J Community Health DOI 10.1007/s10900-013-9790-x
ORIGINAL PAPER
Quality of Life Among Free Clinic Patients Associated with Somatic Symptoms, Depression, and Perceived Neighborhood Environment Akiko Kamimura • Nancy Christensen • Jamie A. Prevedel • Jennifer Tabler • Brian J. Hamilton • Jeanie Ashby • Justine J. Reel
Ó Springer Science+Business Media New York 2013
Abstract Free clinics provide free or reduced fee healthcare to individuals who lack access to primary care and are socio-economically disadvantaged. The purpose of this study is to examine health-related quality of life (HRQoL) among free clinic patients and its association with somatic symptoms, depression, and perceived neighborhood environment. Free clinic patients (n = 186) aged 18 years or older completed a self-administered survey. HRQoL, depression, somatic symptoms, and perceived neighborhood environment were measured using standardized instruments. Overall, the participants reported low level of HRQoL compared to the general healthy population. US born participants (n = 97) reported poorer psychological QoL and social relations, more somatic symptoms, and were more likely to be depressed than non-
US born participants (n = 89). Higher numbers of somatic symptoms were associated with poorer environmental QoL. Depression was associated with all aspects of QoL; a higher level of depression was related to poorer QoL in all aspects. Our findings show that free clinic patients, especially US born patients, have poor HRQoL. Depression and perceived neighborhood satisfaction are key factors to determine HRQoL among free clinic patients. Mental health services and collaboration with other community organizations may help in improving HRQoL among free clinic patients. Finally, health promotion programs at the community level, not just at the clinic level, would be valuable to improve health of free clinic patients as perceived neighborhood environment is associated with their HRQoL.
Human Participants Protection The University of Utah Institutional Review Board approved this study as an Exempt protocol.
Keywords Free clinics Health-related quality of life Depression Somatic symptoms Perceived neighborhood environment
A. Kamimura (&) J. Tabler Department of Sociology, University of Utah, 380 S 1530 E, Salt Lake City, UT 84112, USA e-mail: [email protected] N. Christensen J. Ashby Maliheh Free Clinic, Salt Lake City, UT, USA J. A. Prevedel School of Medicine, University of Utah, Salt Lake City, UT, USA B. J. Hamilton Division of Public Health, University of Utah, Salt Lake City, UT, USA J. J. Reel Department of Health Promotion and Education, University of Utah, Salt Lake City, UT, USA
Introduction Free clinics provide free or reduced fee healthcare to individuals who lack access to primary care and are socioeconomically disadvantaged [1–3]. Started in 1967 with the goal to increase healthcare access, there are approximately 1,200 free clinics that are currently operating throughout the US [1]. Free clinics have taken unique and nontraditional approaches to eliminate barriers that prevent access to care for the underserved in the community [1]. In general, free clinic patients are uninsured or under insured, have low or no income, and are at risk for increased physical and mental health needs [4]. For example, free clinic patients have overall low physical and mental health
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functioning [4] and higher obesity rates [5] compared to the US general population. Although free clinic patients have been identified as ‘‘at risk’’ for chronic diseases (e.g., heart disease), little knowledge exists about free clinic patients’ health related quality of life (HRQoL), and the environmental factors shaping it [6]. Such information would be useful in better understanding the free clinic population and developing health promotion interventions to address health concerns associated with individuals who frequent free clinics. Free clinic patients may be at risk for poor HRQoL outcomes based on the negative correlation between income and HRQoL [7]. HRQoL refers to how a person perceives one’s own well-being including happiness and satisfaction of life related to self-reported chronic conditions and risk factors [8]. Disease specific QoL research is common in clinical research such as breast cancer [9], heart failure [10], or stroke [11]. However, QoL is often related, not only to medical conditions, but also to cultures and socio-demographic characteristics such as age, income, or gender [12]. Somatic symptoms, which are medically unexplained chronic or disabling physical symptoms [13], also impair HRQoL [14]. These symptoms are important mental health problems found amongst nationally representative Latino and Asian populations in the US [13]. Because there is a paucity of research surrounding somatic symptoms among free clinic patients, it is important to investigate how these symptoms are related to HRQoL within this population. Furthermore, HRQoL is also related to depression [15]. For example, poor physical HRQoL is associated with high levels of depression [16]. Given that free clinic patients reported moderate to severe levels of depression [4], depression should be taken into account when examining HRQoL among free clinic patients. An additional factor impacting HRQoL is perceived neighborhood environment. Perceived neighborhood context is associated with health status due to its impact on sleep quality [17] and is related to both physical and mental health [18]. Neighborhood stressors such as perceived violence can be related to increased depressive symptoms [19]. There are, however, very few studies that examine the connection between the health of free clinic patients and their perceived neighborhood environment. The purpose of this study is to examine HRQoL among free clinic patients and its association with somatic symptoms, depression, and perceived neighborhood environment. Results from this study will provide both practical and research implications to improve HRQoL among US born and non-US born free clinic patients and can lead to the development of future interventions for the underserved population in the community. To our knowledge, this is one of the first studies on HRQoL among free clinic
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patients. This study contributes to expanding the literature on culturally diverse, immigrant, and the socio-economically disadvantaged patients being served in a free clinic setting.
