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Enhancing measurement of primary health care indicators using an equity lens: An ethnographic study Wong, Sabrina T; Browne, Annette J; Varcoe, Colleen; Lavoie, Josée G.; Smye, Victoria; Godwin, Olive; Littlejohn, Doreen; Tu, David Sep 5, 2011

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RESEARCH Open AccessEnhancing measurement of primary healthcare indicators using an equity lens:An ethnographic studySabrina T Wong1,2*, Annette J Browne1, Colleen Varcoe1, Josée Lavoie3, Victoria Smye1, Olive Godwin4,Doreen Littlejohn5 and David Tu5,6AbstractIntroduction: One important goal of strengthening and renewal in primary healthcare (PHC) is achieving healthequity, particularly for vulnerable populations. There has been a flurry of international activity toward theestablishment of indicators relevant to measuring and monitoring PHC. Yet, little attention has been paid towhether current indicators: 1) are sensitive enough to detect inequities in processes or outcomes of care,particularly in relation to the health needs of vulnerable groups or 2) adequately capture the complexity ofdelivering PHC services across diverse groups. The purpose of this paper is to contribute to the discourse regardingwhat ought to be considered a PHC indicator and to provide some concrete examples illustrating the need formodification and development of new indicators given the goal of PHC achieving health equity.Methods: Within the context of a larger study of PHC delivery at two Health Centers serving people facingmultiple disadvantages, a mixed methods ethnographic design was used. Three sets of data collected included: (a)participant observation data focused on the processes of PHC delivery, (b) interviews with Health Center staff, and(c) interviews with patients.Results: Thematic analysis suggests there is a disjuncture between clinical work addressing the complex needs ofpatients facing multiple vulnerabilities such as extreme levels of poverty, multiple chronic conditions, and lack ofhousing and extant indicators and how they are measured. Items could better measure and monitor performance atthe management level including, what is delivered (e.g., focus on social determinants of health) and how services aredelivered to socially disadvantaged populations (e.g., effective use of space, expectation for all staff to have welcomingand mutually respectful interactions). New indicators must be developed to capture inputs (e.g., stability of fundingsources) and outputs (e.g., whole person care) in ways that better align with care provided to marginalized populations.Conclusions: The current emphasis on achieving greater equity through PHC, the continued calls for the renewaland strengthening of PHC, and the use of monitoring and performance indicators highlight the relevance ofensuring that there are more accurate methods to capture the complex work of PHC organizations.IntroductionOver the past decade, decision-makers have made impor-tant changes to the organization, financing, and deliveryof primary health care (PHC) services, targeting accessi-bility, continuity, comprehensiveness, and appropriate-ness of care [1-7]. Interest in renewing PHC is based onsolid evidence suggesting that a strong PHC foundationleads to improved population health outcomes, including:reduced risk, duration, and effects of acute and episodicconditions [8-12], as well as reduced risk and effects ofcontinuing health conditions [13-15]. People with accessto a regular PHC provider show improved medicationadherence [16,17], reduced use of emergency services[18-20], shorter hospital stays [16], and lower overallhealth care utilization [17].* Correspondence: sabrina.wong@nursing.ubc.ca1University of British Columbia (UBC) School of Nursing, Critical Research inHealth and Health care Inequities, 2211 Wesbrook Mall, Vancouver, BritishColumbia, V6T-2B5, CanadaFull list of author information is available at the end of the articleWong et al. International Journal for Equity in Health 2011, 10:38http://www.equityhealthj.com/content/10/1/38© 2011 Wong et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.One important goal of strengthening and renewal inprimary healthcare (PHC) is that of achieving healthequity [21]. Equity in health can be defined as theabsence of systematic and potentially remediable differ-ences in one or more characteristics of health acrosspopulations or population groups defined socially, eco-nomically, demographically, or geographically. Healthinequity thus refers to differences in health or access tocare that can result from structural arrangements thatare potentially remedial; in this sense, inequities may bedeemed unjust [7]. While these definitions make explicitthat health inequities can be measured and tracked overtime, debate persists about precisely what should be mea-sured to monitor inequities within the context of PHCservice delivery.There has been a flurry of activity as multiple groups inCanada, the United States of America, and internationallyhave contributed toward the establishment of indicatorsrelevant to the measuring and monitoring of PHC toaccount for the impact of investments and to identifyareas where service delivery could be improved. Specialinterest needs to be paid to vulnerable populations [22].Moreover, more attention needs to be paid to whethercurrent indicators: 1) are sensitive enough to detectinequities in processes or outcomes of care, particularlyin relation to the health needs of vulnerable groups or 2)adequately capture the complexity of delivering PHC ser-vices across diverse population groups. Current PHCindicators also fall short in terms of capturing the inputand outputs that can lead to incremental improvementsin health or quality of life that may be possible for peoplewhose health is also affected by systemic and structuralinequities. For example, when people live in poverty, lackstable or safe housing, are unable to purchase food on adaily basis, experience the effects of on-going violence(e.g., chronic pain), and/or live with severe mental healthand/or substance use issues, current measures may notbe immediately relevant or adequate to capture the scopeof care required and being provided. Measuring the per-centage of women with up-to-date cervical cancerscreening as an indicator of preventive cancer care,although important, will overlook the challenges thatsome groups of women