Stress, Coping Strategies, and Depression –
Uninsured Primary Care Patients
Akiko Kamimura, PhD, MSW, MA; Jeanie Ashby, MPH; Allison Jess, RN; Alla Chernenko, MA;
Jennifer Tabler, MS; Ha Ngoc Trinh, MS; Maziar M. Nourian, BS; Guadalupe Aguilera, BS;
Justine J. Reel, PhD, LPC, CC-AASP
Objectives: People of low socio-econom-
ic status (SES) are particularly at risk for
developing stress-related conditions. The
purpose of this study is to examine depres-
sion, stress, and coping strategies among
uninsured primary care patients who live
below the 150th percentile of the federal
poverty level. Specifically, this study com-
pares the experiences of impoverished
US-born English speakers, non-US-born
English speakers, and Spanish speakers.
Methods: Uninsured primary care patients
utilizing a free clinic (N = 491) completed
a self-administered survey using standard-
ized measures of depression, perceived
stress, and coping strategies in the spring
of 2015. Results: US-born English speak-
ers reported higher levels of depression
and perceived stress compared to non-
A
mong adults, stress contributes to the high
level of risk for development or exacerba-
tion of chronic health problems, such as de-
pression, cardiovascular diseases, diabetes, and
gastrointestinal conditions.1-3 Moreover, people of
low socio-economic status (SES) are particularly
at risk for developing stress-related health prob-
lems because low SES is associated with high lev-
els of stressors, poor coping skills, limited access
to healthcare resources, and lower health status.4
For people of low SES, experiencing persistent and
long-term financial stressors, such as debt,3 can
lead to declining health and decreased perceived
Akiko Kamimura, Assistant Professor, and Alla Chernenko,
Jennifer Tabler, Ha N. Trinh, and Guadalupe Aguilera, doctor-
al students, Department of Sociology, University of Utah, Salt
Lake City, UT. Jeanie Ashby, Executive Director, and Allison
Jess, Healthy Living Educator, Maliheh Free Clinic, Salt Lake
City, UT. Maziar M. Nourian, medical student, School of Medi-
cine, University of Utah, Salt Lake City, UT. Justine J Reel,
Professor, College of Health and Human Services, University
of North Carolina at Wilmington, Wilmington, NC.
Correspondence Dr Kamimura; akiko.kamimura@utah.edu
742
US-born English speakers and Spanish
speakers. US-born English speakers are
more likely to use negative coping strat-
egies than non-US-born English speakers
and Spanish speakers. Perceived stress
and negative coping strategies are signifi-
cant predictors of depression. Conclusion:
US-born English speakers, non-US-born
English speakers, and Spanish speakers
reported different coping strategies, and
therefore, may have different needs for
addressing depression. In particular, US-
born English speakers need interventions
for reducing substance use and negative
psychological coping strategies.
Key words: stress; coping; depression;
uninsured; low socio-economic status
Am J Health Behav. 2015;39(6):742-750
DOI: http://dx.doi.org/10.5993/AJHB.39.6.1
well-being.5 In fact, indicators of poor health among
low SES people often can be attributed to chronic,
rather than acute sources of stress.6
Furthermore, people of low SES may experience
difficulties coping with stress which contributes to
poorer health outcomes.7 The limited capacity and
resources of people of low SES may act as barriers
to developing healthy coping strategies.8 Often, in-
dividuals of low SES develop dysfunctional coping
strategies, that is, a set of unhealthy coping behav-
iors, such as substance use, to manage chronic
stress, resulting in long-term physical and psy-
chological health consequences.1 In addition to the
aforementioned unhealthy behaviors, using avoid-
ance, distraction, and denial as dysfunctional cop-
ing strategies can contribute to mood disturbances
such as depression12 and are not an effective solu-
tion to combating stressors in one’s life.
Despite the importance of developing effective
coping strategies for dealing with stress among
low SES primary care patients, scant research is
available for uninsured primary care patients liv-
ing below the poverty level. In addition, Hispan-
ic migrant and seasonal farmworkers experience

