The Blues Prior, During and After Labor: Es Dificil ser Mujer? The Health Education Action for Latinas (HEAL) Model

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1 The Blues Prior, During and After Labor: Es Dificil ser Mujer? The Health Education Action for Latinas (HEAL) Model Maria Lourdes F. Reyes, MD, MPH Director of California programs, PCI National Healthy Start Association Conference Washington D.C., March7 & 8, 2011

2 Learning Objectives: 1. Define the importance of screening for maternal depression and learn the applications of screening tools. 2. Identify strategies to address mental depression using the Health Education Action for Latinas (HEAL) model. 3. Apply lessons learned from this project. 4. Demonstrate sample HEAL exercises.

3 PCI is a nonprofit health and humanitarian aid organization dedicated to preventing disease, improving community health, and promoting sustainable development worldwide. Impacting Lives PCI is creating real and lasting change in communities around the world. This year, PCI is excited to be celebrating 50 years of Positive Community Impact. Intervention areas: HIV/AIDS, Infectious Disease, Humanitarian Assistance, Women, Children & Youth, Food and Nutrition Security, Economic Empowerment, Water, Sanitation & Hygiene, Community Health.

4 Currently in 16 Countries (2011) Size- 561 employees worldwide (68 in the US: San Diego, National City & D.C.)

5 California Border Healthy Start Funded by DHHS HRSA projects in 38 states, DC & Puerto Rico Help low income women & families in San Diego areas with poorest birth outcomes & highest levels of poverty.

6 Project Objectives: 1. Reduce the number of infant deaths 2. Reduce the % of low birth infants 3. Increase % of pregnant women starting prenatal care in 1 st trimester 4. Increase # of women who complete screening for post-partum depression & domestic violence

7 Project core services: 1. Outreach & client recruitment 2. Case management 3. Health Education 4. Doula program 5. Screening for peri-natal depression and HEAL 6. Interconceptional continuity of care

8 California Border Healthy Start Model Consortium Clinics Media Domestic Violence Support Substance Abuse & Mental Health Treatment Anti-smoking Positive Pregnancy test Program Participants Child 2-years-old Prenatal Care Prenatal Visits, Nutrition, Depression Screening Labor & Delivery Interconceptional Care Well-baby, Well-Mom visits, Depression Screening, Medical Home, Immunizations, Nutrition Doula PN Case Management Risk assessment, screenings, education, referrals, case conferences, home visits, phone calls Home Start Coordination with PHN, CPSP, clinics WIC Clinics & Providers Breastfeeding Support Patient Navigators Health Insurance Enrollment

9 DEPRESSION Depression is not clearly understood in many cultures and our feelings are not easily defined. One in seven Hispanic mothers experiences depression Depression during and after pregnancy has long-term negative consequences for women and their children. For children these include: cognitive delays, school behavior problems, sudden infant death syndrome and increased visits to emergency departments.

10 HEAL What are the roles a woman plays in her life, family, community, work, church, etc.? A Guide A curriculum A discussion

11 HEAL- History Methodology, conducted by PCI from Overall goal: to improve the health and well-being of Latina women by focusing on the area of mental health, while integrating community needs, empirically-based best practices for Latinas. In this model, community health workers ( promotoras ) lead a series of six small group sessions designed around the theme of Es Dificil Ser Mujer? ( Is it Difficult to be a Woman?)

12 HEAL- How does it work? Group setting Guided discussion around specific topics Time set aside for women A program that build self esteem Educational, Psychological, Reflexive, Gender specific

13 Screening All clients are screened for depression twice by Patient Navigators (PNs) Antenatal: Center for Epidemiological Studies Depression Scale (CES-D 10) Postpartum Edinburgh Postpartum Depression Scale Both screening tools are designed for the initial screening of symptoms related to depression or psychological distress A score of 10 or higher on either screening tool generates an automatic referral to the HEAL program

14 Center for Epidemiologic Studies Short Depression Scale (CES-D 10) Below is a list of some of the ways you may have felt or behaved. Please indicate how often you have felt this way during the past week: (circle one number on each line) Rarely or none of the time (less than 1 day) = 0 Some or a little of the time (1-2 days) = 1 Occasionally or a moderate the time (3-4 days) = 2 All of the time (5-7days) = 3 During the past week I was bothered by things that usually don t bother me I had trouble keeping my mind on what I was doing I felt depressed I felt that everything I did was an effort I felt hopeful about the future I felt fearful My sleep was restless I was happy I felt lonely I could not get going Scoring Items 5 & All other items: A score of 10 or greater is considered depressed.

