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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
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.
October 2013 Issue of IMpact