O Pathways to Wellness: Integrating Refugee Health and Well-Being

1. OPathways to Wellness:Integrating Refugee Health and Well-Being Screening Refugees for Anxiety and Depression A program of:

2. Goals of Today’s Presentation Increase understanding about the validated tool (RHS-15) for mental health created through the Pathways to Wellness project Describe how the RHS-15 was developed and it’s use in health practice Facilitate dialogue among participants around the use of cross-cultural tools for refugee mental health

3. The Refugee Experience and Emotional Health

4. The Refugee Experience and Emotional Health

5. The Refugee Experience and Emotional Health

6. The Need: Research and Evidence Because of the high degree of loss and trauma, refugees experience an 8% to 25% prevalence of mental health conditions, primarily depression and anxiety disorders. Although recommended by the CDC, mental health is not addressed systematically during refugee resettlement as standard practice. Refugees are under-represented in community mental health agencies.

7. The Need: Research and Evidence Very few culturally valid measures exist that are capable of identifying refugees with distressing symptoms. Current Available Tools • Vietnamese Depression Scale (Kinzie et al., 1982, 1987) • Harvard Trauma Questionnaire (Mollica et al., 1992) • Hopkins Symptom Checklist – 25 (Derogatis et al., 1974) • Post-traumatic Symptom Scale – Self Report (Foa et al., 1993) • New Mexico Refugee Symptom Checklist -121 (Hollifield et al., 2009) These options are either too long, too specific, or not tested across diverse ethnic populations. Others, such as the PHQ-9, have not been developed or normed among refugees.

8. Pathways to Wellness: Project • Mental health screeningrarely doneduring initial resettlement and/or at primary health care clinics • Local refugee service providers observing refugee clients with emotional distress • Local service agencies unsure where to refer and how • “Mental health” having different meaning and high stigma in refugee communities • Mental health agencies uncertainhow to effectively work with refugees

9. Pathways to Wellness: Vision

10. Pathways to Wellness: RHS-15 Pathways collaborated with refugee communities and a renowned psychiatrist to validate a culturally competent, short screening questionnaire. The RHS-15 (Refugee Health Screener-15) screens refugees for distressing symptoms ofanxiety and depression, including PTSD. It is not DIAGNOSTIC, it is PREDICTIVE. After a rigorous year-long evaluation, the assessment was empirically proven to be reliable and effective, with up to 30% of people showing significant distress

11. Challenges to Early Screeningand Intervention Concerns about: cost, time, follow up – “Seriously? You are going to ask me to do one more thing?!.” Fear about decompensation – “I can’t have people falling apart on me.” Differences in cultural conceptualization – “They won’t understand what we mean anyway. There is too much stigma.” Lack of coordination, especially around referral – “Plus, I don’t know who to refer to.” Concerns about service providers or referral process in the community – “And the places I would refer to don’t know how to work with refugees.”

12. Challenges to Early Screeningand Intervention Where services are available, screening is an important way to find people in distress and get them to care.

13. What is the RHS-15? The RHS-15 is a mechanism to route people who need care into treatment. It is not a diagnostic evaluation. A positive screen means the person scored at or above the cut off rate for significant distressing symptoms that would indicate they are likely to have: Anxiety, including PTSD Depression

14. RHS-15: Addressing the Concerns Designed to be short (5 to 15 minutes) Non-triggering Research-based tool with additional elements of cultural bridging

15. Developing the Refugee Health Screener-15

16. Developing the RHS-15 Goal- create a tool by narrowing down from a broad range of symptoms those that are most predictive of poor mental health High sensitivity: identifies people that actually have a health condition High specificity: identifies those that do not have a health condition – good for second tier clinical assessment

17. Developing the RHS-15 • Initial screening programs in NM and KY utilized instruments that have the best empirical support for assessing relevant symptoms: • The NMRSCL-121 • The HSCL-25 • The PSS-SR • For development of the RHS-15, we utilized: • 27 NMRSCL-121 items as the initial screening instrument • Questions on family history, stress reactivity, and a question on how one copes with stress. • As diagnostic proxies: • The HSCL-25 • The PSS-SR

