The Boston Healthy Start Initiative

1
The Boston Healthy Start Initiative

• Depression Among Black Women in the Boston
  Healthy Start Project Area
• Urmi Bhaumik, MBBS, MS, DSc.
• Local Evaluator, Boston Healthy Start Initiative
• Boston Public Health Commission
• Maia BrodyField, MPH
• Senior Manager
• Boston Public Health Commission

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Objectives of Presentation

• To describe the development and implementation of
  a depression screening initiative among Healthy
  Start women.
• To report on the preliminary findings of the
  Boston Healthy Start womens experience of
  depression during pregnancy and up to 2 years
  after delivery.

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Boston Healthy Start Initiative

• A program designed to reduce perinatal
  disparities in health in Boston areas with the
  highest infant mortality rates.

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BHSI MODEL

• BHSI has a holistic case management model that
  includes services for mental health and
  interconceptional care
• BHSI relies heavily on its Consortium--a
  partnership of community residents and agencies,
  and local government health organizations

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Target Population

• BHSI targets Black women in Boston neighborhoods
  experiencing racial disparities in perinatal
  health
• Black women are defined as
• African American
• Haitian
• Cape Verdean
• African
• Black Latinas

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Needs Assessment

• Focus groups with providers and consumers were
  conducted prior to the latest phase of the Boston
  Healthy Start Initiative
• Depression was identified to be a major problem
  among women of color

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Mental Health Task Force

• Convened to address depression
• Recruitment done through the BHSI Consortium
• Members included
• case managers
• mental health providers
• other frontline staff

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Depression Screening Tools

• BHSI consumers reviewed a number of depression
  screening tools like the Edinburgh PP and the
  self-rating Anxiety Scale
• The Mental Health Task force decided to use the
  Beck tool based on consumer recommendation
• Women are screened three times
• At the point of entry into the program
• At the end of 8 weeks post-partum
• At the end of the first year after delivery

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Women's Health Questionnaire (WHQ)

• In addition women are offered an in-depth health
  assessment using the WHQ
• A self administered tool
• Assesses health and social problems along with
  depression
• It is offered
• At the point of entry
• At the end of the 1st year after delivery
• At the end of the 2nd year after delivery

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Depression Prevalence WHQ

• 506 women have responded to the Womens Health
  Questionnaire at the point of entry
• 13.4 responded as being depressed at present
• 24.1 reported they suffered from depression
  either at present or in the past.

Source Womens Health Questionnaire
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Depression Prevalence BDI

• During Pregnancy

One in three (33.7) women scored positive for
depression using the BDI
Source Beck Depression Inventory Tool
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Depression Prevalence BDI

• At Postpartum Period

Almost two out of ten (19) women scored positive
for depression.
Source Beck Depression Inventory Tool
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Depression Prevalence BDI

• At 1-year Interconception

Eighteen percent of BHSI clients scored positive
for depression.
Source Beck Depression Inventory Tool
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Depression Prevalence
WHQ vs. BDI-II During Pregnancy
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Depression Prevalence

• WHQ vs. BDI-II During Pregnancy
• A notable difference between depression
  prevalence obtained from WHQ responses compared
  to BDI-II scoring
• Likely reason is that BDI-II is designed to
  capture depression if present and WHQ is the
  womens perception of being depressed or not.

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Depression Symptoms
Top 5 symptoms reported as severe

• During Pregnancy
• Changes in Sleeping Pattern
• Loss of Interest in Sex
• Changes in Appetite
• Crying
• Punishment Feelings

• During Postpartum
• Crying
• Changes in Sleeping Pattern
• Loss of Interest in Sex
• Loss of Interest
• Agitation

Source Beck Depression Inventory
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Depression and Ethnicity

• Depression differs across ethnic groups with the
  lowest prevalence among Haitians
• Compared to Haitians
• African Americans are eight times more likely to
  be depressed
• Latinos are almost six times more likely to be
  depressed
• All others are three times more likely to be
  depressed

Source Womens Health Questionnaire
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Depression and Birthplace

• The odds of being depressed are 3.1 times
  (p-value lt 0.001) higher in those born in USA
  compared to those born abroad.

Source Womens Health Questionnaire
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Depression and Other Factors

• Adjusting for demographic and socio-economic
  factors, depression is also associated with
• Family Problem OR 5.4
• Substance Use OR 4.5
• Smoking OR 2.1, p-value
• Health Care Access Problem OR 1.7

p-value lt0.001 p-value lt0.05 p-value
lt0.1
Source Womens Health Questionnaire
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Attitude Towards Depression

• Surveys on attitudes towards depression were
  administered to providers and clients
• Findings show that depression is not perceived as
  a problem by many women scoring high in the BDI

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Attitude Towards Depression

• The BHSI population has a high threshold for
  depression, being consistently exposed to stress
• Denial is a factor for many clients
• Dont want to be labeled as depressed due to fear
  of the mental health system
• Not familiar with variations in mental health
  issues you are crazy or you are not

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Interventions

• Case managers provide education and support about
  depression
• Referrals are made to community based resources
• Women are consistently encouraged and reminded to
  keep their appointments
• Distribution of educational materials on mental
  health/well-being

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BHSI Interventions

• Creative approaches for clients to address
  emotional and physical needs of women
• Sisters Circle addresses the emotional and
  spiritual needs of women through monthly meetings
  and bimonthly individual coaching
• Slim Down Sisters - focuses on the physical
  well being of the women

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Conclusions

• A significant proportion of Black women
  experience depression in addition to those who
  experience postpartum depression, many begin
  their pregnancies depressed
• Holistic case management and creative approaches
  are needed to address this need among inner city
  Healthy Start women

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Conclusions

• Decreasing depression prevalence rates across
  different time points of care

• suggest a positive effect of screening and
  subsequent case referral and management.

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Next Steps.

• Continued case management for Healthy Start
  women, utilizing holistic and creative
  approaches.
• Further evaluation and refinement of BHSI
  interventions for depression.