Perceptions of primary care patients attending a legal health clinic: a qualitative descriptive study

Abstract

Background

There has been increasing recognition of the relationship between social determinants of health and unmet legal needs, with those living in poverty experiencing higher rates of poor health. Medical-legal partnerships (MLPs) are programs that have been developed to offer legal services within a clinical setting to patients who may typically not be able to access these types of services. The Legal Health Check-Up Clinic was initiated to screen and offer legal supports to patients from a Canadian primary care clinic, situated in a diverse, urban medium-sized city. Previous quantitative analyses found significant changes in overall health status as well as income, housing, and food security. The aim of this study was to evaluate participants’ experiences and satisfaction with the Legal Health Check-Up Clinic.

Methods

A qualitative descriptive approach was used and participants from the Legal Health Check-Up Clinic were invited to take part in a one-time, individual interview. Using a thematic analysis approach, each interview was independently coded and then discussed by three researchers, with any differences reconciled by consensus. Coding was iterative with new codes added as relevant ideas emerged from the interviews.

Results

Sixteen interviews were conducted. There were two primary themes: Personal Benefits and Challenges experienced by participants, and Program Structural Elements that fostered or impeded program success. Participants welcomed accessing legal support within the primary care environment and became more aware of their rights and options. Some learned they were not eligible for the program and felt provision of other resources would have been helpful. Participants appreciated the program philosophy of recognizing the relationship between health and social needs and offered constructive feedback for areas of improvement, such as provision of translation services and more time with clients.

Conclusions

The Legal Health Check-Up Clinic was helpful for participants in providing referrals, resources, and concrete direction regarding their legal issue. Clarity in screening potential participant eligibility was suggested. Future work related to interprofessional education of legal and health professionals could support the implementation of a stronger patient-centred approach.

Background

Medical-legal partnerships (MLPs) were developed as a means of providing legal support for those who typically do not have access to this type of assistance. Research suggests that medical-legal clinics can help patients address fundamental legal issues. Issues such as inadequate housing due to eviction or landlord problems, or employment concerns such as workplace injury or harassment can have direct impacts on physical and mental health. For example, pilot work by Ryan et al. [1] found that their medical-legal partnership significantly reduced perceived stress and improved well being in a sample of low-income patients. Other work has similarly found reduced stress and lower emergency room visits, but higher anxiety scores and hospital visits [2]. The authors of this randomized trial suggest that higher anxiety may have resulted from the MLP not being able to manage the patient’s legal concerns, creating further anxiety [2] . Although a range of MLP outcomes have been explored, a recent systematic review found strong evidence that these initiatives improve access and resolution of legal issues along with positively impacting mental health [2]. However, there was a less discernable impact on individual health status [2]. This may be due to the narrow focus of individual studies on a few outcomes such as stress or anxiety.

The relationship between poverty and poor health has been well established [3] with an emerging literature base highlighting the connection between unmet legal needs and health issues [4]. In particular, by situating legal clinics within primary care, there is a reduced burden for patients in receiving support in a known location. The Legal Health Check-Up Clinic at McMaster Family Practice in Hamilton, Ontario was established to offer legal screening and intervention within a primary care practice. [5] This observational study collected comprehensive data about a range of social issues, using an electronic survey tool known as the Legal Health Check-Up, and patients were referred to legal supports if deemed appropriate. [5] Results indicated that 84% (n = 648/770) of those screened had at least 1 unmet legal need. [6] Overall, 94 participants had appointments with lawyers, with 69 completing the appointment. [6] Predominant legal needs centered around employment (78.8%), income (75.6%), and health (77.4%), with family/community (72.5%), and housing (71.6%) also being noted. [6] Evaluation analyses for the 31 participants with both baseline and 6-month data indicated a significant improvement in food insecurity (p < 0.05) and perceived health status (p < 0.05) [6]. A key aspect of the Legal-Health Check-Up Clinic evaluation was understanding participant satisfaction with the clinic. The aim of this research was to understand the experiences and perceptions of primary care patients who were given access to this Legal Health Clinic within their primary care office.

