Well-Integrated Screening And Evaluation For Women Across The Nation Research Articles

Women with Blood Pressure Improvement in the Well-Integrated Screening and Evaluation for Women Across the Nation Program by Race and Ethnicity, 2014-2018.

Background: The Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) program aims to improve the cardiovascular health of women aged 40-64 years with low incomes, and who are uninsured or underinsured. The objective is to examine WISEWOMAN participants with hypertension who had high blood pressure (BP) improvement from January 2014 to June 2018, by race and ethnicity. Also examined was participation in WISEWOMAN Healthy Behavior Support Services (HBSS) and adherence to antihypertensive medication. Materials and Methods: WISEWOMAN data from January 2014 to June 2018 were analyzed by race and ethnicity. BP improvement was defined as at least a 5 mm Hg decrease in systolic or diastolic BP values from baseline screening to rescreening. The prevalence of HBSS participation and antihypertensive medication adherence were calculated among hypertensive women with BP improvement. Results: Approximately 64.2% (4,984) of WISEWOMAN participants with hypertension had at least a 5 mm Hg BP improvement. These improvements were consistent across each race and ethnicity (p = 0.56) in the study. Nearly 70% of women who had BP improvement attended at least one HBSS. Hispanic women (80.1%) had the highest HBSS attendance percentage compared to non-Hispanic Black women (64.1%) and non-Hispanic White women (63.8%; p < 0.001). About 80% of women with BP improvement reported being adherent to antihypertensive medication in the previous 7 days. Conclusions: The proportion of women achieving BP improvement in the WISEWOMAN program was consistent across race and ethnicity. In addition, women with BP improvement reported adherence to antihypertensive medication and participation in HBSS.

Smoking Cessation Efforts Among WISEWOMAN Program Participants, 2014-2018.

Smoking is a preventable risk factor for cardiovascular disease (CVD), indicating the importance of smoking cessation. The Centers for Disease Control and Prevention's Well-Integrated Screening and Evaluation for WOMen Across the Nation (WISEWOMAN) Program funded 21 recipients to provide preventative health services, including healthy behavior support services, to low-income, uninsured, or underinsured women, between 40 to 64 years of age, aimed at lowering CVD risk for women from January 2014 to June 2018. This article explores WISEWOMAN's smoking prevalence and smoking cessation efforts. Analyses were conducted to assess smoking status and other CVD risk factors among 71,671 unique women from all 21 WISEWOMAN funded recipients. Information on CVD risk factors, including smoking status, were collected. Women who were identified as currently smoking during their initial visit were referred to smoking cessation services and their smoking status was revisited during their rescreening. The overall smoking cessation prevalence was 16.9% during the funding cycle. This small increase from the previous iteration of WISEWOMAN (14.9%), supports WISEWOMAN's continued emphasis on smoking cessation through community-clinical linkages. The distribution of smoking cessation did vary by race and ethnicity (p < 0.001). Hispanic women had a higher smoking cessation (38.1%) compared to non-Hispanic American Indian/Alaska Native, non-Hispanic Black, and non-Hispanic White women (17.4%, 15.1%, and 13.7% respectively). In the next iteration of the WISEWOMAN Program, it is anticipated that continued emphasis will be placed on achieving health equity among women who smoke, to reduce CVD risk.

Medical Follow-Up Received by Women with Blood Pressure Alerts in the WISEWOMAN Program by Race and Ethnicity, 2014–2018