face in accessing services. Chal-lenges include a reluctance to seek preventive care bywomen with histories of sexual violence and abuse, over-coming barriers related to stigma and discrimination, anda lack of trusting health care relationships required forsome women to access even a single visit for health care[23-26]. Alternate or additional measures are thereforeneeded to capture the complexities and effectiveness ofPHC delivery.More work is needed to: (i) modify existing indicatorsrelevant to measuring PHC services that are aimed ataddressing issues of equity, and (ii) develop new indicatorsthat are sensitive to change, given the complexities inher-ent in PHC delivery, particularly pertaining to vulnerablepopulations. The purpose of this paper is to contribute tothe discourse regarding what ought to be considered as aPHC indicator and to provide some concrete, practice-based examples that illustrate the need for modification ordevelopment of new indicators, given the goal of PHC inachieving health equity. Our intention is that this paperwill contribute to the groundwork needed to support suchmodification and development. The specific aims are to:1) examine whether elements identified in a commonlyused management accountability framework (the PHCLogic Model, Figure 1) is reflected in the care provided intwo PHC settings that serve highly marginalized popula-tions, 2) consider whether currently existing PHC indica-tors reflect the work at non-governmental organizationswho deliver PHC to marginalized groups; and 3) providerecommendations relevant in relation to the ongoing workof developing and modifying PHC indicators to betterreflect the needs of vulnerable populations.Background: Indicators and a Logic ModelIn this section, we outline a framework for this work; wedescribe different types of indicators, and how a manage-ment accountability framework, the Primary Health CareLogic Model [27], can be used to identify areas of PHCdelivery that could be strengthened. Indicators are stan-dardized measures used to describe population character-istics, community contexts, health status, and healthsystem performance. Indicators, which are identifiedthrough some sort of evidence and consensus/consultativeprocess [28,29], can serve different purposes, includingsystem performance and accountability for financialinvestments. They are designed in part to serve the needof funders to account for the impact of investments inPHC and to also identify areas where PHC service deliverycould be improved.There are three types of indicators: monitoring, perfor-mance and developmental, which vary with respect to thekinds of outcomes they can measure. As one moves alongthe outcome continuum from immediate, to intermediate,to final outcomes, the corresponding degree of attributionfrom PHC diminishes. In the context of PHC, immediate(or direct) outcomes are those for which this sector is themost (but not solely) responsible and accountable, sincethese outcomes represent results where PHC has the mostcontrol and influence. Even these outcomes, however, canbe influenced by external factors and environmental con-texts [30].Monitoring indicators are created in areas where differ-ent organizational models of practice are ‘expected’ tohave an effect or outcome, but for which attribution is notnecessary or possible to demonstrate [30]. Take, for exam-ple, a health authority wants to provide better access toWong et al. International Journal for Equity in Health 2011, 10:38http://www.equityhealthj.com/content/10/1/38Page 2 of 12mental health services. Indicators are needed to determinewhere they are succeeding or where they need to improveon. Monitoring indicators are used to recognize thatchanges in what is being measured may be attributable toa PHC organization’s performance and/or other factors.Monitoring indicators can be developed for intermediateor final outcomes. Performance indicators are used whenit is reasonable to attribute change in what is being mea-sured to an organization’s performance. Performance indi-cators can be used to understand, “How healthy is thehealth care system?” [31]; these indicators report andaccount for the organizations’ (e.g., solo practice, non-gov-ernmental organization, community health centre) inputs,activities, outputs and immediate outcomes [30]. Perfor-mance indicators are used to recognize that changes inwhat is being measured are attributable to the organiza-tion’s performance more so than any other factor. Not sur-prisingly, developmental indicators are those areas needingdevelopment or modification.Each type of indicator differs in the degree to whichperformance can be validly and feasibly measured, and inthe degree to which results will trigger action. Becauseperformance indicators signal changes attributable to theorganization’s performance, under an accountabilityagreement, they can be used to trigger action related toimmediate outcomes, but not for intermediate or finaloutcomes. According to the Auditor General of Canada,accountability is an obligation by government to demon-strate and take responsibility for system performancewhen measured against targets or goals [32]. Agreementsreflect priority setting since they seek to place responsi-bility on an organization for ensuring that public fundingis used and distributed according to the agreed upon pur-poses. Accountability agreements point to government’sdesire for increased emphasis on tying an organization’sfunding to specific deliverables (e.g., performance inquality of care, actual services delivered), while commit-ting the organization to balancing their budget [33].The PHC Logic Model is one type of managementaccountability framework which is useful in determiningwhich domains are appropriate for monitoring versus per-formance indicators. The PHC Logic Model is a heuristicthat attempts to visually convey the connection betweeninputs, activities, outputs, and outcomes [20]. The LogicFigure 1 Results-Based Logic Model for Primary Health Care. Reprinted with a permission from Longwoods Publishing.Wong et al. International Journal for Equity in Health 2011, 10:38http://www.equityhealthj.com/content/10/1/38Page 3 of 12Model identifies areas for which the PHC sector is directlyaccountable as well as areas of influence that are externalto the PHC sector [30]. The Logic Model suggests thatwhere quality of care (e.g., interpersonal communication)and actual services delivered