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Rethinking the Well Woman Visit: A Scoping Review to Identify Eight Priority Areas for Well Woman Care in the Era of the Affordable Care Act

Published:January 23, 2016DOI:https://doi.org/10.1016/j.whi.2015.11.003

      Abstract

      Purpose

      The annual pap smear for cervical cancer screening, once a mainstay of the well woman visit (WWV), is no longer recommended for most low-risk women. This change has led many women and their health care providers to wonder if they should abandon this annual preventive health visit altogether. Changing guidelines coinciding with expanded WWV coverage for millions of American women under the Patient Protection and Affordable Care Act have created confusion for health care consumers and care givers alike. Is there evidence to support continued routine preventive health visits for women and, if so, what would ideally constitute the WWV of today?

      Methods

      A scoping review of the literature was undertaken to appraise the current state of evidence regarding a wide range of possible elements to identify priority areas for the WWV.

      Findings

      A population health perspective taking into consideration the reproductive health needs of women as well as the preventable and modifiable leading causes of death and disability was used to identify eight domains for the WWV of today: 1) reproductive life planning and sexual health, 2) cardiovascular disease and stroke, 3) prevention, screening, and early detection of cancers, 4) unintended injury, 5) anxiety, depression, substance abuse, and suicidal intent, 6) intimate partner violence, assault, and homicide, 7) lower respiratory disease, and 8) arthritis and other musculoskeletal problems.

      Conclusions

      The WWV remains a very important opportunity for prevention, health education, screening, and early detection and should not be abandoned.
      The Patient Protection and Affordable Care Act (ACA) of 2010 mandates that health plans cover a range of preventive services including an annual well woman visit (WWV) for free. Recent publications from the Institute of Medicine (IOM), including Clinical Preventive Services for Women: Closing the Gaps (
      Institute of Medicine
      Clinical preventive services for women: Closing the gaps.
      ) and the Future of Nursing: Leading Change, Advancing Health (

      Institute of Medicine. (2011b). The future of nursing: Leading change, advancing health. Washington, DC.

      ) highlight a significant paradigm shift in U.S. health policy from treating illness to promoting health. In its Future of Nursing report, the IOM articulates a vision for the health care system to intentionally promote wellness and prevent disease, one in which “primary care and prevention are central drivers of the health care system” (

      Institute of Medicine. (2011b). The future of nursing: Leading change, advancing health. Washington, DC.

      , p. S-1). The IOM recommendations for women's preventive services (2011a) envision the WWV as a way to address cost barriers and other disparities associated with obtaining preventive services and to reduce a woman's risk of disease, disability, and illness. These recommendations made important strides to ensure broad and more universal access to certain preventive services for women without the associated costs (such as copays or deductibles) that have been shown to deter women from seeking such services (
      • Olchanski N.
      • Cohen J.T.
      • Neumann P.J.
      A role for research: An observation on preventive services for women.
      ,

      Robertson, R., & Collins, S. R. (2011). Women at risk: Why increasing numbers of women are failing to get the health care they need and how the affordable care act will help. Pub 1502, Vol. 3. The Commonwealth Fund: New York.

      ).
      At the same time that health plans are implementing the ACA-mandated coverage for annual WWVs without cost sharing, certain key components of the traditional WWV, such as the annual Pap smear for cervical cancer screening and the bimanual pelvic examination, are being challenged. Specifically, joint 2012 guidelines from the American Cancer Society (ACS), the American Society for Colposcopy and Cervical Pathology, and the American Society for Clinical Pathology (
      • Saslow D.
      • Solomon D.
      • Lawson H.W.
      • Killackey M.
      • Kulasingam S.
      • Garcia F.A.
      • Waldman J.
      American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer.
      ) as well as by the
      American College of Obstetricians and Gynecologists (ACOG)
      ACOG Practice Bulletin Number 131: Screening for cervical cancer.
      now advocate for cervical cancer screening with a Pap smear only every 3 to 5 years in low-risk women. In 2014, the American College of Physicians issued a new clinical guideline recommending against routine screening pelvic examinations in asymptomatic, nonpregnant adult women (
      • Qaseem A.
      • Humphrey L.L.
      • Harris R.
      • Starkey M.
      • Denberg T.D.
      Clinical Guidelines Committee of the American College of Physicians
      Screening pelvic examination in adult women: a clinical practice guideline from the American College of Physicians.
      ), although the ACOG continues to recommend yearly pelvic examinations (

      American College of Obstetricians and Gynecologists (ACOG). (2014). ACOG practice advisory on annual pelvic examination recommendations. Available: www.acog.org/About-ACOG/News-Room/Statements-and-Advisories/2014/ACOG-Practice-Advisory-on-Annual-Pelvic-Examination-Recommendations.

      ). These changing recommendations and other campaigns to reduce the use of low-value services in health care (

      ABIM Foundation. (2015). Choosing wisely. Available: www.choosingwisely.org. Accessed: July 15, 2015.

      ) have led to popular press headlines and professional editorials questioning the need for any kind of preventive care at all.
      Fortunately, the ACA guarantee for a yearly WWV as a covered benefit without cost sharing has helped to protect these visits from possible extinction. Women's health experts, advocates, and organizations have responded to questions about the value of these visits with guidance for policy makers, clinicians and health care consumers. A Consumer Guide to the WWV (

      National Women's Law Center, Brigham and Women's Hospital & Connors Center for Women's Health. (2014). Consumer guide to a well-woman visit. Available: www.nwlc.org/sites/default/files/final_well-womanbrochure.pdf. Accessed July 15, 2015

      ) a WWV software application (“app”;

      Nurse Practitioners in Women's Health (2014). Well woman visit app. Available at www.npwh.org/pages/mobile-app. Accessed Jan 5, 2016.

      ), and a comprehensive list of age-based recommendations for Components of the Well-Woman Visit from the ACOG Well Woman Task Force (
      • Conry J.A.
      • Brown H.
      Well-Woman Task Force.
      ) have been released in the past year. Nevertheless, more work needs to be done to solidify the value of this preventive health visit, to help clinicians prioritize among the many potential highest value WWV elements, and to educate and empower women to fully utilize their preventive health and screening benefits (
      • Fitzgerald T.
      • Glynn A.
      • Davenport K.
      • Waxman J.
      • Johnson P.A.
      Well-woman visits: Guidance and monitoring are key in this turning point for women's health.
      ,
      • Sawaya G.F.
      Re-envisioning the annual well-woman visit.
      ).

      Methods

      The goal of this scoping review of the literature was to answer the question: What is the state of the literature, evidence for, and current policy recommendations regarding what should be included as components of the WWV? This review followed the five steps outlined by
      • Arksey H.
      • O'Malley L.
      Scoping studies: Towards a methodological framework.
      and further refined by
      • Levac D.
      • Colquhoun H.
      • O'Brien K.
      Scoping studies: Advancing the methodology.
      and
      • Daudt H.M.
      • van Mossel C.
      • Scott S.J.
      Enhancing the scoping study methodology: A large, inter-professional team's experience with Arksey and O'Malley's framework.
      . Because the WWV is generally composed of a package of many different possible services (which may include cancer screenings, behavioral health screenings and interventions, health education and counseling, and reproductive life planning [RLP]), the scoping review method was chosen because it lends itself to rapidly mapping relevant literature covering broader and more complex research or policy-related questions, to assimilating a broad and diverse range of interdisciplinary research and nonresearch sources, and to summarizing and prioritizing among important sources and types of evidence available (
      • Anderson S.
      • Allen P.
      • Peckham S.
      • Goodwin N.
      Asking the right questions: Scoping studies in the commissioning of research on the organisation and delivery of health services.
      ,
      • Davis K.
      • Drey N.
      • Gould D.
      What are scoping studies? A review of the nursing literature.
      ,
      • Mays N.
      • Roberts E.
      • Popay J.
      Synthesizing research evidence.
      ).
      Relevant literature was identified using Medline/Ovid, CINAHL, and Google Scholar to also identify white papers and grey literature. In addition, hand searching of the U.S. Preventive Services Task Force (USPSTF), National Guideline Clearinghouse, and Cochrane databases, as well as the web sites of relevant professional organizations was undertaken to ensure inclusion of all possible practice guidelines or recommendations. Because of the breadth of this review, resources were limited to meta-analysis and clinical guidelines based on such analyses and focused on primary care settings, primary prevention, and preventive health guidelines, unless such resources were not available. References were generally limited to the year 2009 or later unless classic, often cited, or not yet revised/updated resources from earlier years were considered critical to the topic area. All applicable references were collected and organized by topic area in Mendeley (version 1.12, Mendeley Ltd, New York, NY).
      Because this scoping literature review did not include human subjects, no institutional review board approval was required for this project.

