Take 2 Pills and Go Volunteer in the Morning: A Feasibility Study of Engaging Patients as Volunteers
Phase: NA
Conditions: Volunteers
Sponsor: Loyola University

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Title: Take 2 Pills and Go Help in the Morning: A Feasibility Study of Engaging Patients as Volunteers 
Document Date: September 18, 2018 
 

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I. TAKE 2 PILLS AND VOLUNTEER IN THE MORNING:  
A FEASIBILITY STUDY OF ENGAGING PATIENTS AS VOLUNTEERS 
 
II. IMPACT ON REDUCING HEALTH DISPARITIES 
We propose to examine the feasibility and acceptability of a novel intervention in which primary 
care providers in safety net clinics “prescribe” volunteering to their uninsured patients. In a nutshell, we 
plan to develop a brand new intervention that envisions having providers recommend volunteering as part of a 
patient’s treatment plan—alongside, for example, their recomendations for diet and exercise. The initial setting 
would be Loyola Medicine’s Access to Care (ATC) Clinic, a program using attending physicians and residents 
to deliver primary care to approximately 1,000 low-income uninsured patients annually. Willing patients would 
be connected to volunteer opportunities within the Loyola University Health System (LUHS) or to a local 
nonprofit agency situated in their own communities. The purpose of this application is to support research 
activities that would 1) inform the development of an intervention that would be a) acceptable to the target 
population and b) feasible to administer in under-resourced clinical settings; and 2) determine whether (and 
what kind) of preliminary outcomes related to well-being, activation, self-esteem, new skills, connection to 
others, etc. might accrue to patients connected to volunteer activities in an initial test of the intervention.  
Substantial evidence from randomized controlled trials and cohort studies, primarily involving older 
adults, suggests that volunteering contributes to improved mental health, greater longevity1 and beneficial 
health behaviors.2 Surprisingly little research exists on the experience of patients as volunteers.3,4 We posit that 
multiple positive outcomes are likely to accrue from engaging patients, especially vulnerable patients, as active 
participants in helping others.  
Moreover, volunteering has the potential to address multiple social determinants of health—education, 
economic stability, health care services, social integration, and community engagement—that could benefit the 
individual/patient, clinic, and community. Reaching beyond the health status of the patient and into the 
surrounding social structures and economic systems is a worthy investment since socioeconomic factors, such 
as education, employment, income, and social support, are estimated to account for nearly half of health 
outcomes. By contrast, the relative contributions of clinical care and insurance to health outcomes are estimated 
to be only 20%.5 Thus, while changing our health system and increasing insurance coverage are necessary 
strategies to improve health outcomes of the uninsured, advancing population health and achieving health 
equity will require new nonclinical approaches that more deliberately incorporate broader social 
determinants of health. This proposal fits squarely within that broader paradigm, which could also be 
termed “THE OTHER 80%.” 
This project helps fill a gap in health equity research. We target the uninsured, who are often ignored 
by innovations designed to reduce health disparities (e.g., medical homes, accountable care organizations, 
coverage of preventive health services) as these innovations are typically tied to third-party payments. 
Nevertheless, the uninsured constitute a large, costly, and enduring vulnerable population that presents multiple 
challenges—but also untapped abilities. Moreover, their less healthy profile means that they have all the more 
to gain from the potential benefits of the intervention. Approximately 30 million people are projected to remain 
uninsured by 2027.6 It is well documented that they are disproportionately poor, black and Hispanic, nonelderly 
adults. Moreover, health disparities are present across demographic groups like race/ethnicity, socioeconomic 
status, religion, disability, age, geography, gender, etc.—so an intervention that focuses on the uninsured rather 
than a single disparate population group (e.g., African Americans) has the advantage of impacting multiple 
population groups experiencing different kinds of disadvantages.  
From a policy perspective, the lessons learned through this project may be directly applicable to 
contemporary Medicaid policy discussions. For instance, there is now substantial interest in requiring Medicaid 
beneficiaries to work as a condition of eligibility. To date, three states (AR, IN, and KY) have received federal 
approval to enact Medicaid work requirements, and applications are pending in an additional 7 states (AZ, KS, 
ME, MS, NH, UT, and WI). Policymakers, consumer advocates, and safety net providers in these affected states 

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(and any others that might follow suit) trying to preserve Medicaid for the low income (and disproportionately 
minority) beneficiaries subject to the new work requirements might be especially interested in an intervention 
that encourages volunteerism among vulnerable patients since volunteering/community service counts as work 
activities in all but three states’ plans (NH, UT, and WI).  
III. INTRODUCTION/BACKGROUND 
  
