MHRA’s Behavioral Risk Factor (BRF) Screening

Program

Sarah Blust, LMSW, MPH, Program ManagerNatalie Tobier, LMSW, MPH, Project DirectorSamantha Garbers, MPH, Program Evaluator

New York City Alliance Against Sexual AssaultPanel Presentation

December 11th, 2006

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

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

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.

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.

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

MIC nurses conduct the BRF screen at the following visits:

Prenatal Patients• First visit• Third trimester• Postpartum

Family Planning Patients• First visit• Annual

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

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

BRF Program Timeline

MHRA was

awarded HRSA grant

BRF pilot

at MIC W’burg and M’ville

All staff training on new

BRF progra

m

BRF roll-out at MIC

BRF tool is revised

and finalize

d

All staff training on final BRF tool

Final BRF roll-

out at MIC

MIC Patient Feedback Groups

Family Violence Preventio

n Fund Technical Assistanc

e

NYC Center for

Immigrant Health

Technical Assistance

Patient

Focus Group

s

June Sept. Dec. Feb. Dec. May Dec. Feb. March April May

2003 2003 2003 2004 2004 2005 2005 2006 2006 2006 2006

Focus: BRF screening for violence

Technical assistance from the Family Violence Prevention Fund included:

Consultation on wording of questions• Lifetime exposure

Consultation on screening protocolsTraining of screening staffBuilding capacity of social work staff to

meet the needs of patients who screen positive for violence

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?

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?

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?

Data Collection & Quality Assurance

After each BRF screen, the screener documents on a Medical Manager “docuscan”:What BRF issue(s) the patient screened

positive forWhether 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

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)

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

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.

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).

Overlap of IPV & Behavioral Risk Factors Among Patients Screening Positive

Post-Implementation (n=419)

IPV

Substance use(smoking, alcohol, drugs)

Mental Health(depression, anxiety)

11

27 125

77

35

111

50% of patients screening positive for IPV screened positive for at least one other risk factor

33

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

Referral Needs

Mental health services for Spanish-speaking, uninsured and/or undocumented patients

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.

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.

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

Screening Program Recommendations

Clarification regarding “successful screening”

Establish appropriate protocolsConfidentiality & privacyGuidance regarding family/partner interpretersDefinition of screener roleReferralsDocumentation

Screening Program Recommendations, Cont.

Screen and re-screen Onsite expertise Sustained training over time

New employee orientationsRefresher trainingsObservations and feedbackUse of local experts

Case-conferencing

Screening Program Recommendations, Cont.

Sustained technical assistance over timeCommitment from administration

Data collection & quality assuranceFeedback loop

Strong referral networkReferral manualsCommunity breakfast model

Thank you!

Contact InformationSarah Blust, Program Manager

sblust@mhra.org