Methods

Design

This study employed a qualitative descriptive approach [7, 8], and was a complementary component to the larger evaluation study which examined quantitative impacts of the Legal-Health Clinic[6].

This study was approved by the Hamilton Integrated Research Ethics Board (HiREB #20161085).

Participants and setting

Participants were patients who were registered with a physician in the McMaster Family Practice (MFP), one of two practices forming part of the McMaster Family Health Team. MFP serves approximately 12,000 patients and is located in an urban inner-city centre in Hamilton, Ontario, which is an area of socio-economic deprivation[9].

The Legal Health Check-Up Clinic utilized space within the primary care clinic and was a partnership with 2 firms, one with legal expertise in family, criminal, and estate law, and the other in social assistance, human rights, housing, and employment [8]. Those referred to the clinic had a 30 minute appointment with the lawyer who best matched their primary issue. During this appointment they were provided with direction for their legal concern. In many cases, this entailed educating patients about their rights (e.g., as a tenant or for social assistance eligibility) and providing relevant resources. Those requiring ongoing legal assistance were referred to low income legal clinics or private lawyers depending on their income level[8].

Participants who had booked an appointment with the Legal Health Check-Up Clinic were invited by email or phone call by research staff, after 6 months of booking, to participate in a semi-structured one-on-one interview over the phone, with an experienced, Master’s trained research assistant. Convenience sampling was used, with anyone agreeing to take part being interviewed. Interviews were scheduled for 45–60 minutes. Informed written consent had been obtained prior to the onset of the main study, with the interviewer confirming consent orally at the start of each interview. Participants’ family doctors were not aware of their participation and the decision to participate and this did not affect the patient’s’ ability to receive care at the clinic. The research assistant followed a semi-structured interview guide (see Appendix 1) to allow for consistency in responses across interviews as well as opportunity for discussion of other issues as they arose. All interviews were digitally recorded and professionally transcribed. Participants who completed an interview were mailed a grocery store gift card ($5 CDN value).

Analysis

Thematic analysis [10] was conducted by 3 independent researchers. An initial codebook was drafted after the first three interviews. Here, each researcher independently reviewed the transcripts, coding relevant text units. Then they met as a team to discuss the codes generated and whether there were any emerging themes. An initial codebook was developed and then applied to subsequent interviews, with researchers meeting regularly to discuss and update the codebook with any new codes or themes. Any differences in coding were reconciled by consensus. Researchers were mindful of potential personal biases and openly discussed these as a team at the onset of the study. Data were organized in a word processing document and no qualitative software program was utilized. Formal member checking was not conducted, however, throughout each interview, the study research assistant regularly summarized participants’ thoughts, checking in to ensure that their perceptions were being accurately captured.

Results

Sixteen participants from the Legal Health Check-Up Clinic completed interviews, with half being female. Over 40% had completed college or university, and the majority were Caucasian (see Table 1). Table 2 describes some of the health and physical needs of participants, and Table 3 provides an overview of participants’ legal issues.

Table 1.

Legal Health Check-Up Clinic participant demographics

Sample (n = 16)	n, %
Age
18–24  25–34  35–44  45–54  55–64	1, 6.3 7, 43.8 3, 18.8 3, 18.8 2, 12.5
Gender
Female  Male  Transgender	8, 50.0 8, 50.0 0
Race
Hispanic  Multiple/Other  Caucasian  Missing	1, 6.3 2, 12.5 11, 68.8 2, 12.5
Education
Less than High School  High School  Some College or University  College or University Graduate	1, 6.3 3, 18.8 5, 31.3 7, 43.8
Employment Status
Full-Time  Part-Time  Retired  Unable to work  Unemployed  Missing	1, 6.3 3, 18.8 2, 12.5 3, 18.8 3, 18.8 2, 12.5
Receiving Social Service Benefits	12, 75.0
Monthly Household Income ($)
Less than 650  650–1000  1250–1500  1550–1800  1850–2000  2550–3000  More than 3000  Missing	1, 6.3 2, 12.5 2, 12.5 5, 31.3 1, 6.3 2, 12.5 2, 12.5 1, 6.3

Table 2.

