October 23, 2018

How Equity-Oriented Health Care Affects Health:

Key Mechanisms and Implications for Primary Health Care Practice and Policy

October 2018 | Marilyn Ford-Gilboe, C. Nadine Wathen, Colleen Varcoe, Carol Herbert, Beth E. Jackson, Josée G. Lavoie, Bernadette (Bernie) Pauly, Nancy A. Perrin, Victoria Smye, Bruce Wallace, Sabrina T. Wong, Annette J. Browne (for the EQUIP Research Program) | Early View

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.

Keywords: health equity, cohort studies, models (theoretical), social determinants of health, primary health care, quality of care, primary care.

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DOI: 10.1111/1468-0009.12349
Published in 2018

 

Commentary

Customer-Ownership in Equity-Oriented Health Care

Douglas K. Eby