Our health system does not assure affordable, accessible, and equitable care or produce the highest level 
of health for everyone who lives in the United States. Being uninsured is one reason why. 
Negative Consequences of Being Uninsured. Having no insurance is associated with a host of health, 
social, and economic disparities: less access to health care,7,8 poorer treatment,9 worse health outcomes,10 higher 
debt,11,12 and greater social isolation.13  
Beyond issues of inequity, the costs are enormous: the uninsured are estimated to account for $85 billion 
yearly in uncompensated care, which is borne by the individual, employer, health system and society  14,15  
Magnitude of the Uninsured Problem. In 2018, there are an estimated 30 million individuals, mostly 
adults 18-64, who are uninsured, and this number is expected to hold steady over the next decade 6. While the 
Affordable Care Act (ACA) has reduced the number of uninsured by roughly 14 million, the average percentage 
of U.S. residents without insurance is still high: 10.3% across all states, 13.3% in non-Medicaid-expansion 
states (n=18 states), and 8.1% in Medicaid-expansion states (including Illinois). Put differently, that is 1 
uninsured person out of every 12 people living in a Medicaid-expansion state. And that is arguably the best-case 
scenario after the ACA. 
The Uninsured at Loyola’s Access to Care (ATC) Clinic. Closer to home (see Table 1), in ATC 
Clinic’s catchment area, rates of uninsurance are much higher than in Illinois and comparable to or worse than 
uninsurance rates in neighboring Chicago, where residents are more than twice as likely to be uninsured than 
the rest of Illinois. 
Table 1. Uninsurance in ATC Clinic’s Catchment Area 
Characteristic 
Illinois 
Chicago Broadview Berwyn 
Cicero 
Franklin 
Park 
Maywood 
Melrose 
Park 
Population size  
12.8 m 
2.7 m 
7,823 
55,748 
82,992 
18,110 
23,756 
25,229 
Persons <65 w/out health insurance (%) 7.4 
16.3 
16.2 
14.8 
23.9 
16.1 
18.0 
21.0 
Source: U.S. Census, Data as of July 1, 2016. 
It is not coincidental that the ATC Clinic attracts patients from neighborhoods that have large 
percentages of low income and minority residents. Being a member of a racial/ethnic minority group, being low 
income, or being a non U.S. citizen are all risk factors for uninsurance.  
Loyola’s ATC program is a by-product of a partnership between Loyola and “Access to Care,” a Cook 
County program (http://www.accesstocare.org/) sharing the same name. Loyola contracts with Access to Care 
to provide low-cost primary care ($5/visit), laboratory and radiology services ($5), and medications ($5 to $40) 
to low income (<300% of poverty) uninsured and underinsured residents in suburban Cook County. In return, 
the providers receive an annual nominal fee of about $70 per patient. Loyola’s ATC program currently has 952 
active adult patients and provides about 3,000 visits annually. A majority is female (roughly 60%) and ages 
range from 19 to 83. Hispanics comprise the largest racial/ethnic group (78%) followed by African Americans 
(18%). Reflecting their high chronic disease burden, the top diagnoses are diabetes, hypertension, obesity, 
depression, osteoarthritis and dyslipidemia. There is one attending physician, Dr. Fitz, a co-investigator on this 
proposal, who sees patients on Monday, Wednesday and Thursday afternoons and all day on Tuesday.  
The clinic is open on Fridays for acute care visits, and the Loyola Immediate Care centers and Emergency 
Department are available to patients during off-hours or for more urgent needs. LUHS also provides tertiary 
care with consult and procedural support for ATC Clinic patients at the main hospital. The clinic is a residency 
training site, enabling residents to learn from and care for patients during their 3-year training program in a 
continuity care model.  Dr. Fitz oversees 3-4 residents at a time who rotate through the clinic every 5 weeks for 
a total of approximately 20 different residents per year.   

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Ameliorating the Effects of Being Uninsured. In the absence of expanding health insurance 
coverage,16 a policy option that is effective but not feasible in the current political climate, there are steps we 
can take to mitigate the harms of being uninsured. Lessons from the social determinants of health literature 
prompt us to focus our attention outside the health system—i.e., “THE OTHER 80%.” The proposed 
“prescribing volunteerism” intervention is offered in this spirit: an incomplete fix on its own but a strategy that 
would likely garner political support from both sides of the aisle, and one that is arguably an improvement over 
the status quo.  
 
Extent of Volunteerism and Its Benefits. According to 2015 data from the U.S. Bureau of Labor 
Statistics, one in four Americans volunteers each year, with higher participation rates among Whites (26%) than 
African Americans (19%) or Hispanics (16%). Volunteers spend a median of 52 hours per year on volunteer 
activities. The United Nations and governments around the globe encourage volunteerism as a strategy to not 
only engage people in their communities and improve social capital but also to reduce health inequities.1 The 
idea that volunteerism could be “prescribed” by doctors as a way to improve health reached the pages of The 
Atlantic, which suggests that it is not as far-fetched as it might first seem.17 Adding to the large body of 
evidence suggesting a correlation between volunteering and numerous health benefits, the meta-analyses1,18 plus 
randomized controlled trials (RCTs) involving older adults19,20 and adolescents21 showing sustained 
improvements in physical activity and lower cardiovascular risk, respectively, make a convincing case that 
volunteering contributes to better health.  
 Preliminary Work. Given the uncharted nature of the proposed study, we administered a three-
question survey designed to gauge the general acceptability of and demand for volunteering among uninsured 
patients seeking care in the ATC Clinic. Front desk workers distributed the survey over a two-week period in 
April, 2018. Formatted two-sided in English and Spanish, the survey asked about past volunteering experiences, 
level of interest in volunteering, and the likelihood of their volunteering if recommended by their physician. 
In all, we collected 24 completed surveys (50% Spanish; 50% English). A substantial minority (42%) of 
patients have done volunteer work in the past or are currently doing volunteer work, but past volunteering was 
higher among English-speaking (ES) patients (67%) than Spanish-speaking (SS) patients (17%). Fully two-
thirds of patients (67%) said that they are “somewhat interested” to “very interested” in learning about possible 
volunteer jobs, with some differences between ES (75%) and SS (59%) patients. Reassuringly, very few 
reported being not likely (8% ES; 17% SS) while half of the patients said they are “likely” or “very likely” to 
engage in volunteer work if recommended by their doctor. See Appendix B for details.  
Conceptual Framework. Our study is guided by a conceptual model (Figure 1, below) that advances 
volunteering as an intervention that can improve well-being at the patient-, clinic-, and community-level.  It 
does so by increasing patients’ capacity to build communities by way of addressing the social determinants of 
health. In this proposal, we focus on measuring the benefits that may accrue to the patient, reserving the 
Figure 1. A Model for Asset-
Based Community Development  
Patient as Volunteer 
 
 
 
Patient 
Clinic 
Community 
INCREASED WELL-BEING 
Increased life skills 
Increased self esteem 
Increased emotional gratification 
Increased dignity, power, prestige 
Improved health status 
Increased self-efficacy/activation 
Increased networks 
ENHANCED PATIENT-
CENTEREDNESS 
Increased respect for patient 
Increased equality between 
provider-patient 
IMPROVED WELL-BEING 
Increased social capital 
Increased civic engagement 
 
 
 
Focus on the Social Determinants of Health 
Education 
Economic Stability 
 
Health & Health Care 
Social & Community Context 
Neighborhood 
Mutually reinforcing 

