TY - JOUR
T1 - How Equity-Oriented Health Care Affects Health
T2 - Key Mechanisms and Implications for Primary Health Care Practice and Policy
AU - for the EQUIP Research Program
AU - Ford-Gilboe, Marilyn
AU - Wathen, C. Nadine
AU - Varcoe, Colleen
AU - Herbert, Carol
AU - Jackson, Beth E.
AU - Lavoie, Josée G.
AU - Pauly, Bernadette (Bernie)
AU - Perrin, Nancy A.
AU - Smye, Victoria
AU - Wallace, Bruce
AU - Wong, Sabrina T.
AU - Browne, Annette J.
N1 - Funding Information:
The EQUIP Research Program is funded through a Canadian Institutes of Health Research Operating Grant: Programmatic Grants to Tackle Health and Health Equity [#ROH-115210] (www.cihr-irsc.gc.ca). Conflict of Interest Disclosures: All the authors completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. No conflicts were reported. Acknowledgments: We thank both the participants who contributed so generously to the data reflected in this article and the clinics with which we collaborated. We thank our EQUIP research team of coinvestigators, knowledge users, and clinical leaders, listed alphabetically: Patty Belda, Kathy Bresett, Pat Campbell, Margaret Coyle, Anne Drost, Myrna Fisk, Olive Godwin, Irene Haigh-Gidora, Colleen Kennelly, Murry Krause, Marjorie MacDonald, Wendy McKay, Tatiana Pyper, David Tu, Leslie Varley, Cheryl Ward, and Elizabeth Whynot. We also thank Phoebe Long, Joanne Parker, Joanne Hammerton, and Janina Krabbe for their outstanding contributions as research managers on the EQUIP Research Program, and Kelsey Timler, Catherine Blake, Mary Beth Davies, and Meghan Fluit for their work as research assistants.
Publisher Copyright:
© 2018 The Authors The Milbank Quarterly published by Wiley Periodicals, Inc. on behalf of The Millbank Memorial Fund
PY - 2018/12
Y1 - 2018/12
N2 - 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. Context: Significant 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. Methods: Our 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). Findings: Over 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. Conclusions: This 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 across a broader range of health care contexts requires further study.
AB - 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. Context: Significant 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. Methods: Our 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). Findings: Over 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. Conclusions: This 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 across a broader range of health care contexts requires further study.
KW - cohort studies
KW - health equity
KW - models (theoretical)
KW - primary care
KW - primary health care
KW - quality of care
KW - social determinants of health
UR - http://www.scopus.com/inward/record.url?scp=85055492608&partnerID=8YFLogxK
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U2 - 10.1111/1468-0009.12349
DO - 10.1111/1468-0009.12349
M3 - Article
C2 - 30350420
AN - SCOPUS:85055492608
VL - 96
SP - 635
EP - 671
JO - Milbank Quarterly
JF - Milbank Quarterly
SN - 0887-378X
IS - 4
ER -