Screen ing Tool

OMB No. 0990-

Exp Date

XX/XX/20XX

Screening Survey (DIFO) Doing It For Ourselves

Program

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 run by Lyon Martin Health Services and one held at the SF LGBT Community Center. Complete this form to see if you are eligible for the programs. If you are eligible, you can 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 is fortunate to have two programs funded.

Am I Eligible?

To join, program participants have to 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. How old are you? ____ ____

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 main 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

TO BE COMPLETED BY INTERVIEWER OR COMPUTER:

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

7. Is participant eligible for the study?

• Yes

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

The program requires a fairly lengthy time commitment.

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

9. 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

10. 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 (include time of day, days of week, special instructions):

_______________________________________________________________________

Description of the Two Programs: Content of the group programs is similar. Both include physical activity, nutrition information, mindfulness activities, discussion of lesbian and bisexual women’s health issues, individual attention, and group support.

	Women’s Health and Mindfulness (WHAM)	Doing It For Ourselves (DIFO)
Philosophy	A clinic-based model	A peer-based model
Length of the Program	12 weeks led by a clinically-trained therapist	12 weeks led by a trained peer facilitator
Location/Community Partner	Lyon-Martin Health Services and East Bay locations	San Francisco LGBT Community Center and East Bay locations
Meeting Dates/Times	Variable start dates starting in XXX	Variable start dates starting in XXX
Incentives	$25 gift card for each assessment Raffle entries for attendance Online Resources	$25 gift card for each survey Raffle entries for attendance Online Resources
What is Required of You	2 health check ups with lab tests and an interview done at the clinic before and after the program	2-3 surveys done online or by mail at beginning, end and 3 months later: includes questions about health status, nutrition, physical activity, and quality of life

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 12-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 three 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 blood tests for cholesterol and blood sugar. You can choose to receive your results.

• For each session you attend, you will be entered into a monthly raffle.

• Keep a food log (24 hours) to share with the nutritionist a few times during the 12 weeks.

• Some participants will be asked to wear an accelerometer to track physical activity. You will wear this for 3 separate weeks of the intervention. You will be given a $20 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 45 minutes and you will receive an additional $25 gift card.

Upcoming Sessions:

[list dates]

If you have questions, please contact:

Natalie Ingraham, natalie@lyon-martin.org, (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 survey 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 questionnaires that take less than 5 minutes each. For your participation, you will be entered into raffles for prizes.

• Complete a post-program survey immediately after the 12-week program. It will take about 30 minutes and you will receive a $25 gift card when you submit it.

• Complete a follow-up survey 3 months after the program ends. It will take about 15 minutes and you will receive an additional $25 gift card when you submit it.

Upcoming sessions:

[list dates]

If you have questions, please contact:

Deborah Craig, deborah@bpacal.com, 510-465-7884 x211

11. 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 (if so, please choose DIFO ___ or WHAM!___).