Abstract
Introduction
Families in urban poor environments face challenges that affect medical care and satisfaction with life. 1 These challenges include low income, limited access to resources, low-functioning educational systems, and fragmented family units. With the recent economic recession and a childhood poverty rate of nearly 22% in the United States, these challenges will continue to increase. 2
Caring for children with special health care needs—approximately 1 in 7 children—is especially daunting. 3 Advances in medical care and successful policy initiatives have increased long-term survival of children with complex, chronic health care needs. 3 However, the caregivers of these children are directly affected in their own physical and psychological health. 4
The medical home is a primary care delivery model seeking to increase accessibility to comprehensive coordinated care. Birthed in the 1960s, it was not fully implemented until it was accepted by multiple primary care societies in 2007. 5 The medical home has been shown to increase family functioning by decreasing missed days of school, parental aggravation, and barriers to childcare. 6
Spirituality and religion have been shown to be effective coping strategies in other urban and low-income populations. 7 In this pilot study, we sought to investigate the potential associations between life satisfaction, coping, and spirituality in an urban population. Finally, we attempted to identify factors that impact coping and life satisfaction in those caring for children with and without special health care needs.
Methods
To investigate these questions, a written English-language questionnaire was administered to a sample of parents who brought their children (age range 7-18 years) for primary care at an urban, hospital-based medicine-pediatric resident clinic in Waterbury, Connecticut. Participation was voluntary, and written informed consent was obtained for all patients. The study design and materials were approved by the Institutional Review Board at St. Mary’s Hospital and the Human Investigation Committee at Yale University.
Survey Instruments
The survey contained demographic data and 3 validated instruments: the Satisfaction with Life Scale (SWLS), the COPE Inventory, and the Spiritual Involvement and Beliefs Scale (SIBS). The SWLS is widely used to assess general life satisfaction and has been used in varied populations. 8 The SWLS is composed of 5 questions and scored on a Likert-type scale of 1 (strongly disagree) to 7 (strongly agree). The COPE Inventory contains scales that assess adaptive and maladaptive emotional-coping strategies. Participants indicate how frequently they use each strategy on a 4-point scale anchored by usually do not do this at all and usually do this a lot. This inventory evaluates an individual’s response to a stressful environment and incorporates both “problem-focused” and “emotion-focused” coping strategies. Other emotional-coping strategies include acceptance, active coping, disengagement, humor, positive reframing, self-blame, strategy planning, substance abuse, and venting.
The SIBS investigates broad aspects of spirituality. It correlates strongly with other spirituality instruments and acknowledges that spirituality incorporates both attitudes and practices. It consists of 26 questions on a Likert-type scale of 1 (strongly agree) to 5 (strongly disagree). Questions address the broadest aspects of spirituality: (1) internal beliefs, (2) external practices, (3) personal humility, and (4) existential beliefs. The SIBS uses language not specific to the Judeo-Christian tradition, which is important given the diverse backgrounds of the participants.
Statistical Analyses
We used JMP software for statistical analyses. We calculated composite scores of the SWLS, COPE, and SIBS instruments. We used Student’s t tests and chi-square analyses to compare means of survey instruments with demographic variables. Continuous variables were correlated with the Spearman rank-order coefficient. Post hoc power calculations were determined by G*Power software.
Results
In total, 127 individuals completed the survey. The population was diverse and impoverished (Table 1). Overall, 76 respondents (60%) identified as Latino; 65 children (51%) had chronic illness. The mean SWLS score was 21.3 (SD ±9). A lower SWLS (P < .05) correlated with having a child with a chronic medical illness requiring increased medical services. Of those who were in the bottom quartile of the SWLS, families were 4.5 times (P < .03) as likely to have a child with a chronic illness. However, there was no correlation between the SIBS score and other emotional-coping strategies. There was also no significant impact on SWLS or the total SIBS scores based on other demographics—such as employment in the home, neighborhood safety, ability to pay for housing, or adequate childcare.
Demographics (N =127).
The only coping strategy that correlated with the SWLS was “strategy planning” (r = 0.24, P < .01), which comprises questions such as, “I think about what steps to take.” 9 The other emotional-coping strategies showed no statistical difference with the SWLS.