      Results

      An initial search explored mortality and morbidity data and the general reproductive health needs of U.S. women to identify priority areas for the WWV. This initial iterative process is consistent with the experiences described by other researchers who used the scoping review methodology (
      • Arksey H.
      • O'Malley L.
      Scoping studies: Towards a methodological framework.
      ,
      • Daudt H.M.
      • van Mossel C.
      • Scott S.J.
      Enhancing the scoping study methodology: A large, inter-professional team's experience with Arksey and O'Malley's framework.
      ,
      • Levac D.
      • Colquhoun H.
      • O'Brien K.
      Scoping studies: Advancing the methodology.
      ). In addition to addressing reproductive health issues for women, the WWV of today is an important opportunity to address the prevention and modification of risk factors for and/or early detection of the current leading causes of morbidity and mortality. Table 1 presents the most recent data available regarding leading causes of death in women and Table 2 summarizes the leading self-reported sources of disability in women. Modifiable risk factors including smoking, overweight/obesity, high blood pressure, physical inactivity, and high glucose account for more than two of every five deaths in U.S. women (
      • Danaei G.
      • Ding E.L.
      • Mozaffarian D.
      • Taylor B.
      • Rehm J.
      • Murray C.J.L.
      • Ezzati M.
      The preventable causes of death in the United States: Comparative risk assessment of dietary, lifestyle, and metabolic risk factors.
      ), primarily from cardiovascular disease (CVD), lung cancer, stroke, and chronic obstructive pulmonary disease (COPD). As much as one quarter of direct medical costs of the U.S. health system have been attributed to modifiable risk factors (
      • Grunfeld E.
      • Manca D.
      • Moineddin R.
      • Thorpe K.E.
      • Hoch J.S.
      • Campbell-Scherer D.
      • Mamdani M.
      Improving chronic disease prevention and screening in primary care: Results of the BETTER pragmatic cluster randomized controlled trial.
      ).
      Table 1Five Leading Causes of Death among Women in the United States by Age, 2010
      Source: CDC, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS). Available: www.cdc.gov/injury/wisqars
      RankTotal18–44 Years45–64 Years≥65 Years
      1Heart disease (23.8%)Unintentional injury (24.0%)
      The most common causes of unintentional injury include motor vehicle accidents, drug overdose, and unintentional firearm-related deaths.
      Cancer (38.3%)
      Top 3 causes of cancer death in women are lung, breast, and colorectal.
      Heart disease (25.9%)
      2Cancer (22.4%)
      Top 3 causes of cancer death in women are lung, breast, and colorectal.
      Cancer (19.5%)
      Top 3 causes of cancer death in women are lung, breast, and colorectal.
      Heart disease (16.2%)Cancer (19.4%)
      Top 3 causes of cancer death in women are lung, breast, and colorectal.
      3Stroke (6.3%)Heart disease (9.8%)Unintentional injury (5.7%)
      The most common causes of unintentional injury include motor vehicle accidents, drug overdose, and unintentional firearm-related deaths.
      Stroke (7.0%)
      4Chronic lower respiratory disease (6.0%)
      Chronic lower respiratory disease includes chronic obstructive pulmonary disease, chronic bronchitis, and emphysema.
      Suicide (7.1%)Chronic lower respiratory disease (4.8%)
      Chronic lower respiratory disease includes chronic obstructive pulmonary disease, chronic bronchitis, and emphysema.
      Chronic lower respiratory disease (6.4%)
      Chronic lower respiratory disease includes chronic obstructive pulmonary disease, chronic bronchitis, and emphysema.
      5Alzheimer disease (4.8%)Homicide (3.9%)Stroke (3.7%)Alzheimer's disease (5.9%)
      The most common causes of unintentional injury include motor vehicle accidents, drug overdose, and unintentional firearm-related deaths.
      Top 3 causes of cancer death in women are lung, breast, and colorectal.
      Chronic lower respiratory disease includes chronic obstructive pulmonary disease, chronic bronchitis, and emphysema.
      Table 2Five Most Common Self-reported Causes of Disability in U.S. Women ≥18 Years United States, 2005
      Source:
      Centers for Disease Control and Prevention (CDC)
      Prevalence and most common causes of disability among adults – United States, 2005.
      . Prevalence and Most Common Causes of Disability Among Adults – United States, 2005. MMWR Morbidity & Mortality Weekly Report, 58(16), 421–426. Available: www.cdc.gov/mmwr/preview/mmwrhtml/mm5816a2.htm
      ConditionEstimated % of Uninstitutionalized Female Population ≥18 years
      1Arthritis or rheumatism24.3
      2Back or spine problems16.8
      3Heart trouble5.4
      4Lung or respiratory problem4.9
      5Mental or emotional problem4.6
      Although life expectancy at birth has improved in total for U.S. women over the past two decades, morbidity and related rates of disability have increased, with the same modifiable risk factors and alcohol use contributing to the increasing years lived with disability (
      • Fineberg H.V.
      U.S. Burden of Disease Collaborators
      The state of US health, 1990-2010: burden of diseases, injuries, and risk factors.
      ). Some recent statistical modeling predicts more disease and earlier mortality ahead for younger Americans because of the high incidence of obesity and other factors (
      • Reither E.N.
      • Olshansky S.J.
      • Yang Y.
      New forecasting methodology indicates more disease and early mortality ahead for today's younger Americans.
      ). Despite the high costs of the U.S. health system, the US ranks 36th in the world in life expectancy for women (

      World Health Organization. (2013). Responding to intimate partner violence against women: WHO clinical and policy guidelines. World Health Organization: Geneva, Switzerland.

      ), and 48th in maternal mortality indicating that much more can and should be done to ensure the health and longevity of women in this country.
      In this first phase of the scoping review, the morbidity and mortality data discussed were used to identify a framework of eight priority areas for the WWV. Next, separate scoping reviews were conducted for each of the eight priority areas, resulting in a total of 169 references that were collated and extracted. Figure 1 details the overall flow of the scoping review search and selection (
      • Davis K.
      • Drey N.
      • Gould D.
      What are scoping studies? A review of the nursing literature.
      ). To ensure methodological rigor, the detailed search strategies and terms for each of the eight priority areas were documented in detail and are available upon request (
      • Arksey H.
      • O'Malley L.
      Scoping studies: Towards a methodological framework.
      ,
      • Daudt H.M.
      • van Mossel C.
      • Scott S.J.
      Enhancing the scoping study methodology: A large, inter-professional team's experience with Arksey and O'Malley's framework.
      ,
      • Havill N.L.
      • Leeman J.
      • Shaw-Kokot J.
      • Knafl K.
      • Crandell J.
      • Sandelowski M.
      Managing large-volume literature searches in research synthesis studies.
      ). The following sections describe each of the eight proposed priority areas and summarize key findings from the scoping review of each area. Table 3 outlines the number of citations and type of evidence found for each topic area.
      Figure thumbnail gr1
      Figure 1Flow diagram of scoping literature search and selection. Limits applied: English language, full text, 2009–Oct 2014. Reference: based on the flow diagram presented by
      • Davis K.
      • Drey N.
      • Gould D.
      What are scoping studies? A review of the nursing literature.
      .
      Table 3Summary of Citations Reviewed for Each Priority Area
      Priority AreaNo. of Citations ReviewedDetails
      • 1.
        Reproductive life planning and sexual health
      276 systematic reviews, 2 covering STI including HIV screening; 2 looking at contraceptive interventions; majority of articles discursive reviews or expert opinion
      • 2.
        Cardiovascular disease and stroke
      178 clinical guidelines, 5 systematic reviews; strong evidence and high degree of consensus with regards to the goals of primary prevention, although specifics of interventions (e.g., the recommended duration and frequency of exercise) varies slightly from source to source
      • 3.
        Prevention, screening, and early detection of cancers
      31For each type of cancer (breast, ovarian, cervical, colon, lung and uterine) ≥2 sources of guidelines were examined; in most cases the guidelines reviewed were evidenced based, but in some cases—e.g., recommendations regarding pelvic examinations and teaching self-breast awareness—recommendations were based primarily on expert opinion
      • 4.
        Unintended injury
      175 systematic reviews related to brief screening for alcohol use/misuse; no systematic reviews or outcomes-based resources were found regarding prevention of unintended drug overdose, but 2 expert opinion resources and 1 paper describing a validated screening question for primary care were found
      • 5.
        Anxiety, depression, substance misuse, and suicidal intention
      316 systematic reviews regarding depression screening and collaborative care outcomes, 1 meta-analysis; 6 references regarding substance abuse screening; guidelines from Canada and the U.S. regarding routine depression screening do not agree, with the Canadian Task Force on Preventive Health Care recommending against routine screening in primary care and the USPSTF recommending routine screening as long as a collaborative care model is in place; consensus does exist regarding the benefits of alcohol screening and brief interventions in primary care; recommendations regarding drug use screening are based almost entirely on expert opinion at this stage; 10 references regarding suicide screening and prevention in primary care were reviewed, including 3 systematic reviews
      • 6.
        Assault, intimate partner violence, and homicide
      137 systematic reviews highlight the lack of a validated psychometric screening tool for health care settings, lack of improved outcomes data (with the exception of 1 perinatal IPV program) and limited evidence on long-term health benefits of universal screening; controversy in this area exists: ACOG and the USPSTF recommend for the universal screening of women for IPV, whereas WHO and the Canadian Task Force guidelines recommend against routine screening
      • 7.
        Lower respiratory disease
      167 systematic reviews; strong consensus exists regarding the importance of smoking cessation to prevent respiratory (and other) diseases
      • 8.
        Arthritis and musculoskeletal problems
      171 systematic review explored the effects of interventions to improve exercise and physical activity for people with chronic musculoskeletal pain generally; 6 articles were found regarding arthritis, mostly examining the risk factors for and epidemiology of arthritis with evidence mostly from survey data and observational research, although 1 prospective study was consistent with the others in finding that obesity, injury and heavy workload are risk factors for osteoarthritis; no papers regarding interventions for the prevention of arthritis were found

      7 systematic reviews explored evidence for the prevention of and screening for osteoporosis. Clinical guidelines from the North American Menopause Society provided evidence-based recommendations for the role of calcium and vitamin D in perimenopausal and postmenopausal women but offered a stronger recommendation for this intervention than the USPSTF systematic reviews on the topic
      Abbreviations: ACOG, american college of obstetrics and gynecology; HIV, human immunodeficiency virus; IPV, intimate partner violence; STI, sexually transmitted infection; USPSTF, U.S. Preventive Services Task Force; WHO, World Health Organization.

      Priority Area 1: RLP and Sexual Health

      Despite the availability of effective contraceptive methods to prevent unintended pregnancy, one in five sexually active women age 15 to 44 is not using any form of contraception (

      Salganicoff, A., Ranji, U., Beamesderfer, A., & Kurani, N. (2014). Women and health care in the early years of the Affordable Care Act Key Findings from the 2013 Kaiser Women's Health Survey. Kaiser Family Foundation: Menlo Park, CA.