Background: Hypertension is a preventable risk factor for heart disease and stroke. Immediate reduction in blood pressure (BP) is necessary for a person with dangerously high BP to prevent injuries related to heart disease and stroke. Differences in the prevalence of hypertension and dangerously high BP (BP alerts) and the distribution of medical follow-ups were examined by race and ethnicity among participants in the Well-Integrated Screening and Evaluation for WOMen Across the Nation (WISEWOMAN) program. Materials and Methods: Data (January 2014 through June 2018) were used to identify women, aged 40-64 years, with hypertension at their first WISEWOMAN screening. Women with BP alerts were identified as having an average systolic BP >180 mm Hg or diastolic BP >110 mm Hg at WISEWOMAN baseline screening or rescreening. CDC's WISEWOMAN program is a public health practice program and does not conduct human subject research. Results: Among 65,189 WISEWOMAN participants, 25,098 (38.5%) women had hypertension and 586 (2.3%) of those women had BP alerts. There were significant differences among Hispanic, non-Hispanic black (NHB), and non-Hispanic white (NHW) women in the prevalence of hypertension (26.5%, 67.1%, and 40.2%, respectively, p < 0.001) and BP alerts (1.7%, 3.4%, and 2.1%, respectively, p < 0.001). Among women with BP alerts, 74.7% received a medical follow-up within 7 days and 12.4% received a medical follow-up after 7 days. There were no significant differences in the percentage of women with BP alerts who received a follow-up within 7 days among Hispanic, NHB, and NHW women (71.1%, 77.1%, and 74.4%, respectively, p = 0.085). Conclusions: BP alerts occurred in 2.3% of the WISEWOMAN hypertensive population, and approximately three in four women with BP alerts, regardless of race and ethnicity, received timely follow-up care within 7 days.

An Integrated Approach to Addressing Chronic Disease Risk Factors in Financially Disadvantaged Women in South Carolina.

We combined data from the National Breast and Cervical Cancer Early Detection (NBCCEDP) and Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) programs in South Carolina to assess whether cancer screening outcomes in NBCCEDP impacted participation in WISEWOMAN lifestyle interventions, and whether the status of WISEWOMAN baseline risk factors (obesity, diabetes, hypercholesterolemia, hypertension, and smoking) determined subsequent completion of lifestyle interventions. Case-control. Three WISEWOMAN implementation sites in South Carolina. The study comprised 7841 NBCCDEP participants in three WISEWOMAN program sites. The two programs serve financially disadvantaged women. Outcome measures were participation in WISEWOMAN lifestyle interventions and completion of lifestyle interventions. The main predictor measures were cancer screening outcomes and baseline chronic disease risk factors. Covariate measures included age, race, body mass index, smoking status, and education. We used multivariable logistic regression models to examine the odds of participation in and completion of WISEWOMAN lifestyle interventions. The association between cancer screening outcome and participation in WISEWOMAN lifestyle interventions among NBCCEDP participants differed significantly by education and smoking status. Among smokers or highly educated women, having an outcome of cancer or precancerous lesion through the NBCCEDP screening compared to normal screening outcomes was significantly associated with participation in lifestyle interventions, with odds ratios of 2.69 (95% confidence interval [CI], 1.10-6.58) for highly educated women and 1.82 (95% CI, 1.00-3.31) for smokers. Similarly, smokers or diabetics were more likely than nonsmokers or nondiabetics, respectively, to complete lifestyle interventions. Nonsmokers and women with lower education in NBCCEDP may need additional navigation to lifestyle interventions in an integrated program implementation approach to improve participation in and completion of WISEWOMAN interventions.

The West Virginia WISEWOMAN Program

This article describes moving The Well-Integrated Screening and Evaluation for WOMen Across the Nation (WISEWOMAN) Program from research to practice in a population of low-income, uninsured, or underinsured women in West Virginia (WV) between the ages of 40 and 64 years. Cardiovascular disease risk factors were evident using screening and health history data from women in all stages of change as well as in different phases of the program. An indicator of program success was women's increased activities to improve their cardiovascular health. Women using an interactive Web program, coupled with appropriately delivered health information, can and do make behavior changes. As the WV WISEWOMAN Program moved from research to practice, clinician training and changes to policies and procedures were needed. Clinicians became skilled at motivational interviewing and targeting information to connect women to community resources for ongoing support. The program continues to help clinicians alert women to cardiovascular risks and guide them to take responsibility for their health. Partnerships between women and their providers are the key to successful implementation of healthier lifestyles.

