Quality of Life Among Free Clinic Patients Associated with Somatic Symptoms, Depression, and Perceived Neighborhood Environment

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Journal of Community HealthThe Publication for Health Promotionand Disease Prevention ISSN 0094-5145Volume 39Number 3 J Community Health (2014) 39:524-530DOI 10.1007/s10900-013-9790-x

Quality of Life Among Free Clinic PatientsAssociated with Somatic Symptoms,Depression, and Perceived NeighborhoodEnvironment

Akiko Kamimura, Nancy Christensen,Jamie A. Prevedel, Jennifer Tabler, BrianJ. Hamilton, Jeanie Ashby & JustineJ. Reel

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ORIGINAL PAPER

Quality of Life Among Free Clinic Patients Associatedwith Somatic Symptoms, Depression, and PerceivedNeighborhood Environment

Akiko Kamimura • Nancy Christensen •

Jamie A. Prevedel • Jennifer Tabler •

Brian J. Hamilton • Jeanie Ashby • Justine J. Reel

Published online: 12 November 2013

� 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 neigh-

borhood 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 stan-

dardized instruments. Overall, the participants reported low

level of HRQoL compared to the general healthy popula-

tion. US born participants (n = 97) reported poorer psy-

chological 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, espe-

cially 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 per-

ceived neighborhood environment is associated with their

HRQoL.

Keywords Free clinics � Health-related quality of

life � Depression � Somatic symptoms � Perceived

neighborhood environment

Introduction

Free clinics provide free or reduced fee healthcare to

individuals who lack access to primary care and are socio-

economically 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 nontradi-

tional approaches to eliminate barriers that prevent access

to care for the underserved in the community [1]. In gen-

eral, 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

Human Participants Protection The University of Utah Institutional

Review Board approved this study as an Exempt protocol.

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

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DOI 10.1007/s10900-013-9790-x

Author's personal copy

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 environ-

mental 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 condi-

tions 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 con-

text 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 symp-

toms, depression, and perceived neighborhood environ-

ment. 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

patients. This study contributes to expanding the literature

on culturally diverse, immigrant, and the socio-economi-

cally disadvantaged patients being served in a free clinic

setting.

Methods

Overview

The current community-based research project was con-

ducted 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 pre-

ventative 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.

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 ver-

sion) (WHO-5) with permission from the Psychiatric

Research Unit at Hillerød in Denmark. WHO-5 was

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 neigh-

borhood 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/ethnic-

ity, education level, employment status, marital status,

country of origin, and length of years living in the US (non-

US born participants only).

Data Analysis

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 satis-

faction. 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 aver-

age 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 par-

ticipants (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 par-

ticipants 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 educa-

tion was 62.4 (n = 116). Approximately 44 % of the par-

ticipants (n = 82) were employed. About 43 % of the

participants (n = 79) were married. Non-US born partici-

pants (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). Non-

US 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 par-

ticipants (mean = 8.8, SD = 6.5, mild somatization dis-

order) 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 well-

Table 1 Participant socio-demographic characteristics (n = 186)

Total

(n = 186)

US born

(n = 97)

Non-US

born

(n = 89)

p valuea

Mean age (years) 45.6 (14.2) 47.7 (12.9) 43.3 (15.3) \ 0.05

Female 114 (61.3) 59 (60.8) 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

Asian or Pacific

Islander

35 (18.8) 5 (5.2) 30 (33.7) \ 0.01

Some college

or higher

116 (62.4) 62 (63.9) 54 (60.7) NS

Currently

employed

82 (44.1) 39 (40.2) 43 (48.3) NS

Currently

married

79 (42.5) 33 (34.0) 46 (51.7) \ 0.05

Years in the US N/A 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

Table 2 Quality of life, somatic symptoms, depression, and per-

ceived neighborhood environment

Variable M (SD)

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

QoLa56.8 (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

QoLa53.6 (17.2) 51.3 (18.5) 55.9 (15.6) NS

PHQ-15 (somatic

symptoms)b9.9 (6.2) 11.0 (5.6) 8.8 (6.5) \0.05

WHO-5

(depression)c13.0 (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

a Higher score indicates better QoLb Higher score indicates more somatic symptomsc Higher score indicates lower level of depressiond Higher score indicates better perceived neighborhood environmente 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 per-

ceived 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 educa-

tion 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 associ-

ated 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 sat-

isfaction was associated with better psychological QoL,

social relations, and environmental QoL (p \ 0.05).

Discussion

This study examined HRQoL, somatic symptoms, depres-

sion, 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 envi-

ronmental 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 contrib-

uting to the community [28]. Immigrants may also receive

information, resources and assistance through networks

with the community of their home country [29]. Transna-

tional 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 bP value Psychological

QoLa bP value Social

relationsa bP value Environmental

QoLa bP value

Independent variables (constant) 20.6 \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 3.1 NS

Female 1.5 NS 0.5 NS 0.5 NS 0.2 NS

Some college or higher -1.4 NS -2.2 NS -6.6 \0.05 -2.4 NS

Employed 2.6 NS 1.5 NS 1.7 NS 0.1 NS

Married 3.2 NS -0.5 NS 4.6 NS 1.9 NS

PHQ-15b -0.2 NS -0.2 NS 0.1 NS -0.4 \0.05

WHO-5c 1.4 \0.01 1.3 \0.01 2.1 \0.01 1.3 \0.01

Neighborhood safetyd 1.2 NS 2.2 NS 2.7 NS 4.6 \0.01

Neighborhood satisfactiond 2.2 NS 3.4 \0.05 6.2 \0.05 4.3 \0.05

R2 0.4 0.4 0.5 0.5

F 14.3 12.0 13.6 16.4

P value \0.01 \0.01 \0.01 \0.01

a Higher score indicates better QoLb Higher score indicates more somatic symptomsc Higher score indicates lower level of depressiond 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 partici-

pants 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 symp-

tom severity was associated with poorer environmental

HRQoL. In order to better understand the impact of envi-

ronment on somatic symptoms among free clinic patients,

future research should examine whether poor environ-

mental 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. Previ-

ous 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 environ-

ment in terms of safety from crime and overall satisfac-

tion. 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 neigh-

borhood 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 neigh-

borhood environments, especially neighborhood satisfac-

tion among the free clinic patients, were significantly

associated with HRQoL. Developing community-level

collaborative networks to improve environments may be

essential as this is not something that can be accom-

plished 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 dif-

ferent 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 neighbor-

hood satisfaction are key factors related to HRQoL among

free clinic patients. Mental health services and collabora-

tion 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 Col-

lege 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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