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Strengthening the evidence base for maternal and child health programs

New: MCHbest strategies database for sample ESMs

Think Upstream To Plan

MCH Best LogoThe second component of the MCH Evidence Center conceptual model challenges us to plan upstream to ensure that programs/interventions address issues early and are measurable in “turning the curve” on big issues that face MCH populations. To assist us in this proces, a system of shifting the evidence into practice is needed. Implementation science uses the foundational building blocks of evidence to translate root causes of population-based issues into responsive programs that bring about change that can be quantified, brought to scale, and replicated across population groups. Use this page to access specific approaches and tools that the Evidence Center uses to advance health equity and address social determinants of health (SDOH) through our Ready, Set, Go approach.

1. READY: Learn about Results-Based Accountability (RBA).

Video. Start here to learn about the RBA process and tools.

Learn More. Access additional information on RBA and how to use on population and performance levels.

RBA Summary: Use in Title V Planning

We use RBA as one way to align program performance (measurement of ESMs) with population goals (achievement of NPMs & NOMs).

  • RBA helps ensure that ESMs align with and advance NPMs. A set of seven performance accountability questions require programs to consider:
  • Desired impact change on a targeted group.
  • Mechanisms to deliver services effectively.
  • Ways to address barriers, identify resources, and engage appropriate partners.
  • Identification of what specifically works to produce measurable outcomes.

RBA can be used by Title V agencies as a planning process in two ways:

1. To ensure that ESMs measure activities that advance National Performance Measures (NPMs). A set of population and performance accountability questions requires programs to consider:

  • Desired impact on a targeted group.
  • Relevant barriers and facilitators, relevant resources and potential partners.
  • Identification of what works to produce measurable outcomes.
  • Mechanisms to deliver programs effectively.

2. To strengthen measurement of ESMs. A four-quadrant measurement matrix assists programs to move from tracking effort (basic) to assessing effect (advanced). The quadrants are:

  • Quantity of the effort (How much did we do?).
  • Quality of the effort (How well did we do it?).
  • Quantity of the effect (Is anyone better off?).
  • Quality of the effect (How are they better off?).

RBA – also called “moving from talk to action” – is a tool that:

  1. Connects your programs to desired results and supports the development of robust and feasible action plans.
  2. Ensures your programs are connected to your work and advance your goals.

RBA on a Population Level: Work from the Data Backwards to Brainstorming

RBA starts with the ends and works backward, step-by-step, to means. This process can serve as a way to double-check and reinforce your needs assessment process. Gather your staff, partners, and members of the community and ask these seven questions to make sure you have captured the necessary information from your stakeholders and are aligning your goals with NOMs, NPMs, and SPMs:

  1. RESULTS: What are the quality of life conditions we want for the families who live in our community? These are the population results we want (e.g., children living to their first birthday, children are safe on the road).
  2. EXPERIENCE: What would these conditions look like if we could see them? Ask how you would recognize these results in your everyday lives, without worrying about identifying programs or data (e.g., children not dying in their cribs while sleeping, children wearing bike helmets).
  3. INDICATORS: How can we measure these conditions? How would you see these experiences in measurable terms? What data do you already have? What new data could you collect? (e.g., percent of child care facilities that are trained in safe sleep, number of bike helmets distributed). For each indicator, ask yourself how you are doing – are the numbers improving, staying the same, or getting worse?
  4. BASELINE and STORY BEHIND THE CURVE: How are we doing on the most important of these measures? Map out your data over time and develop a baseline that includes 5 years ago to now and a projection 5 years into the future (ask yourself what would the data look like if you did nothing different). Write down the root causes of why the data looks the way it does – include health disparities, behavior change, and social determinants of health. Then map out how you would like the data to look into the future.
  5. PARTNERS: Who are the partners that have a role to play in doing better? For every “cause” in step 4, think of a partner who you can work with to address the need. Include typical and new partners. Then list partners who can work to address disparities. Are they at the table? How can you engage them?
  6. WHAT WORKS: What works to do better, including no-cost and low-cost ideas?Brainstorm possible actions that Title V can work directly to address identified root causes, engage partners, and leverage other programs already in place. Ask yourself “what would it take to make the numbers better?” Use MCH Evidence Center tools to see if your ideas align with the established or emerging evidence for “what works.”
  7. ACTION PLAN: What do we propose to do? The next step is to create an action plan. Start by setting priorities and a timeline: “Now,” “Next 12 Months,” and “2 to 5 years.” No-cost/low-cost actions are natural places to start. Don't wait for the perfect plan to be developed and approved. Get started right away.