      ), and about one-half of pregnancies in the United States are unintended (

      Guttmacher Institute. (2013). Unintended pregnancy in the United States. Available: www.guttmacher.org

      ). Significant racial and socioeconomic disparities in unintended pregnancies, preterm birth, and poor birth outcomes exist (

      Guttmacher Institute. (2013). Unintended pregnancy in the United States. Available: www.guttmacher.org

      ,
      • Malnory M.E.
      • Johnson T.S.
      The reproductive life plan as a strategy to decrease poor birth outcomes.
      ). Only 60% of women report having recently discussed contraception with their health care provider, only half have discussed their sexual history and only about one third recently discussed sexually transmitted infections (STIs;

      Salganicoff, A., Ranji, U., Beamesderfer, A., & Kurani, N. (2014). Women and health care in the early years of the Affordable Care Act Key Findings from the 2013 Kaiser Women's Health Survey. Kaiser Family Foundation: Menlo Park, CA.

      ). Few women prescribed potentially teratogenic medications are provided family planning services at their primary care visits, and an estimated 6% of U.S. pregnancies are exposed to these potentially harmful medications (
      • Schwarz E.B.
      • Parisi S.M.
      • Williams S.L.
      • Shevchik G.J.
      • Hess R.
      Promoting safe prescribing in primary care with a contraceptive vital sign: A cluster-randomized controlled trial.
      ).
      Key themes from the sources reviewed in this topic area were the use of consistent and integrated RLP to reduce unintended and mistimed pregnancies and their consequences (
      • Berg J.A.
      • Olshansky E.
      • Shaver J.
      • Taylor D.
      • Woods N.F.
      Women's health in jeopardy: Failure to curb unintended pregnancies.
      ,
      • Boivin J.
      • Bunting L.
      • Gameiro S.
      Cassandra's prophecy: A psychological perspective. Why we need to do more than just tell women.
      ,

      Centers for Disease Control and Prevention (CDC). (2010a). Folic acid: Data and statistics. Available: www.cdc.gov/NCBDDD/folicacid/data.html. Accessed: October 21, 2014.

      ,
      • Coffey K.
      • Shorten A.
      The challenge of preconception counseling: Using reproductive life planning in primary care.
      ,
      • Johnson K.
      • Posner S.
      • Biermann J.
      • Cordero J.
      • Atrash H.
      • Parker C.
      • Curtis M.
      Recommendations to improve preconception health and health care - United States: A report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care.
      ,
      • Malnory M.E.
      • Johnson T.S.
      The reproductive life plan as a strategy to decrease poor birth outcomes.
      ,
      • Moos M.-K.
      • Dunlop A.L.
      • Jack B.W.
      • Nelson L.
      • Coonrod D.V.
      • Long R.
      • Gardiner P.M.
      Healthier women, healthier reproductive outcomes: Recommendations for the routine care of all women of reproductive age.
      ,
      • Taylor D.
      • James E.A.
      An evidence-based guideline for unintended pregnancy prevention.
      ,
      U.S. Preventive Services Task Force (USPSTF)
      Folic acid for the prevention of neural tube defects: U.S. Preventive Services Task Force Recommendation Statement.
      ,
      • Witt J.
      • Kelly P.
      Choice, not chance: Reproductive life plan assessment as a clinical management framework.
      ). The WWV is also an important venue for preconception care regarding the ways to best promote fertility and a healthy pregnancy when a woman wants to conceive (
      • Cooksey S.
      • Bellanca H.
      • Stranger-Hunter M.
      One Key Question: Better integration of preventive reproductive health info into primary care.
      ,
      • Donnelly K.Z.
      • Foster T.C.
      • Thompson R.
      What matters most? The content and concordance of patients' and providers' information priorities for contraceptive decision making.
      ,
      • Gavin L.
      • Moskosky S.
      • Carter M.
      • Curtis K.
      • Glass E.
      • Godfrey E.
      • Zapata L.
      Providing quality family planning services.
      ,
      • Halpern V.
      • Lopez L.M.
      • Grimes D.A.
      • Stockton L.L.
      • Gallo M.F.
      Strategies to improve adherence and acceptability of hormonal methods of contraception.
      ,
      • Lopez L.M.
      • Tolley E.E.
      • Grimes D.A.
      • Chen M.
      • Stockton L.L.
      Theory-based interventions for contraception.
      ,
      • Paterno M.T.
      • Jordan E.T.
      A review of factors associated with unprotected sex among adult women in the United States.
      ). In addition, the WWV is an opportunity to educate about sexual health in general as well as regarding STI prevention (
      • Buttaro T.M.
      • Koeniger-Donohue R.
      • Hawkins J.
      • Mahan Buttaro T.
      Sexuality and quality of life in aging: Implications for practice.
      ,
      • Moyer V.A.
      U.S. Preventive Services Task Force (USPSTF)
      Screening for HIV: U.S. Preventive Services Task Force recommendation statement.
      ,
      • O'Connor E.A.
      • Lin J.S.
      • Burda B.U.
      • Henderson J.T.
      • Walsh E.S.
      • Whitlock E.P.
      Behavioral sexual risk-reduction counseling in primary care to prevent sexually transmitted infections: An updated systematic evidence review for the U.S. Preventive Services Task Force.
      ). Screening for STIs and intimate partner violence (IPV) or reproductive and sexual coercion should also be considered depending on a woman's age and risk factors (
      American College of Obstetricians and Gynecologists (ACOG)
      ACOG Committee Opinion No. 554: reproductive and sexual coercion.
      ,
      • Paterno M.T.
      • Jordan E.T.
      A review of factors associated with unprotected sex among adult women in the United States.
      ).

      Priority Area 2: CVD and Stroke

      Approximately one in two women in the United States will have some form of CVD—including coronary heart disease and stroke—and one in four woman will die of CVD (
      Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN)
      Women's cardiovascular disease.
      ,
      • Go A.
      • Mozaffarian D.
      • Roger V.
      • Benjamin E.
      • Berry J.
      • Blaha M.
      • Turner M.B.
      on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee
      Heart disease and stroke statistics—2014 update: A report from the American Heart Association.
      ,
      • Mosca L.
      • Benjamin E.J.
      • Berra K.
      • Bezanson J.L.
      • Dolor R.J.
      • Lloyd-Jones D.M.
      • Wenger N.K.
      Effectiveness-based guidelines for the prevention of cardiovascular disease in women–2011 update: A guideline from the American Heart Association.
      ). The high mortality rate from CVD in U.S. women translates to one death per minute (
      • Mosca L.
      • Benjamin E.J.
      • Berra K.
      • Bezanson J.L.
      • Dolor R.J.
      • Lloyd-Jones D.M.
      • Wenger N.K.
      Effectiveness-based guidelines for the prevention of cardiovascular disease in women–2011 update: A guideline from the American Heart Association.
      ). More women die from CVD in this country than men, and CVD is increasing in younger women aged 35 to 44, likely owing to rising obesity rates (
      • Lindquist R.
      • Witt D.R.
      • Boucher J.L.
      Preventing cardiovascular disease in women: How can we do better?.
      ). More women than men die from stroke and although death rates from stroke have decreased in the past decade, stroke is a leading cause of functional impairment leading to permanent disability in up to one-third of stroke suffers (
      • Goldstein L.B.
      • Bushnell C.D.
      • Adams R.J.
      • Appel L.J.
      • Braun L.T.
      • Chaturvedi S.
      • Pearson T.A.
      Guidelines for the primary prevention of stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association.
      ). Although CVD and stroke are largely preventable, many women are either not aware of the risks or underestimate their own personal risk (
      Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN)
      Women's cardiovascular disease.
      ,
      • Mosca L.
      • Mochari-Greenberger H.
      • Dolor R.J.
      • Newby L.K.
      • Robb K.J.
      Twelve-year follow-up of American women's awareness of cardiovascular disease risk and barriers to heart health.
      ) and are therefore less likely to take steps to prevent CVD or modify their risk factors. Even more concerning is the fact that healthcare providers tend to underestimate CVD risk in women, which can lead to missed opportunities for prevention (
      • Pearson T.
      Cardiovascular disease in women: A journey toward a focus on prevention.
      ).
      Evidence from this topic area highlights the importance of consistently measuring and counseling women about their blood pressure and body mass index and encouraging weight loss when indicated (
      • Eckel R.H.
      • Jakicic J.M.
      • Ard J.D.
      • de Jesus J.M.
      • Houston Miller N.
      • Hubbard V.S.
      • Tomaselli G.F.
      2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
      ,
      • Goldstein L.B.
      • Bushnell C.D.
      • Adams R.J.
      • Appel L.J.
      • Braun L.T.
      • Chaturvedi S.
      • Pearson T.A.
      Guidelines for the primary prevention of stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association.
      ,
      • Jensen M.D.
      • Ryan D.H.
      • Apovian C.M.
      • Ard J.D.
      • Comuzzie A.G.
      • Donato K.A.
      • Yanovski S.Z.
      2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society.
      ,
      • LeFevre M.L.
      Behavioral counseling to promote a healthful diet and physical activity for cardiovascular disease prevention in adults with cardiovascular risk factors: U.S. Preventive Services Task Force recommendation statement.
      ,
      • Lindquist R.
      • Witt D.R.
      • Boucher J.L.
      Preventing cardiovascular disease in women: How can we do better?.
      ,
      • Moyer V.A.
      Behavioral Counseling Interventions to Promote a Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in adults: U.S. Preventive Services Task Force recommendation statement.
      ,

      Wilkinson, J., Bass, C., Diem, S., Gravley, A., Harvey, L., Maciosek, M., … Vincent, P. (2013). Preventive services for adults. Institute for Clinical Systems Improvement. Bloomington, MN.

