Clusters of Behavioral Health Risk in Low-Income Mothers: Interrelationships Among Emotional Health Interpersonal Violence, Substance Use and Smoking at First Point of Entry to Community Services

Background and Purpose: Promoting the emotional and behavioral health of pregnant and postpartum women includes explicitly addressing perinatal depression and anxiety, substance use, interpersonal violence and smoking.  National efforts to enhance evidence based services through Maternal, Infant and Early Childhood Home Visiting (MIECHV) have resulted in a comprehensive and data-driven approach to supporting women and infant’s health beginning with pregnancy.  While these supportive interventions are beneficial to families, delays in identification of behavioral and emotional health risks can impede program effectiveness and lead to adverse health outcomes for both women and infants.  In an effort to address this concern, we engaged four communities in a services enhancement pilot to centralize intake and referral for home visiting eligible women and infuse behavioral health risk screening at the first point of contact with community pregnancy and parenting support programs. 

Methods: Emotional and behavioral health risk screening augmented service eligibility assessment.  Intake workers in community settings were trained by project staff in motivational interviewing and SBIRT (screening, brief intervention and referral to treatment).  In this study, community SBIRT data highlight interrelationships among identified areas of emotional and behavioral health “risk triggers” leading to intervention and/or referral.  Data were entered in real time by community intake workers and aggregated across sites via RedCap; subsequent analyses of de-identified data were conducted using SPSS 23.

Results:  In the study sample (N=1,515), the risk trigger for emotional health challenges was the most frequent single area identified (n=326, 21.5%).  Among the 223 women for whom two or more risk factors were identified (n = 223, 14.7% of the overall sample), smoking consistently emerged as a significant correlate accompanying risk for emotional health (χ²=56.44, p<.0005), interpersonal violence (χ²=11.16, p=.001) and substance use (χ²=14.70, p<.0005).  Both emotional health risk (OR = 1.71) and interpersonal violence risk (OR = 1.59) were significant predictors of current smoking.  For women with 3 or more risk factors (n=73, 4.81% of the overall sample) both emotional health risk (n=69, 94.5%) and smoking (n=68, 93.2%) were endorsed by the overwhelming majority of participants (n=63, 87.7%) along with one other risk factor of either IPV or substance use.  Women with multiple, concomitant risk factors were the most likely to be referred to and to utilize home visiting supports.

Conclusions and Implications: Examining the interrelationships among behavioral health risks suggests that emotional well-being and interpersonal violence have a high degree of interrelationship with smoking and substance use.  For these young mothers, behavioral risks (smoking, substance use) may suggest underlying emotional health and interpersonal violence issues which need to be addressed for holistic care and support.   Community service providers, such as home visiting programs, may benefit from expanded education and training to enhance both risk identification and supportive psychosocial interventions for women utilizing this service sector.  Findings from this multi-site pilot reinforce the importance of comprehensive screening and intervention embedded in community systems of care to address the whole person, rather than merely the behavioral symptoms of concern for reproductive health.