Public Square Test. Will your stakeholders understand the priorities and actions that you have decided on based on your needs assessment? Could you stand in a community public square and explain what you want to do? Do your activities have the “power” to be understood? Are they representative? Are they data driven?

  1. Communication Power.Does your proposed activity communicate to a broad and diverse audience?
  2. Proxy Power. Does your activity address a root cause and carry potential to bring about the desired result? Can the activity stand as a proxy or representative for a number of strategies needed to affect change?
  3. Data Power. Do you have quality, timely data? Is the data reliable and consistent?

To prioritize, choose the activities with the best data power, then rank those activities that have the best chance to “make a difference” and be adopted by the community and your partners.

RBA on a Performance Level: Develop and Strengthen ESMs

RBA can also serve as a way to choose and strengthen your ESMs and SPMs. Similar to the population-level process, you could consider seven performance accountability questions once you have set your priorities, identified your NPMs, and are focused on ESMs. Note some key differences in approach:

  1. CUSTOMERS: Who are our customers? Develop a complete list of who these groups are. Remember, your “customers” are the direct recipients of your strategy – they might be providers, an organization, or the MCH population group you are targeting (the customer might not be the mother/infant/child/youth/family).
  2. EFFECT: How can we measure if our customers are better off? Come up with the most meaningful measures, even if you don’t have data or don’t control every aspect of the activity. These might eventually be Quadrant 4 measures (highest measurement).
  3. EFFORT: How can we measure if we’re delivering services well? Your answers will usually measure what staff do and how well your programs perform. These will be Quadrant 1 and 2 measures.
  4. BASELINE and STORY BEHIND THE CURVE: How are we doing on the most important of these measures? Two parts: (1) From strategies in steps 2 and 3, what are the 3 to 5 “headline measures?” Try to get a mix of Category 2 and 4. (2) Graph out your efforts and create a baseline (history and forecast). Tell the story behind the data. Why are things getting better or worse? What are the causes at work?
  5. PARTNERS: Who are the partners? Consider partners inside and outside your organization. Consider active, non-active, and outside-the-box partners. What can they do to help turn the curve?
  6. WHAT WORKS: What works to do better? There are two natural pointers to answer this question: (1) each part of the story behind the curve (the “cause;” e.g., poor lighting is a cause of increased fear of crime) and (2) actions that come from the partners list. Each partner has something important to turning the curve. Evidence is important here. Look at the research for what has worked in other places, both from the MCH Evidence Center’s online toolkits and from best and promising practices. List these strategies.
  7. ACTION PLAN: What do we propose to do? Choose the most powerful actions from the possibilities identified in #6. You can use the criteria list (SiLVeR — specificity, leverage, values, and reach). Organize these actions into a plan that specifies the person responsible for each task, timelines, and necessary resources.
SiLVeR Test. When looking at your ESMs, SPMs, or other strategies, ask yourself if they are SiLVeR? Do they have:
  1. Specificity. Are the strategies focused enough to be implemented? Do they align with the evidence? With a theory of change? With the goal of the NPM?
  2. Leverage. How much difference will the strategies make – will they address a root cause and turn the curve?
  3. Values. Will the strategies be adopted by the community they are targeting? Do they work to address health disparities and social determinants of health?
  4. Reach. Are the strategies feasible and affordable? Can they actually be done and when? Do you have the resources to ensure that the level of activity will be enough to make a change?

Begin with activities that rate highest in the first three areas. Build up to strategies where “reach” is a question.

2. SET: Use RBA to work backwords from your goal to actionable strategies.

You can answer the RBA population and/or performance questions individually or work through Turn-the-Curve (TTC) process.

TTC Image - Described below

TTC is a quick method to strategically think about your needs assessment data and develop strong measures to assess progress we make in changing the trajectory of your work. There are five basic steps to the TTC activity that can be adapted to meet your team’s needs:

  1. Graph or describe the trend of data associated with your outcome.
  2. Analyze and describe the story behind the curve to give your outcome some background and context.
  3. Identify existing and new partners who have a role to play in improving the data.
  4. Brainstorm what works to address the contributing factors and turn the curve.
  5. Develop and implement a comprehensive action plan that includes strong measures.

Tools. There are numerous tools to help you conduct a full or shortened TTC session. Here are specific tools to assist you.

Turn-the-Curve Tool: Developing Population-Level Strategies

Turn-the-Curve (TTC) Strategy Tool. Use this tool to develop new strategies that align with your population needs and advance each NPM. TTC is a quick method to strategically think about your needs assessment data and develop strong measures to assess progress we make in changing the trajectory of your work.

Developing Stronger ESMs: A Review of Using RBA to Develop Strategies

Developing Stronger ESMs. Follow the full RBA process to assist in developing new or reviewing current ESMs.