Methods Overview The current community-based research project was conducted at a free clinic in the Intermountain West. The clinic staff collaborated with this research team to develop the survey instrument, study protocol, participant recruitment strategies, and interpreting study results. The clinic (the data collection site) provides free health care services comprised of mostly routine health maintenance and preventative care for uninsured individuals from both urban and suburban areas. The free clinic, which has been in operation for over 7 years, has no affiliation with religious organizations and is funded by non-governmental grants and donations. The clinic, staffed by six full-time paid personnel and over 250 active volunteers, is open 5 days a week. The number of patient visits was 15,209 in 2012. To qualify for services at the clinic, an individual must live below the 150th percentile poverty level and not have access to employer-provided or government-funded health insurance. The clinic does not ask for patients to provide documentation of legal residency or citizenship. Participants Inclusion criteria for participants included being 18 years or older, speaking and reading English, and being a patient of the clinic. The following patients were excluded: patients who were younger than 18 years, and/or who did not speak and read English. Some clinic patients speak other languages such as Spanish, Tongan, Arabic, Russian, Portuguese, Persian, and Vietnamese. A portion of Spanish speakers also speak English. Most foreign-born patients speak English. The research team examined differences by country of origin (i.e., US born and non-US born) because differences in birthplace, US born or non-US born, have coincided with differences in physical and mental health statuses of free clinic patients [4]. Data Collection Prior to data collection, the institution’s review board approved this study as an exempt protocol. The data were collected several times a week (1–2 h each time) for 2 months in the summer of 2013. Recruitment occurred at the free clinic during open hours by distributing flyers to
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patients in the waiting room. If a potential participant expressed interest in participating in the study, he or she received a consent cover letter and a self-administered paper and pencil survey. Members of the study team were available to answer any questions while participants were taking the survey. Measures Health Related Quality of Life Quality of life during the past 2 weeks was measured using WHOQOL-BREF with permission from US WHOQOL Center, University of Washington and Health Statistics and Health Information Systems, World Health Organization. The WHOQOL-BREF is found to be cross-culturally valid and internally consistent [20]. WHOQOL-BREF has 26 items using a 5-point Likert scale (1 = very poor, 5 = very good; 1 = very dissatisfied, 5 = satisfied; 5 or 1 = not at all, 1 or 5 = an extreme amount; 1 = not at all, 5 = extremely; 1 = not at all, 5 = completely) [21]. Twenty four items are included in one of four domains, including physical health (e.g., To what extent do you feel that physical pain prevents you from doing what you need to do?), psychological health (e.g., How much do you enjoy life?), social relationships (e.g., How satisfied are you with your personal relationships?) and environment (e.g., How satisfied are you with your transport?). Two items asking overall QoL are not scored for the domains. Scoring was performed based on WHOQOL User Manual [22]. Domain scores range from 0 to 100 with higher scores indicating better QoL.
developed by WHO Collaborating Center for Mental Health, Frederiksborg General Hospital [24]. WHO-5 consists of five items (e.g., I have felt cheerful and in good spirits) and has a 6-point Likert scale (5 = All of the time, 0 = At no time). Previous studies confirmed that the results of WHO-5 are highly sensitive and are validated to measure depression [24]. The score range is 0–25. Higher score refers to better mental health well-being. A score below 13 means possible indication for testing for depression under ICD-10. Neighborhood Environment and Socio-Demographic Characteristics The study used two of the sub-scales of Neighborhood Environment Walkability Scale (NEWS) [25], namely ‘‘safety from crime’’ and ‘‘neighborhood satisfaction.’’ The safety from crime sub-scale contains six questions (e.g., My neighborhood streets are well lit at night.) with a 4-point Likert scale (1 = strongly disagree, 4 = strongly agree). Three of the items are reverse coding items. The neighborhood satisfaction sub-scale has 17 items (e.g., Are you satisfied with how easy and pleasant it is to walk in your neighborhood?) with a 5-point Likert scale (1 = strongly dissatisfied, 5 = strongly satisfied). The coding system is a mean of the items for each sub-scale. NEWS has been validated [26] and has been used in multiple countries [27]. Demographic questions included age, gender, race/ethnicity, education level, employment status, marital status, country of origin, and length of years living in the US (nonUS born participants only). Data Analysis
Somatic Symptoms The Patient Health Questionnaire (PHQ)-15 is a valid, 15-item measure of somatic symptoms [23]. The PHQ-15 asks respondents to report somatic symptoms they have experienced in the past 4 weeks using a 3-point Likert scale (0 = Not bothered at all, 1 = Bothered a little, 2 = Bothered a lot). Examples of somatic complaints represented by the items include stomach pain, back pain, and headaches. PHQ-15 scores are defined as: no somatic disorder, 1–4; mild somatization disorder 5–9; moderate somatization disorder 10–14; severe somatization disorder 15?. Depression Depression that has occurred in the past 2 weeks was measured using WHO (five) Well-Being Index (1998 version) (WHO-5) with permission from the Psychiatric Research Unit at Hillerød in Denmark. WHO-5 was
Data were analyzed using SPSS (version 19). Descriptive statistics were used to describe the distribution of the outcome and independent variables. Descriptive data were presented as means with standard deviations (SDs) for continuous variables, and frequencies and percentages for categorical variables. The participants were classified into two groups: participants who were born in the US (US born), and those who were born outside of the US (non-US born). The two groups were compared using Pearson Chi square for categorical variables and independent samples t test for continuous variables. Multiple regression analysis was conducted to test the association between HRQoL and socio-demographic characteristics (i.e., age, US born, gender-female, some college or higher education, currently employed, and married), somatic symptoms, depression, perceived neighborhood safety, and perceived neighborhood satisfaction. Each QoL dependent variable, physical QoL, psychological QoL, social relations, and environmental
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QoL, was examined using separate models. Regression coefficients (standard errors) were used to obtain a 95 % confidence interval.