intense physical and mental stress due to work
conditions, family circumstances, immigration is-
sues, and scarcity of resources that lead to using
negative and positive coping strategies to deal with
stress and depression.13 Conversely, foreign-born
Hispanic women report lower stress levels than
their US-born counterparts because they attribute
to having strong social support.14 Given the mixed
results from previous studies, stress and coping
strategies among immigrant or Spanish-speaking
populations need further examination.
The purpose of this study is to examine how
stress and coping strategies are associated with de-
pression among uninsured primary care patients
who live below the 150th percentile of the US fed-
eral poverty level. Specifically, this study compares
the stress-related experiences of impoverished
US-born English speakers, non-US-born English
speakers, and Spanish speakers. Interestingly,
previous studies have demonstrated differences in
socio-demographic characteristics, physical and
mental health status, healthcare utilization, and
patient satisfaction among these 3 populations.15,16
In particular, the results of previous studies con-
sistently suggest that US-born English speakers
report higher levels of depression and lower levels
of health-related quality of life compared to non-
US-born English speakers and Spanish speak-
ers.16,17 However, adequate explanations for this
tendency have not been provided. In other words,
the reason that Spanish speakers report better
mental health than US-born English speakers,
despite their socio-demographic disadvantages if
among the uninsured population, have not been
identified. Based on previous studies on depres-
sion, stress, and coping, the primary hypothesis of
this study is that higher levels of depression will be
associated with higher levels of stress and poorer
coping strategies among low SES uninsured popu-
lation utilizing primary care, in particular, among
US-born English speakers. The alternative hypoth-
esis is that the levels of perceived stress and cop-
ing strategies affect the levels of depression among
the low-income population and differences in lev-
els of depression among the 3 groups.
This study appears to be one of the first to com-
pare these 3 populations in terms of depression,
perceived stress, and coping strategies in a prima-
ry care setting. This study aims to improve under-
standing of depression, stress, and coping strate-
gies among uninsured immigrant and non-immi-
grant primary care patients in the hope that these
populations can be served better for stress-related
mental health issues in primary care.
METHODS
Overview
The current community-based research project
was conducted at a free clinic in the Intermoun-
tain West. The clinic staff collaborated with this
research team to develop the survey instrument,
study protocol, participant recruitment strate-
Am J Health Behav.™ 2015;39(6):742-750
Kamimura et al
gies, and interpretation of study results. The clinic
provides free healthcare services, mostly routine
health maintenance, and preventative care, for un-
insured individuals who live below the 150th per-
centile of the federal poverty level and do not have
access to employer-provided or government-fund-
ed health insurance. The clinic has an onsite labo-
ratory and pharmacy and is staffed by 6 full-time
paid personnel and over 300 active volunteers, in-
cluding approximately 60 volunteer interpreters.
The clinic, which has been in operation since 2005,
has no affiliation with religious organizations and
is funded by non-governmental grants and dona-
tions. The clinic is open 5 days a week. The num-
ber of patient visits was 18,967 in 2013. The clinic
does not require patients to provide documenta-
tion of legal residency or citizenship and serves un-
documented immigrants in addition to US citizens
and documented immigrants. About half of clinic
patients identified that they are Hispanic.
Study Participants and Data Collection
Participants were persons aged 18 years and old-
er, were able to speak and read English or Span-
ish, and were patients of the identified free clinic.
The data were collected over several months dur-
ing spring 2015 (from January to April) using a
self-administered paper survey. All survey materi-
als including the survey instrument, consent cover
letter, and flyer were available in both English and
Spanish. A bilingual translator converted the origi-
nal English materials into Spanish. Another bilin-
gual translator conducted back-translation from
Spanish to English. The third bilingual translator
checked accuracy of the translation. Recruitment
of participants occurred at the free clinic during
clinic hours by distributing flyers to patients in the
waiting room. If a potential participant expressed
interest in participating in the study, he or she
received a consent form, cover letter, and a self-
administered survey. Members of the study team
were available to answer questions during survey
administration.
Measures
Socio-demographic characteristics. Demo-
graphic questions included age, race/ethnicity,
country of origin, number of years living in the US
(non-US-born participants only), education level,
employment status, marital status, and duration
of being a patient of the clinic (ie, less than 2 years,
or 2 years or longer).
Depression. The Patient Health Questionnaire
(PHQ-9) is a 9-item survey using a 4-point Likert
scale (from 0 = not at all to 3 = nearly every day)
and was used to measure levels of depression. The
PHQ-9 asks how often a participant has been af-
flicted by various types of problems including “little
interest or pleasure in doing things,” “feeling tired,”
or “having little energy, and poor appetite or over-
eating” in the past 2 weeks. PHQ-9 scores for the
level of depression severity are defined as minimal,
DOI: http://dx.doi.org/10.5993/AJHB.39.6.1 743
Stress, Coping Strategies, and Depression – Uninsured Primary Care Patients