The Role of Title V: Adapting and Implementing Strategies

The Role of Title V in Adapting and Implementing Strategies. Read about common strategies that Title V supports.

ESM Development Guide: A Review of the Three MCH Evidence Center Processes

ESM Development Guide. Review all the resources the MCH Evidence Center has to offer, including a summary of the science for each NPM, sample strategies, a planning process for aligning ESMs to NPMs, and additional resources

3. GO: Use RBA to measure strategies over time.

Video. Watch this video to learn about the basics of measurement and how to use the RBA quadrant measurment system to strengthen how you monitor progress.

Learn More. RBA provides an intuitive framework to help you move from reporting “what did we do?” (simplest form of measurement) to “how well did we do it?” and eventually to “is anyone better off from our efforts?” and “how are they better off?” (reporting impact). RBA provides four quadrants of measurement when you look at effort and effect across quantity and quality.

4 Quadrants - Described in text

Once you have identified strategies to use as your ESMs and SPMs, map them across these four quadrants. Think of how you might strengthen your strategies by moving from quadrant 1 to 2 and from 3 to 4, knowing that it’s not always feasible to move up based on data and resources available. However, measurement is important! Spend some time strategizing how to report stronger measures in your MCH Block Grant report and application. Tell the Title V story as having a quantifiable and qualifiable effect on your MCH populations.

Goals in Strengthening Your Measures. When looking at your ESMs, SPMs, or other strategies:
  • Move from measuring quantity to quality.
  • Eventually move from measuring effort to effect.
  • Quadrant 1 strategies should be used sparingly, when no other data exists. Challenge yourself to find ways to report more meaningful accomplishments.
  • The most effective measurement combines strategies in all levels, with most in quadrants 2 and 4.
  • Use all the tools at your fingertips to double-check your strategiess.

Tools. The MCH Evidence Center has developed tools to assist with measurement of strategies based on the RBA structure.

ESM Quadrant Measurement Tool: Assessing Performance-Level Strategies

ESM Quadrant Measurement Tool. Use this tool to develop strong ESMs to measure your strategies.

ESM Report: National Summary

ESM Report: National Summary. This summary examines general trends across ESM detail sheets and action plans from all 59 states and jurisdictions for the 2021 Application/2019 Annual Report of the Title V MCH Services Block Grant.

Need more help? Request technical assistance (TA).

We are eager to talk with you further about your ESMs. We provide TA that is customized to your needs and the time you have.

Addressing complex, systems-based issues is strengthened by a team approach. We collaborate with Evidence-Based Decision Making team of the National MCH Workforce Development Center to identify, develop, measure, and improve your ESMs.

We also collaborate with the Association of Maternal and Child Health Programs (AMCHP) to ensure that you have access to promising practices and tools from other Title V programs across the country. Finally, we coordinate with a wide array of MCHB-funded topical TA centers to make sure you have access to cutting-edge knowledge and resources from the experts.

SMARTIE TA: An Equity-Centric Approach to Our Work

Specifically, we provide SMARTIE TA that leads to:

  • Sharp, Specific, and Systems-based ESMs. We help sharpen ESM goals to more fully advance NPM topics and utilize systems to sustain these strategies.
  • Measurable and Meaningful ESMs. We ensure that your ESMs are measurable and in line with related projects in other states and jurisdictions.
  • Actionable, Achievable, and Aligned ESMs. We ensure that your ESMs inform your actions, are aligned with your needs assessment, and flow from your State Action Plan.
  • Relevant and Research-based ESMs. We connect your ESMs with the published evidence, emerging promising practices, and what other states are currently doing.
  • Translatable, Targeted, and Time-phased ESMs. We engage your team in developing sustained approaches to address specific needs of your populations, including Children and Youth with Special Health Care Needs (CYSHCN).
  • Inclusive and Integrated ESMs. We encourage you to work with all population groups as decision makers in every step of the process to ensure a meaningful partnership draws on the strengths of your communities.
  • Equitable ESMs. We continually ask the tough questions to address disparities, gaps, and issues of equity.

Read about our TA iin our brochure | Read about how our TA promotes implementation science

How To Request TA: Three Easy Ways

It’s easy to connect with us. We work closely with regional project officers to provide the most appropriate assistance. You can:

  • Email us at mchevidence@ncemch.org with specific questions or to set up a time to talk. We’ll get right back with you to get the process started.
  • Use our online form to choose from several different types of TA.
  • Talk with your regional project officer who will contact us to arrange for TA, either for your group individually or as part of a group Title V programs.

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U02MC31613, MCH Advanced Education Policy, $3.5 M. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.