by PHC organizations andproviders has a direct impact (e.g., patient activation), per-formance can be measured. At this juncture, PHC organi-zations and providers can be held accountable; therefore,both monitoring and performance indicators can be used.Where PHC organizations have some degree of influence(e.g. health care system efficiency such as avoidable hospi-talizations), but where there are also other external factors,only monitoring indicators are appropriate for use.The PHC Logic Model can assist in identifying areas inwhich information, evaluation and evidence are needed forpolicy, administrative and practice communities to plan,monitor, guide and report on PHC renewal [13,27]. Thismodel is currently being used to develop performanceindicators that will measure the renewal of PHC in variouscountries, including Brazil, China, and Canada [27,34].MethodsWithin the context of a larger ongoing study which exam-ines the delivery of PHC services to vulnerable popula-tions, and in particular, people who are severely impactedby systemic inequities, a mixed methods ethnographicdesign was used. Context. Our research is currently beingconducted in partnership with two Urban AboriginalHealth Centers (herein called Health Centers), which havebeen in operation for over 15 years, and which are locatedin two different inner cities in Canada. Both Health Cen-ters have an explicit mandate to provide health care forAboriginal people, and to make their services as accessibleas possible to both Aboriginal and non-Aboriginal peopleliving with multiple social disadvantages. Many of thepatients live on less than $1,000 Canadian dollars (CDN)per month (well below Canada’s poverty lines), reside inunstable or unsafe housing, or are homeless. Many of thepatients who self-identify as Aboriginal have been affectedby the legacy of colonialism (in particular, economic mar-ginalization, discrimination and racism, and intergenera-tional traumas associated with residential schools andcurrent forms of state child apprehension) [35,36]. Theeffects of living in poverty intersect with multiple otherdisadvantages, such as a high proportion of patientsexperiencing stigma and discrimination related to mentalillness, substance use and addictions. Many are affected byviolence and have significant chronic pain issues; andincreasingly, many people are affected by HIV, AIDS, andrelated illnesses.Primary health care services at the two Health Centersare organized around: (a) a primary care medical clinicstaffed by physicians, nurses, and nurse practitioners;and (b) outreach and on-site health and social servicesoffered by outreach nurses, addictions counselors, socialworkers, and social support workers. To varying degrees,indigenous approaches to health and healing [37] under-pin the clinics’ models of service delivery. We give abrief overview of the larger study that informs the analy-sis we discuss in this paper, and provide two areas (PHCactivities and outputs) as exemplars where indicatorscould be strengthened.Data collectionThree sets of data were collected. At the time of this ana-lysis (2010), these included: (a) participant observationdata collected during intensive immersion in the HealthCenters (over 850 hours), (b) open-ended, in-depth inter-views with Health Center staff (n = 39) who participatedin face-to-face individual interviews (n = 29) or a focusgroup (n = 10), and (c) open-ended, in-depth interviewswith patients (n = 68) who similarly participated in face-to-face individual interviews (n = 57) or one of three focusgroups (n = 11). Observations focused on the processes ofPHC delivery at the Health Centers. The staff interviewsincluded direct care providers (physicians, nurses, socialworkers, outreach workers and a pharmacist (n = 23) andadministrative and support staff (n = 16). Staff interviewsfocused on the key attributes of service delivery importantin the patients’ life contexts, how staff members work withpatients to facilitate access to health and social services,how continuity of care is established with patients whomight otherwise be lost to follow up, and the types of indi-cators or measures that would be needed to capture theprocess and impact of providing PHC services. Patientinterviews focused on their experiences and reasons foraccessing services at the Health Centers and at otherhealth care settings, what was helpful or unhelpful aboutthe services at the Health Centers, and areas for improve-ment. Staff and patients also provided demographic infor-mation. All data were taped, transcribed, and madeanonymous. This study was approved by the appropriateethics institutional review board (University of BritishColumbia and University of Northern British Columbia)and Memorandums of Understanding were signedbetween the Health Centers and the research team.AnalysisUsing the observational data as contextual information,we conducted an interpretive thematic analysis of theinterview data using procedures for qualitatively deriveddata [38-40]. Interview transcripts and observationalnotes were repeatedly read by the members of the inves-tigative team to identify patterns in the data. NVivo [41],a qualitative computer software package, was used toorganize and code the narrative data. As more data werecollected and analyzed, coding categories were refined.We then examined the themes expressed in the data inWong et al. International Journal for Equity in Health 2011, 10:38http://www.equityhealthj.com/content/10/1/38Page 4 of 12relation to the domains identified in the PHC LogicModel, and in relation to publicly available, existing PHCindicators (e.g. Canadian Institute for Health InformationPan-Canadian PHC Indicators [29]). Because there con-tinues to be data collection as part of the larger study,the analysis discussed in this paper is specifically focusedon the provision of a subset of examples pertaining tothe domains of PHC that are relevant to consider in rela-tion to indicators in order to answer our specific aims.Credibility of the thematic analysis was continually evalu-ated with the members of our research team, whoincluded experts in qualitative research, leaders andexperts in PHC, and a community advisory committeecomprising patient and health care representatives. Tri-angulation of patient, staff, and observational data alsocontributed to the rigor and trustworthiness of the analy-sis [40]. Results are reported for areas where the majority(e.g., 