Winning Abstracts from the 2013 Medical Student Abstract Competition: Legal Needs among Urban Safety Net Clinic Patients
Author: Lauren E. Ayres, University of Colorado School of Medicine, Class of 2015
Introduction: Social determinants cause marked disparities in health across racial, ethnic and socioeconomic lines. In the clinical setting, too little attention is given to the role of the law in addressing the social causes of poor health. Legal problems--from unsafe housing to bankruptcy--are inextricably tied to health. This study sought to: measure the prevalence of legal needs among patients visiting an urban safety net clinic; identify demographic characteristics associated with legal needs; and ascertain whether legal needs are associated with poor health.
Methods: Over a 2-week period, a 29-question written survey (English and Spanish) was presented to all families in the waiting room of Salud Family Health Center, a safety net clinic in metro-Denver. In addition to demographics, participants were asked if they had experienced any of 12 legal problems in the last year, grouped according to the National Center for Medical-Legal Partnership's classification (income, insurance, housing, education, employment, legal status and family safety). Participants who reported at least one legal problem were asked about the impact of the problem(s) on their health. Responses were summarized using proportions and 95% confidence intervals (95CI); odds ratios (OR) and 95CI were calculated to test for associations between patient characteristics and legal needs.
Results: Surveys were collected from 602 patients (334 English, 268 Spanish). Most were under age 40 (56%), female (74%), Hispanic (73%), and indigent (annual income < $25,000) (79%). Significant proportions never graduated from high school (37%), reported "fair" or "poor" health (36%) and reported limitations in performing daily activities (ADLs) because of a chronic health problem (31%). Overall, 403 (66.9%; 95CI: 63.2-70.7) reported at least one legal problem in the past year. Among those with legal problems: 135/321 (42.1%; 95CI: 36.8-47.5) stated their legal problem(s) caused or exacerbated a health condition, and 241/288 (83.7%; 95CI: 79.4-87.9) reported no access to legal services. Legal problems were associated with: poor health (OR: 1.81; 95CI: 1.16-2.82), impaired ability to perform ADLs due to a health condition (OR: 1.89; 95CI: 1.26-2.86), under-employment (OR: 1.68; 95CI: 1.15-2.46), unstable housing (OR: 2.93, 95CI: 1.21-7.08), and annual income < $25,000 (OR: 1.92; 95CI: 1.23-2.96). Legal needs were not associated with ethnicity or language preference. In a multiple logistic regression (n=384), under-employment (OR: 2.04; 95CI: 1.22-3.41) and low income (OR: 2.12; 95CI: 1.2-3.7) were associated with legal needs.
Conclusion: Although limited by different response rates for some questions on the English and Spanish surveys, the results suggest that legal needs among patients visiting an urban safety net clinic are widespread and may be associated with poor health. Additional studies are needed to ascertain the benefit of routine screening for legal needs and the efficacy of medical-legal partnerships in resolving patients' legal problems and improving health outcomes.