Results Table 1 presents the socio-demographic characteristics of the 186 participants. Ninety-seven (97) participants were US born and 89 participants were non-US born. The average age of the participants was 45.6 years (SD = 14.2). Non-US born participants (mean age 43.3 years old, SD = 15.3) were significantly younger than US born participants (mean age 47.7 years old, SD = 12.9) (p \ 0.05). Approximately 60 % of the participants (114) were women. Nearly 70 % of the US born participants were identified as white while approximately 45 % of the non-US born participants were identified as Hispanic. The distribution of race/ethnicity was significantly different between US born and non-US born participants (p \ 0.01). The percentage of participants with some college education or higher education was 62.4 (n = 116). Approximately 44 % of the participants (n = 82) were employed. About 43 % of the participants (n = 79) were married. Non-US born participants (n = 46, 51.7 %) were more likely to be married compared to US born participants (n = 33, 34 %) (p \ 0.05). Among non-US born participants, the average number of years residing in the US was 16.7 (SD = 10.5). The 186 participants represented 31 countries including the
US (n = 97, 52.2 %), Mexico (n = 14, 7.4 %), Tonga (n = 14, 7.4 %), and Brazil (n = 11, 5.9 %). Table 2 summarizes descriptive statistics of HRQoL, somatic symptoms, depression and perceived neighborhood environment and comparison between US born and non-US born participants. The average score of HRQoL for each domain was as follows: physical QoL (mean = 52.5, SD = 14.0), psychological QoL (mean = 56.8, SD = 14.7), social relations (mean = 54.4, SD = 25.0), and environmental QoL (mean = 53.6, SD = 17.2). NonUS born participants were more likely to report better psychological QoL and social relations compared to US born participants (p \ 0.05). The average score of PHQ-15, which measures somatic symptoms, was 9.9 (SD = 6.2). Based on the somatic symptoms scale of PHQ-15 [23], the participants reported mild somatization disorder on average. Non-US born participants (mean = 8.8, SD = 6.5, mild somatization disorder) reported significantly fewer somatic symptoms than US born participants (mean = 11.0, SD = 5.6, moderate somatization disorder) (p \ 0.05). The average score of WHO-5 which measures mental health well-being and depression was 13.0 (SD = 6.1). A score below 13 indicates poor mental health well-being and depression [24]. Non-US born participants (mean = 14.7, SD = 5.6) reported significantly better mental health wellTable 2 Quality of life, somatic symptoms, depression, and perceived neighborhood environment Variable
Total (n = 186)
US born (n = 97)
Non-US born (n = 89)
p valuee
Physical QoLa
52.5 (14.0)
50.9 (14.7)
54.3 (13.1)
NS
Psychological QoLa
56.8 (14.7)
54.2 (15.7)
59.5 (13.1) \0.05
Social relationsa
54.4 (25.0)
48.4 (27.6)
61.3 (1.4)
=0.01
Environmental QoLa
53.6 (17.2)
51.3 (18.5)
55.9 (15.6)
NS
9.9 (6.2)
11.0 (5.6)
8.8 (6.5)
\0.05
13.0 (6.1)
11.4 (6.2)
14.7 (5.6)
\0.01
Neighborhoodd safety
2.9 (0.6)
2.9 (0.6)
2.9 (0.5)
NS
Neighborhoodd satisfaction
3.5 (0.7)
3.5 (0.7)
3.6 (0.7)
NS
Table 1 Participant socio-demographic characteristics (n = 186) Total (n = 186)
US born (n = 97)
Mean age (years)
45.6 (14.2)
47.7 (12.9)
Female
114 (61.3)
59 (60.8)
Non-US born (n = 89)
p valuea
43.3 (15.3) \ 0.05 55 (61.8)
NS
Race/ethnicity White
74 (39.8)
65 (67.0)
9 (10.1) \ 0.01
Hispanic
58 (31.2)
18 (18.6)
40 (44.9) \ 0.01
35 (18.8)
5 (5.2)
30 (33.7) \ 0.01
116 (62.4)
62 (63.9)
54 (60.7)
NS
Currently employed
82 (44.1)
39 (40.2)
43 (48.3)
NS
Currently married Years in the US
79 (42.5)
33 (34.0)
46 (51.7) \ 0.05
Asian or Pacific Islander Some college or higher
N/A
16.7 (10.5)
No. (%) or Mean (SD) a
p value denotes significant Chi Square tests between categorical variables, and independent samples t tests for continuous variables. Comparing US born to their Non-US born participants
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PHQ-15 (somatic symptoms)b WHO-5 (depression)c
a
N/A
M (SD)
Higher score indicates better QoL
b
Higher score indicates more somatic symptoms
c
Higher score indicates lower level of depression
d
Higher score indicates better perceived neighborhood environment
e
p values reported are based on independent samples t tests of means comparing US born to Non-US born participants
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being than US born participants (mean = 11.4, SD = 6.2). The average score of perceived neighborhood safety was 2.9 (SD = 0.6) and of neighborhood satisfaction was 3.5 (SD = 0.7). There was no significant difference between US born participants and non-US born participants in perceived neighborhood safety and neighborhood satisfaction. Table 3 presents results of regression analysis to predict QoL. Older age was associated with poorer social relations and environmental QoL (p \ 0.01). Some college education or higher was related to poorer social relations (p \ 0.05). Greater somatic symptoms were associated with poorer environmental QoL (p \ 0.05). Better mental health well-being (lower level of depression) was associated with better QoL in all of the domains (p \ 0.01). Perceived better neighborhood safety was related to better environmental QoL (p \ 0.01). Higher neighborhood satisfaction was associated with better psychological QoL, social relations, and environmental QoL (p \ 0.05).
Discussion This study examined HRQoL, somatic symptoms, depression, and perceived neighborhood environment among US born and non-US born free clinic patients, and has three main findings. First, US born participants reported poorer psychological QoL and social relations, and more somatic
symptoms, and were more likely to be depressed compared to non-US born participants. Second, depression was associated with all aspects of QoL: a higher level of depression was related to poorer QoL in all aspects while higher level of somatic symptoms was associated with poorer environmental QoL. Third, higher perceived neighborhood satisfaction was associated with a higher level of QoL in psychological, social relations, and environmental aspects. US born participants reported poorer psychological QoL and social relations, and more somatic symptoms, and were more likely to be depressed compared to non-US born participants. This may be because immigrants often rebuild social capital in a destination country and maintain ties with other immigrants from the same country by contributing to the community [28]. Immigrants may also receive information, resources and assistance through networks with the community of their home country [29]. Transnational ties sometimes affect health of immigrants and help in shaping better health outcomes despite socio-economic disadvantages [30]. Such social networks may help non-US born free clinic patients maintain high quality and quantity of social relations, which contributes to good psychological QoL. While non-US born participants reported better HRQoL than US born participants, on average all participants had poorer HRQoL than the healthy population. Healthy adults
Table 3 Predictors of HRQoL (n = 186) Dependent variables
Physical QoLa b
P value
Independent variables (constant)
20.6
Psychological QoLa b
P value
Social relationsa b
P value
Environmental QoLa b
P value
\0.01
29.4
\0.01
17.7
NS
22.0
\0.01
Age
0.009
NS
-0.1
NS
-0.4
\0.01
-0.2
\0.01
US born
3.0
NS
-0.2
NS
-2.3
NS
Female
1.5
NS
0.5
NS
0.5
-1.4
NS
-2.2
NS
-6.6
Employed
2.6
NS
1.5
NS
1.7
Married
3.2
NS
-0.5
NS
4.6
PHQ-15b
-0.2
NS
-0.2
NS
WHO-5c
1.4
\0.01
1.3
Neighborhood safetyd
1.2
NS
2.2
Neighborhood satisfactiond
2.2
NS
3.4
Some college or higher
R2 F P value a
NS
3.1
NS
0.2
NS
-2.4
NS
NS
0.1
NS
NS
1.9
0.1
NS
-0.4
\0.05
\0.01
2.1
\0.01
1.3
\0.01
NS
2.7
NS
4.6
\0.01
\0.05
6.2
\0.05
4.3
\0.05
\0.05
0.4
0.4
0.5
0.5
14.3 \0.01
12.0 \0.01
13.6 \0.01
16.4 \0.01
NS
Higher score indicates better QoL
b
Higher score indicates more somatic symptoms
c
Higher score indicates lower level of depression
d