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assessment of additional benefits to the clinic and community for future studies.  
Our research adopts an asset-based approach. We intentionally leverage (and seek to bolster) the 
abilities of vulnerable patients rather than focus on their needs. If we determine that patients can serve as 
volunteers, our research would suggest new, empowering roles that they can play in an era of patient-centered 
care, and new ways that patients can become healthier, more skilled, more connected, and more civic-minded. 
IV. SPECIFIC AIMS 
The overall objectives of this feasibility study are to evaluate the acceptability and feasibility of 
promoting volunteerism in safety net settings, and to gather preliminary evidence that will inform a larger study. 
Toward these ends, we propose a sequential mixed-methods research design in which information from earlier 
aims will inform the implementation of subsequent aims. We propose the following aims and methods: 
1. Assess the acceptability and feasibility of the “prescribing volunteerism” intervention among 
uninsured patients, providers, and executives in diverse ambulatory care safety net settings. 
 Safety net settings will include an academic medical center ambulatory clinic, free medical clinic, and 
federally qualified health center. These settings disproportionately serve patients at risk for experiencing 
health disparities: low income, uninsured, immigrants, and members of racial/ethnic minority groups.  
 We will carry out focus groups with patients, and key informant interviews with clinical staff and clinic 
executives to help inform Aims 2 and 3, see below.  
2. Establish linkages between the intervention setting and other community-based, nonprofit 
organizations offering volunteer opportunities in Loyola’s catchment area. 
 Loyola Medicine’s ATC Clinic will be the initial intervention setting.  
 We will establish formal linkages between the intervention site and the following: Loyola University 
Medical Center in Maywood, Gottlieb Memorial Hospital in Melrose Park, MacNeal Hospital in Berwyn, 
and other community-based, nonprofit organizations that could offer volunteer opportunities in Loyola’s 
catchment area. [See Appendix C for letters of support from example community partners, Maywood Fine 
Arts, Quinn Community Center in Maywood, and the Illinois Coalition of Immigrant and Refugee Rights, 
which has numerous affiliated partners in the ATC Clinic’s service area.] Feedback from patient focus 
groups will inform our outreach to community organizations as we will seek to find opportunities that 
match patients’ interests and preferences. 
3. Gather preliminary data about the potential effectiveness of a volunteer program in a safety net 
setting.  
 We will implement a small pilot of the intervention in the ATC Clinic to learn if it will be feasible and 
effective on a broad scale.  
 We will recruit 50 uninsured patients, with 25 in the intervention group and 25 in the control group. For 
the 25 uninsured patients who initiate volunteering at one of the designated sites, we will collect data on 
the nature and intensity of their volunteering (e.g., role/position, hours, and # of times) as well as outcome 
measures such as activation, self-esteem, and well-being. We will compare outcomes between the 
intervention group and an uninsured comparison group, which will be comprised of ATC Clinic patients 
who expressed an interest in volunteering on a screening form but were not assigned a volunteer job. 
 We hypothesize that volunteering will be associated with improved outcomes.  
V. PROJECT OUTLINE 
We propose a sequential mixed-methods research design that involves three stages, which align with the 
3 aims. Stage 1 involves collecting qualitative data and developing intervention-related materials and 
procedures. Stage 2 involves establishing linkages with the nonprofits offering volunteering opportunities. Stage 
3 is the initial test of the intervention. Stage 1 informs Stages 2 and 3, and Stage 2 informs Stage 3. By the end 
of the study, we expect to have enlisted approximately 130 research subjects to help us achieve the aims of the 
study, including: 110 uninsured patients, who will participate in focus groups (n=60) or the intervention (n=25 
intervention, n=25 control); 9 clinicians from the ATC Clinic, free clinic, and FQHC; 3 clinic executives 
representing the aforementioned safety net settings; and 7 nonprofit organizations that offer volunteer jobs.   

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Aim 1. Assess the acceptability and feasibility of the “prescribing volunteerism” intervention 
among uninsured patients, providers, and executives in diverse ambulatory care safety net settings. 
Study Design and Methods, Setting, and Subjects. We will use a grounded theory qualitative approach to 
gather information about the project’s acceptability and feasibility from the perspective of patients, clinicians, 
and clinic executives. We plan to use 90-minute focus groups to collect information from patients (n=60) and 
30- to 45-minute key informant interviews for clinicians (n=9) and clinic executives (n=3). Focus groups and 
interviews will be audio-recorded. To increase generalizability of the intervention, the focus groups and 
interviews will be carried out in three safety net settings: ATC Clinic, CommunityHealth free clinic (see 
Appendix C for letter of support), and a FQHC to be determined. Volunteer-based free clinics, which are 
estimated to serve 2 million uninsured adults annually,22 have a well-developed volunteer infrastructure, and 
may be especially apt for enhancing patient centeredness in this intervention as they are well-equipped to offer 
volunteer activities inside their clinics. By contrast, FQHCs use a staff model but are significant providers of 
comprehensive primary care to the uninsured, serving some 5 million uninsured adults annually.23 Potential 
future replication of the intervention in FQHCs would greatly expand reach, so activities in this project help 
prepare us for this opportunity.  
In the focus groups, we will seek input from patients about their past volunteer experiences and the 
motivations for volunteering, perceived benefits of volunteering, reasons for not volunteering, opinions about 
the idea of having a doctor recommend volunteering, reactions to draft marketing materials, perceived 
likelihood of volunteering if recommended by a doctor, and volunteer interests.  
To explore the intervention’s acceptability as well as its practicality and compatibility with the practice 
setting, we will interview clinicians who would play a key role in recommending volunteerism to their patients 
as well as clinic executives who would be responsible for implementation. Where applicable (e.g., free clinic), 
we will explore best practices for recruiting patients into volunteer roles.  
Data Analysis. We will use a combination of professional transcription services and student research 
assistants to transcribe the focus groups and interviews. To facilitate rapid learning, we will code each transcript 
only once and then enter them into NVivo. Team members will meet to discuss learnings, identify themes, and 
come to consensus on the meaning of any ambiguous content. Lessons learned will inform Aims 2 and 3. 
Deliverables. We will: 
 develop marketing materials based on messaging that seems to resonate with patients, and from feedback we 
received on sample posters and flyers during the focus groups.  
 establish procedures for raising awareness about the intervention (who says what and when), ensuring that 
there is a “warm hand-off” from the provider to an ATC Clinic staff person. 
 develop a screening tool (modeled after the 3-question survey about volunteering that we distributed to 
patients) to identify patients who would be interested in volunteering, though we plan to add items about 
demographic and clinical characteristics to aid our matching intervention and control subjects under Aim 3. 
 develop a one-page information sheet about the intervention and its value to educate ATC Clinic medical 
residents about the intervention. Education contacts will commence at the start of each rotation. 
The materials we develop and processes we establish during Aim 1 will be implemented in Aim 3. 
 