Table 1
Socio-demographic Characteristics of Participants
US-born Non-US-born Spanish
Total p-
English Speakers English Speakers Speakers
(N = 491) valuea
(N = 116) (N = 116) (N = 259)
Mean age, years 43.6 (12.6) 40.9 (14.5) 43.2 (13.8) 45.1 (10.7) <.05
Female 316 (64.4) 68 (58.6) 68 (58.6) 180 (69.5) <.05
Race/ethnicity
White 103 (21.0) 84 (72.4) 12 (10.3) 7 (2.7) <.01
Hispanic/Latino/Latina 330 (67.2) 30 (25.9) 51 (44.0) 249 (96.1)
Asian or Pacific Islander 50 (10.2) 4 (3.4) 46 (39.7) 0
Some college or higher 220 (44.8) 71 (61.2) 56 (48.3) 93 (35.9) <.01
Currently employed 248 (50.5) 54 (46.6) 52 (44.8) 142 (54.8) N.S.
Currently married 225 (45.8) 27 (23.3) 63 (54.3) 135 (52.1) <.01
US-born 120 (24.4) 116 (100) 0 4 (1.5)
Years in the US (non-US-born only) N/A 16.4 (11.8) 14.6 (7.5)
Patient of the clinic – 2 years or longer 202 (41.1) 34 (29.3) 53 (45.7) 115 (44.4) <.05

Note.
No. (%) or Mean (SD). N.S. – non-significant.
a = p-value denotes significance from Pearson’s chi-square tests between categorical variables (for cell size =>5 only), and
ANOVA tests for continuous variables comparing US-born English speakers, non-US-born English speakers, and Spanish
speakers.

0 to 4; mild, 5 to 9; moderate, 10 to 14; moderately
severe, 15 to 19; and severe, 20 to 27.18 The PHQ-9
score was used for determining the overall level of
self-reported depression. The responses were not
verified by a clinician. The PHQ-9 is a valid and
reliable tool and has been used previously.19 Cron-
bach’s alpha for this sample was 0.91.
Perceived stress. The Perceived Stress Scale
(PSS)-10 was used to measure levels of perceived
stress during the last month.20 The PSS-10 con-
sists of 10 items (eg, “How often have you been
upset because of something that happened unex-
pectedly?”) that use a 5-point Likert scale (from
never=0 to very often=4). Four of the items are re-
verse scored. The sum of the scores from the 10
items represents the respondent’s total perceived
stress (range 0-40). Higher scores correspond to
higher levels of stress. There is no cut-off point to
determine specific stress levels. The PSS has been
tested for reliability and validity.20 Cronbach’s al-
pha for this sample was 0.84.
Coping strategies. Coping strategies were mea-
sured using the 28-item Brief COPE.21 The Brief
COPE includes the following 14 subscales with 2
items per subscale: self-distraction, active coping,
denial, substance use, use of emotional support,
use of instrumental support, behavioral disen-
gagement, venting, positive reframing, planning,
humor, acceptance, religion, and self-blame. Ex-
amples of items include: “Getting help and advice
from other people” and “Making jokes about it.”
The Brief COPE uses a 4-point Likert scale (from
I haven’t been doing this all=1 to I have been do-
ing this a lot=4). The Brief COPE has been used
in health research to measure coping strategies
across a variety of adult populations22 and has
demonstrated strong reliability.23 The average
score of the 2 items in the same subscale was used
to assess levels of ability to cope and use of coping
strategies (range 1-4). In addition, the subscales
were aggregated into 2 scales, negative (maladap-
tive) and positive (adaptive) coping strategies. The
subscales included among the negative coping
strategies were self-distraction, denial, substance
use, behavioral disengagement, venting, and self-
blame (Cronbach alpha=0.745). Other subscales,
namely active coping, use of emotional support,
use of instrumental support, positive reframing,
planning, humor, acceptance, and religion were
considered positive coping strategies (Cronbach
alpha=0.839).
Data Analysis
Data were analyzed using SPSS (version 22). De-
scriptive statistics were used to describe the distri-
bution of the outcome and independent variables.
The demographic characteristics of the 3 partici-
pant groups were compared using Pearson’s chi-
square tests for categorical variables (if each cell
had 5 or more respondents) and analysis of vari-
ance (ANOVA) for continuous variables. Multivari-
ate analysis of covariance (MANCOVA) was used to

