Evidence Tools
Well-Woman Visit

Emerging:

• Community-Based Program (AZ; 2011)
  
• Culturally Integrated Interventions for Health (UT; 2023)
  
• Free Mobile Health Messaging Service (OK; 2016)

Promising:

• Health Promotion Education Classes (OK; 2018)
  
• Patient Navigator Model (NY; 2019)

Best:

• Community Health Workers to Improve Birth Outcomes (AZ; 2023)

KEY FINDINGS

• There is strong evidence to suggest that patient reminders/invitations are effective, both on their own and in combination with other strategies.
• Other interventions targeting the patient/consumer that appear to be effective are community-based group education and patient navigation.
• Home visits (1-2 total visits) targeting patients/consumers do not appear to be effective.
• On the provider/practice-level, provider reminder/recall systems, provider education, and implementation of a designated clinic/extended hours appear to be effective.
• On the community-level, television media appears to be effective.
• Of interventions targeting payers, there is evidence to suggest that expanded insurance coverage is effective.

IMPLICATIONS

• Findings from the literature on components of the well-woman visit can be applied to implementing multicomponent interventions that target women, health care providers and practices, and communities.
• Further research is needed to better understand the role of health insurance in utilization of women’s preventive services.

EVIDENCE ANALYSIS REPORTS

• Well-Woman Visit: Evidence Review Brief. A three-page summary of report methodologies, results, key findings, and implications.
• Well-Woman Visit: Evidence Review Full Report. A critical analysis and synthesis of the effectiveness of strategies that might be applied to address this NPM to serve as the foundation for accountability across all states and jurisdictions. The evidence review uses a structured approach to evaluate the available empirical evidence and to draw conclusions for MCH programs based on the best available evidence. Read about the evidence analysis report methodology | You can also access the full set of Evidence Analysis Reports.

Watch a short video discussing state-of-the-art, evidence-based/informed strategies that can be used or adapted as ESMs. Experts in the field discuss approaches, the science, and specific ways that Title V agencies can implement and measure these approaches.

• MCH Needs Assessment Toolkit: MCHneeds.net
• Root-Cause Analysis (RCA): Fishbone Diagram Tool
• Results-Based Accountability (RBA) Summary
• Population Turn-the-Curve Strategy Tool
• Performance ESM Quadrant Measurement Tool

Many of the strategies with the strongest evidence supporting them are those that are more clinical or those based in enabling services rather than those that can be easily implemented by Title V agencies. As we look to “move down the MCH Pyramid” with less emphasis on direct services (disease management) to an increased focus on public health services and systems (primary and secondary prevention and population health management), we are often challenged in identifying evidence-based/informed practices to meet the new focus of the transformed MCH Block Grant.¹ 

Where possible, we try to align evidence-based strategies (“what works”) to activities that can be adopted by Title V agencies (“what we can do”). However, there is often the need for adaptation and innovation.² Sometimes it’s difficult to identify the role a Title V agency could take in implementing and/or adopting such evidence-based/informed strategies.

When deciding how best to implement a strategy that seems outside the typical role of Title V, it may be helpful to consider activities that support the strategy while aligning with activities that Title V is charged with,³ such as:

• Assessing ongoing community needs: Title V can use data collected by programs, evaluations, or more formal needs assessment findings to see if the strategy could address identified service gaps or build equity in access and positive health outcomes.
• Informing and educating the public: Title V can provide educational/outreach materials to families/consumers to advance the strategy through training and peer support.
• Engaging community partners and families: Title V can serve as the convener for those groups/organizations that can implement the strategy.
• Integrating systems of public health. Title V can help ensure access, sharing of resources, and coordination of services to assure maximum impact of the strategy (coordinating the public health approach, health care, and related community services).
• Educating the MCH workforce (building capacity): Title V can partner with groups actually conducting this strategy in order to train MCH and healthcare professionals in strategy implementation.
• Developing public health policies and plans: Title V can support adoption of the strategy at a state level.
• Ensuring quality improvement and promoting applied research: Title V can collect data and evaluate programs in the state/jurisdiction that are implementing this strategy to build the evidence base and promote rapid innovation.