90%-100%) of participants shared the same views.ResultsStaff had worked in the clinic for an average of four years,and most had college-level or higher preparation (seeTable 1). Patients who participated in the study reflectedthe populations served by the clinics: 50% were women,75% self-identified as Aboriginal, and 41% had not com-pleted high school. Three-quarters of patients reportedthey were not currently working. While most patientsreported having a place to live (68%), most of theseresided in social or low-income housing, with 10%reporting that they lived in a single occupancy hotelroom, or at a shelter (10%). Seventy-five percent reportedthat their lives had been affected by violence (data notshown).Our findings suggest that modification of existing moni-toring and performance indicators at the PHC activitieslevel is needed if progress toward health equity is to befostered, measured and achieved. At the Inputs and Out-puts level, new indicators need to be developed. PHCactivities can be categorized into three types: (a) policyand governance-level activities and decisions (e.g., finan-cing and regulation), (b) management-level activities anddecisions (e.g., hours of operation, use of teams) and (c)clinical-level activities and decisions that support outputs(e.g., the degree to which clinicians elect to specialize inspecific types of clientele such as marginalized groups)[42]. Our analysis focuses on examples of managementand clinic level activities because the data are mostly ofthese kinds.Suggested Modification of Existing Monitoring andPerformance IndicatorsPHC Activities: management levelAs shown in Table 2, existing objectives and indicators forequity-oriented performance measurement are broad inrelation to management level activities, including itemssuch as: “specialized programs for PHC vulnerable/specialneeds populations,” “support for PHC vulnerable/specialneeds populations” and “PHC family physicians/generalpractice physicians/nurse practitioners working in inter-disciplinary teams” [29]. Our analysis suggests that it isnot merely the presence or absence of such programs andapproaches that matters; rather, measuring what is deliv-ered and how it is delivered can contribute to increasingthe effectiveness of PHC for marginalized groups. Weobserved and heard from the majority of providers abouthow the team approach is enacted to provide a wide rangeof services. For example, at each site, weekly meetingsincluding the full inter-professional team (providers andsupport staff) are held to discuss the complexity of careneeded by clients. There is an intentional flattening ofhierarchical relationships that can arise between profes-sional groups that are typically imbued with differentlevels of power. Effort is intentionally invested in creatingrespectful interactions among staff, and all information isvalued, regardless of professional hierarchies. One officestaff respondent explains why s/he finds it professionallyrewarding to work at the Health Center:“I also think that the fact that it’s a level playing fieldfor everybody that works here makes such a difference.It’s just everybody is considered on the same level,doctors, executive directors like the bosses are, weknow they’re the bosses but they’re also somebodythat can sit beside you and do the same job. Youknow, it’s a level playing field...It’s hard to describe,you’ve been in our meetings, have you ever been toone of our meetings in the mornings? That is to mewhat keeps the life, the heartbeat going in this place.Because we all have the same goal, you know, clientcare, and it shows in everyone and we all have inputwhich is awesome.” [HC #16]Staff members are expected to actively contribute theirinput into how best to provide care. For example, medicaloffice assistants (staff who act as receptionists, do schedul-ing with patients, maintain health records, etc.) routinelyhave important insights to contribute regarding both parti-cular patients, and the processes of care. There is anunderlying expectation that the responsibility of care lieswith the team (rather than with the patient or with a singleprovider), that each staff member has a role, and that,although patients may have strong long term relationshipswith particular providers, more than one health care provi-der works with the client to manage his or her care.Management level decisions intentionally create anenvironment that fosters and nurtures respect forpatients as a strategy to increase accessibility and to opti-mize responsiveness to a range of intersecting healthWong et al. International Journal for Equity in Health 2011, 10:38http://www.equityhealthj.com/content/10/1/38Page 5 of 12issues; this stands in sharp contrast to other types oforganizations offering primary care services in the samegeographic region (e.g., walk-in clinics, solo practiceoffices) that often specify that only one concern can beaddressed at each consultation. We observed the HealthCenters’ purposeful and locally relevant creation of wel-coming atmospheres through the effective use of space,and expectations that most staff have welcoming andmutually respectful health care interactions with allpatients, even when some patients’ behaviors may beviewed as challenging (e.g. under the influence of alcoholor drugs). The physical spaces are tailored to target thepopulations served. For example, because the centersserve many people who lack stable, safe housing and whoare living in inadequate spaces and places, the entrances(layout, appearance, situating of staff) are designed toTable 1 Participant demographicsCharacteristic Provider (n = 39) Patient (n = 68)Clinic site (n)1 13 372 26 31Provider position (n)Primary care physician 8 -Primary care nurse 8Nurse Practitioner 2Pharmacist 1Social Worker/PHC coordinator/Case manager 4Clinic staff (n) 7Medical office assistant/secretary 2Alcohol & Drug counselor 1Aboriginal support worker 1Elder 2Office manager 2Executive director 1Outreach workerAgeMean (SD) 47.5 (13.0) 46 (8.7)Gender (%)Female 62 50Male 38 47Transgender - 3Ethnicity (%)Caucasian 49 21Aboriginal 31 75South Asian 3 -Asian (e.g. Chinese, Filipino, etc.) 5 -Other 12 4Highest Level of Education (%)Less than high school - 41High School 7 38College/post-secondary 18 10Undergraduate 36 3Graduate studies or more 33 -Employment Status (n)Full-time 12 14Part-time 17 1Other - 2Not employed - 51Number of Years employed at health centreMean (SD) 4.0 (4.0) -Wong et al. International Journal for Equity in Health 2011, 10:38http://www.equityhealthj.com/content/10/1/38Page 6 of 12encourage people to escape from the cold and to socializewith other patients over a cup of coffee and/or use thephone and/or computer, regardless of whether they havea health care appointment or not.The importance of enacting welcoming strategies forpeople experiencing continuous social stigma and discri-mination, including racism in health care, cannot beunderestimated [43]. The majority of patients repeatedlydescribed how these efforts resulted in a level of com-fort and increased willingness to access care. The fol-lowing quote from a patient illustrates how theenvironments of the Centers serve to increase access tocare:“You just come in and you feel like right at home,like you can just, like you know everybody andeverybody knows you. You don’t have to sit in aroom like in a doctor’s office and be real square,really uptight. Here, it’s like you see people walkingback and forth, conversations happening all thetime. It’s like you’re a piece of this place, you’re notjust a number. It’s like a home.” [PT #13]PHC Activities: clinic levelFindings from our study show that clinic level decisionsby staff take into account broader social determinants ofhealth, rather than primarily focusing on medical healthTable 2 Examples of the need to modify or develop PHC indicators: Inputs, Activities, OutputsPHC LogicModelExamples from Pan-Canadian PHC Indicators (CIHI) Study recommendationsInput-FiscalResourcesObjective: Provider payment methods that align with primary healthcare goals-PHC provider remuneration method-Average PHC provider incomeby funding modelRecommended Areas for Development of NewIndicators-source(s) of funding-stability of fundingActivity-ManagementlevelObjective: To increase the number of PHC organizations who areresponsible for providing planned services to a defined population:- PHC outreach services for vulnerable/special needs populations- Specialized programs for PHC vulnerable/special needs populations- Support for PHC vulnerable/special needs populationsSuggested Modification of Monitoring andPerformance Indicators-Increase operability of currently available indicators toelucidate how PHC organizations can successfully deliverPHC services to vulnerable/special needs populations:-weekly team meetings of all clinic staff-collaboration and input from all clinic staff on care planand management-number and type of places where care is delivered (e.g.,clinic, home, street)-supportive environment where management rewardsrespectful interactions between all staff-supportive environment where patients feel comfortableActivity-CliniclevelObjective: To facilitate integration and coordination between healthcare institutions and health careproviders to achieve informational and management continuity ofpatient care-Use of standardized tools for coordinating PHC-Collaborative care with other health careorganizations-intersectoral collaboration-PHC team effectiveness-number of patients receiving assistance for housing,food stamps, obtaining welfare-number of patients who have charts with trauma historyrecorded-Use of appropriate skill mix (e.g., physician, nurse, socialworker, drug and alcohol counselor, elder) to providecomplex PHC-Support for individual staff to develop and enhancerespectful communication amongst staff and patients (e.g. time for critical self-reflection, opportunities forproviding/receiving support feedback)Output-quality:Whole PersonCareObjective: To enhance the provision of whole-person comprehensivePHC services, including episodic and ongoing care with increasedemphasis on health promotion, disease and injury prevention andmanagement of common mental health conditions and chronicdiseases:- Scope of PHC services- Health risk screening- Smoking cessation advice in PHC- Alcohol consumption advice in PHC- PHC initiatives for reducing health risks- Smoking rate- Fruit and vegetable consumption rate- Overweight rate- Heavy drinking rate- PHC resources for self-management of chronic conditions- Time with PHC provider- Client/patient participation in PHC treatment planningRecommended Areas for Development of NewIndicators-Assessment of individual’s social environment-Assessment of individual’s emotional health-Treating individual as a person (not a case or a disease)Wong et al. International Journal for Equity in Health 2011, 10:38http://www.equityhealthj.com/content/10/1/38Page 7 of 12service delivery as is typical for the majority of primarycare practices. Given the complex health and socialissues for these patients (e.g., lack of safe or stable hous-ing, histories of trauma, interpersonal violence, mentalhealth issues, substance use and addictions, HIV andother serious chronic illnesses, poverty, inability to affordadequate food, etc.), a purely biomedical approach to“treating” present medical issues in isolation of socialinfluences is insufficient. Rather than organizing to pro-vide a particular service (e.g., an immunization program,an anger management program), clinic level decisions areoriented to providing the appropriate mix of skill andexpertise to meet the intersecting needs of those served.Staffing decisions at the Health Centers are designed toinvolve a team of experts, including: social workers, drugand alcohol counselors, and outreach workers, to tailorPHC services in ways that address the complex socialdeterminants of health and the consequences of thoseinfluences (malnutrition, homelessness, mental healthissues, substance use and addiction). Multidisciplinaryteams, for example, are mobilized to enact action plansto support pregnant women who are at risk of havingtheir children apprehended by the state. The staff workedto help these women find safety away from domestic vio-lence, obtain safe, stable housing, possess adequateamounts of nutritious food, and provide access to prena-tal care, counseling, and parenting support. They alsocoordinate with child protection services to create effec-tive working relationships and optimize parental contactand involvement. At both Health Centers, women whohave known histories of substance use are particularlysupported.Consistent with both Health Centers’ mandates to makeservices as accessible as possible, staff members areexpected to actively convey an accepting attitude towardpatients in a manner that conveys respect both throughtheir spoken words and