Aim 2. Establish linkages between the intervention setting and other community-based, nonprofit 
organizations offering volunteer opportunities in Loyola’s catchment area.  
Study Design and Methods, Setting, and Subjects. As with Aim 1, we will use a qualitative approach, 
relying on key informant interviews to gather information from community nonprofits offering volunteer 
opportunities and organizations that link individuals to volunteer jobs. We will conduct key informant 
interviews with 5 nonprofit organizations offering volunteer activities to learn about their volunteer offerings 
and solicit their input on how to set up effective, two-way communication channels, ensuring that the ATC 
Clinic receives regular reports about volunteer hours completed by patients at the community sites. To learn 
about best practices linking individuals to nonprofit volunteering activities, we will conduct 2 key informant 
interviews with volunteer referral centers at the University of Chicago (https://ucsc.uchicago.edu/) and in New 
York City (https://www.nycservice.org/). Additionally, we expect that repeated communication would be 

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beneficial with our most active nonprofit partners and will establish a learning collaborative with 5 nonprofits 
that can provide regular feedback to the research team through monthly calls. 
Data Analysis: Following the approach from Aim 1, we will have only one coder for each transcript but 
devote ample time for discussion of findings among team members. The findings will be used to develop a 
referral form as well as inform the execution of Aim 3.  
Deliverables. We will develop a referral form that ATC Clinic staff will use to link patients to volunteer 
opportunities. 
Aim 3. Gather preliminary data about the potential effectiveness of a volunteer program in a 
safety net setting. As noted, information from the earlier aims will inform some of the details for the final aim. 
Nonetheless, the general framework for the implementation of the pilot intervention is outlined below. 
  
Study Design, Setting, and Subjects. For this pilot phase, we will use a quasi-experimental difference in 
differences study design that compares two groups, one that volunteers and one that does not. We will recruit 
patients from the ATC Clinic. Patients will be eligible to participate if they: 1) are adults 18+;  2) received care 
at the clinic at least twice in the past year; 3) are not currently volunteering; 4) speak Spanish or English, and 5) 
deemed fit to participate by their provider.   
 
Recruitment.  To meet our recruitment target of 50 patients (n=25 in intervention arm, n=25 in control 
arm), we will use a multi-pronged approach that involves marketing materials (e.g., posters, flyers), repeat 
messaging about the volunteer program, provider education to reinforce messaging, and direct recruitment at the 
clinic visit. All eligible patients will be invited to participate in the study. We will continue to recruit patients 
into the intervention group until 25 participants consent to being referred to one of the volunteer activities that 
were established under Aim 2 during Stage 2. Once the cohort is filled, we will review the completed screening 
forms to identify patients who share similar characteristics with the intervention group and invite them to 
participate in the study as controls. Though our preliminary data would suggest that nearly half of the ATC 
Clinic patients would be interested in the intervention, we conservatively estimate that it will take 4 weeks to 
recruit and consent 25 subjects into the intervention. This estimate is based on the assumption that we can 
recruit just 10% (n=6) of each week’s total patient caseload, which is about 60 per week. Moreover, the 10% 
estimate takes account of the roughly 8% of patients who would be expected to be in current volunteer jobs and 
ineligible for the intervention. We will take an additional three weeks to recruit and consent the control patients.  
 
Intervention. We will link the intervention subjects to volunteer opportunities at Loyola or in their 
communities and track their “referral completion” and volunteer activities through agreed upon communication 
channels devised under Aim 2. Subjects will be engaged in volunteer tasks for at least four months.   
Data Collection/Measures. Data will be collected for all eligible patients (intervention and controls) who 
consent to be part of the study. (See Appendix D for complete details.) We will collect data at two time points, 
at baseline and at the end of the study. At baseline, we will collect demographic and outcome information. 
Upon completion of the study period, we will gather information on outcomes and volunteer job satisfaction 
(for those who volunteered). Additionally, for those who volunteered, we will collect data about the site, nature, 
and intensity of their volunteering activities. All surveys will be interview-administered by the study team. 
Several (previously validated in English and Spanish) instruments will be used to assess outcomes. All subjects, 
regardless of arm, will be assessed on well-being (using word and visual methods), self-esteem, and 
activation/efficacy. Volunteers referred to volunteer jobs will be asked to report on motivation for volunteering, 
satisfaction with volunteer experience, benefits of volunteering (e.g., life skills, networking), and barriers to 
volunteering. To reduce respondent burden and fatigue, the series of baseline and follow-up surveys is each 
expected to take about 30 minutes. 
To compensate patients for their time and contribution to the study, to help address barriers to 
participation, and as a sign of respect, we will provide a $20 Target gift card to all patients who complete the 
baseline assessment and another $20 Target gift card at the study’s completion.  
Data Analysis. We will carry out several analyses. First, we will compare baseline data between those 
who participated in the volunteer program with those who did not. The comparison group will be derived from 
patients who indicated an interest in volunteering but were not assigned a volunteer job. We will select 25 
patients who are “frequency matched” on severity of chronic disease, race/ethnicity, age group, gender, highest 

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level of education, and work status. Second, we will carry out a simple difference in difference estimation 
approach in which we will examine differences in outcomes between baseline and the end of the study between 
the two comparison groups. The idea is that the simple “pre-post” design may be biased because of unobserved 
factors that affect outcomes and that changed along with the intervention. If these unobserved factors also 
affected the control group, then double differencing can remove the bias and isolate the intervention effect. We 
will use basic descriptive statistics and chi-square tests to compare differences in proportions and the t-test or 
the Kruskal-Wallis test to compare means. If the sample size allows it, we will explore regression methods.  
Human Subjects Concerns/Risks. The study presents minimal risks with potential health benefits to 
subjects willing to initiate volunteer activities. While participation is completely voluntary, there is a risk that 
patients might feel coerced to participate in the intervention. To address this concern, staff will reassure patients 
that failure to participate will in no way affect their care at the ATC Clinic. The protocol and all study materials 
will be submitted to the Stritch School of Medicine (SSOM) Institutional Review Board. Interested eligible 
individuals will be guided through standard informed consent processes. All forms, except the consent form, 
will exclude participants’ names and contact information; a participant will only be identifiable via 6-digit 
participant identification code. That code will be attached to the name and contact information in a password-
protected file. This file will be kept in a separate space and will be accessible only to the study team. Nobody 
outside the research team will use or disclose data. Data will be presented or published only in aggregate form.  
Timeline. We propose our timeline as follows. 
Task/Month 
7/18 
8/18 
9/18 
10/18 11/18 12/18 1/19 
2/19 
3/19 
4/19 
5/19 
6/19 
Preparation 
Finalize focus groups/interviews 
 
 
 
 
 
 
 
 
 
 
 
 
Obtain IRB approval for Stage 1 
qualitative inquiry 
 
 
 
