UBC Faculty Research and Publications

Closing the health equity gap: evidence-based strategies for primary health care organizations Browne, Annette J; Varcoe, Colleen M; Wong, Sabrina T; Smye, Victoria L; Lavoie, Josée; Littlejohn, Doreen; Tu, David; Godwin, Olive; Krause, Murry; Khan, Koushambhi B; Fridkin, Alycia; Rodney, Patricia; O’Neil, John; Lennox, Scott Oct 13, 2012

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RESEARCH Open AccessClosing the health equity gap: evidence-basedstrategies for primary health care organizationsAnnette J Browne1*, Colleen M Varcoe1, Sabrina T Wong1,7, Victoria L Smye1, Josée Lavoie2, Doreen Littlejohn3,David Tu3, Olive Godwin4, Murry Krause5, Koushambhi B Khan1, Alycia Fridkin1, Patricia Rodney1, John O’Neil6and Scott Lennox5AbstractIntroduction: International evidence shows that enhancement of primary health care (PHC) services fordisadvantaged populations is essential to reducing health and health care inequities. However, little is known abouthow to enhance equity at the organizational level within the PHC sector. Drawing on research conducted at twoPHC Centres in Canada whose explicit mandates are to provide services to marginalized populations, the purposeof 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 thepoorest in Canada. Using a mixed methods ethnographic design, data were collected through intensive immersionin the Centres, and included: (a) in-depth interviews with a total of 114 participants (73 patients; 41 staff), (b) over900 hours of participant observation, and (c) an analysis of key organizational documents, which shed light on thepolicy 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-competentcare. The operationalization of these key dimensions are identified as 10 strategies that intersect to optimize theeffectiveness of PHC services, particularly through improvements in the quality of care, an improved 'fit' betweenpeople's needs and services, enhanced trust and engagement by patients, and a shift from crisis-oriented care tocontinuity of care. Using illustrative examples from the data, these strategies are discussed to illuminate theirrelevance 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 PHCorganizations 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 ofequity-oriented PHC services when working with marginalized populations, and will have broad application to awide range of settings, contexts and jurisdictions. Future research is needed to link these strategies to quantifiableprocess 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* Correspondence: annette.browne@nursing.ubc.ca1University of British Columbia, School of Nursing, T201 – 2211 WesbrookMall, Vancouver, British Columbia V6T 2B5, CanadaFull list of author information is available at the end of the article© 2012 Browne et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.Browne et al. International Journal for Equity in Health 2012, 11:59http://www.equityhealthj.com/content/11/1/59IntroductionDespite Canada’s commitment to provide high qualityhealth care, health inequities remain a pressing concern.Of particular concern are the persistent and growinghealth and health care inequities affecting marginalizedpopulations [1-5]. In Canada, increasing homelessness;social exclusion experienced by those living withchronic mental illness or substance use; violence againstwomen; and systemic discrimination toward Aboriginalpeoplea and new immigrants are instances of systemichealth and social inequities that can be addressedthrough equity-oriented primary health care (PHC)binterventions, particularly when linked to structuralchanges and policy shifts.As reiterated by the World Health Organization(WHO), one of the most efficient ways of ‘closing theequityc gap’ within a population is to address the healthand health care needs of those most disadvantaged [6].International evidence continues to show that enhance-ment of PHC services for disadvantaged populations isone of the most important means of reducing inequities[7-9]. Repeated calls for PHC renewal are based on solidevidence that a strong PHC foundation leads to improvedpopulation health outcomes, including reduced risk andeffects of acute and chronic conditions; reduced use ofemergency services; lower rates of preventable hospitaladmissions; and lower overall health care utilization[6,7,10]. Conversely, when PHC is not accessible or effect-ive, people delay seeking help, rely on emergency care,and lose the benefits of continuity of care [3,11,12]. Theseissues contribute to the increasing importance of thePHC sector in enhancing efforts to orient services towardmarginalized populations where the greatest gains inredressing inequities can be achieved [7,9,13,14]. Broad-based PHC approaches and interventions – that integrateaccessible, high quality, responsive services with structuraland policy changes to improve people’s access to the so-cial determinants of health – may therefore be one of themost effective means of working towards greater equity.In this article, the terms ‘marginalized,’ ‘vulnerable’ or‘disadvantaged’ refer to the conditions and processes bywhich particular populations are affected by structural in-equities and structural violence in ways that result in adisproportionate burden of ill health and social suffering.We place an emphasis on marginalizing conditions tosuggest that particular populations are not inherentlymarginalized, rather, it is the marginalizing conditionsthat create and sustain inequities. Structural inequitiesrefer to how policies and practices embedded in systemssuch as social welfare, economic, justice and health careoperate to produce inequitable distribution of the deter-minants of health [15]. Structural violence is increasinglyseen in public and population health as a major determin-ant of the distribution and outcomes of health inequitiesand is defined as “a host of offensives against human dig-nity: extreme and relative poverty, social inequalities ran-ging from racism to gender