744
 Kamimura et al

Table 2
Perceived Stress, Depression, and Coping Strategies Comparing US-born
English Speakers, non-US-born English Speakers and Spanish Speakers
Statistical Significance
Dependent Variables Group Mean SD F
(pairwise comparison)
US-born English 19.9 7.4 3.2 (1-2) <.05
Perceived Stress Scale Non-US-born English 17.4 6.0 (1-3) <.01
Spanish 15.6 6.4 (2-3) <.05
US-born English 10.6 7.4 6.7 (1-2) <.01
Depression (PHQ) Non-US-born English 7.3 6.5 (1-3) <.01
Spanish 6.1 5.8
Coping Strategies
US-born English 1.9 0.6 4.2 (1-2) <.05
Negative strategies Non-US-born English 1.7 0.5 (1-3) <.05
Spanish 1.7 0.5
US-born English 2.5 0.5 3.7 N.S.
Positive strategies Non-US-born English 2.4 0.6
Spanish 2.4 0.7
US-born English 2.5 0.9 2.1 N.S.
Self-distraction Non-US-born English 2.2 0.8
Spanish 2.4 0.9
US-born English 2.1 0.8 2.6 (1-2) <.05
Venting Non-US-born English 1.8 0.6 (1-3) <.05
Spanish 1.8 0.7
US-born English 2.2 1.0 8.1 (1-3) <.05
Self-blame Non-US-born English 1.9 0.8
Spanish 1.9 0.7
US-born English 1.8 0.9 8.4 (1-2) =.05
Behavioral disengagement Non-US-born English 1.5 0.7 (1-3) <.01
Spanish 1.4 0.6
US-born English 1.5 0.7 1.2 N.S.
Denial Non-US-born English 1.5 0.7
Spanish 1.6 0.7
US-born English 1.3 0.7 31.3 (1-2) <.01
Substance use Non-US-born English 1.1 0.5 (1-3) <.01
Spanish 1.1 0.2
US-born English 2.8 0.7 2.2 N.S.
Planning Non-US-born English 2.7 0.8
Spanish 2.6 0.9
(continued on next page)

compare depression, stress, and coping strategies
while controlling for sex, educational level, and
years of being a patient of the clinic, among the
3 groups. Multivariate multiple regression analy-
sis was conducted to test the association between
depression (outcome) and perceived stress, coping
strategies, and individual factors (demographic fac-
tors). The individual factors, age, sex, educational
attainment (some college or higher), employment
status (employed or not), marital status (married

Am J Health Behav.™ 2015;39(6):742-750 DOI: http://dx.doi.org/10.5993/AJHB.39.6.1 745

Stress, Coping Strategies, and Depression – Uninsured Primary Care Patients

Table 2 (continued)
Perceived Stress, Depression, and Coping Strategies Comparing US-born
English Speakers, non-US-born English Speakers and Spanish Speakers
Statistical Significance
Dependent Variables Group Mean SD F (pairwise comparison)

US-born English 2.7 0.8 1.2 N.S.