 
 
 
 
 
 
 
 
 
Stage 1: Qualitative Work and Development of Intervention-Related Materials and Procedures 
Conduct focus groups/interviews  
 
 
 
 
 
 
 
 
 
 
 
 
Analyze qualitative data 
 
 
 
 
 
 
 
 
 
 
 
 
Develop marketing materials  
 
 
 
 
 
 
 
 
 
 
 
 
Develop protocol/clinic procedures 
for recommending volunteerism 
 
 
 
 
 
 
 
 
 
 
 
 
Develop 1-page information sheet 
for medical residents/providers 
 
 
 
 
 
 
 
 
 
 
 
 
Develop screening tool to gauge 
interest in volunteering/match arms 
 
 
 
 
 
 
 
 
 
 
 
 
Establish ATC procedures for 
referring patients to volunteer jobs 
 
 
 
 
 
 
 
 
 
 
 
 
Obtain IRB approval for Stages 2 
and 3 (amendment) 
 
 
 
 
 
 
 
 
 
 
 
 
Stage 2: Establishing Linkages with LUHS and Community Nonprofits Offering Volunteer Opportunities 
Establish formal linkages 
 
 
 
 
 
 
 
 
 
 
 
 
Conduct key informant interviews 
 
 
 
 
 
 
 
 
 
 
 
 
Analyze interview data 
 
 
 
 
 
 
 
 
 
 
 
 
Develop referral form 
 
 
 
 
 
 
 
 
 
 
 
 
Stage 3: Conduct pilot at ATC Clinic 
Recruit and consent subjects 
 
 
 
 
 
 
 
 
 
 
 
 
Educate providers/residents 
 
 
 
 
 
 
 
 
 
 
 
 
Implement intervention 
 
 
 
 
 
 
 
 
 
 
 
 
Analyze pilot data, generate results 
 
 
 
 
 
 
 
 
 
 
 
 
Submission of manuscripts and presenting findings at conferences will occur after the funding period. 
VI. OUTCOMES/SUSTAINABILITY 
We have conceived of our entire research endeavor in 4 distinct phases: Phase 1 – feasibility, the focus 
of this application; Phase 2 – exploratory; Phase 3 – efficacy; and Phase 4 – dissemination and 
implementation.24 Our long-range goal is to secure a R01 grant to 1) test the efficacy of the Engaging Patients 

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as Volunteers intervention in a randomized, controlled trial; and 2) replicate the intervention broadly.  
To prepare a successful R01 application, we plan (Phase 1) to first demonstrate the intervention’s 
feasibility and acceptability by the proposed activities. Then, in Phase 2, we will seek additional extramural 
support to further explore the intervention. We will carry out the definitive randomized controlled trial in Phase 
3. And during Phase 4, our focus would shift to replication and broad dissemination. We would anticipate that a 
R01 grant would encompass Phase 3 and (at least some aspects of) Phase 4. 
The results generated from this Phase 1 feasibility project will be used in a National Institutes of Health 
(NIH) National Institute of Minority Health and Health Disparities (NIMHHD) R21 (Phase 2) application, 
which allows direct costs up to $275,000 over two years. NIMHHD is inviting applications on systems-wide 
health services research that test “strategies to organize, manage, finance and deliver health care to improve 
minority health or reduce health disparities.” In particular, the agency is encouraging applications that are 
highly innovative and address larger systemic factors outside the health system (i.e., exactly what we describe 
above as “the other 80%” of what determines health outcomes). The longer duration and larger budget of the 
NIH would allow for scaling up and refining the intervention in the main site, Loyola’s ATC Clinic, as well as 
spreading the intervention to additional safety net sites. The planned qualitative research activities with 
providers, staff, and patients in other clinic settings during Phase 1 will set the stage for expanding the 
intervention to additional settings (Phase 2). 
The Evidence for Action: Investigator-Initiated Research to Build a Culture of Health funding 
opportunity sponsored by the Robert Wood Johnson Foundation would be another potential source of funding to 
consider, either as a substitute for or complement to the NIH R21 application. Similar to the R21 mechanism, 
the Culture of Health grants are typically in the range of $100K to $300K over a period of one to three years. 
Thus, the budget size and duration would be adequate to further test the intervention.  
Besides the above funding opportunities, our team will strive to elevate the profile of this highly 
innovative research and hopefully attract the attention of funders by seeking to disseminate early study findings 
at the American Public Health Association as well as at national and state conferences targeted to free clinics.  
Ongoing student involvement also can help us sustain our connection to the ATC Clinic when grant 
funds from Health EQ are exhausted. For instance, we plan to encourage students in the Master of Public Health 
(MPH) program to pursue their practicum and capstone experiences at the ATC Clinic. Ideally, their 
experiences would include components that would advance this project’s goals. 
VII. TEAM  
The team of key investigators is highly diverse, representing backgrounds in health policy and social 
work (Julie Darnell-PI), medicine (Matt Fitz, Nallely Mora), and epidemiology (Abigail Silva, Mora), with 
English/Spanish bilingual proficiency (Fitz, Silva, Mora). Combining expertise in health disparities research, 
patient care, and collaborations with community-based providers, the team is well qualified to carry out the 
study. The team has formal training in and substantial experience with the proposed quantitative and qualitative 
methods. Faculty are housed in the SSOM Department of Public Health Sciences and in the LUHS Department 
of Internal Medicine. Additionally, the application includes meaningful opportunities for ATC-affiliated 
residents as well as students to become involved in research activities. We anticipate that our community 
partners, which include the safety net providers as well as nonprofits offering volunteer opportunities, will play 
active roles as key informants and advisers throughout the study period. The letters of support demonstrate their 
enthusiasm about our application. Two team members have worked together previously on funded research 
(Darnell and Mora) and Dr. Fitz is a mentor to Dr. Darnell. This application is bringing together two 
investigators (Darnell, Silva) for the first time, though they share an interest in working with safety net 
institutions to address health disparities. The team includes a key staff person (Yvette Lugo) at the ATC clinic, 
who will serve as liaison with the ATC Clinic patients. The roles/responsibilities of each team member is 
provided in the budget justification, which is included in Appendix E. 
VIII. BUDGET/FUNDING 
We request funding in the amount of $49,738 to initiate a new and highly promising frontier of research 
activity that advances the work of several early- and mid-career investigators. Seed funding from the Health-EQ 

