SummaryCommunity mental health agencies in the Seattle, WA, area that work with refugees partnered with the county health department (Public Health – Seattle & King County) and a researcher to implement Pathways to Wellness, a program that identifies and provides appropriate treatment to arriving refugees at high risk of mental health problems such as depression, anxiety, and traumatic stress. The program employs a culturally tailored, 15-question screening tool used by a health department nurse to quickly assess whether arriving refugees are experiencing mental health symptoms. Refugees who score above a predetermined threshold receive a referral to the Pathways program, which connects them with a mental health counselor who completes a formal assessment and diagnosis and, if necessary, provides treatment. In a pilot test with 251 refugees, the program enhanced access to mental health services for at-risk refugees, with 30 percent of those screened testing positive for significant distress and roughly 70 percent of these individuals subsequently being connected with a counselor. In the absence of this program, many refugees with mental health problems likely would not have received treatment or would have done so only when their condition significantly worsened.Suggestive: The evidence consists of post-implementation data on the proportion of refugees served by the program that screened positive for significant distress, along with the percentage of those screening positive that subsequently met with a counselor.
Developing OrganizationsAsian Counseling and Referral Service; Lutheran Community Services Northwest; Michael Hollifield, MD; Public Health Seattle & King County
Use By Other OrganizationsHealth departments in Arizona, Maryland, Florida, Idaho, Oregon, and Maine use the same screening tool, as do agencies in Australia and Canada.
Date First Implemented2010
Patient PopulationThe program serves refugees and asylum seekers arriving in King County, WA, from all over the globe. Since 2010, the majority of new arrivals have been from Iraq, Bhutan, and Burma/Myanmar.Race and Ethnicity > Asian; Vulnerable Populations > Immigrants; Non-english speaking/limited english proficiency
Problem AddressedMany refugees arriving in the United States have mental health disorders, but most health agencies do not screen for them. Refugees with undiagnosed and untreated mental health disorders may be more likely to have long-term health problems and difficulty functioning in American society.
- High prevalence of mental health problems among refugees: Each year the United States resettles tens of thousands of refugees, nearly all of whom have had highly stressful experiences related to events such as war, oppression, migration, and resettlement. As a result, a large minority experience multiple, distressing somatic and psychological symptoms and poor mental health. One review found that 9 percent of adult refugees had posttraumatic stress disorder (PTSD) and 5 percent had major depression.1 In recent decades, King County, WA, has received thousands of refugees from the Middle East, Asia, and Africa, many of whom exhibit symptoms of mental health problems on arrival.
- Lack of screening: Although refugees typically receive rigorous screening for physical health problems as part of the resettlement process, they rarely receive screening for mental health disorders. Barriers to screening include lack of time, high costs, limited availability of services, and language and cultural barriers, including conceptual differences related to perceptions of health.2 In addition, although screening tools exist for specific disorders such as PTSD and depression, until recently a validated test that quickly and effectively identifies individuals at high risk for a range of common mental disorders has not been available. Before the initiation of the Pathways to Wellness program, arriving refugees in King County were not routinely screened for mental health problems.
