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
• 9th 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
• 2nd 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 - 832
– 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
Our Special Project Grant
Development and Evaluation of
Guided Goal Setting (GGS) as a
Behavior Change Approach and
Monitoring Protocol
in Pennsylvania WIC
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, participantcentered 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 preventionoriented 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 foodbased behavior change
– Extend nutrition education by
supplementing contact points with targeted
reinforcements
GGS:
Special Project Grant
Results by Year
2005-2008
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)
Year 1: Data Collection
• 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: Research Study
Participants
Constituency
State Agency Staff*
n
5
Local Agency Directors
24
Nutrition Education Coordinators
18
CPAs/Nutritionists
Participants (all local agencies
represented)
Average Years of
Service in PA WIC
(range)
14.5 years (2-24
years)
19 years (3-31.5
years)
9.5 years (<1-24
years)
100
8 years (<1-24.5
years)
4665
n/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)
Participant Response (n=4,665) Regarding What They
Like About WIC Nutrition Information
Helpful suggestions
from nutritionist
Caring Staff
Handouts and
Brochures
Recipes
Selected 1
response
Selected
more than 1
response
1050 (23%)
2909 (62%)
688 (15%)
2402 (52%)
478 (10%)
2158 (46%)
110 ( 2%)
890 (19%)
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
Literature
Agency Staff
LA Directors
Nutrition Ed
Coordinator
Nutritionists
GGS Module Units & Objectives
GGS Practices Assessment Instruments
Participants
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 1-5
1. 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 6-10
6. 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 Site
β 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 clients
Examples of dialogue with
participants
The importance of goal setting
and the way you present yourself
Allowing the participant to set
goal
Making the goals more specific,
the who, action, number, etc.
OK to brainstorm
Effective communication for
effective goal setting
How to organize information
I really enjoyed the concept
maps
Mapping
To include the WIC participant
when making goals
How to make proper goals and
documentation
How to effectively and realistically
develop customer based goals
GGS Evaluation:
“Least Important Things Learned”
α Site
Mapping
Nutrition
documentation
example
β Site
Mapping
Documentation
Unit 1 and 2
GGS Evaluation:
“How Use Information”
α Site
β Site
Plan to use all aspects
Share with team
Documentation
procedures
Mapping to show problem
areas visually
Better understand staff’s
job
Daily counseling
To bring together aspects
of the visit
Reinforcing positives
Suggestions after Pilot Testing
Based on α Site
Based on β 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
• 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
360/360 323/353 218/323
100%
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
ssword@state.pa.us
Stephanie Taylor-Davis, PhD, RD, LDN
stdavis@iup.edu
Mia Barker, PhD
mabarker@iup.edu
Tracy Kelley
tkelley@homenursingagency.com