Guided Goal Setting: The Logical Next Step to VENA Presented by: Shirley H. Sword, MS, RD, LDN PA Department of Health – Division of WIC October 14, 2010

Objectives To gain insight on the history of the development of Guided Goal Setting To understand the research behind development of the Guided Goal Setting Module To learn the local agency perspective on how Guided Goal Setting is working in the clinics

Facts and Figures About PA 9 th Largest WIC Program 44,817 square miles 274 people per square mile One-third of our 12.4 million residents live in rural areas, the largest non-urban population in the nation 2 nd highest percentage of residents >65 years old in the country

Facts and Figures About PA WIC 67 Counties 24 Local Agencies –Community Action Programs –Medical Centers –County Health Departments –Private, Non-Profits 265,000 Monthly Caseload

Service Delivery System 329 Total WIC Clinics –116 Primary Sites –213 Satellite Sites Users in total – 383 CPAs – 449 Non-CPAs 1767 WIC Authorized Stores On-site, On-demand Check Printing

How It All Got Started

Special Project Grants Special funding from USDA for special State projects of regional or national significance to improve the services of the program Address issues of critical and timely importance Requires a rigorous evaluation component Results are widely disseminated to other States

Development and Evaluation of Guided Goal Setting (GGS) as a Behavior Change Approach and Monitoring Protocol in Pennsylvania WIC Our Special Project Grant

Partners in This Project PA WIC –Shirley Hsi Sword, Project Director Indiana U of PA –Stephanie Taylor-Davis, Principal Investigator –Mia M. Barker, Co-Investigator –William F. Barker, Evaluator –Pao Ying Hsiao, Research Assistant

Goals of this Project To enhance the quality of WIC services provided to PA WIC participants To further VENA initiatives via an evaluated and measurable, participant- centered nutrition education counseling approach that: Maintains continuity from visit to visit Empowers participants Benefits the participant

The Basis for Goal Setting Straight-forward behavioral change approach that accommodates a variety of achievement levels Emphasizes small, progressive steps that are concrete Relevant to address emerging prevention- oriented public health concerns Supported in scientific and behavioral literature with a variety of populations and topic areas

Guided Goal Setting (GGS): Defined An approach used by the nutritionist in conjunction with the participant that involves critical thinking based on assessment to develop strategies for goal setting to achieve desired participant outcomes

Central Mission Identification, development, implementation, and evaluation of GGS as a WIC counseling method to: –Increase participant-centered approach –Enhance staff competency and critical thinking skills –Assess participant commitment to food- based behavior change –Extend nutrition education by supplementing contact points with targeted reinforcements

Results by Year GGS: Special Project Grant

Goals by Year Year 1: “Profile Identification and WIC Evaluation” –Assess the state of being in PA WIC with respect to goal setting as a nutrition education counseling approach Year 2: “Guided Goal Setting Practices & Assessment” –Formalize the GGS process through development and pilot testing of a training module and assessment tools Year 3: “Improvement – Nutrition Education & Outcomes” –Project 1 = Provide standardized training to nutritionists to improve staff competency –Project 2 = Run an experimental protocol with GGS that uses reinforcement and is participant-centered and individualized

Year 1 Projects 1.Interview and survey WIC staff to identify nutrition education best practices and barriers to best practices (n=147) 2.Survey WIC participants (not initially in proposal) (n=4665)

Demographic Survey Written Surveys Semi-structured interviews –Face-to-face –Telephone Nutrition Education Services Survey Director Survey Nutrition Education Coordinator Survey WIC Participant Survey Year 1: Data Collection

Year 1: Research Study Participants Constituencyn Average Years of Service in PA WIC (range) State Agency Staff*514.5 years (2-24 years) Local Agency Directors2419 years ( years) Nutrition Education Coordinators189.5 years (<1-24 years) CPAs/Nutritionists100 8 years (< years) Participants (all local agencies represented) 4665n/a

Results: Year 1 – Staff Insights Common themes for implementing: –Time –Environment –Distractions –Training –Resources –Attitudes about goal setting

Results: Year 1 – Staff Insights Best practices: –Participant-centered –Committed and knowledgeable staff –Receptive participants –Good assessment with critical thinking –Personalizing process –Establish expectation for goal setting

Results: Year 1 – Staff Insights Attributes: –Knowledge –Professional behaviors with participants –Professional behaviors within WIC –Program beliefs –Other –Professional values

Results: Year 1: Participant Insights Participant attitude different than staff perceptions Liked best Helpful suggestions from nutritionist Caring Staff Handouts and brochures Recipes

Results: Participant Insights (cont’d) Selected 1 response Selected more than 1 response Helpful suggestions from nutritionist 1050 (23%)2909 (62%) Caring Staff688 (15%)2402 (52%) Handouts and Brochures 478 (10%)2158 (46%) Recipes110 ( 2%)890 (19%) Participant Response (n=4,665) Regarding What They Like About WIC Nutrition Information