Higher score indicates better perceived neighborhood environment
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in the general population had WHOQOL-BREF scores of higher than 70 in each domain [31] which indicated much better HRQoL than that of the participants of this study. The participants of this study even reported poorer HRQoL than patients with chronic stroke [32]. In the study on patients with chronic stroke, patients reported higher scores in all aspects; physical 60.5 (SD = 21.2), psychological 59.8 (SD = 21.5), social relationships 62.1 (SD = 25.4), and environment 67.9 (SD = 19.1) than the participants of this study. Overall, the results suggest that non-US born participants reported medium somatic symptom severity while US born participants reported high severity based on the validated cut- off point for PHQ-15 [23]. Participants of this study reported fewer somatic symptoms compared to the study of medical outpatients (Hispanic = 14.4, SD = 5.3; Non-Hispanic = 13.4, SD = 5.6) [33]. US born participants, however, reported significantly more somatic symptoms than non-US born participants. Given that the majority of non-US born participants in this study are Hispanic, this result is opposite to that of the medical outpatient study [33]. Furthermore, higher somatic symptom severity was associated with poorer environmental HRQoL. In order to better understand the impact of environment on somatic symptoms among free clinic patients, future research should examine whether poor environmental HRQoL increases somatic symptoms. The level of depression reported by the participants of this study was near the cut-off point to determine further need for depression evaluation. US born participants were found to have higher depression scores on average than non-US born participants. The higher level of depression scoring was associated with all aspects of HRQoL. Previous studies show the concern of depression among free clinic patients [4]. The results of this study indicate that depression is an important issue among free clinic patients and has a negative effect on HRQoL. Reducing the level of depression among free clinic patients is a key to improving their HRQoL and/or vice versa. US born and non-US born participants of this study did not differ in levels of perceived neighborhood environment in terms of safety from crime and overall satisfaction. Yet average perception of safety from crime in neighborhoods among the participants of this study (2.9) indicated poorer perceived neighborhood safety than the low-income participants (3.18 for low walkability neighborhood and 2.97 for high walkability neighborhood) and high income participants (3.54) in a study conducted in Seattle, WA and Baltimore, MD [34]. Perceived neighborhood environments, especially neighborhood satisfaction among the free clinic patients, were significantly associated with HRQoL. Developing community-level collaborative networks to improve environments may be
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essential as this is not something that can be accomplished by one free clinic. Limitations This study has some limitations. It was cross-sectional and could not examine causal relationships. Future research should incorporate a longitudinal design in order to identify causal relationships between HRQoL, somatic symptoms, depression, and neighborhood environment. The non-US born participants were diverse, as they were from 31 different countries. Unfortunately the number of patients was not high enough to break down into groups by country or region to examine differences. Additionally, because the data were collected at one free clinic, generalizability to all free clinics across the US is limited. Most previous studies on free clinics were conducted only at one free clinic, or otherwise nationally surveyed demographic characteristics [35–37]. This may be because it is difficult to reach out to multiple free clinics since there is no formal networks of free clinics, and there is no way to count the actual number of free clinics [1]. It is essential to develop a research networks with multiple free clinics to better understand the health of these vulnerable populations.
Conclusions While free clinics have served the underserved population for over 40 years, there are few generalizable systematic studies on free clinics [6]. The actual outcomes of free clinic services are still not well known. This study added more detailed information about free clinic patients including new insights about HRQoL, somatic symptoms, depression, and perceived neighborhood environment, which few previous studies have examined. Our findings show that free clinic patients, especially US born patients, have poor HRQoL. Depression and perceived neighborhood satisfaction are key factors related to HRQoL among free clinic patients. Mental health services and collaboration with other community organizations may help in improving HRQoL among free clinic patients. Finally, health promotion programs at the community level, not just at the clinic level, would be valuable to improve health of free clinic patients as perceived neighborhood environment is associated with their HRQoL. Acknowledgments This Project was partially funded by the College of Social and Behavioral Science, University of Utah. The authors want to thank the patients who participated in this study and acknowledge the contribution of the staff and volunteers of the Maliheh Free Clinic. In addition, we thank Phat Doan, Anna Horton, Shauna Ma, Jessica McLamb, Usha Ojha, Chris Sparks, Silvia Solis, and Ali Wheatley for their help in data collection and entry.
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18. Gidlow, C., Cochrane, T., Davey, R. C., Smith, G., & Fairburn, J. (2010). Relative importance of physical and social aspects of perceived neighbourhood environment for self-reported health. Preventive Medicine, 51(2), 157–163. 19. Mair, C., Diez Roux, A. V., & Morenoff, J. D. (2010). Neighborhood stressors and social support as predictors of depressive symptoms in the Chicago Community Adult Health Study. Health & Place, 16(5), 811–819. 20. Skevington, S. M., Lotfy, M., O’Connell, K. A., & Group, W. (2004). The World Health Organization’s WHOQOL-BREF quality of life assessment: Psychometric properties and results of the international field trial. A report from the WHOQOL group. Quality of Life Research, 13(2), 299–310. 21. Bonomi, A. E., Patrick, D. L., Bushnell, D. M., & Martin, M. (2000). Validation of the United States’ version of the World Health Organization Quality of Life (WHOQOL) instrument. Journal of Clinical Epidemiology, 53(1), 1–12. 22. World Health Organization. (1998). WHOQOL user manual. Geneva: WHO. 23. Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2002). The PHQ-15: Validity of a new measure for evaluating the severity of somatic symptoms. Psychosomatic Medicine, 64(2), 258–266. 24. Bech, P. (2012). Clinical psychometrics. Oxford: Wiley. 25. Saelens, B. E., Sallis, J. F., Black, J. B., & Chen, D. (2003). Neighborhood-based differences in physical activity: An environment scale evaluation. American Journal of Public Health, 93(9), 1552–1558. 26. Adams, M. A., Ryan, S., Kerr, J., Sallis, J. F., Patrick, K., Frank, L. D., et al. (2009). Validation of the Neighborhood Environment Walkability Scale (NEWS) items using geographic information systems. Journal of Physical Activity & Health, 6(Suppl 1), S113–S123. 27. Adams, M. A., Sallis, J. F., Kerr, J., Conway, T. L., Saelens, B. E., & Frank, L. D. (2011). Neighborhood environment profiles related to physical activity and weight status: A latent profile analysis. Preventive Medicine, 52(5), 326–331. 28. Falicov, C. J. (2007). Working with transnational immigrants: Expanding meanings of family, community, and culture. Family Process, 46(2), 157–171. 29. Bernosky de Flores, C. H. (2010). A conceptual framework for the study of social capital in new destination immigrant communities. Journal of Transcultural Nursing, 21(3), 205–211. 