MHRA’s Behavioral Risk Factor (BRF) Screening Program

1. MHRA’s Behavioral Risk Factor (BRF) Screening Program Sarah Blust, LMSW, MPH, Program Manager Natalie Tobier, LMSW, MPH, Project Director Samantha Garbers, MPH, Program Evaluator New York City Alliance Against Sexual Assault Panel Presentation December 11th, 2006

2. Medical & Health Research Association (MHRA) is an independent, not-for-profit health and human services organization dedicated to improving the health of New Yorkers – particularly underserved individuals at high risk

3. One of MHRA’s largest service programs is MIC - Women’s Health Services, a network of 8 centers located throughout New York City (Brooklyn, Bronx, Queens, Manhattan) • MIC provides prenatal and family planning services to over 18,000 women annually and serves predominantly low-income and newly immigrant women

4. BRF Tool/Program Development • In 2002, MHRA research staff found that a high proportion of MIC patients have symptoms of anxiety and depression • In 2003, MHRA received a grant from the Health Resources Services Administration (HRSA) to develop a behavioral risk factor screening tool to screen for alcohol, depression and domestic violence.

5. BRF Tool/Program Development Because so many behavioral risk factors are co-morbid, MHRA proposed to also include screening questions on smoking, substance abuse, and anxiety.

6. The Behavioral Risk Factor (BRF) screening tool is a screener- administered form that uses carefully scripted questions to ask about: • Smoking • Alcohol Use • Substance Use • Anxiety • Depression • Childhood Exposure to Violence • Physical/Sexual • Adult Exposure to Violence • Physical/Sexual

7. MIC nurses conduct the BRF screen at the following visits: • Prenatal Patients • First visit • Third trimester • Postpartum • Family Planning Patients • First visit • Annual

8. At the end of the interview, all patients, regardless of whether or not they “screen positive” on the BRF, are offered social work services • Each MIC center has an onsite bilingual social worker

9. The BRF was developed with input from the following stakeholders: • Mental Health Workgroup • MHRA staff • MHRA research staff • MIC administrative staff • MIC clinical staff • MIC direct service staff • MIC patients • MHRA Professional Advisory Committee • External experts • Family Violence Prevention Fund • NYC Center for Immigrant Health

10. BRF Program Timeline Family Violence Prevention Fund Technical Assistance NYC Center for Immigrant Health Technical Assistance MIC Patient Feedback Groups MHRA was awarded HRSA grant Final BRF roll-out at MIC BRF pilot at MIC W’burg and M’ville All staff training on new BRF program All staff training on final BRF tool Patient Focus Groups BRF tool is revised and finalized BRF roll-out at MIC June Sept. Dec. Feb. Dec. May Dec. Feb. March April May 2003 2003 2003 2004 2004 2005 2005 2006 2006 2006 2006

11. Focus: BRF screening for violence • Technical assistance from the Family Violence Prevention Fund included: • Consultation on wording of questions • Lifetime exposure • Consultation on screening protocols • Training of screening staff • Building capacity of social work staff to meet the needs of patients who screen positive for violence

12. BRF Questions for Violence Now I am going to ask you some questions about whether or not you have experienced violence. These experiences can affect your health, your pregnancy and your parenting. CHPA-Childhood Physical Abuse • While you were growing up, (during the first 18 years of your life) did a parent or adult living in your home ever hit you so hard that you had marks or were injured? CHSA- Childhood Sexual Abuse • While you were growing up, were you ever made to do something sexual that you didn’t want to do?

13. BRF Questions for Violence APA- Adult Physical Abuse • Have you ever been hit, slapped, kicked or otherwise hurt by your current or former partner? ASA- Adult Sexual Abuse • As an adult, have you ever been made to do something sexual that you didn’t want to do? Emotional/Current Abuse • Do you currently feel afraid or threatened by your current or former partner?

14. BRF Re-screen Questions for Violence During some of your past visits, we have asked you questions about violence – I just wanted to check in with you about this again. • Do you currently feel afraid or threatened by your current or former partner? • Is there anything else you would like to share with me about physical or sexual abuse – now or in the past?