Not all strategies are effective for all population groups, and the evidence is often lacking in terms of using specific strategies to advance health equity.

Once the evidence has been considered for what works generally, it is important to understand if a specific strategy will work for targeted populations, especially those most affected by health disparities. Implementation science helps to translate the science into programs and policies that impact health outcomes in light of multiple social determinants. In finding strategies to meet needs, we have the ability to adopt and/or adapt what works.

ADOPT Strategies to Meet Needs

In choosing to adopt an existing strategy based on existing science and practice, we should consider:²

Is the study sample or population similar to our target audience?

• ​Geography
• Demographic characteristics
• Culture, values, and preference
• Health status
• Other characteristics of interest 

Do we have the resources needed to implement?

• ​Workforce capacity
• Money
• Time
• Leadership 

Does our organization and the broader environment support the strategy? ​

• Political support
• Financial and legal support
• Champions for intervention
• Community norms and partnerships
• Title V priority and jurisdiction
• Favorable environment for change​​

Strategies to Meet Needs

Not all strategies are effective for all populations. To adapt strategies to meet needs, we should consider:⁵

What about the existing strategy works? If we understand the key ingredients of a strategy, we can replicate and/or adapt the effective components. Looking at a strategy through a health behavior theory identifies key ingredients. Here are several to consider:

• Intrapersonal. Theory of Planned Behavior, Health Belief Model, Stages of Change Model.
• Interpersonal. Social Cognitive Theory, Social Norms Theory.
• Community. Diffusion of Innovation, Ecological Models.

How does it work? Being specific about the underlying mechanisms can help us increase the impact. Developing a logic model with program actions, targets, outcomes, and moderators allows you track the process from action to outcome.

For whom does it work, and for whom does it not work? When we know who is and is not responding, we can make targeted adaptations to improve outcomes. Think about the program life cycle:

• Precision. Understand what a strategy entails so you can go beyond “does it work,” to “what about it works” and “for whom does it work.”
• Fast-cycle iteration. Incorporate new ideas as you go – what is working and what is not working.
• Shared learning. Create a mechanism to share learning about success and failures.
• Co-creation. Bring together multiple parties to create a mutually valued outcome.

In what contexts does it work? By evaluating the context in which a strategy is implemented, we can adapt it for other settings. The best way to ensure that a strategy is effective is to conduct a robust evaluation. The MCH Navigator’s Evaluation Spotlight provides trainings and resources related to the steps and standards for effective program evaluation.

• Well-Woman Visit resources from the MCH Digital Library
• Request Technical Assistance from the MCH Evidence Center
• MCH Evidence Center Frameworks and Toolkits:
• MCH Evidence Framework
• Blueprint for Change for CYSHCN Toolkit
• Maternal Health Toolkit
• Life Course and Social Determinants Resource Brief

• Well-Woman Visit: Resource Overview: The American College of Obstetricians and Gynecologists (ACOG) has identified the following resources that may be helpful for OB-GYNs, other health care providers, and patients related to the well-woman visit.
• AMCHP Resources:
  • Health for Every Mother: A Maternal Health Resource and Planning Guide for States. This guide for Title V programs and their partners provides a synthesis of program and policy recommendations and offers a framework to support states in identifying next steps. Contents include strategies and planning tools for strengthening maternal data systems, increasing the value of an investment in maternal health, enabling healthy living, improving access to care, ensuring high quality health care for women, and ensuring readiness and response to obstetric emergencies.
  • Implementation Toolkit for National Performance Measure 1. This toolkit contains examples of state strategies being used to address NPM 1 in Title V programs.
• March of Dimes: Use the five overarching strategies identified in the Advancing Equitable Health Outcomes Project.