Participant health characteristics

Sample (n = 16)	n, %
Overall Health
Poor  Fair  Good  Missing	3, 18.8 5, 31.3 6, 37.5 2, 12.5
Mobility
No Problems  Some Problems  Severe Problems  Missing	4, 25.0 10, 62.5 0 2, 12.5
Pain/Discomfort
No Problems  Some Problems  Severe Problems  Missing	1, 6.3 10, 62.5 3, 18.8 2, 12.5
Anxiety/Depression
No Problems  Some Problems  Severe Problems  Missing	4, 25 8, 50 2, 12.5 2, 12.5
Self-Care
No Problems  Some Problems  Severe Problems  Missing	12, 75.0 2, 25.0 0 2, 12.5
Usual Activities
No Problems  Some Problems  Severe Problems  Missing	2, 12.5 12, 75.0 0 2, 12.5

Table 3.

Summary of participant legal issues

Sample (n = 16)	n, %
Income	13, 81.3
Housing	11, 68.8
Employment	13, 81.3
Health	6, 37.5
Family and Community Supports	14, 87.5

Primary themes identified

There were 2 main overarching themes that emerged from the interviews. The first centred on the Personal Benefits and Challenges experienced by participants, and the second related to Program Structural Elements that fostered or impeded program success. Within each of these 2 broad themes, there were a number of subthemes. Each will be described in more detail below. It should be noted that there is overlap and connection between these themes despite being described separately.

Personal Benefits and Challenges Experienced

Personal Benefits

Received Referral/Directions

The majority of participants reported positive personal benefits from attending the Legal Health Check-Up Clinic. In particular, legal advice received at the clinic provided guidance and a better understanding of potential next steps in further pursuing their legal issue. This included the provision of specific and relevant referrals.

Educational

The clinic provided a starting point for a legal discussion for those who did not initially know they needed legal help (or possibly lacked the confidence, understanding, self-efficacy, or resources to pursue the issue). Two participants realized they did need professional legal direction and advice: “So no it helped, it helped me, it helped me investigate things that I wouldn’t have never investigated anywhere.”(P330). As well, through their encounter with the Legal Health Check-up Clinic, participants gained knowledge about the legal situation. This provided them with a recognition of the need for legal help, a better understanding of what can and can’t be done, and feeling that they can act on the knowledge obtained to bring about a resolution to their legal issue.

Participants obtained knowledge by speaking with lawyers and clinic staff who were able to answer questions, provided participants with legal options, and an idea of what to expect in the legal process. For some this led to a greater understanding and acceptance of their legal situation, leading to a sense of closure and feeling that they were on a ‘healing process.’:

So basically, I was able to be given enough information so that I understood what had happened – good or bad. And my mind was settled. And I’m uhm … this is part of the healing process for me. So, you know, you never know what’s gonna happen when you just do something out there and what it’s gonna do for people. And it can go good or bad, but I really hope you keep this going for people. (P96)

For others, this led to an accepting that they did not have the power to alter the legal situation: “Yes, your program was able to allow me to go full, full circle and calm down, like there’s no way out of this and to accept that I’ve done nothing and this is just something, the cards that were dealt in my life like a lot of other things.” (P330)

Participant empowerment

A number of participants noted that engagement with the clinic was an empowering step, allowing them to use the knowledge received from the clinic to develop an action plan to better or resolve their situation: “… Her advice was solid, you know. She told me the parameters of what- how I could pursue it and there wasn’t anything beyond that for her to tell me about, so she did everything she could.”(P29). By going through the experience of the legal health clinic, some participants felt they could make more informed decisions in the future. Others were informed of their rights and described this experience as “amazing” (P61)

Personal challenges experienced

Did not meet expectations

Some participants felt that the Legal Health Check-Up Clinic did not meet their expectations as they wanted more direct help navigating their legal situation or provision of referrals if they were not suited for the clinic. As one participant noted: “… the person who interview me maybe they can say … you know, your case is not for a … for the lawyer. It is for a … with paralegal. … And you can go to this part or the other part whatever. But I didn’t get that advice.”(P643)