inequality, and the morespectacular forms of violence” [15] (p.8). Inequities arestructural because they are embedded in the political andeconomic organizations of our social world, and they areviolent because they cause injury to people [15]. For ex-ample, discrimination, individual and institutionalized ra-cism, poverty, and social exclusion are consequences ofstructural inequities and structural violence, and havetangible effects on health status and access to health care[3,16-20]. The health of Aboriginal people in Canadaserves as a case in point. Despite improvements in recentyears, inequities persist on virtually every measure ofhealth and social status, for example, lower life expect-ancy, decreased access to health services, and dispropor-tionately high rates of preventable, chronic and acutehealth conditions [1,4,21,22].Focusing on the health effects of inequities necessi-tates attention to the concept of trauma. Trauma is in-creasingly used to frame the health, social, andpsychological effects of structural inequities and struc-tural violence [21,23-35]. Research shows that traumahistories are highly prevalent among marginalizedpopulations [24]. Traumatizing experiences include, forexample, discrimination and social exclusion, poverty,emotional abuse, physical violence, sexual assault, tor-ture and war. Traumatizing experiences can be histo-rical and intergenerational such as the experiences ofAboriginal people in Canada. Despite mounting evi-dence linking trauma with negative health effects (e.g.,chronic pain, problematic substance use, mental healthissues) [25,32,36,37], little is known about how to ad-dress trauma in the context of PHC service delivery tomarginalized populations.Research on PHC delivery highlights several persistentproblems: (i) inverse care (i.e., those who are most mar-ginalized and have the greatest health problems have theleast access to care); (ii) fragmentation and under-resourcing of care for marginalized populations; (iii)significant gaps in knowledge concerning how to makeservices responsive to marginalized populations; and (iv)policy and funding environments inadequate to redressthese problems [7]. Thus, despite a proliferation of callsfor strategies to enhance the ability of the PHC sector todevelop ‘equity-competence’, little is known about (a)key dimensions of equity-oriented services that ought toguide PHC organizations; or (b) the strategies, processesand policies for enhancing the capacity to deliver equity-oriented PHC services, particularly for marginalizedpopulations [7,38-40]. The purpose of this article is todescribe the key dimensions of PHC services, and thestrategies for operationalizing those dimensions whenequity is an explicit goal, and when working withBrowne et al. International Journal for Equity in Health 2012, 11:59 Page 2 of 15http://www.equityhealthj.com/content/11/1/59marginalized populations. Drawing on research at twoPHC Centres in Canada with explicit mandates to pro-vide services to marginalized populations, we discuss therelevance of these strategies for PHC agencies and orga-nizations that aim to address the intersecting health andsocial needs of people experiencing systemic inequities.We begin with an overview of the study. We then out-line key dimensions of equity-oriented PHC. Next, weidentify strategies for operationalizing these dimensionsat the patient-provider, organizational, and system levels.MethodsOverview of studyThe findings discussed in this article are part of a largerfour-year study aimed at (a) extending our understand-ing of how PHC services are provided to meet the needsof people who have been marginalized by systemic in-equities, (b) identifying key dimensions of PHC servicesfor marginalized populations, and (c) developing PHCindicators that can account for the quality, process, andoutcomes of care when marginalized populations are ex-plicitly targeted. In this paper, we focus on the first twoobjectives; an analysis of the work leading to the devel-opment of PHC indicators has been reported elsewhere[41]. Methodologically, this research is informed by crit-ical perspectives of social justice and equity [42-46]. Thecritical theories upon which we draw focus attention onthe development of practical knowledge that has the po-tential to disrupt and transform inequitable social rela-tions. A central methodological concern is thatindividual experiences, including those in health care,need to be interpreted and understood within the con-text of broad social, political and historical relations.Such interpretations are needed to better address sys-temic inequities in health service delivery. These theor-etical perspectives provided a framework that guided ourmethodological approaches and analytical perspectives.Approval to conduct this study was provided by twouniversity research ethics boards and by the PHC agen-cies. Using a mixed methods ethnographic design, theresearch was conducted at two urban PHC Centres inwestern Canada whose explicit mandates are to providePHC services to Aboriginal and non-Aboriginal popula-tions experiencing major social and economic inequities.Both have been in operation since the early 1990s, andare located in the inner city areas of two cities recog-nized as among the lowest socio-economic neighbour-hoods in Canada.The Centres’ combined patient population is 5,500; ahigh proportion identify as Aboriginal people, and themajority live in poverty and experience social exclusion,racialization and discrimination on a daily basis. Manysuffer the consequences of colonization, including thehistorical trauma of displacement, forced attendance atresidential schools, limited educational and employmentopportunities on reserves, the disruption of family andcommunities, the eradication of language and culture,and the ongoing trauma of race-based violence, and dis-crimination (e.g., unemployment). Many of the patientsreside in single room occupancy hotels, have significantmental health and substance use issues, and other stig-matizing health