OPathways to Wellness:
Integrating Refugee Health and Well-Being
Screening
Refugees for
Anxiety and
Depression
A program of:
Goals of Today’s Presentation
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
1.
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.
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.
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 Screening
and 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 Screening
and 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
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
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
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
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.
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
PSS-SR >16
selected by
PTSD
HSCL-25
HSCL-25
diagnosis
Anxiety
Depression
X
X
Any Proxy
BAY
NM 5_1
X
NM 5_12
X
NM 5_19
X
NM 5_22
X
“Coping”
PSS 3
X
X
PSS 5
PSS 11
X
X
X
X
PSS 17
X
X
HSCL 1
X
HSCL 3
X
X
X
X
HSCL 9
X
HSCL 10
X
HSCL 11
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
RHS-15 Cut Score
Proxy Diagnosis
PTSD (64)
DEP (58)
ANX (53)
Any (79)
All (38)
9
10
11
12
13
14
15
58
55
55
53
52
51
49
90.63%
85.94%
85.94%
82.81%
81.25%
79.69%
76.56%
56
54
54
53
53
51
51
96.55%
93.10%
93.10%
91.38%
91.38%
87.93%
87.93%
52
50
49
48
47
45
44
98.11%
94.34%
92.45%
90.57%
88.68%
84.91%
83.02%
71
67
66
63
62
59
57
89.87%
84.81%
83.54%
79.75%
78.48%
74.68%
72.15%
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 Score
9
10
11
12
13
14
15
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
Specificity
0.97
0.78
0.93
0.84
0.93
0.87
0.91
0.90
0.91
0.92
0.88
0.92
0.88
0.96
ANX
Sensitivity
Specificity
0.98
0.76
0.94
0.82
0.93
0.84
0.91
0.87
0.89
0.88
0.85
0.88
0.83
0.91
Any
Sensitivity
Specificity
0.90
0.87
0.85
0.93
0.84
0.96
0.80
0.97
0.79
0.98
0.75
0.98
0.72
1.00
All
Sensitivity
Specificity
1.00
0.69
0.97
0.75
0.97
0.78
0.97
0.81
0.97
0.82
0.97
0.84
0.97
0.87
PTSD
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