30. Acevedo-Garcia, D., Soobader, M. J., & Berkman, L. F. (2007). Low birthweight among US Hispanic/Latino subgroups: The effect of maternal foreign-born status and education. Social Science and Medicine, 65(12), 2503–2516. 31. Skevington, S. M., & McCrate, F. M. (2012). Expecting a good quality of life in health: Assessing people with diverse diseases and conditions using the WHOQOL-BREF. Health Expectations, 15(1), 49–62. 32. Edwards, B., & O’Connell, B. (2003). Internal consistency and validity of the Stroke Impact Scale 2.0 (SIS 2.0) and SIS-16 in an Australian sample. Quality of Life Research, 12(8), 1127–1135. 33. Interian, A., Allen, L. A., Gara, M. A., Escobar, J. I., & DiazMartinez, A. M. (2006). Somatic complaints in primary care: Further examining the validity of the patient health questionnaire (PHQ-15). Psychosomatics, 47(5), 392–398. 34. Sallis, J. F., Slymen, D. J., Conway, T. L., Frank, L. D., Saelens, B. E., Cain, K., et al. (2011). Income disparities in perceived neighborhood built and social environment attributes. Health & Place, 17(6), 1274–1283. 35. Notaro, S. J., Khan, M., Kim, C., Nasaruddin, M., & Desai, K. (2013). Analysis of the health status of the homeless clients utilizing a free clinic. Journal of Community Health, 38(1), 172–177. 36. Gertz, A. M., Frank, S., & Blixen, C. E. (2011). A survey of patients and providers at free clinics across the United States. Journal of Community Health, 36(1), 83–93. 37. Darnell, J. S. (2010). Free clinics in the United States a Nationwide Survey. Archives of Internal Medicine, 170(11), 946–953.
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ORIGINAL PAPER
Quality of Life Among Free Clinic Patients Associated with Somatic Symptoms, Depression, and Perceived Neighborhood Environment Akiko Kamimura • Nancy Christensen • Jamie A. Prevedel • Jennifer Tabler • Brian J. Hamilton • Jeanie Ashby • Justine J. Reel
Ó Springer Science+Business Media New York 2013
Abstract Free clinics provide free or reduced fee healthcare to individuals who lack access to primary care and are socio-economically disadvantaged. The purpose of this study is to examine health-related quality of life (HRQoL) among free clinic patients and its association with somatic symptoms, depression, and perceived neighborhood environment. Free clinic patients (n = 186) aged 18 years or older completed a self-administered survey. HRQoL, depression, somatic symptoms, and perceived neighborhood environment were measured using standardized instruments. Overall, the participants reported low level of HRQoL compared to the general healthy population. US born participants (n = 97) reported poorer psychological QoL and social relations, more somatic symptoms, and were more likely to be depressed than non-
US born participants (n = 89). Higher numbers of somatic symptoms were associated with poorer environmental QoL. Depression was associated with all aspects of QoL; a higher level of depression was related to poorer QoL in all aspects. Our findings show that free clinic patients, especially US born patients, have poor HRQoL. Depression and perceived neighborhood satisfaction are key factors to determine HRQoL among free clinic patients. Mental health services and collaboration with other community organizations may help in improving HRQoL among free clinic patients. Finally, health promotion programs at the community level, not just at the clinic level, would be valuable to improve health of free clinic patients as perceived neighborhood environment is associated with their HRQoL.
Human Participants Protection The University of Utah Institutional Review Board approved this study as an Exempt protocol.
Keywords Free clinics Health-related quality of life Depression Somatic symptoms Perceived neighborhood environment
A. Kamimura (&) J. Tabler Department of Sociology, University of Utah, 380 S 1530 E, Salt Lake City, UT 84112, USA e-mail: [email protected] N. Christensen J. Ashby Maliheh Free Clinic, Salt Lake City, UT, USA J. A. Prevedel School of Medicine, University of Utah, Salt Lake City, UT, USA B. J. Hamilton Division of Public Health, University of Utah, Salt Lake City, UT, USA J. J. Reel Department of Health Promotion and Education, University of Utah, Salt Lake City, UT, USA
Introduction Free clinics provide free or reduced fee healthcare to individuals who lack access to primary care and are socioeconomically disadvantaged [1–3]. Started in 1967 with the goal to increase healthcare access, there are approximately 1,200 free clinics that are currently operating throughout the US [1]. Free clinics have taken unique and nontraditional approaches to eliminate barriers that prevent access to care for the underserved in the community [1]. In general, free clinic patients are uninsured or under insured, have low or no income, and are at risk for increased physical and mental health needs [4]. For example, free clinic patients have overall low physical and mental health
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functioning [4] and higher obesity rates [5] compared to the US general population. Although free clinic patients have been identified as ‘‘at risk’’ for chronic diseases (e.g., heart disease), little knowledge exists about free clinic patients’ health related quality of life (HRQoL), and the environmental factors shaping it [6]. Such information would be useful in better understanding the free clinic population and developing health promotion interventions to address health concerns associated with individuals who frequent free clinics. Free clinic patients may be at risk for poor HRQoL outcomes based on the negative correlation between income and HRQoL [7]. HRQoL refers to how a person perceives one’s own well-being including happiness and satisfaction of life related to self-reported chronic conditions and risk factors [8]. Disease specific QoL research is common in clinical research such as breast cancer [9], heart failure [10], or stroke [11]. However, QoL is often related, not only to medical conditions, but also to cultures and socio-demographic characteristics such as age, income, or gender [12]. Somatic symptoms, which are medically unexplained chronic or disabling physical symptoms [13], also impair HRQoL [14]. These symptoms are important mental health problems found amongst nationally representative Latino and Asian populations in the US [13]. Because there is a paucity of research surrounding somatic symptoms among free clinic patients, it is important to investigate how these symptoms are related to HRQoL within this population. Furthermore, HRQoL is also related to depression [15]. For example, poor physical HRQoL is associated with high levels of depression [16]. Given that free clinic patients reported moderate to severe levels of depression [4], depression should be taken into account when examining HRQoL among free clinic patients. An additional factor impacting HRQoL is perceived neighborhood environment. Perceived neighborhood context is associated with health status due to its impact on sleep quality [17] and is related to both physical and mental health [18]. Neighborhood stressors such as perceived violence can be related to increased depressive symptoms [19]. There are, however, very few studies that examine the connection between the health of free clinic patients and their perceived neighborhood environment. The purpose of this study is to examine HRQoL among free clinic patients and its association with somatic symptoms, depression, and perceived neighborhood environment. Results from this study will provide both practical and research implications to improve HRQoL among US born and non-US born free clinic patients and can lead to the development of future interventions for the underserved population in the community. To our knowledge, this is one of the first studies on HRQoL among free clinic
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patients. This study contributes to expanding the literature on culturally diverse, immigrant, and the socio-economically disadvantaged patients being served in a free clinic setting.