conditions, including HIV/AIDS. Almostall of the patients have experienced inter-related traumasstemming from violence, childhood neglect or abuse, orsexual exploitation. Many, however, reported a strongsense of community connection and belongingness aspeople residing in both inner city areas.To respond to people’s intersecting health and socialneeds, the services at each Centre are organized arounda PHC clinic staffed by physicians, nurses, nurse practi-tioners, social workers, substance use counsellors, andoutreach workers, and include on-site and outreach pro-grams. To different degrees, Indigenous approaches tohealth and healing are integrated, such as the employ-ment of Aboriginal Elders who provide counselling andsupport to both Aboriginal and non-Aboriginal patients.Data collectionThe ethnographic approaches we used are typically under-utilized in medical and health services research and, there-fore, represent innovative qualitative approaches applied tothe study of health equity. Observational and interview datawere collected at the Centres primarily by the principalinvestigators, who are experienced ethnographic research-ers. In-depth interviews were conducted with a total of 114patients and staff, including: (a) individual interviews with62 patients, and three focus groups with 11 patients(n = 73 patients), and (b) individual interviews with 33 staff,and an additional eight staff who participated in focusgroups (n = 41 staff). An analysis of key organizationaldocuments was also completed to shed light on policy andfunding environments. In addition, in-depth interviewswere conducted with two decision-makers employed byHealth Authorities within which the Centres are locatedand funded. Written and verbal consent was obtained priorto conducting interviews or observations, and the voluntarynature of participation was reiterated frequently.The patient interviews were critical to conceptualizingthe approaches to care that were most important in thecontext of people’s lives. Patient interviews focused ontheir reasons for coming to the Centres, their likes anddislikes about the services provided, their working rela-tionships with staff, comparisons with health careexperiences elsewhere, and how services could beimproved to better meet their needs. Staff interviews fo-cused on their experiences working at the Centres, thoseaspects of service delivery that were essential to addressinequities, how they supported and facilitated access toBrowne et al. International Journal for Equity in Health 2012, 11:59 Page 3 of 15http://www.equityhealthj.com/content/11/1/59health and social services in ways that influencedpatients’ overall quality of life, and how continuity ofcare was established with patients who might otherwise‘fall through the cracks.’Participant observation involved over 900 hours of in-tensive immersion, which was essential to developingknowledge about equity-oriented PHC services groundedin the everyday complexities of clinical practice. Partici-pant observation was conducted as unobtrusively as pos-sible in the waiting rooms, at the reception desks, in teammeetings, and during clinical interactions betweenpatients and providers. The focus of observations was on:(i) the general organizational milieu at the Centres (e.g.,the use of spaces to create a welcoming environment,staff approaches with patients in the waiting room, howpatients were greeted at the reception desk, how conflictwas dealt with, and the strategies used to prioritizepatients); and (ii) the staff members’ patterns of interact-ing, relating, and working with patients and with one an-other, including how they attended to patients, what theypaid attention to, and how the socio-economic or culturalcontexts of patients’ lives were taken into consideration.Using purposeful sampling, patients were recruited toreflect a diversity of ages, genders and positive and nega-tive experiences with the Centres. Recruitment to partici-pate in interviews also involved obtaining consent toparticipate in observations. Several approaches were usedin recruitment: the waiting rooms contained posters andflyers about the study, and interested patients wereinvited to identify themselves to the reception staff, whoin turn notified the researchers; during the process of par-ticipant observation, researchers informed patients aboutthe study and invited their subsequent involvement; lastly,to invite the participation of diverse patients, staff andpatients identified individuals who were known to havevaried experiences with the Centres. Observational dataprovided a context for discussing, clarifying and exploringissues raised in interviews, and vice versa. Among thepatients who participated (n = 73), 52% were women,45% were men, and 3% identified as transgender.Seventy-seven percent self-identified as Aboriginal, 22%as Euro-Canadian, and 1% as members of a visible minor-ityd [47]. Ages ranged from 20 to 72 (mean = 45 yearsold). Of the Centres’ staff who participated (n = 41), 24%were nurses or nurse practitioners, 22% were physicians,22% were medical office assistants (MOAs) and officemanagers, 10% were in administrative leadership posi-tions, 7% were social workers, 5% were substance usecounsellors, and 10% were other staff including an Elder,an outreach worker, a support worker and a pharmacist.Data analysisAn interpretive thematic analysis was conducted usingprocedures for qualitatively derived data [48-50]. Interviewtranscripts and observational notes were repeatedly readby the members of the investigative team to identify recur-ring and contradictory patterns in the data, and possiblelinkages to theoretical perspectives. A qualitative computersoftware package (NVivo, QSR International, 2010) wasused to organize and code the narrative data. Theresearchers met regularly during the coding process to as-sess inter-rater reliability, resolve discrepancies, and ensureconsistency. For example, as the code-book was beingdeveloped, each interview was coded by at least twoexperienced