The Effect of the Missouri WISEWOMAN Program on Control of Hypertension, Hypercholesterolemia, and Elevated Blood Glucose Among Low-Income Women

IntroductionThe Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) public health program is designed to reduce the risk of heart disease and stroke among low-income, underinsured or uninsured women through clinical screenings, risk factor assessment, and lifestyle interventions. We assessed the effect of the Missouri WISEWOMAN program on the control of high blood pressure, total cholesterol, and blood glucose levels.MethodsWe calculated the proportion of participants (N = 1,130) with abnormal blood pressure, total cholesterol, or blood glucose levels at an initial screening visit who gained control at a follow-up visit 11 to 18 months later during a 7-year period from June 30, 2005, to June 29, 2012. We used logistic regression to identify sociodemographic characteristics and other factors associated with achieving control.ResultsMany WISEWOMAN participants gained control of their blood pressure (41.2%), total cholesterol (24.7%), or blood glucose levels (50.0%). After controlling for sociodemographic factors, smoking status, weight status, medication use, and number of lifestyle interventions, nondiabetic women with stage II hypertension (adjusted odds ratio [AOR] = 0.36, 95% confidence interval [CI] = 0.21–0.60) and diabetic women with stage I (AOR = 0.54, 95% CI = 0.32–0.92) and stage II (AOR = 0.23, 95% CI = 0.07–0.77) hypertension were less likely to achieve control of their blood pressure than nondiabetic women with stage I hypertension. Women aged 45 to 64, women with less than a high school education, women who were obese in the initial visit, women who gained 7% or more of their weight, and women who did not participate in any lifestyle intervention sessions were significantly less likely to achieve total cholesterol control than their counterparts.ConclusionThe Missouri WISEWOMAN program helps many participants achieve control of blood pressure, total cholesterol, and blood glucose levels; the lifestyle intervention is likely to help participants control total cholesterol. More efforts are needed for women with diabetes and stage II hypertension to achieve blood pressure control.

The WISEWOMAN program: smoking prevalence and key approaches to smoking cessation among participants, July 2008-June 2013.

Tobacco use is a major risk factor for cardiovascular disease (CVD) and is the leading preventable cause of death, disease, and disability in the United States. The CDC's Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) program addresses the heart health of low-income under- or uninsured women between the ages of 40 and 64 years. This article discusses WISEWOMAN's key approaches to smoking cessation and their impact on WISEWOMAN participants' cardiovascular health. A longitudinal retrospective analysis was conducted using data from 21 funded CDC programs from July 2008 to June 2013. Data were collected on 149,767 women to assess CVD risk, smoking status, and utilization of programs related to tobacco cessation. The overall prevalence of smoking among the WISEWOMAN population during this period was 28%. Increases in referrals to tobacco quitlines, tobacco-cessation counseling, lifestyle interventions, and other community-based tobacco-cessation programs contributed to a 15% smoking-cessation rate among smokers who returned for a rescreening assessment over the 5-year program period. The WISEWOMAN program has observed a smoking-cessation rate of 15% over the 5-year program period. WISEWOMAN's key approaches include continuous technical assistance that highlights quitline referrals, motivational interviewing done by program staff, and professional-development strategies for WISEWOMAN healthcare providers. WISEWOMAN will continue its programmatic emphasis on smoking cessation by partnering with state tobacco-cessation programs to work toward a lower smoking-prevalence rate among program participants.

WISEWOMAN: Addressing the Needs of Women at High Risk for Cardiovascular Disease

In the United States, the cardiovascular health of women is affected by the disparate impact of cardiovascular diseases (CVDs) on many minority ethnic and racial groups. Women with low income also endure a disproportionate impact of the burden of CVD. The Centers for Disease Control and Prevention's (CDC's) Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) Program was authorized by Congress in 1993 to extend the preventive health services offered to participants of the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). These are low-income, uninsured, and underinsured women. The intent was to expand services of an existing federal program to address cardiovascular health concerns in this vulnerable, high-risk population. CDC funds 19 state health departments and 2 tribal organizations (both in Alaska) to implement WISEWOMAN. In the first 2 years of the current 5-year funding cycle, which began in June 2008, the WISEWOMAN grantees succeeded in providing almost 78,000 screenings, of which 46% were to women of minority racial and ethnic groups. The individual successes are important, and the WISEWOMAN Program also has achieved success in the broader arenas of healthcare and the communities in which WISEWOMAN is implemented. WISEWOMAN impacts clinical systems of care, provider education, physician extenders, and the broader community and will continue to play an important role in connecting low-income, uninsured, and underinsured women with clinical systems of care and other community resources that will result in the prevention, treatment, and management of their CVD risk.