      ). A cardiovascular risk calculator can also be used to assess and counsel regarding risk (
      • Goff D.C.
      • Lloyd-Jones D.M.
      • Bennett G.
      • Coady S.
      • D'Agostino R.B.
      • Gibbons R.
      • Wilson P.W.F.
      2013 ACC/AHA guideline on the assessment of cardiovascular risk: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
      ,
      The Fifth Joint Task Force on the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice
      European guidelines on cardiovascular disease prevention in clinical practice (version 2012).
      ). A woman's obstetric history should also be assessed because a history of preeclampsia or gestational diabetes can increase her risk of CVD (
      • Mosca L.
      • Benjamin E.J.
      • Berra K.
      • Bezanson J.L.
      • Dolor R.J.
      • Lloyd-Jones D.M.
      • Wenger N.K.
      Effectiveness-based guidelines for the prevention of cardiovascular disease in women–2011 update: A guideline from the American Heart Association.
      ). Screening for tobacco use at every visit and offering advice about quitting is also very important for the prevention of CVD and stroke (
      • Glantz S.
      • Gonzalez M.
      Effective tobacco control is key to rapid progress in reduction of non-communicable diseases.
      ,
      • Goldstein L.B.
      • Bushnell C.D.
      • Adams R.J.
      • Appel L.J.
      • Braun L.T.
      • Chaturvedi S.
      • Pearson T.A.
      Guidelines for the primary prevention of stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association.
      ). Finally, the cardiovascular benefits of regular physical activity and a healthy diet should be stressed (
      • Kulick D.
      • Langer R.D.
      • Ashley J.M.
      • Gans K.M.
      • Schlauch K.
      • Feller C.
      Live well: A practical and effective low-intensity dietary counseling intervention for use in primary care patients with dyslipidemia - a randomized controlled pilot trial.
      ,
      • McCullough M.L.
      • Patel A.V.
      • Kushi L.H.
      • Patel R.
      • Willett W.C.
      • Doyle C.
      • Gapstur S.M.
      Following cancer prevention guidelines reduces risk of cancer, cardiovascular disease, and all-cause mortality.
      ,
      • Rees K.
      • Dyakova M.
      • Wilson N.
      • Ward K.
      • Thorogood M.
      • Brunner E.
      Dietary advice for reducing cardiovascular risk (Review).
      ,
      • Wang X.
      • Ouyang Y.
      • Liu J.
      • Zhu M.
      • Zhao G.
      • Bao W.
      • Hu F.B.
      Fruit and vegetable consumption and mortality from all causes, cardiovascular disease, and cancer: Systematic review and dose-response meta-analysis of prospective cohort studies.
      ).

      Priority Area 3: Prevention, Screening, and Early Detection of Cancers

      Although the WWV has historically been associated with a pap smear for cervical cancer screening, a U.S. woman today is 20 times more likely to die from lung cancer, 10 times more likely to die from breast cancer, and 8 times more likely to die from colon cancer than from cervical cancer (

      American Cancer Society (ACS). (2014b). The lifetime probability of developing and dying from cancer, 2008-2010. Available: www.cancer.org/acs/groups/content/@research/documents/document/acspc-041777.pdf. Accessed: November 3, 2014.

      ). The WWV is an opportunity to discuss cancer prevention with patients, because lifestyle factors can impact a woman's chance of developing many cancers.
      Smoking is linked to at least 15 different types of cancer and is estimated to cause about one-third of all U.S. cancer deaths, while overweight and obesity are estimated to contribute to one-sixth of cancer deaths, including from breast cancer (

      American Cancer Society (ACS). (2014a). Seven steps to reduce your cancer risk. Available: www.cancer.org/myacs/newengland/areahighlights/seven-steps-to-reduce-your-cancer-risk. Accessed: November 3, 2014.

      ).
      • Lee I.-M.
      • Shiroma E.J.
      • Lobelo F.
      • Puska P.
      • Blair S.N.
      • Katzmarzyk P.T.
      Effect of physical inactivity on major non-communicable diseases worldwide: An analysis of burden of disease and life expectancy.
      estimated that physical inactivity causes approximately 12% of the burden of disease for breast and colon cancer in the United States. Although a light to moderate level of alcohol intake may be associated with cardiovascular benefits (
      • O'Keefe J.H.
      • Bybee K.A.
      • Lavie C.J.
      Alcohol and cardiovascular health. The razor-sharp double-edged sword.
      ), alcohol intake of more than 1 drink per day for women is linked to a variety of cancers, in particular breast cancer. The relative risk of breast cancer increases by 5% to 11% for light drinking (of up to 1 drink/day) and by 22% to 40% for alcohol intake of two to three drinks per day (
      • Demark-Wahnefried W.
      • Goodwin P.J.
      To your health: How does the latest research on alcohol and breast cancer inform clinical practice?.
      ). Certain strains of the human papilloma virus (HPV) are associated with vulvar, vaginal, cervical, anal, and oropharyngeal cancers in women and prevention of these high risk HPV infections can decrease the incidence of these cancers (
      • Petrosky E.
      • Bocchini J.
      • Hariri S.
      • Chesson H.
      • Curtis R.
      • Unger E.
      • Markowitz L.
      Use of 9-valent human papillomavirus (HVP) Vaccine: Updated HVP vaccination recommendations of the Advisory Committee on Immunization Practices.
      ).
      Cancer experts encourage cancer prevention by vaccination against HPV (
      • Petrosky E.
      • Bocchini J.
      • Hariri S.
      • Chesson H.
      • Curtis R.
      • Unger E.
      • Markowitz L.
      Use of 9-valent human papillomavirus (HVP) Vaccine: Updated HVP vaccination recommendations of the Advisory Committee on Immunization Practices.
      ), avoidance of tobacco products (including secondary smoke), maintenance of a healthy body mass index, regular physical activity, avoiding or limiting alcohol intake, and eating a healthy diet (

      American Cancer Society (ACS). (2014a). Seven steps to reduce your cancer risk. Available: www.cancer.org/myacs/newengland/areahighlights/seven-steps-to-reduce-your-cancer-risk. Accessed: November 3, 2014.

      ,

      International Agency for Research on Cancer, World Health Organization. (2014). European code against cancer: 12 ways to reduce your cancer risk. Available: http://cancer-code-europe.iarc.fr/index.php/en/. Accessed Jan 5, 2016.

      ). Analysis of observational data from the Women's Health Initiative study found that women who most closely followed the ACS guidelines for nutrition and physical activity had a 22% lower incidence of breast cancer, a 52% lower incidence of colorectal cancer, and a 27% lower incidence of endometrial cancer as compared to women who did not or only very minimally followed the guidelines (
      • Thomson C.A.
      • McCullough M.L.
      • Wertheim B.C.
      • Chlebowski R.T.
      • Martinez M.E.
      • Stefanick M.L.
      • Neuhouser M.L.
      Nutrition and physical activity cancer prevention guidelines, cancer risk, and mortality in the women's health initiative.
      ).
      In addition to discussing ways to reduce the risk of cancer, the WWV is also an opportunity to educate patients about and perform or refer patients for recommended cancer screenings. Cancer screenings are now free under the ACA, but many disparities have existed in the rates of screening among obese women and women of difference race and ethnicity, socioeconomic status, and geographical location (
      Centers for Disease Control and Prevention
      Cancer screening - United States, 2010.
      ,
      • Cohen S.S.
      • Palmieri R.T.
      • Nyante S.J.
      • Koralek D.O.
      • Kim S.
      • Bradshaw P.
      • Olshan A.F.
      Obesity and screening for breast, cervical, and colorectal cancer in women: A review.
      ). Current rates of screening for breast, cervical, and colon cancers are significantly below Healthy People 2020 targets. The primary risk factor contributing to cervical cancer deaths today is being rarely or never screened (
      • Saslow D.
      • Solomon D.
      • Lawson H.W.
      • Killackey M.
      • Kulasingam S.
      • Garcia F.A.
      • Waldman J.
      American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer.
      ). Although about three-quarters of American women have had cervical and breast cancer screening, only 59% of eligible women report being up to date with screening for colon cancer (
      Centers for Disease Control and Prevention
      Cancer screening - United States, 2010.
      ). In the case of ovarian and uterine cancers, no routine screening tests are available.
      Key themes from the literature reviewed for this topic area include the importance of systematically screening for tobacco use and acting to help women quit (

      Wilkinson, J., Bass, C., Diem, S., Gravley, A., Harvey, L., Maciosek, M., … Vincent, P. (2013). Preventive services for adults. Institute for Clinical Systems Improvement. Bloomington, MN.

      ). In addition, the WWV provides an opportunity to educate women about the cancer prevention benefits of HPV vaccination, a healthy diet, moderate alcohol intake, and maintaining a normal body mass index (
      • Aune D.
      • Chan D.
      • Vieira A.
      • Navarro-Rosenblatt D.
      • Vieira R.
      • Greenwood D.
      • Norat T.
      Fruits, vegetables and breast cancer risk: A systematic review and meta-analysis of prospective studies.
      ,
      • Danaei G.
      • Ding E.L.
      • Mozaffarian D.
      • Taylor B.
      • Rehm J.
      • Murray C.J.L.
      • Ezzati M.
      The preventable causes of death in the United States: Comparative risk assessment of dietary, lifestyle, and metabolic risk factors.
      ,
      • Demark-Wahnefried W.
      • Goodwin P.J.
      To your health: How does the latest research on alcohol and breast cancer inform clinical practice?.
      ,
      • Thomson C.A.
      • McCullough M.L.
      • Wertheim B.C.
      • Chlebowski R.T.
      • Martinez M.E.
      • Stefanick M.L.
      • Neuhouser M.L.
      Nutrition and physical activity cancer prevention guidelines, cancer risk, and mortality in the women's health initiative.
      ). Screening for breast, cervical, ovarian, colon, and lung cancers should be encouraged according to current guidelines and based on individual and genetic risk factors (
      • Moyer V.A.
      Screening for lung cancer: U.S. Preventive Services Task Force Recommendation Statement.
      ,
      • Moyer V.A.
      U.S. Preventive Services Task Force
      Risk assessment, genetic counseling, and genetic testing for BRCA-related cancer in women: U.S. Preventive Services Task Force recommendation statement.
      ,
      • Seibert D.
      Genomics & nurse practitioner practice.
      ,
      • Smith R.A.
      • Mannassaram-Baptiste D.
      • Brooks D.
      • Doroshenk M.
      • Fedewa S.
      • Salslow D.
      • Wender R.
      Cancer screening in the United States, 2015: A review of current American Cancer Society Guidelines and current issues in cancer screening.
      ). Finally, it may be beneficial to educate women regarding the warning signs for breast, ovarian, and endometrial cancers and for health care providers to have a high index of suspicion in women presenting with such symptoms so that further screening for cancer can be offered, as indicated (
      American College of Obstetricians and Gynecologists (ACOG)
      ACOG Committee Opinion No. 477: The role of the obstetrician – gynecologist in the early detection of epithelial ovarian cancer.
      ,

      American College of Obstetricians and Gynecologists (ACOG). (2014). ACOG practice advisory on annual pelvic examination recommendations. Available: www.acog.org/About-ACOG/News-Room/Statements-and-Advisories/2014/ACOG-Practice-Advisory-on-Annual-Pelvic-Examination-Recommendations.

