Transcript Slide 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
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 screeneradministered 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
MIC Patient
Feedback
Groups
MHRA
was
awarded
HRSA
grant
June Sept.
2003 2003
Family
Violence
Prevention
Fund
Technical
Assistance
BRF
pilot at
MIC
W’burg
and
M’ville
All staff
training
on new
BRF
program
Dec. Feb. Dec.
2003 2004 2004
NYC Center for
Immigrant
Health
Technical
Assistance
BRF rollout at
MIC
May
2005
Patient
Focus BRF tool
is
Groups
revised
and
finalized
Dec. Feb.
2005 2006
March
2006
Final
All staff
BRF
training roll-out
on final at MIC
BRF tool
April
2006
May
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 protocols
 Training of screening staff
 Building 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 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
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:1.53.9), 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)
50% of patients screening
positive for IPV screened
positive for at least one other
risk factor
IPV
77
35
111
Mental Health
(depression, anxiety)
11
27
33
125
Substance use
(smoking, alcohol, drugs)
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 protocols
 Confidentiality & privacy
 Guidance regarding family/partner interpreters
 Definition of screener role
 Referrals
 Documentation
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
Screening Program
Recommendations, Cont.

Sustained technical assistance over time


Data collection & quality assurance


Commitment from administration
Feedback loop
Strong referral network
Referral manuals
 Community breakfast model

Thank you!
Contact Information
Sarah Blust, Program Manager
[email protected]