Lifestyle Intervention, Behavioral Changes, and Improvement in Cardiovascular Risk Profiles in the California WISEWOMAN Project

The Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) program in California (Heart of the Family) implements lifestyle interventions to improve health behaviors while reducing cardiovascular disease (CVD) risk factors among low income, uninsured, or underinsured Hispanic women aged 40-64 who participate in the Cancer Detection Programs: Every Woman Counts (CDP: EWC). This study reports the first-year results of the California WISEWOMAN program. Heart of the Family is a within-site randomized controlled study with an enhanced intervention group (EIG) and a usual care group (UCG). The study was conducted between January 2006 and June 2007 at four community health centers in Los Angeles and San Diego counties. Lifestyle counseling focusing on health behaviors was provided by bilingual, bicultural (Spanish and English) community health workers. The study examines two outcome measures: changes in health behaviors; and changes in the CVD risk profile, as measured by the 10-year probability of having a coronary heart disease (CHD) event. Women in the EIG group (n = 433), compared to those in the UCG group (n = 436), experienced more improvements in health behaviors, both eating habits and physical activity. The improvement in the 10-year CHD risk was greater for EIG than UCG women. Multiple regression results indicate that this improvement was significantly greater when the women's CHD risk levels were in the upper quartile at baseline. Compared with UCG women, women in the EIG were more likely to improve their health behaviors. The CVD risk profile, as measured by the 10-year CHD risk, improved in women with the highest baseline risk.

Factors Associated with Control of Hypertension, Hypercholesterolemia, and Diabetes Among Low-Income Women in West Virginia

Adequate control of cardiovascular risk factors, such as hypertension, hypercholesterolemia, and diabetes, requires management. Low-income women living in rural areas with limited health services may experience special challenges in managing chronic conditions. In 2008, we conducted an analysis of the baseline, cross-sectional survey of 733 uninsured, low-income, rural women aged 40-64 years participating in the Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) project in West Virginia to characterize prevalence, treatment, and control of hypertension, hypercholesterolemia, and diabetes. Data were collected from 2004 to 2007. About 56% of the women had hypertension (38% of which was untreated or uncontrolled), 45% had hypercholesterolemia (31% of which was untreated or uncontrolled), and 19% had diabetes (26% of which was untreated or uncontrolled). Multivariable analyses showed that those with a regular physician were less likely than those without a physician to have uncontrolled hypertension (adjusted odds ratio [AOR] 0.34, 95% CI 0.13-0.88) and hypercholesterolemia (AOR 0.14, 95% CI 0.04-0.47). Education level was also a significant predictor for uncontrolled hypertension, and physical activity level (measured by total metabolic equivalent [MET] hours) significantly predicted uncontrolled hypercholesterolemia (AOR 1.01, 95% CI 1.001-1.02). For diabetes, race/ethnicity was the main predictor; white women were less likely than other groups to have untreated or uncontrolled diabetes. High proportions of women in the WV-WISEWOMAN project had uncontrolled hypertension, hypercholesterolemia, and diabetes at baseline. These study results should be used to inform programs seeking to increase access to health services in order to reduce consequences of uncontrolled chronic conditions.

Self-Reported and Clinical Measurement of Three Chronic Disease Risks among Low-Income Women in West Virginia

This study assessed the validity of several self-reported cardiovascular risk factors among low-income women aged 40-64 years in West Virginia. A cross-sectional survey was conducted of 733 women participating in the Well Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) project in West Virginia to examine agreement between self-report and clinical screenings in the prevalence of risk factors related to coronary heart disease (CHD). Women participating in the study were interviewed face-to-face before administration of clinical screenings that assessed height, weight, Quetelet's index, high blood pressure (systolic > or =140 mm Hg or diastolic > or =90 mm Hg), and elevated total cholesterol concentrations (> or =200 mg/dL and > or =240 mg/dL). The overall results showed high sensitivity and specificity for each of the risk factors examined; for overweight/obesity, the sensitivity was 96% and specificity was 93%; for cholesterol > or =240 mg/dL, sensitivity was 85% and specificity was 67%; for hypertension, sensitivity was 77% and specificity was 86%. Using a threshold value of > or =240 mg/dL for hypercholesterolemia led to higher sensitivity but a lower specificity than for a value of > or =200 mg/dL. This study found that among low-income women at higher risk for cardiovascular disease (CVD), self-reported values for high body mass index (BMI), hypercholesterolemia, and hypertension were well correlated with clinical measures, as indicated by high sensitivity values. Thus, self-reported values can be used for surveillance, targeted screenings, and health promotion activities, including lifestyle changes.