      ,
      • Bloomfield H.E.
      • Olson A.
      • Greer N.
      • Cantor A.
      • MacDonald R.
      • Rutks I.
      • Wilt T.J.
      Screening pelvic examinations in asymptomatic, average-risk adult women: An evidence report for a clinical practice guideline from the American College of Physicians.
      ,
      • Goff B.A.
      Ovarian cancer: Screening and early detection.
      ,
      • Lockwood-Rayermann S.
      • Donovan H.S.
      • Rambo D.
      • Kuo C.W.
      Women's awareness of ovarian cancer risks and symptoms.
      ,
      • Qaseem A.
      • Humphrey L.L.
      • Harris R.
      • Starkey M.
      • Denberg T.D.
      Clinical Guidelines Committee of the American College of Physicians
      Screening pelvic examination in adult women: a clinical practice guideline from the American College of Physicians.
      ,
      • Smith R.A.
      • Mannassaram-Baptiste D.
      • Brooks D.
      • Doroshenk M.
      • Fedewa S.
      • Salslow D.
      • Wender R.
      Cancer screening in the United States, 2015: A review of current American Cancer Society Guidelines and current issues in cancer screening.
      ).

      Priority Area 4: Unintended Injury

      Unintended injury is the leading cause of death in females under 45 and causes almost one-quarter of the deaths to women aged 18 to 44. These deaths are primarily from motor vehicle accidents and accidental drug overdose (

      CDC National Center for Injury Prevention and Control. (2014b). Web-based Injury Statistics Query and Reporting System (WISQARS). Available: www.cdc.gov/injury/wisqars. Accessed: July 7, 2014.

      ). Alcohol, sleep deprivation, and distracted driving have been shown to significantly increase the risk of injuries and collisions (
      • Anderson P.
      • Chisholm D.
      • Fuhr D.C.
      Effectiveness and cost-effectiveness of policies and programmes to reduce the harm caused by alcohol.
      ,

      CDC National Center for Injury Prevention and Control. (2014a). Savings lives and protecting people: preventing motor vehicle-related injuries. Available: www.cdc.gov/injury/about/focus-mvs.html. Accessed: October 21, 2014.

      ,
      • Senthilvel E.
      • Auckley D.
      • Dasarathy J.
      Evaluation of sleep disorders in the primary care setting: History taking compared to questionnaires.
      ,
      • Ship A.
      The most primary of care - Talking about driving and distraction.
      ). Unintended injury deaths from poisonings, primarily by illegal and prescription drug overdose, increased 172% for women and girls between 1999 and 2005 (
      • Hu G.
      • Baker S.P.
      Trends in unintentional injury deaths, U.S., 1999-2005: Age, gender, and racial/ethnic differences.
      ).
      A previous 2007 recommendation to counsel patients about seatbelt use was not updated by the USPSTF in 2014 owing to lack of evidence for efficacy in primary care settings (

      U.S. Preventive Services Task Force (USPSTF). (2014). Motor vehicle occupant restraints, inactive topic. Available: www.uspreventiveservicestaskforce.org/BrowseRec/InactiveTopic/243. Accessed Nov 19, 2014.

      ). In fact, most of the references found for this topic area highlighted that the most proven strategies for reducing unintended injuries occur at the local community, state, or national level. For motor vehicle injuries, laws such as those mandating child seats, seatbelts, motorcycle helmets, prohibiting driving with a blood alcohol level over 0.08%, and distracted driving have a proven track record for saving lives (
      • Ship A.
      The most primary of care - Talking about driving and distraction.
      ,

      U.S. Preventive Services Task Force (USPSTF). (2014). Motor vehicle occupant restraints, inactive topic. Available: www.uspreventiveservicestaskforce.org/BrowseRec/InactiveTopic/243. Accessed Nov 19, 2014.

      ). Mass media campaigns to educate the public have also proven to be successful at reducing rates of unintended injuries. Examples of successful campaigns have included public education about the risks of impaired driving (calling or texting, sleep deprivation, drug or alcohol impairment) and prescription overdose as well as the benefits of seatbelts, bicycle and motorcycle helmets (
      • Anderson P.
      • Chisholm D.
      • Fuhr D.C.
      Effectiveness and cost-effectiveness of policies and programmes to reduce the harm caused by alcohol.
      ,

      CDC National Center for Injury Prevention and Control. (2014a). Savings lives and protecting people: preventing motor vehicle-related injuries. Available: www.cdc.gov/injury/about/focus-mvs.html. Accessed: October 21, 2014.

      ,

      CDC National Center for Injury Prevention and Control. (2014b). Web-based Injury Statistics Query and Reporting System (WISQARS). Available: www.cdc.gov/injury/wisqars. Accessed: July 7, 2014.

      ;

      CDC National Center for Injury Prevention and Control. (2014a). Savings lives and protecting people: preventing motor vehicle-related injuries. Available: www.cdc.gov/injury/about/focus-mvs.html. Accessed: October 21, 2014.

      ,

      Community Preventive Services Task Force. (2015). munity preventive services. Available: www.thecommunityguide.org.

      ).
      Evidence for this priority area highlights the role that screening for sleep disorders, distracted driving, and alcohol and illicit drug use and misuse may help to identify women at risk of unintended injury and brief and repeated primary care counseling interventions or discussions may be effective in reducing problem substance use and its associated risks (
      • Botelho R.
      • Engle B.
      • Mora J.C.
      • Holder C.
      Brief interventions for alcohol misuse.
      ,
      • Clossick E.
      • Woodward S.
      Effectiveness of alcohol brief interventions in general practice.
      ,
      • Dinh-Zarr T.
      • Goss C.
      • Heitman E.
      • Roberts I.
      • DiGuiseppi C.
      Interventions for preventing injuries in problem drinkers.
      ,
      • Jonas D.
      • Garbutt J.
      • Amick H.
      Behavioral counseling after screening for alcohol misuse in primary care.
      ,
      • Kaner E.F.S.
      • Beyer F.
      • Dickinson H.O.
      • Pienaar E.
      • Campbell F.
      • Schlesinger C.
      • Ed P.
      Effectiveness of brief alcohol interventions in primary care populations.
      ,
      • Kanny D.
      • Liu Y.
      • Brewer R.
      • Garvin W.
      Vital signs: Binge drinking prevalence, frequency and intensity among adults – United States, 2010.
      ,

      Kottke, T., Baechler, C., Canterbury, M., Danner, C., Erickson, K., Hayes, R., … Wilkinson, J. (2013). Healthy lifestyles. 5th Ed. Institute for Clinical Systems Improvement: Bloomington, MN.

      ,
      • Moyer V.A.
      U.S. Preventive Services Task Force (USPSTF)
      Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: U.S. Preventive Services Task Force recommendation statement.
      ,
      • Smith P.
      • Schmidt S.
      • Allensworth-Davies D.
      • Saitz R.
      A single-question screening test for drug use in primary care.
      ).

      Priority Area 5: Anxiety, Depression, Substance Misuse, and Suicidal Intention

      One in four women surveyed in 2008 reported having depression or anxiety in the past 5 years (

      Ranji, U., & Salganicoff, A. (2011). Women's health care chartbook: Key findings from the Kaiser Women's Health Survey. The Kaiser Family Foundation: Menlo Park, CA.

      ). Women are particularly at risk for depression during pregnancy and the postpartum period. Suicide is the fourth leading cause of death in women age 18 to 44 (

      CDC National Center for Injury Prevention and Control. (2014b). Web-based Injury Statistics Query and Reporting System (WISQARS). Available: www.cdc.gov/injury/wisqars. Accessed: July 7, 2014.

      ).
      High levels of stress related to work or financial issues are reported by approximately one-quarter of women surveyed (

      Ranji, U., & Salganicoff, A. (2011). Women's health care chartbook: Key findings from the Kaiser Women's Health Survey. The Kaiser Family Foundation: Menlo Park, CA.

      ). Results from the National Health Interview Survey conducted by the CDC found that among women 25 or younger with less than a high school diploma, 8% serious psychological distress in the past 30 days (
      Centers for Disease Control and Prevention
      QuickStats: Percentage of adults aged ≥25 years with serious psychological distress, by education level and sex - National Health Interview Survey, United States, 2010-2013.
      ). Anxiety and depression very often coexist with each other and with other physical illness, substance misuse, chronic pain, and/or eating disorders (
      • Joffres M.
      • Jaramillo A.
      • Dickinson J.
      • Lewin G.
      • Pottie K.
      • Shaw E.
      • Tonelli M.
      Recommendations on screening for depression in adults.
      ,
      • Mitchell J.
      • Trangle M.
      • Degnan B.
      • Gabert T.
      • Haight G.
      • Kessler D.
      • Rossmiller D.
      Adult depression in primary care.
      ). Women with anxiety and depression tend to have more complex medical needs and may present for health care at three to five times the rates of women without mental health issues, but research suggests these women tend to get fewer preventive health services (

      Anxiety and Depression Association of America. (2014). Facts & statistics. Available: www.adda.org. Accessed: November 3, 2014.