A few participants felt a patient-centred care approach was lacking in the legal health clinic as they did not feel enough time was taken to ask them questions to better understand their case:

… for me my expectation at that time was to talk if I have something legal to pursue … I can get help. But nothing like that happened. Just couple of minutes then get out from the office. For me that isn’t enough time to see the case completely because everyone has a different case. I have a lot of expectations for that … when I ask for an appointment with that service. But after that, I don’t … personally I don’t recommend anybody for that kind of service”. (P643)

Personal lack of motivation

For some participants, their personal lack of motivation impeded the potential impact of the legal health clinic. One participant noted that they were not motivated to make an appointment with a legal professional although they qualified for one: “[in response to, ‘did you experience any barriers when using the service’] … “other than my own lack of motivation, no” (P729). This highlights the need for follow-up with potential clients to assess and problem-solve potential personal barriers to access.

Frustration with legal process

Finally, for some, there was a general feeling of frustration about the overall legal process. One participant described the frustration of having various different players involved in their legal situation (mediator, landlord, Ontario Welfare) and wanted more support and recognition of their ongoing struggles.

Program facilitators and barriers

Along with personal benefits and challenges experienced in the Legal Health Check-Up Clinic, there were a number of structural and programmatic issues that contributed towards perceived program success. These are examined in more detail below.

Facilitators of program success

Two main factors contributed to program success: 1) Program Set-up, and 2) Underlying Program Philosophy.

Program set-up

Participants appreciated that the program was in a familiar location and this provided a sense of comfort. The existing rapport participants had with their physician led to feelings of trust, confidence, and safety with the legal referral process.

Participants also appreciated how they could conveniently access a healthcare worker and a legal professional simultaneously. This saved them time, required no additional costs and was easy to access by public transportation. The process of receiving legal advice through the doctor’s office was straightforward, and helped alleviate the stress and time needed to seek legal help independently. Participants were pleased with the ease of setting up an appointment.

Underlying program philosophy

The Legal Health Check-Up Clinic program philosophy of linking physical and social health through a ‘dual service’ was appreciated. This allowed participants to more concretely understand how physical and mental health can be impacted by a variety of factors, including legal issues. One participant mentioned how emotions inevitably accompany legal problems and that it was helpful having their physician involved. Another recognized the benefit of this connection of health and legal services and felt that if it had been implemented earlier, they would have had a more positive legal experience and possibly better health outcomes. Understanding that physical health can be impacted by the stress of legal issues was an important learning for many participants.

Barriers to program success

Program scope

Many participants felt that the scope of service provided could have been broader or program eligibility better advertised. For example, some were deemed ineligible if they already had a lawyer (and wanted a second opinion) or had access to existing resources: I was intrigued as to what was happening and so I attended an … I think it was an orientation session with … one of the lawyers. And then it was at that point that the lawyer made it very clear to me that I just … . You know, I didn’t qualify for the service that they were targeting.”(P684)

Additionally, language barriers sometimes created issues, as translation services were not provided. One participant experienced a lawyer not having skills or patience to manage their language barrier which impacted their ability to receive advice.

Lack of proper communication with clinic

One participant was deemed not eligible to be referred to subsidised legal counsel at an external office as their issue related to divorce and this was not promptly communicated to them, leading to presuming a negative scenario: “… number one thing is communication. You know like I … thought because I hadn’t heard anything … ., no communication at all …. because when there’s no communication, people assume the worst.” (P582)

Suggestions for legal health check-up clinic changes

This study provided useful information about program strengths and areas for improvement, many of which can be easily implemented (see Table 4). First, it was suggested that having more clarity around program scope and communicating this to potential participants could help with matching participant expectations with the program’s aims and purpose. This could be achieved with a concrete screening where those who are not eligible could be offered referrals for other services. Legal staff training regarding patient centred care could ameliorate participants feeling rushed and not listened to. Finally, it was noted that the inclusion of a patient advocate role could help in a more active manner to assist with communicating the patient voice on their behalf. While not all of these suggestions are feasible, they offer some important structural suggestions that could improve both the delivery and experience of the Legal Health Check-Up Clinic.

