Responsiveness and Innovation

The Women's Health Questionnaire was developed as a result of information gathered during case-by-case interviews for Boston's infant mortality reviews in the early 1990s. The findings showed significant gaps between women's needs and the services received, patient dissatisfaction with care, undetected infections, and high levels of stress. Due to the persistent racial disparity in infant mortality reviews, particular attention was paid to African American women's health in Boston, because the problem did not seem to be adequacy of prenatal care but poor health prior to conception. The goal of the WHQ was to learn more about women’s health and identify and address risk factors prior to their becoming pregnant. Using an advisory group with experts in many fields, the WHQ was developed to cover several non-traditional topics, such as environmental health exposures, neighborhood safety, violence, economic concerns, and patient satisfaction with care.

The model for the WHQ is also unique in that the document is scanned and produces reports for both the patient and her provider. Once the woman has completed the WHQ, she works with a case manager to help address some of the needs that were identified. With the reports, the case manager is able to work closely with the patient, providing referrals and advocacy, and to work with her medical provider to best meet the needs of the patient. The model requires the case manager to be integrated into the primary team, creating a new system of care for women.

LHD and Community Collaboration

In 1998, the Boston Public Health Commission (BPHC) convened the Health of Women and Infants Working Group (HWIWG) to meet monthly and advise BPHC on how best to address a variety of maternal and child health issues. The group is comprised of clinical providers, public health practitioners, researchers, and community members and advocates, and it represents the city's academic research institutions, community health centers, hospitals, community-based agencies, and the state department of public health.

A first priority for HWIWG was to look closely at the problem of high infant mortality rates, specifically the racial disparities among birth outcomes for African American women. The focus quickly became how to improve women's health prior to conception and how to learn more about a woman's health status and her experience with health care. Members with various areas of expertise worked together over the course of a year to design the Women's Health Questionnaire, a tool that asks patients questions about traditional medical history as well as other factors, such as patient-provider communication, access to health care, psychosocial risks, safety, and stress. Initially, the WHQ was implemented at five community health centers and hospital outpatient clinics through the Women's Health Demonstration Project/ REACH 2010.

One year later, the Boston Healthy Start Initiative adopted the WHQ and is currently using it in their 14 agencies. Both projects offer case management services and target African American women, but the Boston Healthy Start Initiative works with pregnant and parenting women. The HWIWG maintains oversight of the WHQ and is currently revising the tool based on feedback from patients and providers. They hear quarterly project updates from the sites using the WHQ and review data collected.

Initial costs include a computer consultant to design the WHQ program software ($35,000), an instrument design consultant including field-testing and focus groups ($25,000), and instrument translation to Spanish ($1,800). Other costs include computers ($1,500 per site), scanners ($500 per site), printers ($900 per site), and Fine Reader Software licenses ($800 per site). Funding for the development of the WHQ came primarily from the City of Boston. Some monies were also received from the Boston Foundation and the Massachusetts Chapter of the March of Dimes. At clinical sites, WHQ was implemented with support from the Boston Healthy Start Initiative and REACH 2010 funding.

Evaluation

The Women's Health Questionnaire is currently used in the Women's Health Demonstration Project/REACH 2010 and the Boston Healthy Start Initiative. The evaluation for WHDP is first a process evaluation on the experience of the women, providers and health center managers regarding the use of the WHQ. Second, the evaluation will review the extent to which the case management and outreach approach has improved the use of primary care services.

Sustainability

One of the challenges to using the WHQ is the time that it takes a woman to complete the questionnaire. Patients have the option of completing the form on their own or with the assistance of the case manager. Many women have opted to have the case manager help them complete the form, which tends to take longer but is also an opportunity for the case manager to have a conversation with the woman about her health and about concerns she may want to address with the doctor. This is also a time when health education can be introduced.At some sites using the WHQ, providers often do not have time to read the provider report carefully before seeing the patient. Some case managers have women come in a day before their provider appointment in order to have time to complete the WHQ and to allow time for the provider to review it before the visit.

The main element needed for replication of this project is for providers, site administrators, and case managers to agree to use the Women's Health Questionnaire. The staff needs limited training on how to effectively use the tool and integrate this information into patient care plans. It is an excellent tool that can help identify concerns affecting the health of women, but it does require additional time for patient visits. At some sites, the WHQ has replaced the intake form, but at others, it is additional paperwork for staff and patients. One of its greatest strengths is its capacity to help restructure the service delivery system for female patients.

Overview

The Women’s Health Questionnaire (WHQ) is a 10-page comprehensive health assessment (in English and Spanish) designed to identify medical and social risk factors among women of childbearing age in an effort to improve their health prior to conception. The WHQ is used in over 15 sites in Boston, both community health centers and outpatient hospital clinics. A case manager introduces the WHQ prior to a woman’s appointment with her medical provider.

Once completed, the form is scanned into a computer that instantly generates two reports based on the information provided, one for the patient and one for the provider. The patient report is an empowerment tool and gives the woman a summary of some of the information she indicated, including suggestions for topics she could address during the provider visit. The provider report highlights some of the important information from the WHQ as a personalized checklist for the visit, including medical risks, evidence of domestic violence, substance abuse, and it flags other concerns the provider would not necessarily have time to cover otherwise.