      ,
      • Grunfeld E.
      • Manca D.
      • Moineddin R.
      • Thorpe K.E.
      • Hoch J.S.
      • Campbell-Scherer D.
      • Mamdani M.
      Improving chronic disease prevention and screening in primary care: Results of the BETTER pragmatic cluster randomized controlled trial.
      ). Although substance misuse was also discussed in priority area 4: injury prevention, women who misuse or are dependent on drugs and/or alcohol often have untreated comorbid depression and anxiety. Mental health problems are often intricately intertwined with substance misuse and increase suicide risk, impacting quality of life, relationships and work. Women who abuse substances are at higher risk of suicide (
      • LeFevre M.
      U.S. Preventive Services Task Force
      Screening for suicide risk in adolescents, adults, and older adults in primary care: U.S. Preventive Services Task Force recommendation statement.
      ), and people with a history of substance abuse have higher rates of depression (
      • Joffres M.
      • Jaramillo A.
      • Dickinson J.
      • Lewin G.
      • Pottie K.
      • Shaw E.
      • Tonelli M.
      Recommendations on screening for depression in adults.
      ). In addition to the risk of injury, substance abuse is associated with higher rates of IPV, homelessness, infectious diseases, (including STIs), and unplanned pregnancy (
      • Goodman D.J.
      • Wolff K.B.
      Screening for substance abuse in women's health: A public health imperative.
      ).
      Evidence from this topic area supports the promotion of adequate sleep and teaching of cognitive and/or mindfulness based strategies to buffer the effects of stress and promote wellness (

      Kottke, T., Baechler, C., Canterbury, M., Danner, C., Erickson, K., Hayes, R., … Wilkinson, J. (2013). Healthy lifestyles. 5th Ed. Institute for Clinical Systems Improvement: Bloomington, MN.

      ). Screening for anxiety and depression is recommended for women in the postpartum period as well as other times if these conditions are suspected based on clinical presentation, other risk factors, or comorbidities and brief screening tools are available and can be easily integrated into primary care settings (
      • Combs H.
      • Markman J.
      Anxiety disorders in primary care.
      ,
      • Croicu C.
      • Chwastiak L.
      • Katon W.
      Approach to the patient with multiple somatic symptoms.
      ,
      • Gilbody S.
      • House A.O.
      • Sheldon T.A.
      Screening and case finding instruments for depression.
      ,
      • Kroenke K.
      • Spitzer R.L.
      • Williams J.B.W.
      • Löwe B.
      An ultra-brief screening scale for anxiety and depression: The PHQ–4.
      ,
      • Mitchell J.
      • Trangle M.
      • Degnan B.
      • Gabert T.
      • Haight G.
      • Kessler D.
      • Rossmiller D.
      Adult depression in primary care.
      ,
      • Narayana S.
      • Wong C.J.
      Office-based screening of common psychiatric conditions.
      ,
      • O'Connor E.A.
      • Whitlock E.P.
      • Beil T.L.
      • Gaynes B.N.
      Screening for depression in adult patients in primary care settings: A systematic evidence review.
      ). Screening for drug and alcohol misuse as part of the WWV may help to identify women with mood or anxiety disorders as well as women at risk for suicide (
      • Agerwala S.M.S.
      • McCance-Katz E.F.
      Integrating Screening, Brief Intervention, and Referral to Treatment (SBIRT) into clinical practice settings: A brief review.
      ,
      • Connor E.O.
      • Gaynes B.N.
      • Burda B.U.
      • Soh C.
      • Whitlock E.P.
      Screening for and treatment of suicide risk relevant to primary care: A systematic review for the U.S. Preventive Services Task Force.
      ,
      • Goodman D.J.
      • Wolff K.B.
      Screening for substance abuse in women's health: A public health imperative.
      ,
      • Halloran L.
      Substance abuse in primary care.
      ,
      • Pilowsky D.J.
      • Wu L.
      Screening for alcohol and drug use disorders among adults in primary care: A review.
      ,
      • Saitz R.
      Alcohol screening and brief intervention in primary care: Absence of evidence for efficacy in people with dependence or very heavy drinking.
      ,
      • Shapiro B.
      • Coffa D.
      • McCance-Katz E.F.
      A primary care approach to substance misuse.
      ). Women who screen positive or are suspected of having anxiety or depression, substance abuse, and/or suicidal ideation should be treated promptly and provided with follow-up care (
      • Ahmedani B.K.
      • Simon G.E.
      • Stewart C.
      • Beck A.
      • Waitzfelder B.E.
      • Rossom R.
      • Solberg L.I.
      Health care contacts in the year before suicide death.
      ,
      • Archer J.
      • Bower P.
      • Gilbody S.
      • Lovell K.
      • Richards D.
      • Gask L.
      • Coventry P.
      Collaborative care for depression and anxiety problems.
      ,
      • Butler M.
      • Kane R.L.
      • McAlpine D.
      • Kathol R.
      • Fu S.S.
      • Hagedorn H.
      • Wilt T.
      Does integrated care improve treatment for depression? A systematic review.
      ,
      • LeFevre M.
      U.S. Preventive Services Task Force
      Screening for suicide risk in adolescents, adults, and older adults in primary care: U.S. Preventive Services Task Force recommendation statement.
      ,
      • McDowell A.K.
      • Lineberry T.W.
      • Bostwick J.M.
      Practical suicide-risk management for the busy primary care physician.
      ).

      Priority Area 6: Assault, IPV, and Homicide

      Two out of every five women report some form of sexual violence in their lifetime, with 19% of women reporting being raped (
      • Breiding M.J.
      • Smith S.G.
      • Basile K.C.
      • Walters M.L.
      • Chen J.
      • Merrick M.T.
      Prevalence and characteristics of sexual violence, stalking, and intimate partner violence victimization — National Intimate Partner and Sexual Violence Survey, United States, 2011.
      ). Almost one-half of those rapes are by an intimate partner (
      • Breiding M.J.
      • Smith S.G.
      • Basile K.C.
      • Walters M.L.
      • Chen J.
      • Merrick M.T.
      Prevalence and characteristics of sexual violence, stalking, and intimate partner violence victimization — National Intimate Partner and Sexual Violence Survey, United States, 2011.
      ). Almost one in three women report having experienced physical violence by an intimate partner in her lifetime (
      • Breiding M.J.
      • Smith S.G.
      • Basile K.C.
      • Walters M.L.
      • Chen J.
      • Merrick M.T.
      Prevalence and characteristics of sexual violence, stalking, and intimate partner violence victimization — National Intimate Partner and Sexual Violence Survey, United States, 2011.
      ). Forty percent of women who are murdered are killed by an intimate partner (
      • Feldman M.D.
      Screening for intimate partner violence: The time is now.
      ).
      Women with IPV exposure experience more depressive symptoms and report higher levels of poor health than women who have never been abused (
      • Bonomi A.E.
      • Anderson M.L.
      • Rivara F.P.
      • Thompson R.S.
      Health outcomes in women with physical and sexual intimate partner violence exposure.
      ) and tend to have more chronic health problems (
      • Zolotor A.J.
      • Denham A.C.
      • Weil A.
      Intimate partner violence.
      ). IPV is associated with increased risks of STIs and poor pregnancy outcomes (
      • Zolotor A.J.
      • Denham A.C.
      • Weil A.
      Intimate partner violence.
      ). IPV may also be associated with sexual and reproductive coercion, increased rates of STIs transmitted infections and unintended pregnancy (
      American College of Obstetricians and Gynecologists (ACOG)
      ACOG Committee Opinion No. 518: Intimate partner violence.
      ,
      American College of Obstetricians and Gynecologists (ACOG)
      ACOG Committee Opinion No. 554: reproductive and sexual coercion.
      ,
      • Hess K.L.
      • Javanbakht M.
      • Brown J.M.
      • Weiss R.E.
      • Hsu P.
      • Gorbach P.M.
      Intimate partner violence and sexually transmitted infections among young adult women.
      ).
      There is a rich and prolific literature base looking at IPV screening and outcomes, including an active controversy regarding the benefits of universal versus targeted screening for IPV (
      American College of Obstetricians and Gynecologists (ACOG)
      ACOG Committee Opinion No. 518: Intimate partner violence.
      ,
      • Feldman M.D.
      Screening for intimate partner violence: The time is now.
      ,
      Institute of Medicine
      Clinical preventive services for women: Closing the gaps.
      ,
      • Moyer V.A.
      Screening for intimate partner violence and abuse of elderly and vulnerable adults: U.S. Preventive Services Task Force recommendation statement.
      ,
      • Nelson H.D.
      • Bougatsos C.
      • Blazina I.
      Screening women for intimate partner violence: A systematic review to update the U.S. Preventive Services Task Force recommendation.
      ,
      • O'Campo P.
      • Kirst M.
      • Tsamis C.
      • Chambers C.
      • Ahmad F.
      Implementing successful intimate partner violence screening programs in health care settings: Evidence generated from a realist-informed systematic review.
      ,
      • Rhodes K.V.
      Taking a fresh look at routine screening for intimate partner violence: What can we do about what we know?.
      ,

      World Health Organization. (2013). Global health observatory data repository. Retrieved June 15, 2015. Available: http://www.who.int/gho/database/en/.

