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

A program of:

OPathways to Wellness:Integrating Refugee Health and Well-Being

Screening

Refugees for

Anxiety and

Depression

Goals of Today’s Presentation

1. Increase understanding about the validated tool (RHS-15) for mental health created through the Pathways to Wellness project

2. Describe how the RHS-15 was developed and it’s use in health practice

3. Facilitate dialogue among participants around the use of cross-cultural tools for refugee mental health

The Refugee Experience and Emotional Health

The Refugee Experience and Emotional Health

The Refugee Experience and Emotional Health

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.

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 testedacross diverse ethnic populations.

Others, such as the PHQ-9, have not been developed ornormed among refugees.

The Need: Research and Evidence

Pathways to Wellness: Project

Mental health screening rarely done during 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 uncertain how to effectively work with

refugees

Pathways to Wellness: Vision

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 of anxiety 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

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.”

Challenges to Early Screeningand Intervention

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

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

RHS-15: Addressing the Concerns

Designed to be short (5 to 15 minutes)

Non-triggering

Research-based tool with additional elements of cultural bridging

Developing the Refugee Health Screener-15

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

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

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

Developing the RHS-15

Participatory Translation ProcessCommunity 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

Developing the RHS-15

Instruments were translated into 4 languagesKey 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.

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.

Items

selected by

BAY

PSS-SR

>16

PTSD

diagnosis

HSCL-25

Anxiety

HSCL-25

Depression

Any Proxy

NM 5_1

NM 5_12

NM 5_19

NM 5_22

“Coping”

PSS 3

PSS 5

PSS 11

PSS 17

HSCL 1

HSCL 3

HSCL 9

HSCL 10

HSCL 11

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

Sensitivity 1.00 0.89 1.00 1.00 0.96

Specificity 0.94 0.83 0.91 0.93 0.86

Metrics of the RHS-15

Number (%) with Diagnoses at Different Cut Scores, Total N = 190

Proxy Diagnosis

RHS-15 Cut Score

9 10 11 12 13 14 15

PTSD (64) 58 55 55 53 52 51 49

90.63% 85.94% 85.94% 82.81% 81.25% 79.69% 76.56%

DEP (58) 56 54 54 53 53 51 51

96.55% 93.10% 93.10% 91.38% 91.38% 87.93% 87.93%

ANX (53) 52 50 49 48 47 45 44

98.11% 94.34% 92.45% 90.57% 88.68% 84.91% 83.02%

Any (79) 71 67 66 63 62 59 57

89.87% 84.81% 83.54% 79.75% 78.48% 74.68% 72.15%

All (38) 38 37 37 37 37 37 37

100.00% 97.37% 97.37% 97.37% 97.37% 97.37% 97.37%

Metrics of the RHS-15

Sensitivity and Specificity to Diagnostic Proxies at Various Cut Scores, N = 190

Proxy Diagnosis

  RHS-15 Cut Score9 10 11 12 13 14 15

PTSD

Sensitivity 0.91 0.86 0.86 0.83 0.81 0.80 0.77

Specificity 0.79 0.84 0.87 0.90 0.91 0.92 0.94

DEP

Sensitivity 0.97 0.93 0.93 0.91 0.91 0.88 0.88Specificity 0.78 0.84 0.87 0.90 0.92 0.92 0.96

ANX

Sensitivity 0.98 0.94 0.93 0.91 0.89 0.85 0.83Specificity 0.76 0.82 0.84 0.87 0.88 0.88 0.91

Any

Sensitivity 0.90 0.85 0.84 0.80 0.79 0.75 0.72Specificity 0.87 0.93 0.96 0.97 0.98 0.98 1.00

All

Sensitivity 1.00 0.97 0.97 0.97 0.97 0.97 0.97Specificity 0.69 0.75 0.78 0.81 0.82 0.84 0.87

Eliminating Stigma: Setting the Context

Setting the Context

WHO can administer the RHS-15?o Health workers, interpreters, others involved in patient care.

o 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?o 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?o Self-administered if client is literate

o Interpreter assisted (over the phone or in person) if client is pre-literate

Setting the Context

At start of visit consider the following steps:

1. 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.”

2. 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.

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.”

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?

o Good idea to have a crisis referral but this relates less to RHS-15 than just general protocol.

Scoring the RHS-15

Pathways in King County, WA

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?”

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.

Questions?

Beth Farmer, LICSW

bfarmer@lcsnw.org

206-816-3252