Collective Voice: Year 1 Findings –TIME –Staff issues –Perceptions –Participant issues –Training issues –Resources –Sites –Information –Communication

Year 2 Projects Develop & test a standardized, yet flexible, theory-based, user-friendly training module and associated instrumentation that will strengthen staff skills and competencies to facilitate the GGS Process

General Concept of GGS Module Development GGS Module Units & Objectives Agency Staff LA Directors Nutrition Ed Coordinator NutritionistsParticipants GGS Practices Assessment Instruments Literature

Theoretical Basis: GGS Framework

Additional Year 1 Project Findings Incorporated “Key principles, assumptions and expected components of a GGS contact” document Recommendations regarding time and delivery system to support nutritionist and paraprofessional training Best practices and success story reports from semi-structured interviews

The GGS Module Ten, 15 to 20-minute hands-on units Activity rich Case study oriented Learner workbook Evaluations: pre, one minute, post, workshop evaluation, and 6 week follow-up with “skill set use” Pilot tested using facilitated group training

GGS Module: Units Definition and Relevance 2.Counseling Strategy for Behavior Change 3.Assessment and the Contribution of the WIC Staff 4.Personalizing the Process 5.Linking Risk Codes to Participant Goals

GGS Module: Units The Team Approach and Goal Priority 7.Structure of Measurable Goals 8.Documentation 9.Follow-Up and Goal Achievement 10. Action Plan

Year 3 Projects 1.Staff Training using GGS module 2.Experimental protocol to test effectiveness of GGS with participants

Year 3 Results: Staff Training Alpha testing (February 2008)  n=10 Beta testing (July 2008)  n=12 Pre- and post-training surveys One minute evaluations for each unit Overall workshop evaluation Six week follow-up “skill set use” survey

GGS Training Evaluations

GGS Evaluation: “Most Important Things Learned” α Siteβ Site How to set goal with more emphasis on client perspective Participant satisfaction is a goal we want to maintain; be more supportive to our participants Different approaches to clientsOK to brainstorm Examples of dialogue with participants Effective communication for effective goal setting The importance of goal setting and the way you present yourself How to organize information Allowing the participant to set goal To include the WIC participant when making goals Making the goals more specific, the who, action, number, etc. How to make proper goals and documentation How to effectively and realistically develop customer based goals I really enjoyed the concept maps Mapping

GGS Evaluation: “Least Important Things Learned” α Siteβ Site Mapping Nutrition documentation example Documentation Unit 1 and 2

GGS Evaluation: “How Use Information” α Siteβ Site Plan to use all aspectsShare with team Documentation procedures Better understand staff’s job Mapping to show problem areas visually Daily counseling To bring together aspects of the visit Reinforcing positives

Suggestions after Pilot Testing Based on α Site Modified the units to make them more consistent in presentation style Added a small amount of time to each unit Most substantial revision was to Unit 6 – TEAM approach Modified the way the documentation template was introduced in Unit 8 Added the ‘Modified’ response option to Skill Set Survey Instrument Based on β Site Spend more time on the last five units and less time on the overview Split into two sessions More examples of goals and documentation Fewer evaluations or group them Good information but could go at faster pace

Conclusions after Pilot Testing By establishing a baseline and a consistent structure for participant goal setting within PA WIC, there are now parameters upon which to evaluate the nutritionist-participant interaction and assess the efficacy of this counseling method to support participant behavior change. The GGS Training Module and Assessment Instruments provide a mechanism to address staff (both CPA/Nutritionist and Other Staff) competency to facilitate the goal setting process with WIC participants.

The Local Agency Perspective

The Old Days

The New Age - GGS

Staff Reaction Better working relationship with the clients More open communication between staff and clients More aware of the client’s perception of their family’s nutritional needs

Client Reaction “Your nutritionist was very well informed and offers great ideas and information.” “Staff was very friendly and explained everything in detail and offered excellent help.” “Staff made us feel comfortable with her advice and help.” “The Staff spoke to me, not at me.”

Hurdles to Cross Don’t jump to conclusions! Set small, achievable goals Time Documentation

Effect on Clinic Operations No change in staff duties No operational changes within the clinic Continuing education for professional and paraprofessional staff

Our Results Number of Participants with a Goal Established Number of Participants with Follow-up Completed Number of Clients who achieved their Goal 360/360323/353218/ %91.5%67%

Acknowledgements USDA, Food and Nutrition Service FNS Project Officers –Cherisa Toomer (May 2007 – December 2008) –Carol Stiller, MS, RD (September 2005 – April 2007) –Home Nursing Agency staff and participants –Adagio Health, Inc. PA Department of Health, Bureau of Information Technology and Ciber, Inc.

Contact Information Shirley H. Sword, MS, RD, LDN Stephanie Taylor-Davis, PhD, RD, LDN Mia Barker, PhD Tracy Kelley