Methods Overview The current community-based research project was conducted at a free clinic in the Intermountain West. The clinic staff collaborated with this research team to develop the survey instrument, study protocol, participant recruitment strategies, and interpreting study results. The clinic (the data collection site) provides free health care services comprised of mostly routine health maintenance and preventative care for uninsured individuals from both urban and suburban areas. The free clinic, which has been in operation for over 7 years, has no affiliation with religious organizations and is funded by non-governmental grants and donations. The clinic, staffed by six full-time paid personnel and over 250 active volunteers, is open 5 days a week. The number of patient visits was 15,209 in 2012. To qualify for services at the clinic, an individual must live below the 150th percentile poverty level and not have access to employer-provided or government-funded health insurance. The clinic does not ask for patients to provide documentation of legal residency or citizenship. Participants Inclusion criteria for participants included being 18 years or older, speaking and reading English, and being a patient of the clinic. The following patients were excluded: patients who were younger than 18 years, and/or who did not speak and read English. Some clinic patients speak other languages such as Spanish, Tongan, Arabic, Russian, Portuguese, Persian, and Vietnamese. A portion of Spanish speakers also speak English. Most foreign-born patients speak English. The research team examined differences by country of origin (i.e., US born and non-US born) because differences in birthplace, US born or non-US born, have coincided with differences in physical and mental health statuses of free clinic patients [4]. Data Collection Prior to data collection, the institution’s review board approved this study as an exempt protocol. The data were collected several times a week (1–2 h each time) for 2 months in the summer of 2013. Recruitment occurred at the free clinic during open hours by distributing flyers to
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patients in the waiting room. If a potential participant expressed interest in participating in the study, he or she received a consent cover letter and a self-administered paper and pencil survey. Members of the study team were available to answer any questions while participants were taking the survey. Measures Health Related Quality of Life Quality of life during the past 2 weeks was measured using WHOQOL-BREF with permission from US WHOQOL Center, University of Washington and Health Statistics and Health Information Systems, World Health Organization. The WHOQOL-BREF is found to be cross-culturally valid and internally consistent [20]. WHOQOL-BREF has 26 items using a 5-point Likert scale (1 = very poor, 5 = very good; 1 = very dissatisfied, 5 = satisfied; 5 or 1 = not at all, 1 or 5 = an extreme amount; 1 = not at all, 5 = extremely; 1 = not at all, 5 = completely) [21]. Twenty four items are included in one of four domains, including physical health (e.g., To what extent do you feel that physical pain prevents you from doing what you need to do?), psychological health (e.g., How much do you enjoy life?), social relationships (e.g., How satisfied are you with your personal relationships?) and environment (e.g., How satisfied are you with your transport?). Two items asking overall QoL are not scored for the domains. Scoring was performed based on WHOQOL User Manual [22]. Domain scores range from 0 to 100 with higher scores indicating better QoL.
developed by WHO Collaborating Center for Mental Health, Frederiksborg General Hospital [24]. WHO-5 consists of five items (e.g., I have felt cheerful and in good spirits) and has a 6-point Likert scale (5 = All of the time, 0 = At no time). Previous studies confirmed that the results of WHO-5 are highly sensitive and are validated to measure depression [24]. The score range is 0–25. Higher score refers to better mental health well-being. A score below 13 means possible indication for testing for depression under ICD-10. Neighborhood Environment and Socio-Demographic Characteristics The study used two of the sub-scales of Neighborhood Environment Walkability Scale (NEWS) [25], namely ‘‘safety from crime’’ and ‘‘neighborhood satisfaction.’’ The safety from crime sub-scale contains six questions (e.g., My neighborhood streets are well lit at night.) with a 4-point Likert scale (1 = strongly disagree, 4 = strongly agree). Three of the items are reverse coding items. The neighborhood satisfaction sub-scale has 17 items (e.g., Are you satisfied with how easy and pleasant it is to walk in your neighborhood?) with a 5-point Likert scale (1 = strongly dissatisfied, 5 = strongly satisfied). The coding system is a mean of the items for each sub-scale. NEWS has been validated [26] and has been used in multiple countries [27]. Demographic questions included age, gender, race/ethnicity, education level, employment status, marital status, country of origin, and length of years living in the US (nonUS born participants only). Data Analysis
Somatic Symptoms The Patient Health Questionnaire (PHQ)-15 is a valid, 15-item measure of somatic symptoms [23]. The PHQ-15 asks respondents to report somatic symptoms they have experienced in the past 4 weeks using a 3-point Likert scale (0 = Not bothered at all, 1 = Bothered a little, 2 = Bothered a lot). Examples of somatic complaints represented by the items include stomach pain, back pain, and headaches. PHQ-15 scores are defined as: no somatic disorder, 1–4; mild somatization disorder 5–9; moderate somatization disorder 10–14; severe somatization disorder 15?. Depression Depression that has occurred in the past 2 weeks was measured using WHO (five) Well-Being Index (1998 version) (WHO-5) with permission from the Psychiatric Research Unit at Hillerød in Denmark. WHO-5 was
Data were analyzed using SPSS (version 19). Descriptive statistics were used to describe the distribution of the outcome and independent variables. Descriptive data were presented as means with standard deviations (SDs) for continuous variables, and frequencies and percentages for categorical variables. The participants were classified into two groups: participants who were born in the US (US born), and those who were born outside of the US (non-US born). The two groups were compared using Pearson Chi square for categorical variables and independent samples t test for continuous variables. Multiple regression analysis was conducted to test the association between HRQoL and socio-demographic characteristics (i.e., age, US born, gender-female, some college or higher education, currently employed, and married), somatic symptoms, depression, perceived neighborhood safety, and perceived neighborhood satisfaction. Each QoL dependent variable, physical QoL, psychological QoL, social relations, and environmental
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QoL, was examined using separate models. Regression coefficients (standard errors) were used to obtain a 95 % confidence interval.