Clinic-Based Nutrition and Lifestyle Counseling for Hispanic Women Delivered by Community Health Workers: Design of the California WISEWOMAN Study

The Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) program in California, named Heart of the Family, implements and evaluates the effectiveness of lifestyle interventions to improve nutrition and physical activity while reducing cardiovascular disease (CVD) risk factors among low-income, uninsured or underinsured Hispanic women aged 40-64 who participate in the Cancer Detection Programs: Every Woman Counts (CDP:EWP). This paper reports the study design and baseline findings of the California WISEWOMAN program. Heart of the Family, a within-site randomized controlled study at four community health centers in Los Angeles and San Diego, featured a unique set of strategies meeting the state population in implementing a California WISEWOMAN program. The program exclusively targeted Hispanic women who are at risk of developing CVD, provided lifestyle intervention using a validated intervention material in Spanish and English to motivate behavioral changes, and used bilingual (English and Spanish) community health workers (CHWs) to provide individually based face-to-face counseling. Women meeting enrollment criteria were randomly assigned either to an enhanced intervention group (EIG), who received lifestyle intervention, or usual care group (UCG), who received the usual care for elevated blood pressure or cholesterol. A total of 1093 women enrolled between January 2006 and August 2006. Demographic and baseline CVD risk profiles are similar in both groups. Some notable characteristics of the California participants are lower smoking rate (5%), higher average body mass index (BMI) (31.9), and a significantly higher percentage with less than high school education (70%). With its unique study design and large number of enrolls, Heart of the Family will enable future public health efforts to better meet the health needs of Hispanic women by addressing education levels, economic considerations, and cultural and linguistic needs.

Status of Women in Cardiovascular Clinical Trials

Cardiovascular disease (CVD) is the most common cause of death in American women and accounts for a full one-third of all deaths.1 Although the common perception may be that CVD affects mainly men, there is equal prevalence of this disease between the genders by the age of 40, and by the age of 60 more women than men are affected. More women than men have died from CVD causes on a yearly basis since the mid 1980s, and whereas the CVD mortality has steadily declined in men over the past 30 years, it has remained steady in women until very recently when CVD mortality was noted to decrease for both genders.2 See accompanying article on page 277 The impact of cardiovascular disease (CVD) on the health status of American women is gaining more recognition and has become the focus of public education efforts such as the “Go Red for Women” campaign sponsored by the American Heart Association and the “Red Dress” project sponsored by the Department of Health and Human Services, the National Institutes of Health (NIH), and the National Heart Lung and Blood Institute (NHLBI). These programs are, in part, a response to the increasing awareness of cardiovascular disease as a major source of morbidity and mortality in U.S. women. The importance of CVD as a major source of mortality in women was recognized early on by federally funded institutes including the Public Health Service Task Force, which brought attention to concerns about the health information available to women and the historical lack of research focus on women’s health in its 1985 Report of the Public Health Service Task Force on Women’s Health Issues .3 In response to this report, the National Institutes of Health adopted a policy for the inclusion of women in clinical research …

Impact of travel distance on WISEWOMAN Intervention attendance for a rural population

Objective The Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) is a program designed for financially disadvantaged women ages 40–64 and funded by the Centers for Disease Control and Prevention (CDC). This study investigates the role that travel distance plays in determining whether these women will attend an intervention program. Method Women in the Iowa WISEWOMAN program were offered an optional health care education program. Distance from the woman's house to the intervention class site was calculated for participants from October 2002 through July 2005 resulting in 787 women. A generalized additive model is used in determining the combined effects of distance, demographic variables, and lifestyle variables on whether women in the study attend the intervention session or not. Results Distance plays an important role in attendance, although its impact depends on the age of the woman and the setting (urban or rural) of the intervention. In particular, older rural women were much more likely to attend if the intervention was close to home. Conclusion The probability of attendance is affected by many factors, but travel distance appears to play an important role, particularly for older rural women.