Table 4.

Legal Health Check-Up Clinic suggested program changes

Suggested Change	Illustrative Quotes
1. Improved Program Scope
a. Better advertising of program details	“… it would be good that … if it is more advertised and if people are aware of the benefits of it, so it would be more useful” (P767).
b. Offer supports for those above low income thresholds.	“I just think that it was geared towards people in like a lower income bracket … the people who don’t have the necessary means to afford legal help. So I can see the benefit for that purpose. Having said that, I think that as patients of the {clinic}, you probably have a wide variety of patients, and it should encompass all income brackets and all living situations.” (P338).
c. Provision of Translation Services	“But doesn’t take enough time to hear what was the problem is. [E]special[ly] for the people who doesn’t is fluent in the language, I mean the English. For me I understand I have lots of barrier to explain. But I expect even if people doesn’t understand me, they asking me again. That way I can explain in another way, looking for another word to make myself understand the other person.” (P643)
Improved Screening Process with Supports	(So, you would have liked to know, if he couldn’t answer your question, what the next step would be?) Yeah … . here’s a card for somebody that, you know, you could call.” (P582)
3. Training on Patient Centered Care	But take the time to hear the person because … the person who is in there is because they have something who worry about in their life … (P643)
4. Inclusion of Patient Advocate Role to attend meetings/appointments	Like maybe like a patient advocate. That would have actually been quite helpful. … So like if it was tribunal, it would have been helpful to have someone from the legal/medical community to be able to say this is what’s going on, this is acceptable?” (P409)

Discussion

This study sought to understand patient experiences and satisfaction with the Legal Health Check-Up Clinic located in a primary care clinic. Findings identified personal benefits such as increased understanding of legal situation and personal rights, and receipt of referrals, while others experienced challenges with eligibility, communication challenges due to lack of translation services provided, and a lack of a patient centred approach. Related to this were programmatic factors that contributed towards or detracted from program success. It is these latter factors which future program developers can attend to in order to better meet patient needs.

While there was a range of experiences described by participants, a few elements are particularly noteworthy. Participants appreciated the comfort and security of being able to access legal supports in a familiar place. This has also been found in previous work and affirms the influence of program design decisions on participant experience and satisfaction [4]. Other research supports co-location as a means of more direct communication between health and legal practitioners. [11] Information sharing was critical for patients to understand their rights and options, and many were thankful that there was acknowledgement and awareness of their legal and health issues.

Some participants, however, felt that legal professionals did not display the patient centered care approach they were familiar with and sometimes felt rushed or unheard. Patients were used to having translation services with their health care providers and not having this at the on-site MLP was challenging. Other research has found that language to be a barrier to MLP implementation[12]. As well, it has been suggested that MLPs focus on fostering trust between participants and MLP lawyers to facilitate effective communication[13].

Some of the challenges experienced by these participants could result from the differing interpersonal perspectives taken within health and legal professions, whereby clinicians are trained to be patient centred and lawyers are not. To bridge this gap, having a more purposeful approach to interprofessional education has been suggested so each can learn about and from each other’s professional roles [14]. A systematic review of the impacts of educational programs on trainees knowledge and attitudes found increased knowledge of social determinants of health by medical trainees when engaged with medical legal partnerships [15]. Future work could include reciprocal training whereby law students gain exposure to the adverse health outcomes incurred by patients who have not have their legal needs met.

Since the conduct of this study, a number of reviews regarding medical legal partnerships have been published. [4, 14–16] Martinez and colleagues completed a systematic review on the impact of medical legal partnerships for people experiencing health disparities [16]. Screening was an important part of these programs, and often served as the impetus to justify the need to establish an MLP. For example, a number of studies completed legal needs assessments or screening to demonstrate the scope of issues needing attention and in particular populations[16]. As implied, screening acts as a filter with not everyone meeting program criteria. In the present study, some participants voiced wanting more clarity about program eligibility. The development of more focussed participant information materials as well as patient centred care training for legal staff are suggested next steps for this program.