non-verbal communication. Giventhe high proportion of Aboriginal people in the local areasand the aims of the Centers, Aboriginal art and welcomingsigns (in one site in a local indigenous dialect) conveyrespect for the cultural heritage of Aboriginal people andtheir communities. As one provider points out:“I think it’s a balancing act between appearing profes-sional and knowledgeable and capable...and addres-sing people in a friendly manner and very often usingfirst names...I think one of the important things whenyou are consulting with a patient is small talk...we’lltalk about experiences in a patient’s life that I knowabout...showing interest in a patient as a whole per-son as opposed to a list of diseases.” [HCP #8]Our study showed that engagement in what may seemlike “small talk” held particular significance for mostpatients, all of whom are often dismissed or treated in anabrupt manner in everyday social interactions. Thesesocial processes and ways of communicating have animportant impact on healthcare access. For example, staffreported that many patients attend the Health Centers’outreach or drop-in activities (e.g., women’s wellness pro-gram or drop-in lunches) for months before accessingprimary care providers. Staff also worked to create thissame environment outside the Health Center walls. Centerphysicians and outreach workers from various disciplinesroutinely see their patients when they are hospitalized,thus modeling respectful, safe interactions in an institu-tional setting. Staff also worked to enhance positive atti-tudes, understanding of, and action on the marginalizingconditions patients face in the wider health and social ser-vice sectors and the general public. For example, staff inboth settings work on community housing initiatives.Finally, providers are afforded the flexibility of deliveringPHC services on a drop-in basis, even outside of the clinicschedule, if needed. One provider commented, “...youknow it’s got to be flexible and you’ve got to be able to livewith chaos...” [HCP #4]. These management decisions andresulting work processes have had a positive impact onthe subsequent outputs and outcomes. The services, andthe way in which these services are provided, produce out-puts such as continuity of care and comprehensiveness ofservices, as this health care provider describes:“...the amount of interactions that our patients havewith health care professionals has greatly increasedsince we have been here...maybe they spent longhours in the emergency department prior to usbeing here...if patients feel very comfortable cominghere and just saying, “can I talk?”...their connectionwith health care professionals is much strongernow...if we weren’t here they wouldn’t have access tothese services or they wouldn’t know where to start.”[HCP #12]To summarize, some publicly available indicators likelyrequire greater attention to the measurement of what isbeing delivered and how it is being delivered. Our resultssuggest areas (Table 2) where gaps currently exist inoperationalizing monitoring and performance indicatorswithin the area of PHC activities at the management andclinic level. Examples of monitoring indicators at themanagement and clinic level that would be important forincreasing health equity include: weekly team meetingsincluding all clinic staff, number and type of placeswhere care is delivered (e.g., clinic, home, street), andnumber of patients who have charts with trauma historyrecorded. Importantly, more work is needed in relationto what should be measured as monitoring and perfor-mance indicators.Wong et al. International Journal for Equity in Health 2011, 10:38http://www.equityhealthj.com/content/10/1/38Page 8 of 12Recommended Areas for Development of New IndicatorsInputs: fiscal resourcesAn exemplar of where new indicators are needed is in thearea of inputs, or Fiscal Resources. In the PHC LogicModel, this domain refers to funding of the organization.What is unique about the Health Centers is that they areboth not-for-profit non-governmental organizations withmandates to deliver PHC. They receive and obtain fund-ing from various sources. Our observations of the HealthCenters’ sources of funding suggest that the amount offunding, the source of funding, and the stability of thesefunds over the long term has implications for the organi-zations’ ability to hire appropriate staff and for the healthservices offered. Currently there are no indicators formeasuring fiscal resources in the PHC sector, aside fromabsolute counts of dollars received by PHC organizations.Indicators are also needed to measure the sources offunding, the focus of funding sources (appropriateness)and the stability of these funds [44].Outputs: quality, whole person careAnother exemplar of where new indicators need to bedeveloped is in the area of outputs, or whole person care.Upon closer examination of how it is currently measured(see Table 2), whole person care is equated with the provi-sion of a comprehensive range of PHC services [29]. Cur-rent indicators for measuring whole person care focus onwhether or not different services are provided by PHCorganizations, such as “health risk screening” and “smok-ing cessation advice in PHC;” however, our analysis illus-trates that such screening of advice is likely to beineffectual unless broader contexts are taken into account.This suggests that whole person care should be definedmore broadly, aligning more with Haggerty, et al.’s defini-tion, “The extent to which a clinician elicits and considersthe physical, emotional, and social aspects of a patient’shealth and considers the community context in their care”(p. 340) [45]. Indicators are needed to measure the physi-cal, emotional, and social aspects of a person within thecontext of his/her community. In relation to equityoriented PHC, care processes need to take into accountfactors such as: the root causes of chronic conditions, suchas chronic pain; challenges associated with meeting basicneeds for shelter, food, and a safe living environment; andexperiences of everyday discrimination and stigma, andthe impact on health and access to health care.Findings indicate that whole person care is illustratedwhen the provider not only takes into account the neces-sary medical tests, procedures, and treatments, but alsothe person’s emotional and social aspects. As two patientsdescribe:“It’s like I’m not better than them, they’re [healthcare providers at the