      ,
      • Zolotor A.J.
      • Denham A.C.
      • Weil A.
      Intimate partner violence.
      ). No single, reliable, or validated screening tool for IPV in primary care settings was found in this review (
      • Bair-Merritt M.H.
      • Lewis-O'Connor A.
      • Goel S.
      • Amato P.
      • Ismailji T.
      • Jelley M.
      • Cronholm P.
      Primary care-based interventions for intimate partner violence: A systematic review.
      ,
      • Rabin R.F.
      • Jennings J.M.
      • Campbell J.C.
      • Bair-Merritt M.H.
      Intimate partner violence screening tools.
      ,
      • Taft A.
      • O'Doherty L.
      • Hegarty K.
      • Ramsay J.
      • Davidson L.
      • Feder G.
      Screening women for intimate partner violence in healthcare settings.
      ). Nevertheless, given the potential physical, social, sexual, and psychological harm that comes from IPV, the sources highlight the need for expanded and coordinated primary care and public health efforts to provide support for and resources to women who disclose IPV (
      • Moracco K.E.
      • Cole T.B.
      Preventing intimate partner violence: Screening is not enough.
      ).

      Priority Area 7: Lower Respiratory Disease

      Chronic obstructive pulmonary disease is an umbrella term that includes emphysema and chronic bronchitis, and together these three chronic respiratory diseases are the fourth leading cause of death in U.S. women (

      CDC National Center for Injury Prevention and Control. (2014b). Web-based Injury Statistics Query and Reporting System (WISQARS). Available: www.cdc.gov/injury/wisqars. Accessed: July 7, 2014.

      ). At least 40% of these deaths could be prevented (
      • Yoon P.W.
      • Bastian B.
      • Anderson R.N.
      • Collins J.L.
      • Jaffe H.W.
      Potentially preventable deaths from the five leading causes of death — United States, 2008 – 2010.
      ). Although second-hand smoke and indoor, outdoor, and occupational pollutants contribute to the development of lower respiratory disease in the United States, smoking is a factor in 90% of chronic obstructive pulmonary disease cases (
      • Dolan P.
      Preventing and treating COPD: Why taking a chronic care approach to smoking cessation is an effective way to battle the third leading cause of death in the United States.
      ). Rates of smoking in U.S. women have increased in recent decades and so too has the prevalence of chronic obstructive pulmonary disease in women, who may even be more susceptible to the effects of smoking (

      Global Initiative for Chronic Obstructive Lung Disease. (2014). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Available: http://www.goldcopd.org/guidelines-global-strategy-for-diagnosis-management.html. Retrieved Nov 3, 2014.

      ). Encouraging smoking cessation is the most effective intervention health care providers can make to improve quality of life and increased life span (
      • McIvor A.
      • Kayser J.
      • Assaad J.
      • Brosky G.
      • Demarest P.
      • Desmarais P.
      • Weinberg R.
      Best practices for smoking cessation interventions in primary care.
      ). Research in England has shown that although women are more likely to use tobacco cessation services, they are less likely to achieve short-term success with quitting (
      • Bauld L.
      • Bell K.
      • McCullough L.
      • Richardson L.
      • Greaves L.
      The effectiveness of NHS smoking cessation services: A systematic review.
      ). U.S. national ambulatory medical care survey data were used to estimate the prevalence of office visits where smoking treatment was prescribed (
      • Ritchey M.
      • Wall H.
      • Gillespie C.
      • George M.
      • Jaman A.
      Million Hearts: Prevalence of leading cardiovascular disease risk factors – United States, 2005-2012.
      ). Despite what is known about the risks of smoking and benefits of quitting, that research showed no improvement in the rates at which health care providers provided smoking cessation assessments or treatment between 2005 and 2010, suggesting that there is considerable room for improvement in how the health care system delivers smoking cessation interventions (
      • Ritchey M.
      • Wall H.
      • Gillespie C.
      • George M.
      • Jaman A.
      Million Hearts: Prevalence of leading cardiovascular disease risk factors – United States, 2005-2012.
      ).
      Evidence for this topic area supports the use of consistent and integrated primary care–based smoking cessation counseling and other supportive smoking cessation interventions such as nicotine replacement and pharmacotherapy (
      • Aveyard P.
      • Begh R.
      • Parsons A.
      • West R.
      Brief opportunistic smoking cessation interventions: A systematic review and meta-analysis to compare advice to quit and offer of assistance.
      ,
      • Chaney S.E.
      • Sheriff S.
      Evidence-based treatments for smoking cessation.
      ,

      Fiore, M., Jaen, C., Baker, T., Bailey, W., Benowitz, N., … Wewers, M. (2008). Treating tobacco use and dependence: 2008 update Clinical Practice Guideline. Rockville, MD. US Department of Health and Human Services. Available: http://bphc.hrsa.gov/buckets/treatingtobacco.pdf. Accessed Nov 10, 2014.

      ,
      • Hartmann-Boyce J.
      • Stead L.F.
      • Cahill K.
      • Lancaster T.
      Efficacy of interventions to combat tobacco addiction: Cochrane update of 2012 reviews.
      ,
      • Joseph A.M.
      • Fu S.S.
      • Lindgren B.
      • Rothman A.J.
      • Kodl M.
      • Lando H.
      • Hatsukami D.
      Chronic disease management for tobacco dependence.
      ,
      • Lai D.T.
      • Cahill K.
      • Qin Y.
      • Tang J.-L.
      Motivational interviewing for smoking cessation.
      ,
      • McIvor A.
      • Kayser J.
      • Assaad J.
      • Brosky G.
      • Demarest P.
      • Desmarais P.
      • Weinberg R.
      Best practices for smoking cessation interventions in primary care.
      ,
      • Papadakis S.
      • McDonald P.
      • Mullen K.-A.
      • Reid R.
      • Skulsky K.
      • Pipe A.
      Strategies to increase the delivery of smoking cessation treatments in primary care settings: A systematic review and meta-analysis.
      ,
      • Rice V.H.
      • Hartmann-Boyce J.
      • Stead L.F.
      Nursing interventions for smoking cessation.
      ,

      U.S. Preventive Services Task Force (USPSTF). (2015). Final recommendation statement: Tobacco Smoking Cessation in Adults and Pregnant Women: Behavioral and Pharmacotherapy Interventions. Available: http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/tobacco-use-in-adults-and-pregnant-women-counseling-and-interventions1#Pod10. Accessed Dec 19, 2015.

      ).

      Priority Area 8: Arthritis and Musculoskeletal Problems

      At least one in five U.S. women report having been diagnosed with arthritis, and significantly larger percentages of African American and Latina women report having this condition (
      • Brady T.J.
      • Jernick S.L.
      • Hootman J.M.
      • Sniezek J.E.
      Public health interventions for arthritis: Expanding the toolbox of evidence-based interventions.
      ,
      Centers for Disease Control and Prevention (CDC)
      Prevalence and most common causes of disability among adults – United States, 2005.
      ,

      Ranji, U., & Salganicoff, A. (2011). Women's health care chartbook: Key findings from the Kaiser Women's Health Survey. The Kaiser Family Foundation: Menlo Park, CA.

      ). Arthritis is not only very prevalent, but it is the most common cause of disability in Americans. Arthritis—a term that can refer to many different rheumatic diseases and conditions that effect the joint—causes activity and work limitations and severe joint pain for millions of American women. Osteoporosis is another condition that affects millions of U.S. women. One in two women over age 65 experience an osteoporosis-related fracture (
      • Powell H.
      • O'Connor K.
      • Greenberg D.
      Adherence to the U.S. Preventive Services Task Force 2002 osteoporosis screening guidelines in academic primary care settings.
      ). These fractures are associated with high cost, high mortality, and functional limitations (
      • Lim L.S.
      • Hoeksema L.J.
      • Sherin K.
      Screening for osteoporosis in the adult U.S. population: ACPM position statement on preventive practice.
      ).
      Evidence supports education regarding maintaining a healthy body mass index, even modest weight loss, if indicated, and regular physical activity to promote optimal joint health and reduce joint-related morbidity for women (
      • Blagojevic M.
      • Jinks C.
      • Jeffery a.
      • Jordan K.P.
      Risk factors for onset of osteoarthritis of the knee in older adults: A systematic review and meta-analysis.
      ,
      • Brady T.J.
      • Jernick S.L.
      • Hootman J.M.
      • Sniezek J.E.
      Public health interventions for arthritis: Expanding the toolbox of evidence-based interventions.
      ,
      Center for Disease Control and Prevention (CDC)
      Prevalence of doctor-diagnosed arthritis and arthritis-attributable activity limitation — United States, 2007 – 2009.
      ,
      • Coakley E.H.
      • Kawachi I.
      • Manson J.E.
      • Speizer F.E.
      • Willet W.C.
      • Colditz G.A.
      • Willett W.
      Lower levels of physical functioning are associated with higher body weight among middle-ages and older women.
      ,
      • Howe T.E.
      • Shea B.
      • Dawson L.J.
      • Downie F.
      • Murray A.
      • Ross C.
      • Creed G.
      Exercise for preventing and treating osteoporosis in postmenopausal women.
      ,
      • Jordan J.L.
      • Holden M.A.
      • Mason E.E.
      • Foster N.E.
      Interventions to improve adherence to exercise for chronic musculoskeletal pain in adults.
      ,
      • Toivanen A.T.
      • Heliovaara M.
      • Impivaara O.
      • Arokoski A.
      • Knekt P.
      • Lauren H.
      • Kroger H.
      Obesity, physically demanding work and traumatic knee injury are major risk factors for knee osteoar.
      ). In addition, a healthy diet including adequate calcium and vitamin D may reduce the risk of osteoporosis (
      • Bilezikian J.P.
      • Holick M.F.
      • Nieves J.W.
      • Weaver C.M.
      The role of calcium in peri- and postmenopausal women: 2006 position statement of the North American Menopause Society.
      ,
      • Moyer V.A.
      Vitamin D and calcium supplementation to prevent fractures in adults: U.S. Preventive Services Task Force recommendation statement.
      ,
      • Rawlins S.
      Approaches to osteoporosis: Screening and implementing treatment in clinical practice.
      ) and appropriate screening for low bone density offers opportunities for intervention (
      • Nelson H.
      • Haney E.
      Screening for osteoporosis: An update for the US Preventive Services Task Force (USPSTF).
      ).