10 
 
will allow our team to produce preliminary data that will make future extramural applications more competitive.  
We provide details about the budget in Appendix E.  
IX. PROTECTION OF HUMAN SUBJECTS 
Please note that we have spelled out our methods for protecting human subjects for only the patient focus 
groups, the first activity in our qualitative study. We will append this section with additional details about 
the key informant interviews as well as the intervention in subsequent amendments.  
The qualitative portion of our study involves focus groups with clinic patients and key informant interviews 
with healthcare professionals. We have taken steps to protect the human subjects involved in these activities. In 
general, we propose to use research information sheets (Research Info Sheet for Patient Focus Groups is 
attached in this application; the Research Info Sheet for Key Informant Interviews is under development) in lieu 
of obtaining written informed consent.  
Participation in the qualitative study is voluntary. Patients will be recruited with flyers displayed and distributed 
in the clinic. Healthcare professionals for key informant interviews will be recruited directly by email and/or by 
phone.  
We will be asking patients to participate in focus groups lasting approximately two hours, and healthcare 
professionals to participate in key informant interviews lasting approximately 30 to 45 minutes. The focus 
groups will be conducted in person while the key informant interviews will be conducted both in person and by 
phone.  
Immediately before the focus groups and in advance of the key informant interviews, patients and healthcare 
professionals will be given a copy of the corresponding research information sheet, which is being used in place 
of obtaining written consent, a noted above. We anticipate that we will send the research information sheet to 
key informants as an attachment in an email. Regardless of participant type, all participants will also be verbally 
reminded of their rights and the risk of the study immediately prior to their participation. Starting from 
recruitment, all participants will be regularly encouraged and given the opportunity to ask questions via email, 
phone, and in-person.  
At the start of the focus group or key informant interview, participants will be asked to fill out a background 
survey. (Survey for Focus Groups is attached & Survey for Key Informant Interviews is under development). 
No identifying information will be recorded on the surveys, and all results of this survey will be kept 
anonymous and de-identified. 
The focus groups and key informant interviews will be audio recorded. We will record only the participant’s 
first name plus his/her first initial of his/her last name (e.g., Maria B.) in all handwritten notes and 
transcriptions. Members of the research team will be keeping the handwritten notes, audio recordings, and 
computer files. All research materials will be kept on password-protected computers. All audio recordings will 
be destroyed once the key informant interviews have been transcribed. There are no plans to destroy the 
handwritten notes, transcribed notes, and computer files, as these materials may be useful for future grant 
applications. 
We assure all our participants that no information identifying them will be used in any reports or presentations 
at scientific meetings. Eventually, we may publish what we learn from the focus groups and key informant 
interviews. Again, all written reports/articles will not include any information that identifies any specific 
person. A participant’s individual privacy will be maintained in all published and written data resulting from the 
study. Furthermore, no information about the participants during the research will be disclosed to others 

11 
 
(besides members of the research team) without their written permission, except if necessary to protect their 
rights or welfare.  
The risk associated with this study for both clinic patients and healthcare professionals is the potential loss of 
confidentiality. Furthermore, the risk of losing confidentiality is potentially greater for the focus group 
participants since other participants may repeat what they heard during the focus group. We cannot and do not 
guarantee or promise that participants will receive any benefits from this study. 
Non-Loyola-affiliated professionals involved in the key informant interviews will be offered $50 Target gift 
card for their participation. Clinic patients will be compensated with a $30 Target gift card for participating in 
the two-hour focus groups. 
All of the researchers involved in the study have completed the CITI training. 
APPENDIX A. REFERENCES 
 
1. 
Jenkinson CE, Dickens AP, Jones K, et al. Is volunteering a public health intervention? A systematic 
review and meta-analysis of the health and survival of volunteers. BMC public health 2013;13:773. 
2. 
Kim ES, Konrath SH. Volunteering is prospectively associated with health care use among older adults. 
Social Science & Medicine 2016;149:122-9. 
3. 
Keys LM. Former patients as volunteers in community agencies: a model work rehabilitation program. 
Hospital & community psychiatry 1982. 
4. 
Seville J. The Good Samaritan Program: Patients as Volunteers. Activities, Adaptation & Aging 
1985;6:73-8. 
5. 
Hood CM, Gennuso KP, Swain GR, Catlin BB. County Health Rankings. American journal of 
preventive medicine 2016;50:129-35. 
6. 
Congressional Budget Office. Federal Subsidies for Health Insurance Coverage for People Under Age 
65: 2017 to 2027. Washington, DC: Congress of the United States; 2017. 
7. 
Broadwater-Hollifield C, Madsen TE, Porucznik CA, et al. Predictors of patient adherence to follow-up 
recommendations after an ED visit. The American journal of emergency medicine 2015;33:1368-73. 
8. 
Hadley J. Insurance coverage, medical care use, and short-term health changes following an 
unintentional injury or the onset of a chronic condition. Jama 2007;297:1073-84. 
9. 
Boevers E, McDowell BD, Mott SL, Button AM, Lynch CF. Insurance status is related to receipt of 
therapy and survival in patients with early-stage pancreatic exocrine carcinoma. Journal of cancer 
epidemiology 2017;2017. 
10. 
Powell DJ, Xirasagar S. Excess deaths among the uninsured before the Affordable Care Act (ACA), and 
potential post-ACA reductions. Journal of Public Health Management and Practice 2017;23:e18-e28. 
11. 
Majerol M, Newkirk V, Garfield R. The uninsured: a primer. Key Facts About Health Insurance and the 
Uninsured in the Era of Health Reform: Kaiser Foundation 2015. 
12. 
Gunja MZ, Collins SR, Blumenthal D, Doty MM, Beutel S. How Medicaid Enrollees Fare Compared 
with Privately Insured and Uninsured Adults. 2017. 
13. 
Institute of Medicine. Shared Destiny : Community Effects of Uninsurance. 2002. 
14. 
Hadley J. Sicker and poorer—The consequences of being uninsured: A review of the research on the 
relationship between health insurance, medical care use, health, work, and income. Medical Care 
Research and Review 2003;60:3S-75S. 
15. 
Coughlin TA, Holahan J, Caswell K, McGrath M. An estimated $84.9 billion in uncompensated care 
was provided in 2013; ACA payment cuts could challenge providers. Health Affairs 2014;33:807-14. 
16. 
Sommers BD, Gawande AA, Baicker K. Health insurance coverage and health—what the recent 
evidence tells us. Mass Medical Soc; 2017. 
17. 
Hamblin J. The Physiological Power of Altruism. TheAtlantic com, Dec 2015;30. 