Results Table 1 presents the socio-demographic characteristics of the 186 participants. Ninety-seven (97) participants were US born and 89 participants were non-US born. The average age of the participants was 45.6 years (SD = 14.2). Non-US born participants (mean age 43.3 years old, SD = 15.3) were significantly younger than US born participants (mean age 47.7 years old, SD = 12.9) (p \ 0.05). Approximately 60 % of the participants (114) were women. Nearly 70 % of the US born participants were identified as white while approximately 45 % of the non-US born participants were identified as Hispanic. The distribution of race/ethnicity was significantly different between US born and non-US born participants (p \ 0.01). The percentage of participants with some college education or higher education was 62.4 (n = 116). Approximately 44 % of the participants (n = 82) were employed. About 43 % of the participants (n = 79) were married. Non-US born participants (n = 46, 51.7 %) were more likely to be married compared to US born participants (n = 33, 34 %) (p \ 0.05). Among non-US born participants, the average number of years residing in the US was 16.7 (SD = 10.5). The 186 participants represented 31 countries including the
US (n = 97, 52.2 %), Mexico (n = 14, 7.4 %), Tonga (n = 14, 7.4 %), and Brazil (n = 11, 5.9 %). Table 2 summarizes descriptive statistics of HRQoL, somatic symptoms, depression and perceived neighborhood environment and comparison between US born and non-US born participants. The average score of HRQoL for each domain was as follows: physical QoL (mean = 52.5, SD = 14.0), psychological QoL (mean = 56.8, SD = 14.7), social relations (mean = 54.4, SD = 25.0), and environmental QoL (mean = 53.6, SD = 17.2). NonUS born participants were more likely to report better psychological QoL and social relations compared to US born participants (p \ 0.05). The average score of PHQ-15, which measures somatic symptoms, was 9.9 (SD = 6.2). Based on the somatic symptoms scale of PHQ-15 [23], the participants reported mild somatization disorder on average. Non-US born participants (mean = 8.8, SD = 6.5, mild somatization disorder) reported significantly fewer somatic symptoms than US born participants (mean = 11.0, SD = 5.6, moderate somatization disorder) (p \ 0.05). The average score of WHO-5 which measures mental health well-being and depression was 13.0 (SD = 6.1). A score below 13 indicates poor mental health well-being and depression [24]. Non-US born participants (mean = 14.7, SD = 5.6) reported significantly better mental health wellTable 2 Quality of life, somatic symptoms, depression, and perceived neighborhood environment Variable
Total (n = 186)
US born (n = 97)
Non-US born (n = 89)
p valuee
Physical QoLa
52.5 (14.0)
50.9 (14.7)
54.3 (13.1)
NS
Psychological QoLa
56.8 (14.7)
54.2 (15.7)
59.5 (13.1) \0.05
Social relationsa
54.4 (25.0)
48.4 (27.6)
61.3 (1.4)
=0.01
Environmental QoLa
53.6 (17.2)
51.3 (18.5)
55.9 (15.6)
NS
9.9 (6.2)
11.0 (5.6)
8.8 (6.5)
\0.05
13.0 (6.1)
11.4 (6.2)
14.7 (5.6)
\0.01
Neighborhoodd safety
2.9 (0.6)
2.9 (0.6)
2.9 (0.5)
NS
Neighborhoodd satisfaction
3.5 (0.7)
3.5 (0.7)
3.6 (0.7)
NS
Table 1 Participant socio-demographic characteristics (n = 186) Total (n = 186)
US born (n = 97)
Mean age (years)
45.6 (14.2)
47.7 (12.9)
Female
114 (61.3)
59 (60.8)
Non-US born (n = 89)
p valuea
43.3 (15.3) \ 0.05 55 (61.8)
NS
Race/ethnicity White
74 (39.8)
65 (67.0)
9 (10.1) \ 0.01
Hispanic
58 (31.2)
18 (18.6)
40 (44.9) \ 0.01
35 (18.8)
5 (5.2)
30 (33.7) \ 0.01
116 (62.4)
62 (63.9)
54 (60.7)
NS
Currently employed
82 (44.1)
39 (40.2)
43 (48.3)
NS
Currently married Years in the US
79 (42.5)
33 (34.0)
46 (51.7) \ 0.05
Asian or Pacific Islander Some college or higher
N/A
16.7 (10.5)
No. (%) or Mean (SD) a
p value denotes significant Chi Square tests between categorical variables, and independent samples t tests for continuous variables. Comparing US born to their Non-US born participants
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PHQ-15 (somatic symptoms)b WHO-5 (depression)c
a
N/A
M (SD)
Higher score indicates better QoL
b
Higher score indicates more somatic symptoms
c
Higher score indicates lower level of depression
d
Higher score indicates better perceived neighborhood environment
e
p values reported are based on independent samples t tests of means comparing US born to Non-US born participants
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being than US born participants (mean = 11.4, SD = 6.2). The average score of perceived neighborhood safety was 2.9 (SD = 0.6) and of neighborhood satisfaction was 3.5 (SD = 0.7). There was no significant difference between US born participants and non-US born participants in perceived neighborhood safety and neighborhood satisfaction. Table 3 presents results of regression analysis to predict QoL. Older age was associated with poorer social relations and environmental QoL (p \ 0.01). Some college education or higher was related to poorer social relations (p \ 0.05). Greater somatic symptoms were associated with poorer environmental QoL (p \ 0.05). Better mental health well-being (lower level of depression) was associated with better QoL in all of the domains (p \ 0.01). Perceived better neighborhood safety was related to better environmental QoL (p \ 0.01). Higher neighborhood satisfaction was associated with better psychological QoL, social relations, and environmental QoL (p \ 0.05).