researchers. Discrepancies were discussed andaddressed as the concepts and themes reflected in thecodes were further refined.As data were collected and analyzed, coding categorieswere refined. In the final stages, the analysis shifted to amore abstract and conceptual representation of themesand the key dimensions of PHC. Importantly, observa-tional data provided a means of triangulating interviewdata, adding to the methodological rigour.The credibility of our analysis, as a criterion for rigourin qualitative research, was continually evaluated bymembers of our research team, who included experts inethnographic research, PHC services and health equity,and a community advisory committee comprised ofpatients, and health care providers external to the Cen-tres. Throughout, the research team held regular meet-ings with groups of patients and staff to discuss theanalytical insights and themes. We used diverse strat-egies including: co-hosting lunches with peer-supportworkers, during which we invited patients to providefeedback on the findings; engaging in outreach activitiessuch as community tours with patients and staff to gainfurther insights; consulting with Aboriginal Elders to en-sure their perspectives were taken into account; andconsulting frequently with the community advisory com-mittee to seek their input. These stakeholders confirmedthat the identified themes reflected in the data resonatedwith their experiences and interpretations, and that theframework we proposed captured the essential featuresof equity-oriented PHC. For example, at a lunch hostedfor ~ 25 patients, the patients completely took over thediscussion of the proposed strategies, emphasizing theirimportance. One man commented, “I thought I was justcoming for lunch, but this was the best meeting ever.”Throughout, an audit trail of analytical insights anddecisions was maintained.Results and discussionThrough the analysis we identified (a) four key dimensionsof equity-oriented PHC services, which are particularlyrelevant when working with marginalized populations, (b)10 strategies to guide organizations to enhance their cap-acity for equity-oriented services, and (c) outcomes relatedto these dimensions and strategies (see Figure 1).Browne et al. International Journal for Equity in Health 2012, 11:59 Page 4 of 15http://www.equityhealthj.com/content/11/1/59Conceptually, the four key dimensions provide aframework for understanding the essential elements ofequity-oriented PHC services when working with mar-ginalized populations. The dimensions are interrelatedand overlapping, and include: Inequity-Responsive Care: explicitly addressing thesocial determinants of health as legitimate and routineaspects of health care, often as the main priority. Trauma- and Violence-Informed Care: recognizingthat most people affected by systemic inequities andstructural violence have experienced, and oftencontinue to experience, varying forms of violence withtraumatic impact. Such care consists of respectful,empowerment practices informed by understandingthe pervasiveness and effects of trauma and violence,rather than ‘trauma treatment’ such as psychotherapy. Contextually-Tailored Care: expanding the conceptof patient-centred care to include services that areexplicitly tailored to the populations served and localcontexts. This may include organizational tailoringto address the local population demographics andsocial trends (e.g., programs or services addressingHIV, seniors, women’s or men’s issues, support fornew immigrants, etc.). Culturally-Competent Care: taking into account notonly the cultural meaning of health and illness, butequally importantly, people’s experiences of racism,discrimination and marginalization and the waysthose experiences shape health, life opportunities,access to health care, and quality of life.The operationalization of these key dimensions is identi-fied in this paper as strategies that intersect to optimize theeffectiveness of services, particularly through improvementsin the quality of care, an improved ‘fit’ between people’sneeds and services, enhanced trust and engagement bypatients, and a shift from crisis-oriented care to continuityof care [37,41]. As shown in Figure 1, both patients and pro-viders directly linked these specific strategies to short-termoutcomes such as an increase in patients’ capacities to man-age their own health, and increased access to resourcesessential to support health. Both also identified longer-termimprovements in health and quality of life, with the poten-tial for reducing health inequities at the population level.These 10 overlapping strategies are discussed below toillustrate their relevance at three inter-related levels:organizational, clinical programming, and patient-providerinteractions. These are proposed as principles of equity-oriented services, recognizing that PHC organizations,agencies and practices will have to tailor the extent to whichthey can implement each strategy in their local context.Ten strategies to guide organizations in enhancingcapacity for equity-oriented services1. Explicitly articulate the commitment to equity in themission, vision and other organizational policystatementsWhen PHC organizations acknowledge the impact ofhealth and social inequities on health, illness and access tohealth care, the possibility of organizing and deliveringInequity-Responsive CareContextually-Tailored Care Trauma- and Violence-Informed CareCulturally-Competent Care10 Strategies to Guide Organizations in Enhancing Capacity for Equity-Oriented Services • Make an explicit commitment to equity• Develop supportive structures, policies, and processes• Revision use of time• Attend to power differentials• Tailor care, programs and services to context• Actively counter oppression• Promote community + patient participatory engagement• Tailor care, programs and services to histories• Enhance access to social determinants of health• Optimize use of place and space4 Key Dimensions of Equity-Oriented PHC Services Outcomes Longer term: • improved