18. Developing the RHS-15 • 251 refugees 14 years or older in four groups screened • 93 Iraqi • 75 Nepali Bhutanese • 36 Karen • 45 Burmese Speaking (Karenni and Chin ethnic groups) • 190 were followed up with and diagnostic proxies completed within 2-4 weeks of screening • Those missed were due to shortage in available interpreters, out-migration, and other reasons

19. Participatory Translation Process Community Orientation Translation Company Back Translation 1 Community Members reconcile both products Company provides clean and track changes version. Review by 1 community member Translation company finalizes product

20. Developing the RHS-15 Instruments were translated into 4 languages Key components to ensure cultural responsiveness A rigorous back and forth translation process, and consensus processes semantic and semiotic meaning and culturally responsive items in each language group. Focus group questions evoked a deeper understanding of language specific idioms of distress, insight into groups’ own terms, vocabulary, opinions, attitudes and reasoning about distress and healing.

21. Analysis Conducted Three methods used to establish the set of items that best classify persons as most likely to be have diagnostic level anxiety, depression, or PTSD: discriminate analysis (DA) naïve Bayesian classification (BAY) chi-square (CHI) for each item by diagnostic proxy Items that were high for classifying persons by at least 2 of the 3 methods were then subjected to BAY to maximize for classification sensitivity. Analyzing ALL items (27 initial screen, HSCL-25, PSS-SR) culminated in a validated tool.

23. Metrics of the RHS-15

24. Metrics of the RHS-15

25. Eliminating Stigma: Setting the Context

26. Setting the Context WHO can administer the RHS-15? Health workers, interpreters, others involved in patient care. Pathways also recommends training interpreters IF POSSIBLE since many interpreters come from refugee communities may hold the same stigma and beliefs around mental health. WHEN should a healthcare worker administer the RHS-15? Best if done early in the resettlement process while refugees still have coverage from Medicaid. HOW does a healthcare worker administer and score the RHS-15? Self-administered if client is literate Interpreter assisted (over the phone or in person) if client is pre-literate

27. Setting the Context At start of visit consider the following steps: Introduce Screening:“In addition to blood draws, medical review, etc., your visit today will involve questions about how you are doing in your body and in your mind.” Re-Introduce & Normalize:Before handing out the RHS-15, remind the family that this is the last part of the visit and each person over the age of 14 will be asked the questions about sadness, worries, body aches and pain, and other symptoms that may be bothersome to them.

28. Setting the Context • The health worker explains … “….some refugees have these symptoms because of the difficult things they have been through, and because it is very stressful to move to a new country. These questions help us find people who are having a hard time and who might need extra support. The answers are not shared with employers, USCIS, teachers, or anyone else without your permission.”

29. Assurances on “lifting the lid” Screening is the vehicle to connect someone for more comprehensive evaluation Offering screening is not a diagnostic---a screen with good psychometric properties is the first tier in the diagnostic process Will asking about symptoms of anxiety, depression or PTSD re-trigger someone? In Pathways experience, clients express relief about being asked. Some clients may cry or show distress, but do not decompensate to the point where this is an issue What are available resources should someone need emergent care? Good idea to have a crisis referral but this relates less to RHS-15 than just general protocol.

33. Scoring the RHS-15

34. Pathways in King County, WA

35. Pathways Referral Script “From your answers on the questions, it seems like you are having a difficult time. You are not alone. Lots of refugees experience sadness, too many worries, bad memories, or too much stress, because of everything they have gone through and because it is so difficult to adjust to a new country. In the United States, people who are having these types of symptoms sometimes find it helpful to get extra support. This does not mean that something is wrong with them or that they are crazy. Sometimes people need help through a difficult time. I would like to connect you to a counselor. In the United States, a counselor/therapist is a type of healthcare worker who will listen to you and provide any guidance and/or support. You will talk about what is bothering you and they will work with you to create a plan for what we hope will make you feel better. This person keeps everything you say confidential, which means they cannot by law share the information with anyone without your agreement. Are you interested in being connected to these services?”

36. Typically what happens once a patient enters services An intake is set up by the agency Diagnosis and treatment plan generated Agencies that serve refugees are sensitive to: Appreciating the legal, physical, intellectual, spiritual, and emotional implications of being a refugee. Offering the client the chance to speak their language or utilize interpreters effectively. Understanding different forms of communication, body language, expression, coping mechanisms, etc.

37. Questions? Beth Farmer, LICSW bfarmer@lcsnw.org 206-816-3252