15. Data Collection & Quality Assurance • After each BRF screen, the screener documents on a Medical Manager “docuscan”: • What BRF issue(s) the patient screened positive for • Whether or not the patient accepted or declined social work services • Docuscan information is organized into an online reporting system, which can be reviewed by program, research and clinic staff

16. Findings from Medical Manager A review of our docuscan data reveals that since the inception of the project, MIC staff have conducted: 20,554 screenings (June 2005 – October 2006)

17. Findings from Medical Manager • In June 2006, the finalized BRF questions were implemented at all 8 MIC Centers. • Among all patients (prenatal and family planning) screened at their first visit between June 2006 – November 2006; N = 2,864: • 85 (3%) disclosed physical violence during childhood • 114 (4%) disclosed sexual violence during childhood • 93 (3%) disclosed physical violence during adulthood • 27 (1%) disclosed sexual violence during adulthood NOTE: These categories are NOT mutually exclusive

18. Post-implementation Evaluation • A post-implementation evaluation included all new family planning and prenatal patients screened January-March 2006 (n=1,502). • Statistical differences in the frequencies of screening positive by patient characteristics were assessed using chi-square tests. Bivariate odds ratios were calculated to assess the risk of screening positive for other risk factors according to IPV history. Using logistic regression, adjusted odds ratios were calculated for screening positive for IPV and patient type, controlling for other screening outcomes. • Among the 1,502 women in the sample, most were Latina (64%) and foreign-born (58%), representing 49 countries of birth.

19. Post-implementation Evaluation • Among the patients screened, 11% reported any IPV. • No differences in IPV history were found by ethnicity, primary language, birthplace, age, or parity. • Compared to the patients who did not screen positive for IPV, patients who reported a history of IPV were significantly more likely to screen positive for depression (OR=4.6,95%CI:3.0-7.1), anxiety (OR=2.4,95%CI:1.5-3.9), and smoking (OR=3.7,95%CI:2.5-5.5), but not substance use. • Family planning patients were significantly more likely to report IPV than prenatal patients, even when controlling for other risk factors (AOR=1.7,95%CI:1.2-2.4).

20. 50% of patients screening positive for IPV screened positive for at least one other risk factor Overlap of IPV & Behavioral Risk Factors Among Patients Screening PositivePost-Implementation (n=419) 33 111

21. What happens when a patient screens positive? • If the patient accepts social work services, the patient is seen by the social worker either the same day or an appointment is made for her to return within the week • Social worker conducts psychosocial assessments, safety planning and provides external referrals • If the patient declines social work services, hotline numbers and safety planning information is given

22. Referral Needs • Mental health services for Spanish-speaking, uninsured and/or undocumented patients

23. Our response MHRA piloted and created an onsite mental health treatment program to provide cognitive behavioral therapy to patients with symptoms of anxiety and/or depression.

24. Unexpected Findings • To date, of the 50 women who initiated onsite treatment, 60% reported a history of relationship trauma. • However, over half the women initially seeking mental health treatment dropped out either before starting or after only sporadic attendance. • We hypothesize that many are unable to remain in care due to chronic psychosocial stressors, particularly relationship stress ranging from emotional, to economic, to sexual, to physical abuse.

25. Our response • Development of on-site treatment modality that addresses issues related to trauma and violence • Development of care-management services to address psychosocial stressors

26. Screening Program Recommendations • Clarification regarding “successful screening” • Establish appropriate protocols • Confidentiality & privacy • Guidance regarding family/partner interpreters • Definition of screener role • Referrals • Documentation

27. Screening Program Recommendations, Cont. • Screen and re-screen • Onsite expertise • Sustained training over time • New employee orientations • Refresher trainings • Observations and feedback • Use of local experts • Case-conferencing

28. Screening Program Recommendations, Cont. • Sustained technical assistance over time • Commitment from administration • Data collection & quality assurance • Feedback loop • Strong referral network • Referral manuals • Community breakfast model

29. Thank you! Contact Information Sarah Blust, Program Manager sblust@mhra.org