12 
 
18. 
Okun MA, Yeung EW, Brown S. Volunteering by older adults and risk of mortality: A meta-analysis. 
Psychology and Aging 2013;28:564. 
19. 
Tan EJ, Rebok GW, Yu Q, et al. The long-term relationship between high-intensity volunteering and 
physical activity in older African American women. Journals of Gerontology: Series B 2009;64:304-11. 
20. 
Tan EJ, Xue Q-L, Li T, Carlson MC, Fried LP. Volunteering: a physical activity intervention for older 
adults—the experience Corps® program in Baltimore. Journal of Urban Health 2006;83:954-69. 
21. 
Schreier HM, Schonert-Reichl KA, Chen E. Effect of volunteering on risk factors for cardiovascular 
disease in adolescents: A randomized controlled trial. JAMA pediatrics 2013;167:327-32. 
22. 
Darnell JS. Free clinics in the United States: a nationwide survey. Archives of internal medicine 
2010;170:946-53. 
23. 
2016 National Health Center Data - Table 4 Selected Patient Characteristics. 2018. (Accessed April 23, 
2018, 2018, at https://bphc.hrsa.gov/uds/datacenter.aspx?q=tall&year=2016&state=.) 
24. 
Gitlin LN. Introducing a new intervention: An overview of research phases and common challenges. 
American Journal of Occupational Therapy 2013;67:177-84. 
25. 
Hibbard JH, Mahoney ER, Stockard J, Tusler M. Development and testing of a short form of the patient 
activation measure. Health services research 2005;40:1918-30. 
26. 
Hibbard JH, Stockard J, Mahoney ER, Tusler M. Development of the Patient Activation Measure 
(PAM): conceptualizing and measuring activation in patients and consumers. Health services research 
2004;39:1005-26. 
27. 
Cella D, Yount S, Rothrock N, et al. The Patient-Reported Outcomes Measurement Information System 
(PROMIS): progress of an NIH Roadmap cooperative group during its first two years. Medical care 
2007;45:S3. 
28. 
Hays RD, Bjorner JB, Revicki DA, Spritzer KL, Cella D. Development of physical and mental health 
summary scores from the patient-reported outcomes measurement information system (PROMIS) global 
items. Quality of Life Research 2009;18:873-80. 
29. 
Rosenberg M. Society and the adolescent self-image: Princeton university press; 2015. 
30. 
Bell IR, Cunningham V, Caspi O, Meek P, Ferro L. Development and validation of a new global well-
being outcomes rating scale for integrative medicine research. BMC Complementary and Alternative 
Medicine 2004;4:1. 
31. 
Otto LM, Howerter A, Bell IR, Jackson N. Exploring measures of whole person wellness: integrative 
well-being and psychological flourishing. Explore: The Journal of Science and Healing 2010;6:364-70. 
32. 
Statistics Canada. General Social Survey - Giving, Volunteering and Participating 2018n.d. 
33. 
Hibbard JH, Stockard J, Mahoney ER, Tusler M. Development of the Patient Activation Measure 
(PAM): conceptualizing and measuring activation in patients and consumers. Health Serv Res 
2004;39:1005-26. 
34. 
Cella D, Riley W, Stone A, et al. The Patient-Reported Outcomes Measurement Information System 
(PROMIS) developed and tested its first wave of adult self-reported health outcome item banks: 2005-
2008. J Clin Epidemiol 2010;63:1179-94. 
35. 
Petersen W. <strong>Society and the Adolescent Self-Image.</strong> Morris Rosenberg. Princeton 
University Press, Princeton, N.J., 1965. xii + 326 pp. $6.50. Science 1965;148:804-. 
36. 
Otto LM, Howerter A, Bell IR, Jackson N. Exploring Measures of Whole Person Wellness: Integrative 
Well-Being and Psychological Flourishing. Explore: The Journal of Science and Healing;6:364-70. 
 
 
 

13 
 
APPENDIX B. PRELIMINARY WORK - VOLUNTEERING SURVEY 
         Table 2. Survey of ATC Clinic Patients about Volunteering, April 2018 
English Survey 
1. Have you ever done volunteer work for an organization (example: school, church, or hospital)? 
1) Yes, I am currently doing volunteer work 
2) Yes, I have done volunteer work in the past 12 months 
3) Yes, I have done volunteer work, but it was longer than 12 months ago 
4) No, I have never done volunteer work 
2. Would you be interested in learning about possible volunteer jobs? 
1) Not at all Interested 
2) Somewhat Interested 
3) Moderately Interested 
4) Very Interested 
3. If your doctor advised you to do volunteer work as part of your treatment plan, how likely is it that you would 
volunteer? 
1) Very Unlikely 
2) Not Likely 
3) Neutral 
4) Likely 
Spanish Survey 
1. ¿Alguna vez ha hecho trabajo voluntario para una organización (por ejemplo: escuela, iglesia, hospital)? 
a. 
Sí, actualmente estoy haciendo trabajo voluntario 
b. Sí, he hecho trabajo voluntario en los últimos 12 meses 
c. 
Sí, he hecho trabajo voluntario, pero fue hace más de 12 meses 
d. No, nunca he hecho trabajo voluntario  
2. ¿Le interesaría aprender más sobre posibles trabajos voluntarios? 
a. 
Nada Interesado(a) 
b. Poco Interesado(a) 
c. 
Moderadamente Interesado(a) 
d. Muy Interesado(a) 
3. Si su médico le aconseja que haga trabajo voluntario como parte de su plan de tratamiento, ¿qué tan probable es que 
usted haga trabajo voluntario? 
a. 
Muy Improbable 
b. No Probable 
c. 
Neutral 
d. Bastante Probable 
e. 
Muy Probable 
Item 
Response 
All 
n=24 
English 
n=12 
Spanish 
n=12 
Past Experiences Volunteering 
Currently volunteering 
8% 
8% 
8% 
Volunteered in past 12 
months 
17% 
25% 
8% 
Volunteered more than 12 
month ago 
17% 
33% 
0% 
Never Volunteered 
58% 
33% 
83% 
Interest in Volunteering 
Not Interested 
33% 
25% 
42% 
Somewhat Interested 
21% 
42% 
0% 
Moderately Interested 
38% 
33% 
42% 
Very Interested 
8% 
0% 
17% 
Likelihood of Volunteering if 
Recommended by MD 
Very Unlikely 
0% 
0% 
0% 
Not Likely 
17% 
8% 
17% 
Neutral 
33% 
42% 
33% 
Likely 
33% 
50% 
33% 
Very Likely 
17% 
0% 
17% 

14 
 
APPENDIX C: LETTER OF SUPPORT-MAYWOOD FINE ARTS 
APPENDIX C: LETTER OF SUPPORT-QUINN COMMUNITY CENTER 
APPENDIX C: LETTER OF SUPPORT-ILLINOIS COALITION OF IMMIGRANT & REFUGEE 
RIGHTS (ICIRR) 
APPENDIX C: LETTER OF SUPPORT-COMMUNITYHEALTH (FREE CLINIC) 
PLEASE NOTE: THE LETTERS OF SUPPORT (FORMATTED AS SEPARATE PDFS) ARE OMITTED FROM THIS VERSION OF THE 
PROTOCOL. 
 