Acceptance Non-US-born English 2.6 0.8
Spanish 2.5 0.9
US-born English 2.4 1.1 0.3 (1-2) <.01
Religion Non-US-born English 2.8 1.0 (1-3) <.01
Spanish 2.8 1.1
US-born English 2.7 0.8 3.0 N.S.
Active coping Non-US-born English 2.5 0.9
Spanish 2.6 1.0
US-born English 2.6 0.8 0.7 N.S.
Positive reframing Non-US-born English 2.5 0.9
Spanish 2.4 0.9
US-born English 2.2 0.8 0.0 N.S.
Use of instrumental support Non-US-born English 2.2 0.8
Spanish 2.3 0.8
US-born English 2.2 0.8 2.5 N.S.
Use of emotional support Non-US-born English 2.0 0.7
Spanish 2.0 0.9
US-born English 2.1 0.9 0.7 N.S.
Humor Non-US-born English 2.1 0.9
Spanish 1.9 0.9

Note.
MANCOVA tests comparing US-born English speakers, non-US-born English speakers and Spanish speakers. Sta-
tistical significance is based on pairwise comparison (1. US-born English speakers N = 116, 2. non-US-born English
speakers N = 116, and 3. Spanish speakers N = 256). The F statistics indicate effect of group. Covariates=female sex,
some college or higher education, and clinic patient 2+ years. Female sex was significant (p < .05) based on multi-
variate tests.
N.S. – non-significant

or not), and years of being a patient (2 or more
years or less) were selected based on previous
studies which examined depression and mental
health among the same target population.16,17,24-26
RESULTS
Table 1 summarizes the socio-demographic
characteristics of a convenience sample of 491
participants (116 US-born English speakers; 116
non-US-born English speakers; and 259 Spanish
speakers). Participants who took the survey in Eng-
lish were coded as English speakers and partici-
pants who took the survey in Spanish were labeled
Spanish speakers for the purpose of this study. The
mean age of the participants was 43.6. More than
60% of participants were women. Spanish speak-
ers had a higher percentage of female participants
compared to non-US-born English speakers and
US-born English speakers. Forty-five percent of
the participants had some college or higher levels
of education. US-born English speakers had high-
er levels of education than non-US-born English
speakers and Spanish speakers. Half of the partici-
pants had a full or part-time job. Nearly half of the
participants were married. Non-U.S. born English
speakers and Spanish speakers had higher per-
centage of married participants compared to US-
born English speakers. One-fourth of the partici-
pants were born in the US. Non-US-born partici-
pants were from 46 countries in Latin America, Pa-

746
 Kamimura et al

Table 3
Predictors of Depression (N = 491)
95% Confidence 95% Confidence
B p-value Interval Interval
Lower Bound Upper Bound
Age -0.03 N.S. -0.1 0.01
Female -0.1 N.S. -1.3 1.1
US-born English speakers a
1.2 N.S. -0.2 2.6
Non-US-born English speakersa 0.5 N.S. -1.1 2.0
Some college or higher -0.2 N.S. -1.4 1.0
Employed -0.6 N.S. -1.7 0.5
Married -1.2 <0.05 -2.5 0.0
Clinic patient 2+ years 0.1 N.S. -1.1 1.3
Perceived stress 0.4 <.01 0.3 0.5
Negative coping strategies 4.8 <.01 3.1 6.5
Positive coping strategies -0.8 N.S. -1.8 0.3
(Constant) -3.8 N.S. -7.7 0.1
R2 0.6
F 31.5
p-value <.01