- Significant consequences of undiagnosed mental health disorders: Anecdotal reports and a small but growing body of research suggest that inadequate treatment of mental disorders often can be an obstacle to refugees' ability to function and thrive in American society. For example, the Centers for Disease Control and Prevention's Office of Refugee Settlement issued a report in 2012 documenting 16 suicides among Bhutanese refugees over a 3-year period; the report also called for improvements in mental health screening and treatment for refugees.3
Description of the Innovative ActivityCommunity mental health agencies in the Seattle, WA, area that work with
refugees partnered with the county health department (Public Health
– Seattle & King County) and a researcher to implement Pathways to Wellness, a program that identifies and provides appropriate treatment to arriving refugees at high risk of mental health problems such as depression, anxiety, and traumatic stress. The program employs a culturally tailored, 15-question screening tool used by a health department nurse to quickly assess whether arriving refugees are experiencing mental health symptoms. Refugees who score above a predetermined threshold receive a referral to the Pathways program, which connects them with a mental health counselor who completes a formal assessment and diagnosis and, if necessary, provides treatment. A detailed program description follows:
- Administration of screening tool: Within 90 days of their arrival in King County, a nurse with the public health department administers the screening tool to arriving refugees age 14 years and older as part of a larger 2-hour medical screening. The tool is administered to refugees who speak the languages in which the tool is available: Russian, Somali, Farsi, Burmese, Karen, Nepali, and Arabic. In 2012, approximately 800 refugees were screened. Including the mental health screening in the larger examination makes it easier to administer and minimizes the potential stigma refugees may associate with mental health problems. The nurse typically administers the screening after she has reviewed the individual's medical history, conducted a physical examination, taken blood samples, and given relevant immunizations. The tool comes in multiple languages to reflect the diversity of the refugee population, and each version has been designed to be sensitive to refugees' native cultures. For example, in the United States, people understand that the word "blue" denotes melancholy or sadness. In many countries, the word simply denotes the color, with no emotional connotation; a direct translation of "blue" would be correct but incomprehensible. To translate meaning, not just words, focus groups comprised of native language speakers were convened. (The Planning and Development Process section provides additional details on the development of the tool's cultural aspects). In most cases, refugees complete the questionnaire themselves in less than 10 minutes. Refugees can ask for help from an interpreter if they cannot read or find the questions confusing. The tool includes four sections:
- Current symptoms: The tool begins with nine questions about current mental health symptoms such as "feeling down, sad, or blue most of the time;" "feeling helpless;" "nervousness, dizziness, or weakness;" and "crying easily." For each question, refugees circle one of five choices: not at all (zero points), a little bit (one point), moderately (two points), quite a bit (three points), or extremely (four points).
- Traumatic experiences: Refugees respond to four questions about past traumatic experiences during war and migration, using the same scoring system. For example, refugees rate how often in the past month they have experienced physical reactions when reminded of a past trauma (e.g., breaking out in a sweat, experiencing a rapid heartbeat) and how often they have felt emotionally numb, such as feeling sad but being unable to cry, or being unable to have loving feelings.
- Coping ability: Refugees answer one question about coping ability that asks: "Generally over your life, do you feel that you are able to handle anything that comes your way (zero points), able to handle most things (one point), able to handle some things but not able to cope with other things (two points), unable to cope with most things (three points), unable to cope with anything (four points)?"
- Level of distress: The final question asks refugees to circle a number from 1 to 10 on a drawing of a thermometer, with 0 labeled "no distress" and "things are good" and 10 labeled "extreme distress" and "I feel as bad as I ever have."
- Scoring to identify at-risk refugees: The nurse tabulates a score for each refugee. Those who score 12 points or more on the first 14 questions (the first 3 sections) or who circle 5 or higher on the distress thermometer are considered to be at high risk of mental health disorders.
- Referral to counselor for those identified: When a refugee screens positive, a health worker explains that many arriving refugees experience symptoms such as sadness, worries, and stress; that those in the United States who have these types of symptoms sometimes find it helpful to get outside support from a counselor; and that counseling is confidential. The health worker then asks the refugee if he or she is interested in seeing a counselor. If so, the health worker completes a referral form and faxes it to the program's central office, administered by the nonprofit Lutheran Community Services Northwest. A staff member at this office identifies a clinician at this agency or a partner agency (based on geography, language, and expertise) that has a mental health counselor available to meet with the refugee and calls the refugee to schedule an appointment.
- Initial counseling session and as-needed followup care: At the first meeting, the counselor and refugee discuss the refugee's symptoms, their effect on day-to-day living, and the traumatic experiences that preceded them. Based on this discussion, the refugee may decide to begin meeting regularly with the counselor or to participate in a community support group.
Context of the InnovationPublic Health – Seattle & King County in King County, WA, is the one of the largest metropolitan health departments in the United States, with 1,500 employees, 14 sites, and an annual budget of $318 million. The department serves a resident population of 1.9 million people, including several thousand refugees arriving each year (making the county one of the largest resettlement sites in the United States). The department performs a general health screening within 90 days of each refugee's arrival in the United States.