Discussion This study examined HRQoL, somatic symptoms, depression, and perceived neighborhood environment among US born and non-US born free clinic patients, and has three main findings. First, US born participants reported poorer psychological QoL and social relations, and more somatic
symptoms, and were more likely to be depressed compared to non-US born participants. Second, depression was associated with all aspects of QoL: a higher level of depression was related to poorer QoL in all aspects while higher level of somatic symptoms was associated with poorer environmental QoL. Third, higher perceived neighborhood satisfaction was associated with a higher level of QoL in psychological, social relations, and environmental aspects. US born participants reported poorer psychological QoL and social relations, and more somatic symptoms, and were more likely to be depressed compared to non-US born participants. This may be because immigrants often rebuild social capital in a destination country and maintain ties with other immigrants from the same country by contributing to the community [28]. Immigrants may also receive information, resources and assistance through networks with the community of their home country [29]. Transnational ties sometimes affect health of immigrants and help in shaping better health outcomes despite socio-economic disadvantages [30]. Such social networks may help non-US born free clinic patients maintain high quality and quantity of social relations, which contributes to good psychological QoL. While non-US born participants reported better HRQoL than US born participants, on average all participants had poorer HRQoL than the healthy population. Healthy adults
Table 3 Predictors of HRQoL (n = 186) Dependent variables
Physical QoLa b
P value
Independent variables (constant)
20.6
Psychological QoLa b
P value
Social relationsa b
P value
Environmental QoLa b
P value
\0.01
29.4
\0.01
17.7
NS
22.0
\0.01
Age
0.009
NS
-0.1
NS
-0.4
\0.01
-0.2
\0.01
US born
3.0
NS
-0.2
NS
-2.3
NS
Female
1.5
NS
0.5
NS
0.5
-1.4
NS
-2.2
NS
-6.6
Employed
2.6
NS
1.5
NS
1.7
Married
3.2
NS
-0.5
NS
4.6
PHQ-15b
-0.2
NS
-0.2
NS
WHO-5c
1.4
\0.01
1.3
Neighborhood safetyd
1.2
NS
2.2
Neighborhood satisfactiond
2.2
NS
3.4
Some college or higher
R2 F P value a
NS
3.1
NS
0.2
NS
-2.4
NS
NS
0.1
NS
NS
1.9
0.1
NS
-0.4
\0.05
\0.01
2.1
\0.01
1.3
\0.01
NS
2.7
NS
4.6
\0.01
\0.05
6.2
\0.05
4.3
\0.05
\0.05
0.4
0.4
0.5
0.5
14.3 \0.01
12.0 \0.01
13.6 \0.01
16.4 \0.01
NS
Higher score indicates better QoL
b
Higher score indicates more somatic symptoms
c
Higher score indicates lower level of depression
d
Higher score indicates better perceived neighborhood environment
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in the general population had WHOQOL-BREF scores of higher than 70 in each domain [31] which indicated much better HRQoL than that of the participants of this study. The participants of this study even reported poorer HRQoL than patients with chronic stroke [32]. In the study on patients with chronic stroke, patients reported higher scores in all aspects; physical 60.5 (SD = 21.2), psychological 59.8 (SD = 21.5), social relationships 62.1 (SD = 25.4), and environment 67.9 (SD = 19.1) than the participants of this study. Overall, the results suggest that non-US born participants reported medium somatic symptom severity while US born participants reported high severity based on the validated cut- off point for PHQ-15 [23]. Participants of this study reported fewer somatic symptoms compared to the study of medical outpatients (Hispanic = 14.4, SD = 5.3; Non-Hispanic = 13.4, SD = 5.6) [33]. US born participants, however, reported significantly more somatic symptoms than non-US born participants. Given that the majority of non-US born participants in this study are Hispanic, this result is opposite to that of the medical outpatient study [33]. Furthermore, higher somatic symptom severity was associated with poorer environmental HRQoL. In order to better understand the impact of environment on somatic symptoms among free clinic patients, future research should examine whether poor environmental HRQoL increases somatic symptoms. The level of depression reported by the participants of this study was near the cut-off point to determine further need for depression evaluation. US born participants were found to have higher depression scores on average than non-US born participants. The higher level of depression scoring was associated with all aspects of HRQoL. Previous studies show the concern of depression among free clinic patients [4]. The results of this study indicate that depression is an important issue among free clinic patients and has a negative effect on HRQoL. Reducing the level of depression among free clinic patients is a key to improving their HRQoL and/or vice versa. US born and non-US born participants of this study did not differ in levels of perceived neighborhood environment in terms of safety from crime and overall satisfaction. Yet average perception of safety from crime in neighborhoods among the participants of this study (2.9) indicated poorer perceived neighborhood safety than the low-income participants (3.18 for low walkability neighborhood and 2.97 for high walkability neighborhood) and high income participants (3.54) in a study conducted in Seattle, WA and Baltimore, MD [34]. Perceived neighborhood environments, especially neighborhood satisfaction among the free clinic patients, were significantly associated with HRQoL. Developing community-level collaborative networks to improve environments may be
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essential as this is not something that can be accomplished by one free clinic. Limitations This study has some limitations. It was cross-sectional and could not examine causal relationships. Future research should incorporate a longitudinal design in order to identify causal relationships between HRQoL, somatic symptoms, depression, and neighborhood environment. The non-US born participants were diverse, as they were from 31 different countries. Unfortunately the number of patients was not high enough to break down into groups by country or region to examine differences. Additionally, because the data were collected at one free clinic, generalizability to all free clinics across the US is limited. Most previous studies on free clinics were conducted only at one free clinic, or otherwise nationally surveyed demographic characteristics [35–37]. This may be because it is difficult to reach out to multiple free clinics since there is no formal networks of free clinics, and there is no way to count the actual number of free clinics [1]. It is essential to develop a research networks with multiple free clinics to better understand the health of these vulnerable populations.
Conclusions While free clinics have served the underserved population for over 40 years, there are few generalizable systematic studies on free clinics [6]. The actual outcomes of free clinic services are still not well known. This study added more detailed information about free clinic patients including new insights about HRQoL, somatic symptoms, depression, and perceived neighborhood environment, which few previous studies have examined. Our findings show that free clinic patients, especially US born patients, have poor HRQoL. Depression and perceived neighborhood satisfaction are key factors related to HRQoL among free clinic patients. Mental health services and collaboration with other community organizations may help in improving HRQoL among free clinic patients. Finally, health promotion programs at the community level, not just at the clinic level, would be valuable to improve health of free clinic patients as perceived neighborhood environment is associated with their HRQoL. Acknowledgments This Project was partially funded by the College of Social and Behavioral Science, University of Utah. The authors want to thank the patients who participated in this study and acknowledge the contribution of the staff and volunteers of the Maliheh Free Clinic. In addition, we thank Phat Doan, Anna Horton, Shauna Ma, Jessica McLamb, Usha Ojha, Chris Sparks, Silvia Solis, and Ali Wheatley for their help in data collection and entry.
J Community Health
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