Note.
p-value denotes statistical significance from multivariate regression analysis. N.S. – non-significant. B – Unstandard-
ized coefficients.
a = Reference is Spanish speakers

cific Islands, the Middle East, Africa, Western and
Eastern Europe, and Asia. Mexico had the largest
number of participants (N = 200, 52.9% of the non-
US-born participants), followed by Tonga (N = 28,
7.4% the non-US-born participants) and Peru (N
= 18, 4.8% of the non-US-born participants; data
not shown). On average, non-US-born participants
lived in the US for 16.4 years among non-US-born
English speakers and 14.6 years among Spanish
speakers. Approximately 40% of the participants
had been a patient of the clinic for 2 years or lon-
ger. Non-US-born English speakers and Spanish
speakers had a higher percentage of participants
that had been a patient of the clinic for 2 years or
longer compared to US-born English speakers.
Table 2 presents descriptive findings related to
depression, perceived stress, and coping strategies
and comparison among the 3 groups with covari-
ates, female, education levels, and years of being
a patient of the clinic. US-born English speakers
reported the highest level of depression compared
to non-US-born English speakers and Spanish
speakers. Based on the cut-off points of PHQ-9,
US-born English speakers demonstrated moderate
levels of depression whereas non-US-born Eng-
lish speakers and Spanish speakers were mildly
depressed. US-born English speakers reported the
highest level of perceived stress followed by non-
US-born English speakers and Spanish speakers.
US-born English speakers were more likely to use
negative coping strategies than non-US-born Eng-
lish speakers and Spanish speakers. Non-US-born
English speakers and Spanish speakers were more
likely to use religion as a coping strategy compared
to US-born English speakers. US-born English
speakers were more likely to use venting, self-
blame, behavioral disengagement, and substance
use as coping strategies compared to non-US-born
English speakers and Spanish speakers.
Table 3 describes predictors of depression. High-
er levels of perceived stress and negative coping
strategies were associated with higher levels of de-
pression. Married participants were more likely to
have less depression than single participants.
DISCUSSION
This study examined stress and coping strate-
gies among uninsured primary care patients who
live below the 150th percentile of the federal poverty
line in the US and includes comparisons between
US-born English speakers, non-US-born English
speakers, and Spanish speakers. This study con-
tributes 3 main findings to the literature on de-
pression, stress, and coping strategies. First, US-

Am J Health Behav.™ 2015;39(6):742-750 DOI: http://dx.doi.org/10.5993/AJHB.39.6.1 747