Regarding families’ spiritual lives, satisfaction correlated significantly with the external axes (r = 0.23, P < .01) and the humility axes (r = 0.18, P < .05). The external axes address issues such as the number of times attending worship services, prayer services, and other spiritual activities. The humility/relational axes address one’s approach to interpersonal relationships, such as forgiveness and reconciliation. This axis is explored by questions such as “When I wrong someone, I make an effort to apologize,” and “When I am ashamed of something I have done, I tell someone about it.” 10 Multivariate regression models, incorporating the SIBS and emotional coping axes accounts for 23% of the variance of SWLS (P < .02). There was no difference when controlling for income, ethnic group, or home or neighborhood safety. Using post hoc analyses, for the Spearman’s rank correlation coefficients, with a sample size of 127, an α = .05, and an effect size of 0.5, the study’s power is 0.92. 11
Discussion
The data reveal several provocative findings. First, the population is quite poor, with 84% making <$20 000 a year. In 2013, the poverty level for a family of 4 in the United States was $23 500. 12 More than 50% of respondents had a household income of <$10 000, which is 2 times below the poverty level. Second, more than half of the children had chronic illness. This is unlike the general US population where 1 in 7 children are considered to have special health care needs. While most families had stable housing, many were challenged to pay rent reliably, had struggles around childcare, and lived in an unsafe neighborhood (Table 1). However, these socioeconomic variables had no significant correlation for life satisfaction, despite being adequately powered. This suggests that other intrinsic qualities—such as spirituality and emotional coping—have an important influence in this vulnerable population.
Third, despite these stressors, life satisfaction is rather high. While 12% were extremely dissatisfied and 35% were dissatisfied, most respondents were satisfied with their lives. The mean SWLS score of 21.3 is higher than many other populations with greater economic resources. For example, the mean SWLS of an aggregate of more than 200 emergency physicians was 20.3, suggesting that our patients may have a higher satisfaction of life than the physicians who treat them. 13
Fourth, in this urban population with many stressors, certain aspects of patients’ spirituality correlated with improved life satisfaction—namely the external (r = 0.23, P < .01) and the humility/relational (r = 0.18, P < .05) dimensions. These data suggest that active, involved faith practices, which also include a high priority on meaningful relationships, is correlated with improved life satisfaction. Despite life stressors, patients who navigate the complexities of their lives with a meaningful spiritual practice, coupled with constructive relationships, seem to be more resilient.
Fifth, strategy planning was the only emotional-coping strategy that correlated with life satisfaction. Equally important are those domains that were not significant: disengagement, distraction, venting, self-blame, and substance abuse. Coupled with the importance of spirituality and interpersonal relationships, these data suggest a personality that survives, even thrives, with positive life satisfaction despite urban poverty. Namely, a patient who has a regular overt practice of faith extends that faith to others toward reconciliation and has a proactive approach to solving problems.
Limitations of this study include its small cohort size and generalizability. The population was quite impoverished and overwhelmingly comprised ethnic minorities, so results may not apply to all populations. Furthermore, the survey instruments are not validated for Spanish. Although written for a sixth-grade reading level, given the high prevalence of Spanish speakers in the clinic population, there were potential participants who likely did not participate due to a language barrier. While this study does give an important perspective on the coping of the urban poor, these findings are correlative only. Positive associations do not imply causation.
What is the implication for primary care practitioners? The urban poor have significant emotional and spiritual coping strategies that may improve life satisfaction. In a resource-poor community, encouraging religious activities and proactive coping strategies may have positive benefits for overall wellbeing. These data may also support the idea of inviting family members who cope well in the urban environment to serve as advisors to those families who struggle. Modeling positive coping through facilitated groups may foster meaningful relationship to promote family wellness and improved life satisfaction. In this pilot study, these findings suggest the need for prospective trials to further elucidate the importance of religion and positive coping.
Footnotes
Acknowledgements
The authors wish to thank Morgan Deblecourt and Elizabeth Cook for their assistance in the preparation of this article.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.