health and qualityof life• reduced health inequities at population level Shorter term:• increased effectiveness of  services • increased ‘fit’ between  people’s needs and services • increased access to health  care and social resources • increased patient capacity to manage healthFigure 1 Enhancing equity-oriented PHC delivery.Browne et al. International Journal for Equity in Health 2012, 11:59 Page 5 of 15http://www.equityhealthj.com/content/11/1/59services that foster equity for vulnerable patients and popu-lations is promoted. Key to positioning equity as an explicitmandate is the articulation of related commitments in gov-ernance, mission statements, and organizational-level policystatements. This requires strong leadership within theorganization, and the continual reflection of mission state-ments in job postings, staff orientations, staff performancereviews, and related documents and activities. The activitiesof the organizational leaders are important in reinforcingthe organization’s commitment to equity, including for ex-ample, the kinds of advocacy and social justice or policywork that leaders engage in within the wider community.One of the Centres’ administrative leaders commented:Trying to articulate what our mission and vision andvalues are. . ..I mean it’s a big piece of work. So youdon’t just ignore it once you’ve produced thedocument. We agonized over those. So we darn wellbetter make sure it’s entrenched in what we do.At the organizational level, hiring practices need toensure a match between staff and the organizationvalues, philosophy, and the approaches to care that rep-resent the operationalization of the mission statement.Declaring an organizational commitment to fosteringequity can contribute to solidifying an organization’sidentity and can serve to attract employees who sharesimilar values regarding PHC and social justice, asnoted by this physician: “it’s not a hidden agenda – it’sright out there. . .it’s part of what you’re getting into.”Working within a PHC organization distinguished byan explicit, organizational commitment to equity canrepresent a defining feature of practice for direct ser-vice providers, as this staff member discussed:I think to have it [a commitment to equity] as a sharedvalue is very central to what we do. . .That’s what’sdifferent, if you’ve ever worked anywhere where peopledon’t really talk about these things, never mind work onthem and try to make it a central core.At the level of direct clinical care, mission and visionstatements also provide a sense of perspective and pur-pose when progress toward achieving improved healthfor particular patient-groups is slow or ostensibly back-sliding, as a provider explained:It is easy to talk about the rhetoric [related to equity],but when you’re here and the patient is, you know, it’sthe ninth time you’ve seen them in a month andyou’re not getting anywhere. She or he [theorganizational leader] is a person who can take youback to the vision and can take you back to, youknow, how to see the bigger picture.Commitments to equity, however, cannot be enacted andwill not be sustainable without supportive funding andpolicy environments.2. Develop and advocate for structures, policies, andprocesses to support the enactment of equityFunding and policy environments that are supportive ofequity-oriented aims are needed. This means that leadersmust develop appropriate structures, policies and processeswithin their organizations and advocate within larger con-texts for the conditions necessary to achieve these aims.Within the Centres, leaders created an organizational cul-ture that supported interdisciplinary team meetings andthe active participation of all team members in planningcare, programs, and case management. These activitiesneed to be supported by stable funding arrangements toenhance the ability of the organization to enact a philo-sophical commitment to equity, and by social policy thatenhances access to social determinants of health. Thus,Centre leaders were active at local community, city, provin-cial and federal levels advocating for adequate social hous-ing, better access to income supports, and allocation ofhealth care funding within their own and other health careorganizations (to support, for example, methadone pro-grams and other harm reduction activities).Efforts to create conditions to support the enactmentof equity were also influenced by factors beyond theCentres. For example, leaders negotiated for physiciansto be paid by salary rather than fee-for-service to enabletheir participation beyond direct patient care in interdis-ciplinary meetings and case conferences; however, suchmeetings were constantly under threat due to fiscal pres-sures and questions raised by funders about how clinicalstaff were using time – pressures that varied with the de-gree of independence each Centre had in relation totheir funding bodies. The Centres varied in the extent towhich their contractual funding arrangements permittedthem to enact the strategies of equity-oriented care. Forexample, block-funding arrangements with longer termspermitted greater flexibility at one Centre, whereas atthe other, year-to-year and fragmented funding andchronic underfunding limited the range of services inplace to address the complexities associated with vio-lence, poverty, homelessness, or substance use. Fundingis also needed to provide counselling or debriefing forstaff who are dealing with the vicarious effects of struc-tural violence and trauma, as discussed further in strat-egy eight. A manager explained:[Our funders were]. . .micro managing. . .telling youwhat your priorities were going to be. . .telling usalmost on a day-to-day or week-to-week basis whatyou’re going to be doing with your time and thoseBrowne et al. International Journal for Equity in Health 2012, 11:59 Page 6 of 15http://www.equityhealthj.com/content/11/1/59kinds of things. We just kind of said, “No! No, that’snot the way it works.” And to some extent thatworked. But they still control the purse strings