Overall, there was a common thread through these reviews that there is a stronger focus on addressing legal issues with less emphasis on health outcomes or social determinants of health [16]. While most MLPs are created with public funds, variations have been noted based on country and their structure for health care. [14] In the United States due to lack of universal healthcare, MLPs are usually located in clinical settings serving low-income individuals, whereas they are more broadly located in a range of locations in the UK and Australia (i.e. outside of primary care) [14]. Some research in these settings have focused on mental health [2; 14], with few examining impact on physical health. [14;17] Other MLPs have a particular focus such as trauma patients [18], immigrant populations [19], or veterans [20]. The Legal-Health Check-Up clinic was broad in scope and its quantitative results demonstrated a positive change not only in legal issues addressed but improvements in health status[8].

This study contributes to the literature base by providing an example of a Canadian initiative. While the practice of improving accessibility through provision of language supports such as translation services has been used outside of Canada [19, 21], this should be integrated into Canadian MLPs given multi-cultural context within Canadian healthcare. This study also offers some tangible suggestions for how to improve participant clinic experience which may be helpful to other MLP developers. This includes providing referrals for those not eligible and additional support to access referrals when given (e.g. patient advocate).

Study limitations

This study offers concrete direction for future developers of legal health clinics; however a number of limitations should be noted. First, though there were no restrictions on who could take part in an interview, our response rate was small, influencing the generalizability of findings. Our sample was also well educated and lacked cultural diversity which is likely not representative of the population who attends these types of clinics. However, few in our sample were working full-time, and income levels were low, highlighting economic disparities which is a key reason for the establishment of MLPs. Despite this, adequate information power [22] was achieved. Future work with a broader cross section of participants is needed.

Conclusion

The Legal Health Check-Up Clinic demonstrated value to participants through provision of referrals and improved knowledge of legal situation. Suggestions for program improvements include offering translation services, improved patient-centred approach by legal staff, and direction for those not eligible for the program.

Appendix 1: Participant interview guide

The Legal Health Check-Up Program (eLHP) Interview Guide

Patient Version

Preamble:

• Thanks and welcome

• Nature of a focus group (information, multiway, all views acceptable, disagreement okay)

• There are no right or wrong answers, all about finding out what people think

• Audio recording

• Going to be talking about their experience with the Legal Health Check-Up Program

Satisfaction/Benefits of the Legal Health Check-Up

• Were you satisfied with the help you received through the eLHP program?

• What were the benefits of having legal help available through your doctor’s office?

• Would you have sought legal help with Legal Aid Ontario or the Hamilton Legal clinic without the screening tool and availability within McMaster Family Practice?

Barriers to Use:

• Did you encounter any barriers to the use of the legal services offered at McMaster Family Practice?

• Did you encounter any barriers to the use of the legal services after your initial assessment in the McMaster Family Practice legal clinic?

Types of Legal Help:

• What kind of legal help did you receive? (Let them know they can be vague).

• Did the help you received make a positive impact on your life, a negative one?

Improvement:

• Do you have any suggestions of how we could improve this program?

Thank you and goodbye.

Author contributions

GA and DE designed the study. BD was involved in the data collection, and GA, AZ, AP, KN in the data analysis. GA, KN, SC, DE, HT prepared the manuscript. All authors read and approved the final manuscript.

Funding

This work was supported by the Local Poverty Reduction Fund through the Ontario Trillium Foundation (Project No. PR10028). HCLC and LAO provided in-kind legal staffing coverage for the Legal Health Check-Up Clinic during the time period of the study.

Data availability

All data generated or analysed during this study are included in this published material.

Declarations

Ethics approval and consent to participate

This study received approval from the Hamilton Integrated Ethics Board #20161085 and was conducted in accordance with the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans. All participants signed a consent form.

Consent for publication

Not applicable; All data has been de-identified and anonymized.

Competing interests

The authors declare no competing interests.