For Women’s and Maternal Health (WMH), Guam’s Title V program selected National Performance Measure (NPM) 1: Percent of women, ages 18 through 44, with a preventive medical visit in the past year. This NPM was selected because it is foundational to women’s health throughout the life course, is supported by population health data demonstrating a need for continued improvement, and relates directly to several priorities voiced by women and families through community listening forums, including awareness of community resources, transportation, social support, and health care access and quality.

 While NPM 1 directly measures annual preventive medical visits, it should be viewed as part of a continuum of primary and preventive care that also includes preconception, reproductive and sexual health, family planning, prenatal, and postpartum care, and that consists of a full spectrum of medical, mental and behavioral health, oral health, and other supports and services.

Women’s and Maternal Health outcomes are impacted by the social determinants of health (SDOH), or the conditions in which people are born, live, work, play, learn, and age. SDOH includes socioeconomic status, education, community environment, employment, social supports, and access to health care services. Systematic differences in the distribution of power and resources due to racism and other biases are the root causes of inequities in access, availability, and quality of SDOH. All ten priorities that emerged from community members' input during the needs assessment revolve around SDOH and inequities. These factors and inequities influence the health outcomes of both individuals and entire communities.

The Guam Title V program strives to contribute to broad-based efforts to address inequality and social determinants of health. Strategies focus on improving outreach to find and engage high-need women and their families in health insurance and health care; Increasing knowledge of available community resources and supports; working with community stakeholders to

improve the delivery of care and services; the development of supports, opportunities and social norms that promote and facilitate healthy behaviors across the lifespan; involving community members in program implementation and policy; and promoting community engagement and mobilization to address bias and racism and other community proactively and

systems-level factors are impacting racial and ethnic disparities.

The Title V Program will lead the following specific program and policy activities to advance this strategy over the upcoming grant cycle:

• Through the MCH program, work with diverse community stakeholders, including community residents, to identify and collaboratively address issues and barriers affecting maternal and infant health outcomes at the community level, including activities to:
• Actively participate in community advisory boards, consortiums, or coalitions to address perinatal and infant health issues and identify effective strategies for addressing the social determinants impacting those outcomes.
• Engage and collaborate with diverse stakeholders from various community sectors, including community residents, grassroots organizations, community-based service organizations, health care providers, local government, local foundations, and local businesses.
• Work collaboratively to address relevant community issues such as safe housing, availability and accessibility of resources and services (e.g., health care, mental health, substance abuse services, home visiting, family support resources), social norms (e.g., related to use of preventive care services, breastfeeding, or personal health behaviors), and community mobilization to identify and address community problems effectively.

Through the MCH program, provide supports to individual clients and their families to address behavioral, social determinants of health outcomes, including specific program activities to:

• Provide information on available community resources for needs related to housing, food, employment and job training, transportation, and other essential needs;
• Conduct screenings using standardized, evidence-based, or validated tools for domestic violence, substance use, smoking, and depression, and make referrals for follow-up as needed;
• Help families connect and use/ enroll in enhanced social support resources and programs including parenting classes, peer support groups, childbirth education, and resources to develop birth and postpartum care plans, and breastfeeding education, and directly support clients to build delivery plans;
• Provide professional development support for MCH and Project Bisita staff members to deliver these services, including annual training on how to talk with families about complex topics like mental health and depression, using a trauma-informed care approach, and managing emergencies.

By 2025, Guam MCH is planning to use two strategies to increase our understanding of the reasons behind why or why not women of reproductive age schedule and attend a well-woman visit. The first strategy is to find and use already developed questions or develop our questions for the Guam Behavioral Risk Factor Surveillance Survey (BRFSS). Currently, the BRFSS asks, “About how long has it been since you last visited a doctor for a routine checkup?” While this question answers how many women visited a doctor for a routine checkup, it does not offer guidance on the reasons behind respondents' answers. We plan to include questions asking BRFSS respondents the barriers and facilitators of vising a doctor for a routine checkup.

Our second strategy is to form a coalition of community partners and organizations that work with women of reproductive age to create a strategic plan that will guide future activities. Working with other experts in our community, we plan to make consistent messaging that all coalition members can educate the women in their communities. We plan to invite partners representing different sectors of our target population to ensure that we reach all women. Through these two strategies, we hope to build on the information we received a couple of years ago from the focus groups to create a plan that caters to the specific needs of the women in Guam.

The ESM selected for this priority is the “Percentage of women served by the Guam Maternal, Infant and Early Childhood Home Visiting or Family Planning Program who received a referral to prenatal care when the need was indicated.”

At a Well Woman and/or prenatal visit, clients receive education and counseling on the recommended preventive screenings that optimize health. Information on height, weight, body mass index, and blood pressure is gathered at each visit. After interviewing the client, further education, testing, and/or referrals are provided based on identified needs. Educational topics include sexually transmitted infection screening, pap tests, mammogram referral, hemoglobin testing, sickle cell screening, total cholesterol or cholesterol screening referral, wet mount, pregnancy testing, and fecal occult blood testing. The client is also screened for immunization status, smoking, alcohol, illicit drug use or abuse, human trafficking, and intimate partner violence. 

The Family Planning Program offers a spectrum of sexual and reproductive health services, including birth control methods, testing treatment for sexually transmitted infections, well women visit, and perception care. They also offer tailored community-based clinical outreach and education. Collaboration between Family Planning and Title V will provide opportunities to improve care for women and children by maximizing women's reproductive health and their children's health. The Chronic Disease and Prevention Division aim to provide information and resources to make it easier to make life choices. Chronic diseases are diseases that last one year or more and require ongoing attention or limit activities of daily living or both. Most chronic diseases can be prevented by eating well, exercising, avoid tobacco and excessive drinking, and getting health screening. MCH will continue a partnership with the Chronic Diseases Division to promote smoking cessation, heart health, and intimate partner violence. A relationship with chronic disease will provide an understanding of how MCH and chronic disease morbidity intersect. Communicable Diseases Division provides information and services to prevent, test for, and treat infectious diseases such as Human Immunodeficiency Virus (HIV), Sexually Transmitted Disease (STD), and Tuberculosis (TB). A partnership between MCH and Communicable Diseases will allow. Activities geared to identify ways to improve women's health before they conceive and help them manage any chronic diseases during the perinatal period.

By 2025, MCH plans to strengthen the relationship with the FQHCs (NRCHC and SRCHC) in the territory to develop an integrated network that coordinates services and client access. A Community-based system of care will appropriately address the health issues of the underserved and vulnerable population. Such a relationship will ultimately improve health outcomes while promoting cost-effective care. MCH will continue collaborations with Family Planning, Chronic Disease, and Communicable Diseases, and other community partners and establish a stronger relationship with the FQHCs to promote wellness among the women population, provide access to comprehensive services and deliver better client outcomes.