      Discussion

      By applying a population health perspective and a clearly defined scoping review method to explore the current state of evidence for and policy recommendations regarding what should be included as components of the WWV, at least eight priority areas were identified. This approach is useful today, but can also evolve with changing epidemiologic evidence to inform, guide, and shape priority areas for the WWV of today and in the future.
      In terms of the scoping review process itself, it was clear that no one database or search term provided even close to a totality of relevant references for each of the eight priority areas. The challenge of searching multiple data bases and using many search terms and strategies highlights the importance of systematic and scoping reviews as an opportunity to provide comprehensive summary information to busy primary care providers and policy makers. In addition to the challenges of conducting thorough and comprehensive reviews, disparities in levels of evidence were found between topic areas.
      There was an abundance of practice guidelines, systematic reviews, and generally higher quality evidence found regarding prevention of CVD and stroke, smoking cessation, cancer screening and early detection, and screening for IPV. However, when multiple guidelines exist, they often fail to agree (such as regarding routine screening for depression or IPV) and may not always be evidence based (
      • Ferket B.
      • Colkesen E.
      • Visser J.
      • Spronk S.
      • Kraajenhagen R.
      • Steyerberg E.
      • Hunink M.
      Systematic review of guidelines on cardiovascular risk assessment.
      ,
      • Wright J.D.
      • Pawar N.
      • Gonzalez J.S.R.
      • Lewin S.N.
      • Burke W.M.
      • Simpson L.L.
      • Herzog T.J.
      Scientific evidence underlying the American College of Obstetricians and Gynecologists' practice bulletins.
      ). The literature search of other topic areas, such as RLP and sexual health, injury prevention for adults, and prevention of arthritis and muscular skeletal disorders, revealed recommendations based primarily on expert opinion, indirect observational evidence, and/or general consensus. In these areas, a more systematic analysis of interventions and outcomes is clearly needed.
      A limitation of the scoping review presented here was the use of only a single reviewer. The use of a formal appraisal tool by a team of reviewers in the field of women's health would certainly strengthen any priority recommendations that develop from this or future scoping reviews.

      Implications for Policy and/or Practice

      Although epidemiologic data formed the basis for these eight proposed areas of prevention in well woman care, this scoping review found relatively little data regarding the cost/benefit of these WWV preventive services.
      • Olchanski N.
      • Cohen J.T.
      • Neumann P.J.
      A role for research: An observation on preventive services for women.
      reviewed the cost-effectiveness literature related to preventive services for women and found a gap in health economic research, particularly related to screening and counseling of women in the primary care setting. Such research would be necessarily difficult and expensive to conduct because it may take decades to see the outcomes and cost/benefit of this package of services. However, there is some precedent for testing a package of services.
      • Grunfeld E.
      • Manca D.
      • Moineddin R.
      • Thorpe K.E.
      • Hoch J.S.
      • Campbell-Scherer D.
      • Mamdani M.
      Improving chronic disease prevention and screening in primary care: Results of the BETTER pragmatic cluster randomized controlled trial.
      showed that a “prevention practitioner” within a primary care setting could implement clinically important prevention and screening for chronic disease in a cost-effective manner. In addition,
      • Maciosek M.V.
      • Coffield A.B.
      • Flottemesch T.J.
      • Edwards N.M.
      • Solberg L.I.
      Greater use of preventive services in U.S. health care could save lives at little or no cost.
      analyzed a package of 20 preventive services including tobacco cessation advice and assistance, alcohol abuse screening, some cancer screenings, depression screening, and daily aspirin use and found that such a package could extend or save lives at neutral cost—even at a net cost savings. With a more clearly defined and comprehensive package of WWV services such as those proposed in this review, health promotion interventions for the WWV could become operationalized and outcomes measurement of the suggested priority WWV services could be undertaken.
      As with cost–benefit research, it would also take decades to measure the health outcomes of many of the WWV interventions suggested in this paper, limiting the usefulness of evidence-based research to make policy and clinical care decisions today. In addition, less tangible aspects of a yearly WWV may not be measured adequately by outcomes-based research. More than a decade ago, in an editorial in the Annals of Internal Medicine,
      • Laine C.M.P.H.
      The annual physical examination: Needless ritual or necessary routine?.
      wondered how we could measure these less tangible aspects of the yearly physical examination ritual, such as patient–provider relationship. One possible answer to that question comes from
      • Jones D.E.
      • Carson K.A.
      • Bleich S.N.
      • Cooper L.A.
      Patient trust in physicians and adoption of lifestyle behaviors to control high blood pressure.
      , who found that trust in a patient's physician was predictive of attempts to lose weight among patients with hypertension. In a survey of New England women,
      • Becker H.I.
      • Longacre M.R.
      • Harper D.M.
      Beyond the Pap: Assessing patients' priorities for the annual examination.
      found that women considered the patient–provider relationship as one of the most important aspects of the annual examination visit, over test seeking. In

      Andrist, L.C. (1993). A model of women-centered practice: Shared decision-making between breast cancer surgeons and patients, #9322337, UMI Dissertation Abstracts International: Ann Arbor, MI.

      study of breast cancer surgeons and their attempt at providing symmetry in the patient–physician relationship, she found that the “use of self in patient encounters” and “empowering patients” were tools that patients' found positive in the patient–provider relationship. The ritual of a more or less yearly WWV exchange between patient and provider has the potential to build a relationship from which interventions to promote health may become more effective over time.
      Although cost, effectiveness, and resource availability remain important in considering the WWV of today, how best to support health care providers providing this service remains another important concern. Health care providers who are used to doing a particular test (pap smear) or procedure (bimanual examination) may feel they lack the confidence or experience to provide less tangible education and counseling services. Some health care providers may need education and support as they gain comfort conducting many of the brief screening and counseling interventions discussed herein. A shift may be necessary to promote policy strategies and support health care providers as they work to integrate more education and counseling into the WWV (

      National Women's Law Center (2014). Policy strategies for better integration of education and counseling in primary care [White Paper]. Washington, DC. Available: www.nwlc.org/sites/default/files/v2_nwlc_whitepaper_well-woman.pdf.

      ).
      • Brown R.L.
      Configuring health care for systematic behavioral screening and intervention.
      proposes a two-tier, stepped-care model for behavioral screening and intervention, which may be a helpful way of thinking about the role of the WWV provider. The WWV provider would serve to provide a first tier level of assessment, intervention, and follow-up services to address mild to moderate behavioral risks or conditions. The second tier would include a variety of specialty-based referral resources for patients in greatest need. The current trend toward innovative health care delivery models such as medical homes and population management programs means that preventive health and health promotional services can be offered to patients from an integrated team of physicians, nurses, social workers, mental health, public health professionals, and lay health educators working together (
      • Brown R.L.
      Configuring health care for systematic behavioral screening and intervention.
      ,
      • Doolan-Noble F.
      • Smith D.
      • Gauld R.
      • Waters L.D.
      • Cooke A.
      • Reriti H.
      Evolution of a health navigator model of care within a primary care setting: A case study.
      ). Also extremely important is the need for better reimbursement for the most effective primary care prevention interventions, which could certainly improve implementation (
      • Yarnell K.S.
      • Pollak K.
      • Ostbye T.
      • Krause K.
      • Michener J.
      Primary care: Is there enough time for prevention?.
      ).
      A final and significant concern to any practicing health care provider is a lack of time to accomplish or even touch on all of the eight intervention/topic areas recommend by this review. The ACA mandate for WWV does take into account that more than one visit may be necessary to cover all the WWV elements (
      Institute of Medicine
      Clinical preventive services for women: Closing the gaps.
      ). In addition, not every woman will require each intervention every year and many women see more than one provider so that each provider may cover certain elements of the WWV (

      Ranji, U., & Salganicoff, A. (2011). Women's health care chartbook: Key findings from the Kaiser Women's Health Survey. The Kaiser Family Foundation: Menlo Park, CA.

      ,
      • Stormo A.
      • Sariya M.
      • Hing E.
      • Henderson J.
      • Sawaya G.
      Women's clinical preventive services in the United States: Who is doing what?.
      ).

      Conclusions

      Cervical cancer screening and pelvic examinations—the most commonly associated elements of the WWV—no longer warrant annual implementation for most women. However, Epidemiologic evidence suggests that a number of other important and evidence-based preventive services, screenings, and interventions need to be a priority if the WWV of today is going to deliver on its promise to reduce a woman's risk of disease, disability, illness, and death.
      WWV recommendations need to continue to evolve, as epidemiologic evidence, community, and individual needs change over time. Evidence-based and timely prevention has the potential to reduce healthcare costs, disability, and death while improving the quality and quantity of women's lives. It is time for health care providers and policymakers alike to rebrand the WWV visit of today as a yearly comprehensive visit for RLP, prevention, screening, and health promotion—not just a pap smear and pelvic examination anymore.

      Acknowledgments

      The authors acknowledge Professor Linda C. Andrist, PhD, WHNP-BC, Assistant Dean of Graduate Studies, School of Nursing, MGH Institute of Health Professions for her contributions to the development of this scoping review project.

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      Biography

      Alisa Pascale, DNP, WHNP-BC, is a Women's Health Nurse Practitioner with Vincent Gynecology, and Clinical Instructor and preceptor, MGH Institute of Health Professions. Her clinical interests include the provision of well woman preventive health services and care of women with vulvovaginal disorders.
      Margaret W. Beal, PhD, CNM, is a Professor at the MGH Institute of Health Professions. She has served in leadership positions in the American College of Nurse-Midwives and is a member of the Massachusetts Board of Registration in Nursing.
      Thérèse Fitzgerald, PhD, MSW, is Director, Women's Health Policy and Advocacy Program, the Connors Center for Women's Health and Gender Biology; and Instructor, Harvard T.H. Chan School of Public Health. Her work focuses on the impact of U.S. health care reform on women's health and gender inequity in research.

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