and assuch they still have a lot of kind of ‘leverage over’ –because they can always say, if you’re not going tobehave the way we want you to, we’ll find anotheragency that will.Importantly, funding arrangements varied in terms ofhow professional time could be flexibly deployed, for in-stance, for patient care, team meetings and collaborativecase management. Revisioning the use of time was acritical strategy.3. Revision use of time to meet the needs of clientpopulationsTime and its use are crucial considerations, in terms ofexpectations regarding ‘how long’ it should take to seehealth improvements, and how providers use time. Work-ing with populations whose health is so closely linked withsocial and economic conditions can seem slow or stagnantwith respect to improvements in short- and long-term out-comes. Rather than constructing patients as ‘non-compliant’ or as failing to achieve goals, the Centre’sproviders recognized how broader contexts influencedpeople’s health trajectories and decisions. The collectiveexpertise of staff and interdisciplinary teams was used todetermine when to support or ‘push’ patients to go a stepfurther in moving toward their potential. This wasparticularly evident in relation to substance use andaddictions issues, adhering to anti-retroviral treatments,safe-guarding against interpersonal violence, or workingtoward healthy parenting skills. Staff sought patient’sinput about goals, discerning the patients’ readiness andsupporting steps to prepare for change – a processthat required long-term strategies and commitment.A patient described the impact of not “approachingme too fast”:What this place did for me was, actually, it really didhelp me out. Because it gave me a sense of security, asense of trust with these people. And for me that’s ahard thing to do, just to trust people. Especiallymanagers and staff members of any type. . ..And staffmembers don’t approach me too fast, too hard and tooquick, which is important, I believe. So, it’s, let me sortof come to you. And because it’s hard for me to ask forthings. . .it’s hard for me to ask for help. So the staffhere are patient with that. And I think they understandthat, which is important.Revisioning the use of time also refers to cultivatinghealth care relationships over time. Time is required forparticipatory engagement of patients, and is fostered byadopting clinic structures that encourage ‘patient activa-tion’, such as patient-initiated appointments scheduledon a drop-in or pre-booked basis. Such scheduling struc-tures need to be creative, fluid, and innovative to accom-modate people’s rapidly shifting priorities and concerns,as this provider explained:So someone might come in and you think that theyare going to be here for their ear infection. But then,you get to know them on a broader level, so you cansay like, "how are things going at home?” And toreally be able to see people in an ongoing way, andsay like, "so where are you living now? And you knowand how’s it going?". . . So then you can have theopportunity and the time and the resources to addressthose issues.Revisioning time also means recognizing the com-plexity of the work involved in providing PHC to mar-ginalized populations. Organizationally, this requiredrecog nizing the need (and scheduling time) for inter-disciplinary meetings; putting in place adequate timeand processes to support staff to provide care to peoplewho are highly traumatized; and providing flexibility inscheduling so that patients with greater needs areprovided more time. This strategy in turn requirescollaborative decision-making.4. Engage in decision-making on the basis of criticalanalyses of power differentials, flattened hierarchieswithin interdisciplinary teams, and shared leadershipapproachesTo address the health effects of persistent powerinequities, stigma, everyday social exclusion, andsystemic discrimination experienced by many margina-lized patients, organizations must first reflect critically,and purposefully, on power relations within theirorganization – in relation to interactions with patients,staff, management, the wider community, and othersectors and organizations. For service providers includ-ing receptionists, professional staff, and management,this requires critical self-reflection on how power differ-entials are managed, particularly with patients who mayfind it challenging to relate with or trust people in posi-tions of authority [20,51]. A physician with years ofexperience working at one of the Centres described thisprocess:You’re trying to reflect on, you know, check myattitude: was I being condescending? And I’m suremany times I am, because you know, like, you slipinto that role right? You’re the doctor.Browne et al. International Journal for Equity in Health 2012, 11:59 Page 7 of 15http://www.equityhealthj.com/content/11/1/59Another physician described the approach she takes toengage in critical reflexivity:You have to look at the privileges that you gained as aconsequence [of your professional status and sociallocation], and that’s very uncomfortable for people.At the organizational level, attention must be paid topower inequities that often shape staff dynamics. For ex-ample, engaging in team meetings and sharing leader-ship in ways that intentionally aim to flatten professionalhierarchies among staff are critical and prerequisite toaddressing power differentials in relation to patientpopulations. Team meetings or case conferences can beconducted in ways to signal all staff input is important –including reception staff who often have the most fre-quent contact with patients and play an influential rolein shaping access to services. Scheduling team meetingsat regular intervals also is essential to foster interdiscipli-narity and comprehensiveness of services – and is crit-ical to developing synergy among staff and within theorganization about how to maintain equity-orientedstrategies.5. Tailor care, programs and services to the context ofpeople’s lives (e.g., cultural, social, gender, anddemographic