underserved women.

: We conducted a formative assessment of the perceived opportunities, challenges, and strategies associated with integrating WISEWOMAN into community health center settings. A panel of stakeholders that included health center and WISEWOMAN representatives was convened in 2002, and a semistructured discussion guide was used to elicit perspectives about integration. We also conducted an in-depth review of WISEWOMAN's history of collaboration with health centers in North Carolina.

: Stakeholders perceived a clear need for integrating WISEWOMAN within health center settings, indicating that centers have few other resources to expand preventive services delivery and offer effective lifestyle interventions for underserved populations. Perceived barriers to integration included competing demands on health center resources, difficulties hiring staff for new programs, and administrative burdens associated with data collection and reporting. Experiences within North Carolina's WISEWOMAN project demonstrate, however, that lifestyle interventions can be designed in ways that facilitate integration by health centers.

: Integration strategies need to be tailored to the resources, skills, and capacities available within health centers. As health centers and WISEWOMAN projects gain more experience in collaborating, additional research should be conducted to identify how best to achieve integration within specific institutional and community contexts.

: Compelling success stories, rich with details about real-life events and people, are a tool that health agencies can use to convey how their health promotion programs work, why they are successful, what lessons they have learned, and how others can launch similar programs. Success stories describe project accomplishments that are not easily captured by quantitative evaluation methods, such as surveys.

: Although success stories have not been widely used in public health, the North Carolina Department of Health and Human Services developed a series of stories, the Community Change Chronicles, to highlight environmental and policy changes that promote cardiovascular health. In 2003, the Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) program used the Community Change Chronicles as a model to develop success stories about WISEWOMAN projects.

: WISEWOMAN Works: A Collection of Success Stories from Program Inception Through 2002 includes 12 stories and offers advice on how to create and use success stories in public health. This paper reviews the rationale for developing the stories, presents one success story as an example, and describes the process used to gather information, write the stories, and produce a resource for others interested in developing success stories. We also discuss how the WISEWOMAN success stories are being used to promote women's health and cardiovascular health.

: As the WISEWOMAN experience suggests, healthcare providers and organizations can use success stories to gain support for successful activities, inform the public about program benefits, complement other quantitative and qualitative evaluation methods, and publicly acknowledge the contributions of staff and organizational partners.

: In today's healthcare environment, public health resources are scarce. Thus, interventions to improve the public's health must be rigorously evaluated to ensure that they make the best use of available resources.

: The Centers for Disease Control and Prevention (CDC) provides a general framework for program evaluation. This paper presents additional details on several key evaluation areas within CDC's framework.

: Successful evaluations will be built into the program design; will be multifaceted, incorporating both quantitative and qualitative methods; will assess both process and outcome measures; and will engage stakeholders to ensure utility of results.

: Well-planned evaluations can lead to less burdensome yet more effective assessment and better program performance and can increase the knowledge base for health promotion practice.