Lutheran Community Services Northwest, the lead agency in the Pathways to Wellness program, is a nonprofit agency whose services include a refugee and immigrant children's program. Lutheran Community Services Northwest works with a number of other nonprofit agencies that are also active in resettlement efforts, including Asian Counseling and Referral Services, Jewish Family Services, International Rescue Committee, and World Relief.
The impetus for Pathways to Wellness began when staff at Lutheran Community Services Northwest and Asian Counseling and Referral Service began to informally discuss the number of refugee mental health cases they were seeing that were either acute or in crisis. Both agencies felt that it was critical to identify and treat refugees early in the resettlement process, before they fell through the cracks.
ResultsThe program enhanced access to mental health services for at-risk refugees, with 30 percent of those in a pilot test screening positive for significant distress, and roughly 70 percent of these individuals subsequently being connected with a counselor. In the absence of this program, many refugees with mental health problems likely would not have received treatment or would have done so only when their condition significantly worsened.
Suggestive: The evidence consists of post-implementation data on the proportion of refugees served by the program that screened positive for significant distress, along with the percentage of those screening positive that subsequently met with a counselor.
- Many at-risk individuals identified: In a pilot test conducted between April and November of 2010, 30 percent of 251 refugees screened positive for significant levels of distress.
- Most connected to a counselor: In the pilot test described above, 70 percent of those identified as being at high risk for mental health disorders subsequently met with a counselor.
Planning and Development ProcessKey steps included the following:
- Forming partnership: In 2008, staff at Lutheran Community Services Northwest and Asian Counseling and Referral service convened a series of community meetings to discuss refugee mental health and brainstorm solutions. Out of these meetings, a partnership was formed between the two organizations, Public Health Seattle & King County, and Michael Hollifield, MD, a researcher affiliated with Pacific Institute for Research and Evaluation who has extensively studied refugee mental health.
- Securing funding: In 2008, the Pathways project received its first funding, a $20,000 grant from United Way of King County. These funds were leveraged to further develop the project and bring in other funders including the Bill and Melinda Gates Foundation (2009), the Robert Wood Johnson Local Funding Partnership (2010), Boeing Employee Community Fund (2010), the Medina Foundation (2010), the M.J. Murdock Charitable Trust (2011), and the Seattle Foundation (2011).
- Developing screening tool: In 2010, the partners developed the screening tool in four languages (Burmese, Arabic, Karen, and Nepali). To do so, they first reviewed existing, lengthier English-language screening tests, such as the New Mexico Refugee Symptoms Checklist-121, the Hopkins Symptom Checklist-25, and the Post-traumatic Symptom Scale-Self Report. They also held separate focus groups with refugees who speak each of these languages. These focus groups helped the partners develop culturally sensitive translations of the questions. For example, they paid close attention to which words to use to convey concepts such as "down," "sad," and "blue" based on differences in how various cultures perceive well-being and illness.
- Validating and refining tool: After refining the 4 translations based on feedback from the focus groups, the partners evaluated the screening tool's effectiveness in a 6-month pilot test at the county health department between April and November 2010. This test compared the performance of the translated versions of the tool to that achieved by the lengthier screening tests in prior evaluations. Early pilot test results led to additional refinements, including minor wording changes, the deletion of one question, and the addition of one question.
- Training nurses: During the pilot test, project staff initially administered the screening tests, and then trained a department nurse on how to administer it. Because the tool is brief and simple to administer, this training only required one 1-hour-long session with the nurse.
- Preparing for full implementation: During the pilot test, it became clear that support existed among key stakeholders (including the health department nurses) to make the screening a permanent part of the intake examination. In anticipation of integrating this into the health screening visit for refugees at Public Health – Seattle & King County, the partners drafted scripts the nurses could refer to when administering the test and referring patients for counseling, identified a network of counselors in the community willing to handle patient referrals and trained them to provide culturally sensitive care, and worked with refugee communities to raise awareness about mental health disorders and the availability of treatment.