15 1. In the past week I have been able to laugh and see the funny side of things: - As much as I always could - Not quite so much now - Definitely not so much now - Not at all 2. In the past week I have looked forward with enjoyment to things: - As much as I ever did - Rather less than I used to - Definitely less than I used to - Hardly at all 3. *In the past week I have blamed myself unnecessarily when things went wrong: - Yes, most of the time - Yes, some of the time - Not very often - No, never 4. In the past week I have been anxious or worried for no good reason: - No, not at all - Hardly ever - Yes, sometimes - Yes, very often 5. *In the last week I have felt scared or panicky for no very good reason - Yes, quite a lot - Yes, sometimes - No, not much - No, not at all Edinburgh Postnatal Depression Scale (EPDS) 6. *In the past week things have been getting on top of me: - Yes, most of the time I haven't been able to cope at all - Yes, sometimes I haven't been coping as well as usual - No, most of the time I have coped quite well - No, I have been coping as well as ever 7. *In the past week I have been so unhappy that I have difficulty sleeping: - Yes, most of the time - Yes, sometimes - Not very often - No, not at all 8. *In the past week I have felt sad or miserable: - Yes, most of the time - Yes, quite often - Not very often - No, not at all 9. *In the past week I have been so unhappy that I have been crying: - Yes, most of the time - Yes, quite often - Only occasionally - No, never 10. *In the past week the thought of harming myself has occurred to me: - Yes, quite often - Sometimes - Hardly ever - Never QUESTIONS 1, 2, & 4 (without an *)Are scored 0, 1, 2 or 3 with top box scored as 0 and the bottom box scored as 3. QUESTIONS 3, 5-10 (marked with an *)Are reverse scored with the top box scored as a 3 and the bottom box scored as 0. Maximum score: 30 Possible Depression: 10 or greater Always look at item 10 (suicidal thoughts)

16 PRIME-MD Patient Health Questionnaire- PHQ-9 Scoring Method For Diagnosis Major Depressive Syndrome is suggested if: Of the 9 items, 5 or more are circled as at least "More than half the days" Either item 1a or 1b is positive, that is, at least "More than half the days" Minor Depressive Syndrome is suggested if: Of the 9 items, b, c, or d are circled as at least "More than half the days" Either item 1a or 1b is positive, that is, at least "More than half the days" For question 1: Score Action <4 The score suggests the patient may not need depression treatment. > 5-14 Physician uses clinical judgment about treatment, based on patient s duration of symptoms and functional impairment. >15 Warrants treatment for depression, using antidepressant, psychotherapy and/or a combination of treatment

17 Depression screenings Total screened- 484 * Antenatal- CESD-10 and * Post partum- Edinburgh Total referred to HEAL- 162 (34%) * PHQ-9- pre and post sessions

18 Support Groups The HEAL Educator lead a series of six small group sessions designed around the theme of Es Dificil Se Mujer? ( Is it Difficult to be a Woman? ) to help women identify areas of their lives they wish to change or improve Sessions address stress, depression and provide women with the information, skills, and support necessary to deal appropriately with these issues Curriculum is designed to reduce stigma around mental health issues and promote communication, empowerment and expanded self-care, including proper nutrition, exercise and general well-being

19 What is depression? Why do we get depressed? Our childhood Weekly sessions: Major life events A woman s upbringing What to do? & Where to go?

20 What is depression? (5 of 9 symptoms) Keep feeling sad Lose interest in things Eat a lot or very little Problem going to sleep or sleep too much Move slowly or restless Not excited, tired or little energy Feel guilty, powerless, useless Can t concentrate or remember chores Thoughts about death & suicide Session homework: stress list

21 Why do we get depressed? Reasons Our childhood Major life events Physical factors (chemical, inherited, head injury, hormones) A woman s upbringing Social factors Session homework- stress list & other family member s input

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23 Our childhood: Factors Rejection Abandonment Indifference Lack of love

24 Major life events: Death/separation Legal problem Job loss Illness Abortion/miscarriage Alcohol Sexual difficulties

25 A woman s upbringing: Discuss phases of growing up as a woman Session workup: draw woman and the participants make up a story about woman s life and discuss

26 What to do? Define what is happening Re-evaluate self: how to handle mistakes and good qualities Change in beliefs: role, love, suffering Expressing fear, sadness & anger New ways to perceive environment New ways to behave: share, communicate & ask for help

27 Where to Go? Discuss community resources:

28 Where to Go? Discuss community resources Referrals The HEAL Educator provide referrals for treatment and other support services, follow up to ensure client compliance PNs coordinate mental health referrals with core partner clinics as well as private practitioners and other programs in the community The PN and HEAL Educator screen provides for cultural and linguistic competence before making referral

29 Barriers More women prefer home sessions vs. group- more staff time Missed sessions due to other priorities Spouses/ partners see sessions as threat- women fear

30 Outcomes: General Latina women: improved depression scores by 40% Pregnant women: improved depression scores by 60%

31 References: Es Dificil Ser Mujer: Una Guia Sobre Depresion by Maria Asuncion Lara Lara, M. A.; Navarro, C.; Rubí, N. A.; Mondragón, L. American Journal of Orthopsychiatry. Vol 73(1), Jan 2003, Outcome results of two levels of intervention in low-income women with depressive symptoms. American Public Health Association poster presentation Reyes, ML, Huerta, C., Cano-Hays, R, Batche,Y. California Border Healthy Start: Improving Maternal Mental Health

32 Thank you! Gracias!