contexts)This strategy rests on the premise that PHC servicesneed to be meaningful to the patient-populationserved. The notion of ‘tailoring’ builds on and extendsthe notion of patient-centred care, and refers to theadaptations that can occur when the social and cul-tural contexts of local patient-populations are takeninto account in the process of delivering care. Theseadaptations are significant when working with patient-populations who, in the process of seeking health care,often encounter dismissiveness, stereotyping and nega-tive assumptions related to poverty, racism, substanceuse and mental illness [19,20].Depending on the local community context, and thepopulations served, tailoring that attends to the socialand cultural context of people’s lives could include:attention to styles of communication (both verbal andnon-verbal); efforts to provide services (where pos-sible) in local languages; and adapting clinical practiceguidelines in ways that align with the priorities ofpatients’ lives (which can be chaotic or stable at vari-ous times). Most often, responsiveness to social con-texts requires interdisciplinary team-based responses;at the organizational level, this means ensuring thatstaffing levels are adequate to assist patients with, forexample, completing lengthy disability forms, liaisingwith social-services, child protection services andother state authorities, and coordinating with otherhealth care organizations.At the level of patient-provider interactions, tailoringis essential to draw in, rather than limit access to careby marginalized patient-populations. For example, whatmight be seen as excellent interpersonal communica-tion in one cultural context might be seen as discrim-inatory or alienating in another. At the two PHCCentres, initial greetings among people who identify asAboriginal often incorporate the phrase, “where areyou from?” to signal an awareness of the importanceof place and community of origin as an essential as-pect of one’s identity. Among some immigrant groups,however, this phrase can signal that one is viewed as‘Other’. Similarly, when working with women with his-tories of trauma who are at high risk of experiencingre-traumatization during physical assessments, offeringchoices and easing into health care encounters canoffer high impact ways of recognizing people’s vulner-ability and foster trust as an essential component ofaccess to PHC.Openly discussing various approaches to harm reduc-tion, including how to manage opiate prescribing prac-tices when there are high rates of substance use amongthe patient population, is an example of tailoring thatcan take place at organizational and provider levels.These organizational-level discussions are critical whenworking with client populations with high rates of sub-stance use or chronic addictions combined with mul-tiple forms of discrimination; conveying acceptance andnon-judgmental approaches are imperative to support-ing people’s access to PHC services. As one patientexplained:The whole thing of addiction is having people listenand not judging. And most doctors, I know, exceptfor the select few that are here, they are all judging,very judgmental of addicts.Organizational policies can be tailored to meet theneeds of individual patients by implementing clinicalpractice guidelines that are flexible, dynamic and can beadapted to the person’s life context, personal circum-stances, and highest priorities. For example, rather thanbeginning with their substance use issues per se, staff atthe Centres working with mothers who use substancesoften began with the women’s top priorities – support-ing women to increase contact with children appre-hended by state authorities, or supporting women toparent their children to prevent child apprehension. Asone provider explained:From a care provider perspective. . .if I can help youkeep your five-year-old daughter from going to fosterBrowne et al. International Journal for Equity in Health 2012, 11:59 Page 8 of 15http://www.equityhealthj.com/content/11/1/59care, you know, that is very rewarding for me, if Icould be part of that solution – and very meaningfulfor her, and more so for the five-year-old.6. Actively counter the impact of intersectingoppressions on health, access to care, and qualityof lifePHC providers and organizations need to be aware ofhow marginalizing practices and social exclusion operatein structures and institutions, including health care,thereby shaping people’s health care experiences and ac-cess to services; then, they can actively implement strat-egies to counter these barriers. Our data aligns with thegrowing body of evidence showing that disempowermentand alienation of marginalized groups in society aremajor obstacles to achieving health equity [1,22,40,52].The positive impact of actively conveying respect and ac-ceptance to individuals – and attending to power differ-entials, is highly significant, particularly for people whoexperience social exclusion on an everyday basis. Awoman who is a patient shared the impact:Because a person doesn’t have that courage, youknow, they’ll sit there on the street thinking, it’ll be[such a huge thing to go in for health care]. . .That’swhy I come – because they’ll let everyone in. . .You’remissing so much on that connection – not connectedto anybody. . .Those kinds of just simplegestures. . .just that little bit of, you know, goodhuman touch, once in a blue moon, can really helpsomebody get to the next step, right? Good humaninteraction and connections.Our findings showed how countering racism, discrimin-ation, stigmatization, and social exclusion can be achievedby conveying unconditional positive regard for patients re-gardless of their circumstances, and fostering the humandignity of all persons even in informal interactions in wait-ing rooms, at reception desks, over the telephone, or dur-ing clinical encounters. Affirming approaches can beostensibly ‘small’ gestures, achieved through non-verbalcommunication, tone of voice, and other types of commu-nication, as