Resources Used and Skills Needed
- Staffing: One public health department nurse handles the program's screening component as part of her regular job responsibilities. In addition, several Lutheran Community Services Northwest staff members coordinate referrals among counselors at five community mental health agencies, who provide care as part of their regular job responsibilities.
- Costs: The cost to develop and pilot test the screening tool totaled roughly $700,000. However, other agencies can use the tool at no cost if they contact the program director and sign an agreement indicating they will use it as intended. (The Tools and Other Resources section provides more information.) Ongoing program costs tend to be minimal, since the partners perform program-related duties as part of their regular job responsibilities. From the patient perspective, Medicaid typically covers mental health services, and all refugees have Medicaid during their first 8 months in the United States. Some refugees have Medicaid beyond 8 months because they qualify under other criteria for health insurance.
Funding SourcesRobert Wood Johnson Foundation; Bill and Melinda Gates Foundation; Boeing Employee Community Fund; M.J. Murdock Charitable Trust; Seattle Foundation; Medina Foundation
Tools and Other ResourcesMore information about the Pathways to Wellness program, including a video featuring interviews with participants, is on the Lutheran Community Services Northwest Web site, available at: http://www.lcsnw.org/pathways/.
An English language version of the screening tool (available for demonstration purposes only—this version is not intended for actual screening) is available at: http://www.lcsnw.org/pathways/pdf/RefugeeHealthScreener.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software .). As noted, interested individuals and organizations can use the screening tool if they contact Pathways to Wellness program director Beth Farmer and sign a use agreement. This agreement and additional relevant background information is on the Refugee Health Technical Assistance Center Web site, available at: http://www.refugeehealthta.org/files/2012/09/RHS15_Packet_PathwaysToWellness.pdf.
Getting Started with This Innovation
- Assess local availability of mental health services: Before integrating mental health screening into the initial health screening for newly arriving refugees, assess the capacity of the local mental health provider system to handle the influx of refugee patients. Some providers may not have the capacity or willingness to treat these patients, whereas others may need training to learn to serve them effectively. If adequate capacity is not available, first work to build up a network of providers capable of providing high-quality care.
- Develop strong partnerships: A successful program requires strong communication and teamwork from a range of participants. To that end, create partnerships with representatives from the local county or municipal health department, resettlement agencies, health care providers (including physicians and social service workers), and potential funding sources.
- Start small: If the local refugee population is diverse, it may not be feasible to implement screening for all subgroups right away. In this case, start by serving an easily identified subset of refugees, such as those who speak a certain language.
Sustaining This Innovation
- Track refugee population: Be aware of changes in the local refugee population and adapt accordingly. For example, if an influx of refugees from a new region becomes likely due to world events, see if a version of the screening tool is available in the appropriate language.
- Monitor proportion of positive screens: Program leaders should continually track the percentage of refugees screening positive. A sudden increase or decrease may indicate a problem that requires further investigation and remediation, such as someone administering the test improperly or a flaw in a newly translated version of the screening tool.
Contact the InnovatorBeth Farmer, MSW
Project Director, Pathways to Wellness
Lutheran Community Services NW
4040 South 188th Street, #200
SeaTac, WA 98188
Innovator DisclosuresIn addition to the grants received from funders listed in the Funding Sources section, Ms. Farmer reported receiving reimbursement of travel expenses for annual conferences and honoraria for consulting work related to this program from the Robert Wood Johnson Foundation.
References/Related ArticlesHollifield M, Verbillis-Kolp S, Farmer B, et al. The Refugee Health Screener-15 (RHS-15): development and validation of an instrument for anxiety, depression, and PTSD in refugees. Gen Hosp Psychiatry. 2013;35(2):202-9. [PubMed]
Fazel M, Wheeler J, Danesh J. Prevalence of serious mental disorder in 7000 refugees resettled in western countries: a systematic review. Lancet. 2005;365(9467):1309-14. [PubMed]
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Original publication: August 14, 2013.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: August 14, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.