clinic] not better than me andit’s okay to talk about it.” [PT #01]“That’s one of the reasons why I come here is I justfeel comfortable. I come here and do my blood workbecause I was a [drug] user...it’s a trigger for mecoming just to get my blood work...people hereknow how to deal with the veins, they know how todeal with all the scars and all that crap...that’s why Icome here. I feel comfortable and they offer somuch, I’ve got my HIV services right here...I haveeverything there, I have counselors...I usually see thedoctor, and they just offer everything.” [PT #05]We repeatedly heard from the majority of patientsthat the approach had profound effects, as this patientdescribes,“That’s how they support me, keep me on my feetand keep me positive thinking...I feel very safe withthem [Health Center Staff]. If they were not here, Ithink I would be right on the junk [drugs]... I feel socomfortable [here]...” [PT #09]The majority of providers noted that when the generalmilieu and non-verbal communication were dismissive,care likely would be discontinuous, even when medicalservices were provided, because patients would notreturn for needed health services. Patients and providersdiscussed that addressing patients as people by “checkingin” and saying, “it’s good to see you,” “thank you for com-ing in,” or “I’m glad you’ve come back again” [HCP #10],and letting patients direct their care is integral to achiev-ing better care outcomes:“Sometime, you know, people aren’t here to talkabout their smoking.....or lots of times it might say“pap test” on my daybook, but the person gets in hereand they’ve just had a fight with their boyfriend andthey’ve been kicked out of their house...had a bunchof triggers to go and use [illicit drugs] and they’vetried not to and they are involved with the ministry[because their children are either wards of the pro-vince or he/she is being monitored for their parentingabilities]... and sometimes [a visit] can go down acompletely different road...They [patients] do needtheir usual primary care indicators done right...youknow, their lipids, A1C, pap, or whatever...you knowit’s always this balance of your agenda and thepatient’s agenda and how do you mix those thingstogether. I think that is how we would achieve bettercare, being able to balance the provider agenda withthe patient agenda.” [HCP #23]Our analysis suggests that new and expanded items areneeded to more fully measure whole person care. Exam-ples of possible items include: taking into account aWong et al. International Journal for Equity in Health 2011, 10:38http://www.equityhealthj.com/content/10/1/38Page 9 of 12person’s social environment (e.g., lack of income formaintaining adequate food, or unsafe housing) andrecognition of the patient as a person. Such items wouldreflect a broader definition that recognizes a person’sphysical, emotional, and social aspects of her/his life andthe environment in which s/he lives in. A provider’s abil-ity to form a therapeutic relationship with patients andsubsequently influence health outcomes could bestrengthened through improving the provision of wholeperson care.DiscussionPrimary health care system effectiveness in deliveringservices and its role in helping the health system achievethe goal of equity continues to evolve. While the PHCLogic Model framework is reflected in the care providedby these two Health Centers serving highly vulnerablegroups, continued work on measurement for the pur-poses of monitoring and performance is needed. Similarto findings at Canada’s most recent Health IndicatorsConsensus conference [46], our results suggest that cur-rently available PHC indicators continue to fall short ofalignment with the goal of equity, and that more work isneeded. Our results suggest that currently existing PHCindictors do not reflect important work that organiza-tions serving vulnerable groups are carrying out and thatnew knowledge from a variety of sources (e.g., clinicians,patients, decision-makers) and models of PHC delivery(e.g., non-governmental organizations, community healthcenters, group practices, solo practices) are needed. Insome areas, such as activities at the management level,better operationalization of indicators is needed. In otherareas, new indicators ought to be introduced based on abroader and agreed upon conceptualization of the con-struct. Other ongoing research similarly suggests there isa particular lack of fit between some of the existing PHCindicators and relevant key attributes of service deliveryin the context of socially disadvantaged people’s lives[45].Examination of current PHC indicators suggests that thenotion of “vulnerable populations” has been constructedas a somewhat static concept [or label] applied to particu-lar groups of people. However, research continues to showthat the conditions that lead to vulnerability are dynamicand shifting, and that vulnerability along a number ofdimensions can be experienced by anyone, depending ontheir circumstances, history, and life opportunities [47,48].Measuring performance should not simply be whether ornot programs are offered to vulnerable groups, but rather,what is offered in terms of PHC activities and outputs.Structural conditions, such as lack of social housing, aminimum wage that lags far behind the cost of living,increasing restrictions on eligibility for social welfare, andsocial welfare payments that fall well below the povertyline profoundly influence health and access to health care.As Starfield suggests, overall improvements to equity inhealth will likely require generic interventions aimed atthe person [and populations] rather than ones aimed atspecific manifestations of illness (such as substance use,anger management, disease) [7].A core set of PHC indicators could be developed, forboth monitoring and performance measurementpurposes, as defined by provincial and/or federal jurisdic-tional mandates. For example, funders focused onincreasing health system equity may require a specific setof core indicators that requires particular attention bepaid to vulnerable populations or to how the social deter-minants of health can be addressed in the process ofdelivery PHC services. It is also likely that at the organi-zational, or practice level, some PHC indicators may beconsidered monitoring and performance indicators,whereas for other organizations, these same indicatorsmay be considered only monitoring indicators. What isconsidered monitoring