How Equity‐Oriented Health Care Affects Health: Key Mechanisms and Implications for Primary Health Care Practice and Policy

Abstract

Policy Points A consensus regarding the need to orient health systems to address inequities is emerging, with much of this discussion targeting population health interventions and indicators. We know less about applying these approaches to primary health care.This study empirically demonstrates that providing more equity‐oriented health care (EOHC) in primary health care, including trauma‐ and violence‐informed, culturally safe, and contextually tailored care, predicts improved health outcomes across time for people living in marginalizing conditions. This is achieved by enhancing patients’ comfort and confidence in their care and their own confidence in preventing and managing health problems.This promising new evidence suggests that equity‐oriented interventions at the point of care can begin to shift inequities in health outcomes for those with the greatest need. ContextSignificant attention has been directed toward addressing health inequities at the population health and systems levels, yet little progress has been made in identifying approaches to reduce health inequities through clinical care, particularly in a primary health care context. Although the provision of equity‐oriented health care (EOHC) is widely assumed to lead to improvements in patients’ health outcomes, little empirical evidence supports this claim. To remedy this, we tested whether more EOHC predicts more positive patient health outcomes and identified selected mediators of this relationship.MethodsOur analysis uses longitudinal data from 395 patients recruited from 4 primary health care clinics serving people living in marginalizing conditions. The participants completed 4 structured interviews composed of self‐report measures and survey questions over a 2‐year period. Using path analysis techniques, we tested a hypothesized model of the process through which patients’ perceptions of EOHC led to improvements in self‐reported health outcomes (quality of life, chronic pain disability, and posttraumatic stress [PTSD] and depressive symptoms), including particular covariates of health outcomes (age, gender, financial strain, experiences of discrimination).FindingsOver a 24‐month period, higher levels of EOHC predicted greater patient comfort and confidence in the health care patients received, leading to increased confidence to prevent and manage their health problems, which, in turn, improved health outcomes (depressive symptoms, PTSD symptoms, chronic pain, and quality of life). In addition, financial strain and experiences of discrimination had significant negative effects on all health outcomes.ConclusionsThis study is among the first to demonstrate empirically that providing more EOHC predicts better patient health outcomes over time. At a policy level, this research supports investments in equity‐focused organizational and provider‐level processes in primary health care as a means of improving patients’ health, particularly for those living in marginalizing conditions. Whether these results are robust in different patient groups and a...

Exploring women's health care experiences through an equity lens: Findings from a community clinic serving marginalised women

“…Items from the larger EQUIP study reflect the key dimensions of equity‐oriented health care as identified by the EQUIP research team and were modified for use in the NP clinic to explore women's experiences of EOHC, including 30 Likert‐based items as outlined in Table (Browne et al, , ; Ford‐Gilboe et al, ). As outlined above, the larger set of items were developed by the EQUIP team based on a comprehensive literature review of a variety of different scales and analyses related to equity‐based care (Browne et al, , ; Ford‐Gilboe et al, ; ). The larger set of items were developed from item response theory using patient cohort data ( n = 567) for the larger EQUIP study (Browne et al, , ; Ford‐Gilboe et al, ; ).…”

“…As outlined above, the larger set of items were developed by the EQUIP team based on a comprehensive literature review of a variety of different scales and analyses related to equity‐based care (Browne et al, , ; Ford‐Gilboe et al, ; ). The larger set of items were developed from item response theory using patient cohort data ( n = 567) for the larger EQUIP study (Browne et al, , ; Ford‐Gilboe et al, ; ). The development of those items is discussed in detail in a prior publication and is summarised below (Ford‐Gilboe et al, ).…”

“…The larger set of items were developed from item response theory using patient cohort data ( n = 567) for the larger EQUIP study (Browne et al, , ; Ford‐Gilboe et al, ; ). The development of those items is discussed in detail in a prior publication and is summarised below (Ford‐Gilboe et al, ).…”

“…Drawing on theory and methods developed as part of a larger research programme titled “Equip Primary Health Care for Equity” (known as “EQUIP”), equity‐oriented health care (EOHC) is defined as “an approach that aims to reduce the effects of structural inequities, the impact of multiple and intersecting forms of racism, discrimination and stigma, and the frequent mismatches between dominant approaches to care” (Browne et al, , p. 2). The larger EQUIP research programme involved a multiple‐case study design focused on examining the process and impacts of implementing an organizational‐level health equity intervention in primary health care clinics (Browne et al, ; Browne, Varcoe, Ford‐Gilboe, & Wathen, ; Ford‐Gilboe et al, ). The EQUIP research programme was particularly focused on tapping into the perspectives of marginalised patients to inform strategies for enhancing the capacity of clinics and health care organisations to provide EOHC—and the results of the EQUIP study are published elsewhere (Browne et al, ; Ford‐Gilboe et al, ; Lavoie, Varcoe, Wathen, Ford‐Gilboe, & Browne, ).…”

“…The larger EQUIP research programme involved a multiple‐case study design focused on examining the process and impacts of implementing an organizational‐level health equity intervention in primary health care clinics (Browne et al, ; Browne, Varcoe, Ford‐Gilboe, & Wathen, ; Ford‐Gilboe et al, ). The EQUIP research programme was particularly focused on tapping into the perspectives of marginalised patients to inform strategies for enhancing the capacity of clinics and health care organisations to provide EOHC—and the results of the EQUIP study are published elsewhere (Browne et al, ; Ford‐Gilboe et al, ; Lavoie, Varcoe, Wathen, Ford‐Gilboe, & Browne, ). For purposes of the CQI project discussed in the current paper, EOHC was explored using items developed as part of the EQUIP research programme to explore patients' experiences of care, and adapted for use in a women's only primary health care clinic serving marginalised women.…”