 
 

15 
 
APPENDIX D: MEASURES FOR PILOT INTERVENTION SUBJECTS 
Table1. Proposed Measures for Pilot Intervention Subjects 
 
 
Demographics. Demographic data will include: name, city residence, date of birth, gender, marital status, 
number and ages of children, highest level of education, work status, occupation, and annual income.   
 
Instruments 
Measures  
Respondent 
Time estimate 
Baseline 
Follow up 
Informed Consent   IRB-approved versions in English and Spanish to 
be developed for this project. 
Intervention & 
Controls 
10-12 min  NA 
Demographics  
Name, city residence, date of birth, gender, marital 
status, number of children, highest level of 
education, work status, occupation, annual income   
Intervention & 
Controls 
3 min  
NA 
Patient Activate 
Measure 
(PAM)25,26  
Assesses a consumer’s knowledge, skills and 
confidence for self-management. PAM segments 
people into one of four progressively higher levels 
of activation. A validated Spanish version is 
available.  
Intervention & 
Controls 
5 min  
5 min  
Patient-Reported 
Outcome 
Measurement 
Information 
System 
(PROMIS)27 28  
Ten self-reported global health items, which are part 
of the Patient-Reported Outcome Measurement 
Information System (PROMIS) project. Items 
measure physical, mental, and social well-being.  A 
validated Spanish version is available. 
Intervention & 
Controls 
5 min  
5 min  
Rosenberg Self-
Esteem Scale 29 
Ten statements are included in the self-report 
measure that pertain to self-worth and self-
acceptance.  A four-point scale ranging from 
“strongly agree” to “strongly disagree.” The items 
were selected as a Guttman scale with 7 “contrived 
items.”  A validated Spanish version is available. 
Intervention & 
Controls 
 5 min  
 5 min  
Arizona 
Integrative 
Outcomes Scale 
(AIOS)30 31 
A global well-being scale, is a one-item, 100-mm 
visual analogue scale.  As a purely visual tool, 
Spanish validation is not applicable. 
Intervention & 
Controls 
2 min  
2 min  
Volunteer 
Participation32  
   
We will extract 36 items from a survey from 
Statistics Canada on Giving, Volunteering, and 
Participating. We will use items measuring: 
Motivation to Volunteer, Benefits of Volunteering, 
Satisfaction with Volunteer Experience, Skills 
Used, and Barriers to Volunteering. Items will be 
translated by team member who is a native Spanish 
speaker. 
Intervention 
NA 
10-15 min  
Total estimated time of survey administration    
 30 min  
27-32 min 

16 
 
Patient Activation Measure (PAM). The PAM  10  measurement  instrument assesses  a  consumer’s  
knowledge,  skills  and  confidence  for  self-management. PAM  segments  people  into  one  of  four  
progressively  higher  levels  of  activation.  The measure was developed using Rasch analyses and is an interval 
level, unidimensional, Guttman-like measure.25,33 
 
Patient-Reported Outcomes Measurement Information System (PROMIS®).  A 10 self-reported global health 
items obtained from an internet survey as part of the Patient- Reported Outcome Measurement Information 
System (PROMIS) project. Two  dimensions  representing  physical  and mental  health  underlie  the  global  
health  items  in  PROMIS. These  global  health  scales  can  be  used  to  efficiently  summarize  physical  and  
mental  health  in  patient-reported outcome  studies.  PROMIS is a set of person-centered measures that 
evaluates and monitors physical, mental, and social health in adults and children. It can be used with the general 
population and with individuals living with chronic conditions. The Patient-Reported Outcomes Measurement 
Information System (PROMIS) provides item banks that offer the potential for efficient (minimizes item 
number without compromising reliability), flexible (enables optional use of interchangeable items), and precise 
(has minimal error in estimate) measurement of commonly studied patient-reported outcomes.34 
 
Rosenberg Self-Esteem Scale. The RSE Scale is a 10-item Likert-type scale designed to measure global self-
esteem (Rosenberg, 1965). The items are rated on a 4-point scale from “strongly disagree” to “strongly agree.” 
The RSE Scale contains an equal number of positively and negatively worded items. Positive items in the 
measure include: “I feel that I’m a person of worth, at least on an equal basis with others.” Negative items 
include: “At times I think I am no good at all.” A total score is derived by reversing the ratings of the five 
negative items and summing them with the ratings for the five positive items. The higher the score, the higher 
the self-esteem. Convergent, discriminant, and predictive validity have been supported in numerous studies.35 
 
Arizona Integrative Outcomes Scale (AIOS) (24 h = 24-hour form, 1 m: 1-month form). AIOS is a global well-
being scale is a one-item, 100-mm visual analogue scale (range, 0-100, with higher scores indicating greater 
sense of well-being). Subjects self-rate their combined physical, mental, emotional, social, and spiritual sense of 
well-being in the present moment. Arizona Integrative Outcomes Scale was specifically developed for use in 
complexity theory–driven research in Whole systems of complementary and alternative medicine, and has 
demonstrated that it will distinguish healthy from unhealthy populations as measured by physical health, and is 
inversely related to psychological distress.30,36 
 
Volunteering Survey. A 36 item survey assessing the following aspects regarding volunteering:  Motivation to 
Volunteer, Benefits of Volunteering, and Satisfaction with Volunteer Experience, Skills Used, and Barriers to 
Volunteering. Questions originate from a Canadian General social survey-giving, volunteering and 
participating, 2018. Survey was designed by the Bureau of Statistics Canada.