versus performance indicatorswill depend on the accountability agreement between thefunder(s) and the respective PHC organization. Forexample, some organizations clearly have a mandate fordelivery of PHC services for populations made vulnerabledue to intersecting determinants of health such as pov-erty, lack of housing and no social support. For thesetypes of organizations, performance indicators may focuson how the organization delivers PHC services, includingan intentionally flat management hierarchy and weeklyteam meetings. That is, indicators of performance forthese types of organizations may have less focus on pre-ventive indicators such as “smoking cessation advice” or“fruit and vegetable consumption rate,” and more focuson whether life conditions conducive to smoking cessa-tion can be fostered, whether food can be purchased, andwhether the person has a place to prepare food.Using both the PHC Logic Model and the results fromour data underscore the complexity of delivering PHCgenerally, and more specifically to populations who aremost affected by systemic and structural inequities. PHCorganizations and providers need to deliver high qualitytechnical and interpersonal care as well as share a philo-sophical commitment to social justice and fosteringequity in the everyday provision of PHC, includingapproaches that take into account the social determi-nants of health. Moreover, mobilization, at the manage-ment level, of additional resources is needed to movetowards more equitable PHC service delivery (e.g. use ofa PHC team that includes social worker, mental healthcounselor, not just clinicians). Our work suggests thattailoring of PHC programs, support services, and out-reach is important to the delivering of services thataddress the multiple complexities of PHC among variouspopulation groups.Wong et al. International Journal for Equity in Health 2011, 10:38http://www.equityhealthj.com/content/10/1/38Page 10 of 12This work is limited in that the data were collected intwo urban Health Centers in Western Canada that servepopulations who are severely impacted by systemic inequi-ties, and who face multiple complexities in their everydaylives. We focused solely on management and clinic levelindicators, thus, further work is required at other levels.Future work in refinement of PHC indicators needs to beinformed by both population health and health servicesresearch frameworks. Population health frameworks focuson ecologic or multilevel determinants such as cultural,community, social, environmental, and other contextualfactors [49]. Health services research frameworks canguide the development of processes of care that can influ-ence quality, including both technical and interpersonalprocesses of care, such as whole-person care. Indicatorsneed to be developed that take into account organiza-tional, administrative, and clinical determinants of care.ConclusionsDespite these limitations, our study clearly illustratesthat more work is required to develop indicators thatadequately capture the complex work of PHC. Ongoingdialogue and work is needed by clinicians, PHC organi-zations, and decision-makers regarding what can beused to capture the work of PHC. Moreover, simplymeasuring PHC organizations on reaching specific clini-cal target rates does not take into consideration thecomplexity of peoples’ lives, or the interdisciplinary andcomplex nature of care that is mobilized to respond topeoples’ diverse needs. Sophisticated analytic techniquesand the incorporation of newer measures (e.g., CanadianIndex of Wellbeing [50] and Indicators of HealthInequalities [51]) are also needed. Given that perfor-mance is mainly based on what is measured, and thatimprovement in performance will be driven by what iscurrently measured, more work is needed to fullydevelop organizational and interpersonal indicators tocapture work at this level in order to ensure adequatefunding, involve a proper mix of provider expertise, andaddress the social determinants of health. The currentemphasis on achieving greater equity through PHC, thecontinued calls for renewal and strengthening of PHC,and the use of monitoring and performance indicatorshighlight the relevance of ensuring that there are moreaccurate methods to capture the complex work of PHCorganizations.AcknowledgementsFunding for this study was provided by the Canadian Institutes of HealthResearch (CIHR). Drs. Wong and Browne were supported by CIHR NewInvestigator awards and Michael Smith Foundation for Health ResearchScholar awards. We thank our research team members, particularlyKoushambhi Khan and Alycia Fridkin, who contributed to this analysis, ourclinic partners, and the research participants who generously shared theirperspectives.Author details1University of British Columbia (UBC) School of Nursing, Critical Research inHealth and Health care Inequities, 2211 Wesbrook Mall, Vancouver, BritishColumbia, V6T-2B5, Canada. 2UBC, Centre for Health Services and PolicyResearch, 201-2206 East Mall, Vancouver, British Columbia, V6T-1Z3, Canada.3University of Northern British Columbia, Department of Community HealthSciences, 3333 University Way, Prince George, British Columbia, V2N-4Z9,Canada. 4Central Interior Native Health Society, 1110 4th Avenue, PrinceGeorge, British Columbia, V2L-3J3, Canada. 5Vancouver Native Health Society,449 Hastings Street East, Vancouver, British Columbia, V6A-1P5, Canada. 6UBCSchool of Medicine, Department of Family Medicine, 5950 UniversityBoulevardVancouver, British Columbia, V6T-1Z3, Canada.Authors’ contributionsAll authors conceived of the study, participated in its design, and developedthe initial draft of this manuscript. 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The Canadian Index of Wellbeing: 2011 [http://www.ciw.ca/en/TheCanadianIndexOfWellbeing/DomainsOfWellbeing/HealthyPopulations.aspx].51. Population health promotion expert group, Healthy living issue group:Indicators of Health Inequalities. Pan-Canadian Public Health Network;2009.doi:10.1186/1475-9276-10-38Cite this article as: Wong et al.: Enhancing measurement of primaryhealth care indicators using an equity lens: An ethnographic study.International Journal for Equity in Health 2011 10:38.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitWong et al. International Journal for Equity in Health 2011, 10:38http://www.equityhealthj.com/content/10/1/38Page 12 of 12


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