Linking Clinical Care to Community Resources for Cardiovascular Disease Prevention: The North Carolina Enhanced WISEWOMAN Project

The Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) project addresses the need for effective cardiovascular disease (CVD) prevention among underserved, midlife women. We describe an Enhanced Intervention that addressed environmental and individual factors within the context of a clinic-based intervention. We also present the study design and baseline results of the randomized trial to evaluate the enhanced intervention. The multicomponent behavior change intervention addressed many elements of the Chronic Care Model (CCM), including the community resources and policy element, wherein Enhanced Intervention participants were encouraged to overcome environmental barriers to a healthy lifestyle by using community resources. Study participants were enrolled at one community health center; all were low-income, underinsured, midlife (40-64 years) women. A total of 236 participants were randomized to receive the Enhanced Intervention or the Minimum Intervention. At baseline, over three fourths of the participants were overweight or obese. Participants reported a variety of problematic neighborhood characteristics, including a paucity of restaurants with healthy food choices (41% reported as a problem); not enough farmer's markets or produce stands (50%), not enough affordable exercise places (52%), not enough physical activity programs that met women's needs (42%), heavy traffic (47%), and speeding drivers (53%). Overall, women knew little about affordable exercise venues and nutrition classes. In this clinic-based intervention, we addressed environmental factors related to a healthy lifestyle. Results indicate the need for effective and feasible intervention strategies to address the environments in which individuals are making behavior changes. The effectiveness of the WISEWOMAN Enhanced Intervention will be assessed in a randomized trial.

Integrating preventive health services within community health centers: lessons from WISEWOMAN.

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.

Expanding the evidence for health promotion: developing best practices for WISEWOMAN.

Implementing effective programs to prevent chronic disease holds the promise of reducing morbidity and mortality, reducing health disparities, and promoting health. Yet many programs have demonstrated success only in highly controlled research settings and few address the needs of low-income, uninsured, minority women. Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN), a demonstration program funded by the Centers for Disease Control and Prevention (CDC), that provides chronic disease risk factor screening and lifestyle interventions for low-income, 40-64-year-old women is learning from our own successful programs but is also charting new territory. As the CDC, state health departments, tribal organizations, and other WISEWOMAN partners approach the end of the first decade of WISEWOMAN demonstration projects, we are seeking to understand what has worked and what has not. This paper describes the rationale and proposed methodology for assessing best practices in the WISEWOMAN program through a participatory process that will examine scientific evidence and quantitative and qualitative program data. By emphasizing practicality in addition to scientific rigor, we are expanding the base of evidence considered to identify effective approaches for reducing cardiovascular disease (CVD) risk in financially disadvantaged, ethnically diverse women. Results of the 3-year project will be disseminated in a format intended to encourage programs to select and adapt those strategies best suited to their particular contexts.

Using success stories to share knowledge and lessons learned in health promotion.

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.

Racial/ethnic disparities in coronary heart disease risk factors among WISEWOMAN enrollees.

We used the baseline data collected for the Well-integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) participants to provide a snapshot of cardiovascular disease (CVD) risk on enrollment and to address racial/ethnic disparities in the following CVD risk factors: body mass index (BMI), systolic and diastolic blood pressure, high-density lipoprotein (HDL) and total cholesterol, diabetes and smoking prevalence, 10-year coronary heart disease (CHD) risk, and treatment and awareness of high cholesterol, hypertension, and diabetes. We used linear regression analysis to (1) assess the presence of racial/ethnic disparities and test whether existing disparities can be explained by (2) differences in individual characteristics or by (3) differences in individual and community characteristics. Our results reveal a high degree of CVD risk among the WISEWOMAN participants and statistically significant racial/ethnic disparities in risk factors. Black participants were at the greatest risk of CVD, and Hispanic and Alaska Native participants were healthier in terms of CVD risk than white participants. Some racial/ethnic disparities were explained by differences in individual and community characteristics, but other disparities persisted even after controlling for these factors. Because differences in community characteristics explain many of the racial/ethnic disparities in CVD risk factors, eliminating disparities may require community-wide interventions. Successful WISEWOMAN projects are likely to not only reduce CVD risk factors overall but also to lessen racial/ethnic disparities in these risk factors.

Implementing the WISEWOMAN Program in Local Health Departments: Staff Attitudes, Beliefs, and Perceived Barriers

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.