Group Intervention Sereening Questionnaire

Form Approved

OMB No. 0990-

Exp. Date XX/XX/20XX

Group Intervention Screening Questionnaire (WHAM) Women’s Health and Mindfulness Program

THIS CONTENT WILL BE INCLUDED IN BOTH WEB-BASED SURVEYS AND PAPER VERSIONS OF THE GROUP INTERVENTION SCREENING QUESTIONNAIRE.

INTRODUCTION

Welcome to the enrollment page for the San Francisco Bay Area Lesbian/Bisexual Women’s Health Projects. We are recruiting participants for two similar health programs, one at Lyon Martin and one at the SF LGBT Community Center. Complete this form to determine if you are eligible for the programs. If you are eligible, you will review the two program descriptions and decide which one is right for you.

These programs are historic! For the first time in the history of federal funding priorities, the Office on Women’s Health, a department of the federal government, earmarked money specifically to develop programs for older lesbian and bisexual women. The San Francisco bay area was fortunate to have two programs funded.

Am I Eligible?

The funding agency requires that program participants meet certain requirements.

1. Do you identify as a woman? Yes No

2. Do you identify as lesbian, bisexual, queer woman, two spirit, same-gender loving or a similar term and/or consistently have relationships with other women? Yes No

3. Are you age 40 or older? ____

These programs focus on a variety of health issues such as nutrition, physical activity and stress. Part of the eligibility criteria is height and weight, although the programs are not focused on weight loss as a goal. We do have to collect information on weight and height for our reports.

4. How tall are you? ___ feet ___ inches

5. How much do you weigh? _____ pounds

The program requires a fairly lengthy time commitment.

6. Are you willing to commit to attending the majority of weekly sessions for the 12 or 16 week intervention? Yes No

7. Are you willing to complete questionnaires at regular intervals during the study period? (You will be compensated with gift cards for completing surveys.) Yes No

8. If yes, would you prefer to do surveys: ___ online ___ in paper/pencil mail-in format

Name: ____________________________ email: ___________________________________

Phone: ____________________________ mailing address: _____________________

Best way to reach you:

Description of the Two Programs:

	WHAM	DIFO
Length of the Program	16 weeks	12 weeks
Location	Lyon-Martin Health Services	LGBT Community Center
Meeting Dates/Times	TBD	TBD
Content of the Program
Exercise	Group classes held weekly	Health Coach
Nutrition/Healthy Eating	Nutrition consultant & food logs	Health Coach
Mindfulness/Stress Reduction	Weekly mindfulness sessions & journal	Weekly Mindfulness Sessions
Incentives	$25 gift card for assessment & post-testing Raffle entries for attendance Online Resources	$25 gift card for assessment & post-testing Raffle entries for attendance Online Resources
Assessments Taken	Health Assessment: - Free blood test for cholesterol & blood sugar - Height & Weight - Blood pressure Pre/post-surveys at program end	Self-Assessment: - Height & Weight Waist Circumference (taken by health coach) Weekly feedback form Baseline and 9 month follow-up survey

Women’s Health and Mindfulness (WHAM)

Lyon-Martin Health Services in partnership with RTI has developed a program to improve health outcomes related to chronic diseases in lesbian and bisexual (LB) women. Our innovative 16-week group support program combines mindfulness-based stress reduction, nutrition and physical activity. Participants will meet once a week for an hour and a half over four months.

What you will get:

• Free, weekly support group sessions that use mindfulness exercises to focus on:

  • Stress reduction

  • Improved nutrition

  • Increased physical activity

• Free weekly exercise classes with personal trainer consultation

• Free tailored nutrition guidance using food records.

• A free journal to record your thoughts and progress.

• Access to web-based resources for healthy eating, physical activity ideas and stress reduction practices.

What we need from you:

• Complete a questionnaire and health assessment at Lyon-Martin Health Services before the program starts. It will take about 1 hour and you will receive a $25 gift card.

  • The health assessment will include height, weight and a blood sample to test your cholesterol and blood sugar.

• At weekly sessions, complete short surveys that take less than 5 minutes each. For each session you attend, you will be entered into a monthly raffle.

• Keep a food log (24 hours) to share with the nutritionist 1-2 times during the 16 weeks.

• Some participants will be asked to wear an accelerometer to track physical activity, similar to a pedometer. You will wear this for 3 separate weeks of the intervention. You will be given a $25 gift card for each week you wear it.

• Keep a journal for mindfulness activities and reflection during the process.

• Complete a follow-up questionnaire and health assessment immediately after the program ends. It will take about 1 hour and you will receive an additional $25 gift card.

Upcoming Sessions:

[list dates]

If you have questions, please contact:

Natalie Ingraham, [email protected], (415) 565-7667

“Doing It For Ourselves” (DIFO)

Doing It for Ourselves (DIFO) is a community-based collaboration of, by, and for lesbian and bisexual (LB) women that addresses barriers to health in the LB community, and promotes overall health and wellbeing. This 12-week program meets once a week for 2 hours at the San Francisco LGBT Community Center. The meetings will foster a safe and acceptance-based atmosphere, cover topics related to lesbian and bisexual women’s community stressors, and focus on health and nutrition.

What you will get:

Each weekly session will be led by a trained facilitator and will include: a gentle physical activity, a healthy snack, and opportunities for discussion with other women interested in pursuing healthy lifestyles. In addition, each participant will receive personalized consultation with a health coach to discuss individual health goals for physical activity and nutrition. Participants also will receive many web and paper resources about health, specifically geared to lesbian and bisexual women—including information about local options for improving health, including gyms, pools, LB-friendly trainers, and traditional and alternative health care options. All of these groups and resources are free of charge.

What we need from you:

• Complete a questionnaire before the program starts. It will take about 30 minutes and you will receive a $25 gift card when you submit it.

• At weekly sessions, complete short surveys that take less than 5 minutes each. For your participation, you will be entered into raffles for prizes.

• Complete a follow-up questionnaire 9 months after the program ends. It will take about 15 minutes and you will receive an additional $25 gift card when you submit it.

9. Please indicate which program you are interested in, and we will contact you with more information. Thank you!

___ Doing It For Ourselves (DIFO) at the SF LGBT Center.

___ Women’s Health and Mindfulness (WHAM), at Lyon-Martin Health Services.

___ I’m interested in both.

___ I cannot participate at this time, but am interested in participating in the future.

___ I’m not interested in participating in these programs, but may be interested in being part of a comparison group. Comparison group members will be asked to complete two surveys and receive a $25 gift card for each survey completed.

TO BE COMPLETED BY INTERVIEWER OR COMPUTER:

10. RECORD BMI: _____ _____._____ (BMI: COMPUTER WILL CALCULATE IN WEB-SURVEY ADMINISTRATION; INTERVIEWER WILL CALCULATE USING BMI TABLE IF PAPER ADMINISTRATION).

11. Is participant eligible for the study?

• Yes

No  Thank participant for answering the questions and for their interest in the study. Explain that they are not eligible to participate.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-xxxx . The time required to complete this information collection is estimated to average 4 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:  U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201,   Attention: PRA Reports Clearance Officer