Stress, Coping Strategies, and Depression – Uninsured Primary Care Patients
born English speakers reported higher levels of
depression and perceived stress compared to non-
US-born English speakers and Spanish speak-
ers. Second, US-born English speakers were more
likely to use negative coping strategies than non-
US-born English speakers and Spanish speakers.
Third, perceived stress and negative coping strate-
gies represented significant predictors of depres-
sion. The hypotheses of this study were supported:
(1) Higher levels of depression were associated with
higher levels of stress and poor coping strategies
among low SES population utilizing primary care,
particularly among US-born English speakers;
and (2) The levels of perceived stress and coping
strategies affect the levels of depression among the
low-income populations and differences in levels of
depression among the 3 groups.
The results of this study show that US-born
English speakers were more likely to be depressed
and stressed compared to non-US-born English
speakers and Spanish speakers whereas US-born
English speakers were moderately depressed and
the other 2 groups were mildly depressed. The re-
sults regarding depression are consistent with pre-
vious studies.16,17 According to the results of the
national survey conducted in 2009,27 the average
score of the PSS was 15.52 for men and 16.14 for
women. Whereas US-born and non-US-born Eng-
lish speakers in the current study reported higher
levels of perceived stress than the national aver-
age, Spanish speakers reported lower levels of
perceived stress. The PSS scores among US-born
English speakers in the current study are compa-
rable to those among low income ($25,000 or less)
populations in the national study.27
Given that the finding suggest coping strategies
differed among the 3 groups (ie, US-born English
speakers, non-US-born English speakers, and
Spanish speakers), it is noteworthy that these 3
populations also may have different needs for ad-
dressing coping strategies. Although US-born
English speakers tended to use a variety of coping
strategies, they were also more likely to use nega-
tive coping strategies such as venting, self-blame,
behavioral disengagement, and substance use
compared to non-US-born English speakers and
Spanish speakers. Differences in coping strategies
between Hispanics and non-Hispanic Whites may
be used as evidence to support the Hispanic health
paradox that states that Hispanics are healthier
than US-born Whites despite the socio-economic
disadvantages.28 The Hispanic paradox may be ap-
plicable to the findings of this study. Interventions
for US-born English speakers should focus on
promoting positive coping strategies and reducing
negative coping strategies. Lifestyle factors such
as exercise and body mass index account for the
majority of perceived stress among primary care
patients.29 Fostering healthy lifestyles (ie, healthy
eating, physical activities) as well as interventions
for substance use and negative psychological cop-
ing strategies might help US-born English speak-
748
ers improve or gain healthy coping strategies.
Higher levels of perceived stress and negative
coping strategies were associated with higher lev-
els of depression, and positive coping strategies did
not have an impact on depression. These results
indicate that reducing perceived stress and nega-
tive coping strategies serve as the keys to address-
ing mental health concerns, particularly depres-
sion, among the uninsured low SES populations.
The results that suggest a positive relationship
between perceived stress and depression are con-
sistent with previous studies.30,31 Not many stud-
ies have examined stress management strategies
for low-income men and women utilizing primary
care for the underserved. As our results suggest,
treating substance use and psychological negative
coping strategies, such as venting, self-blame, and
behavioral disengagement may help reduce lev-
els of depression, especially for US-born English
speakers.
Limitations
Although this study contributes to knowledge
about depression, stress, and coping strategies
among underserved immigrants and Spanish
speakers, it has some limitations. The cross-sec-
tional study design was limited for the examina-
tion of causal directions among variables. Non-US-
born English speakers were not homogeneous and
included diverse populations such as Hispanic/
Latinas, Pacific Islanders, Asians, Middle Eastern,
African, and European individuals. Furthermore,
there were no safeguards in place to prevent a
patient from completing more than one question-
naire. However, because participants did not re-
ceive any incentives, it is unlikely that participants
wanted to take the survey more than once. The
research assistants reported that patients who al-
ready completed the survey declined participation
on the basis that they had already been surveyed.
According to the clinic’s annual report, the distri-
bution of patient race/ethnicity was 48% Hispan-
ics, 31% White and 14% Asian/Pacific Islanders.
This information suggests that, compared to the
entire clinic patient population, we sampled a larg-
er percentage of Hispanic participants and smaller
percentages of Whites and Asian/Pacific Islanders.
Finally, it should be acknowledged that this study
was conducted at one free clinic and the results
may not be generalized to all other free clinical
across the US.
Conclusions
Whereas stress-related health issues can be ad-
dressed in a general primary care setting, diverse
patient needs are not always addressed due to
limited time and resources.29 This gap in mental
health services is particularly evident for clinics
working with underserved populations. This study
examined depression, perceived stress, and cop-
ing strategies among uninsured primary care pa-
tients in poverty. US-born English speakers, non-

US-born English speakers, and Spanish speakers
reported different coping strategies, and therefore,
may have different needs for addressing coping
strategies. In particular, US-born English speak-
ers need interventions for reducing substance use
and negative psychological coping strategies. Their
higher levels of perceived stress and negative cop-
ing strategies potentially relate to higher levels of
depression. These results do not mean that oth-
er 2 groups, non-US-born English speakers and
Spanish speakers, do not need interventions for
depression, stress, and coping because they are
only mildly depressed. In addition, non-US-born
English speakers reported higher levels of per-
ceived stress compared to the norm from the na-
tional study. Resources and interventions should
be tailored based on population because our re-
sults suggest the differences in coping strategies
among the 3 groups. Further research is neces-
sary to identify particular causes and contexts of
perceived stress among US-born English speakers
to develop and evaluate intervention programs for
these populations as well as non-US-born English
speakers and Spanish speakers.
Human Subjects Statement
This study was approved by the Institutional
Review Board of the University of Utah (document
number 72275) prior to the collection of any data.
Conflict of Interest Statement
All authors declare they have no conflicts of in-
terest to report.
Acknowledgments
This project was funded by the Public Service
Professorship, Lowell Bennion Community Ser-
vice Center at the University of Utah. The authors
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 Nushean Assasnik, Emily Carpenter,
Jason Chen, Eno Etokidem, Lea Hunter, Misael
Lanza, Anthony Mills, Tamara Stephens, and Truc
Tran for their help in data collection, data entry,
and translation services.
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