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Closing the health equity gap: evidence-based strategies for primary health care organizations

Annette J Browne1*, Colleen M Varcoe1, Sabrina T Wong17, Victoria L Smye1, Josée Lavoie2, Doreen Littlejohn3, David Tu3, Olive Godwin4, Murry Krause5, Koushambhi B Khan1, Alycia Fridkin1, Patricia Rodney1, John O’Neil6 and Scott Lennox5

Author Affiliations

1 University of British Columbia, School of Nursing, T201 – 2211 Wesbrook Mall, Vancouver, British Columbia, V6T 2B5, Canada

2 University of Northern British Columbia, School of Health Sciences, 3333 University Way, Prince George, British Columbia, Canada

3 Vancouver Native Health Society, 440 East Hastings Street, Vancouver, British Columbia, Canada

4 Prince George Division of Family Practice, Prince George, British Columbia, Canada

5 Central Interior Native Health Society, 1140 4th Avenue, Prince George, British Columbia, Canada

6 Simon Fraser University, Faculty of Health Sciences, 8888 University Drive, Burnaby, British Columbia, Canada

7 University of British Columbia Centre for Health Services and Policy Research, 201-2206 East Mal, Vancouver, British Columbia, Canada

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International Journal for Equity in Health 2012, 11:59  doi:10.1186/1475-9276-11-59

Published: 13 October 2012

Abstract

Introduction

International evidence shows that enhancement of primary health care (PHC) services for disadvantaged populations is essential to reducing health and health care inequities. However, little is known about how to enhance equity at the organizational level within the PHC sector. Drawing on research conducted at two PHC Centres in Canada whose explicit mandates are to provide services to marginalized populations, the purpose of this paper is to discuss (a) the key dimensions of equity-oriented services to guide PHC organizations, and (b) strategies for operationalizing equity-oriented PHC services, particularly for marginalized populations.

Methods

The PHC Centres are located in two cities within urban neighborhoods recognized as among the poorest in Canada. Using a mixed methods ethnographic design, data were collected through intensive immersion in the Centres, and included: (a) in-depth interviews with a total of 114 participants (73 patients; 41 staff), (b) over 900 hours of participant observation, and (c) an analysis of key organizational documents, which shed light on the policy and funding environments.

Results

Through our analysis, we identified four key dimensions of equity-oriented PHC services: inequity-responsive care; trauma- and violence-informed care; contextually-tailored care; and culturally-competent care. The operationalization of these key dimensions are identified as 10 strategies that intersect to optimize the effectiveness of PHC services, particularly through improvements in the quality of care, an improved 'fit' between people's needs and services, enhanced trust and engagement by patients, and a shift from crisis-oriented care to continuity of care. Using illustrative examples from the data, these strategies are discussed to illuminate their relevance at three inter-related levels: organizational, clinical programming, and patient-provider interactions.

Conclusions

These evidence- and theoretically-informed key dimensions and strategies provide direction for PHC organizations aiming to redress the increasing levels of health and health care inequities across population groups. The findings provide a framework for conceptualizing and operationalizing the essential elements of equity-oriented PHC services when working with marginalized populations, and will have broad application to a wide range of settings, contexts and jurisdictions. Future research is needed to link these strategies to quantifiable process and outcome measures, and to test their impact in diverse PHC settings.

Keywords:
Primary health care; Health equity; Health inequity; Marginalized populations; Vulnerable populations; Aboriginal people; Structural violence; Trauma-informed care; Qualitative research; Ethnographic methods