one provider described:I’ll stop and have a small conversation with theperson, or I’ll say, you know, I’m really happy to seeyou here today, to let them know that they’reappreciated. Because other than that, people neversee them [as people].Creating an accepting, non-judgmental PHC environ-ment also manifests in the ways staff respond topatients’ expressions of frustrations or anger. Thisrequires that staff continually reflect on the personal andsocial contexts which give rise to patients’ expressions ofanger, as a physician narrated:I had a woman, 20-something, working the street,HIV positive, heroin-addicted, comes in very angry,hostile. . .I agreed to take her on for methadone andHIV care, and she started out really hostile, but shekept coming back. And then, after a year. . .she’s like,“no, I wouldn’t go anywhere else” and, “I’m sothankful for being here.” I just needed to acceptthat. . .she might be angry and hostile for a whilebut. . .eventually. . .the real person will emerge. . .At an organizational level, actively countering the im-pact of intersecting oppressions requires policies thatsupport a low barrier health care environment whereinpatients are, as one staff member described, “just allowedto be.” They do not have to transform themselves intosomething else to be seen as legitimate or credible.One indicator of accessibility, especially for peoplewho are marginalized or ‘hard to reach’, is when patientsdrop in or hang out at a Centre, without a specific ap-pointment. A patient described the benefits:It’s more or less come in and have coffee, you know.You’re welcome. You won’t be chased out. And I feelcomfortable coming here, and like I said, because Isee a lot of my people here. And a lot of the staff, youknow, talk to you. . .Like I said there are times where Idon’t even need to be here, but I come here to talk toa friend or have a coffee, you know, and just go home.Our observational data showed that these strategieshad a visible impact; expressions of frustration or hostil-ity by patients were infrequent, despite sometimes longwait times in waiting rooms, and despite some peoplebeing visibly under the influence of substances. On occa-sion, when some people’s behaviours approached a dis-ruptive level, staff (usually receptionists) respectfullyused communication styles to diffuse tensions and setlimits, which were usually respected. This contrastedwith our prior research in emergency departments wherewe observed security guards routinely deal with beha-viours in ways that often resulted in escalating frustrationand aggressive behaviours, and ended in dismissal orbanning of patients and police involvement [19,20,53].PHC organizations can also exercise leadership withintheir communities by increasing awareness of how racia-lization and discrimination operate in health care set-tings such as emergency departments, and in the widercommunity, and by working to counter such oppression.For example, a nurse at one of the Centres informed themedia about methadone dispensing pharmacies thatBrowne et al. International Journal for Equity in Health 2012, 11:59 Page 9 of 15http://www.equityhealthj.com/content/11/1/59were exploiting vulnerable patients for economic gain;this action contributed to an investigation and policychanges to prevent such exploitation in the future.7. Create opportunities to promote and fosterengagement with community and other sectors,including participatory engagement by patientsEnhancing equity-capacity within PHC organizationsideally will involve engagement and collaboration withvarious sectors in the local community and beyond tomaximize opportunities to address the social contexts ofpatients’ lives. For example, tailoring care, programs andservices to the contexts of patients’ lives could involve li-aising with child welfare agencies to develop ways to sup-port women at risk of having their children apprehended.Actively countering discrimination could involve hostingan in-service at the emergency departments known to befrequented by patients to discuss possible anti-racistapproaches. Recognizing that not all PHC organizationsor staff have the flexibility to engage in these ways, thisstrategy is held out as an ideal to work towards, and as astarting point for meaningful dialogues within and be-tween a range of health and social sectors. Such engage-ment also requires action at the level of policy, so thatvalues related to equity can be effectively and democrat-ically operationalized [54]. Following our example above,liaising with child welfare agencies to develop ways tosupport women would include, for instance, working onhealth policies related to child health assessments andsocial policies related to income support.Participatory engagement of patients can take manyforms and PHC organizations can play a role in provid-ing a sense of meaningful belongingness, for example, byproviding paid or volunteer opportunities including peersupport programs. These experiences offer powerfulpoints of connection for people marginalized by socialand structural inequities, who often experience social ex-clusion. Having a meaningful focus and daily routine isparticularly relevant for patients who are homeless orliving in shelters, or who are unemployed or unable tobe employed due to persistent chronic physical or men-tal illness, or substance use issues. At both Centres, forexample, patients are periodically hired on a part-timebasis (according to the availability of funds) to assistwith peer support activities, focus groups, and women’sor men’s wellness programs. In one of the Centres, re-search funds for a self-management HIV program wereused to hire patients as peer interviewers and researchassistants. Patients often expressed a sense of ownershipand responsibility in relation to ‘their’ Centre. In manycases, patients who used the Centres regularly played arole in shaping the physical and social milieu by volun-tarily making coffee and replenishing supplies in thewaiting areas, voluntarily helping with janitorial or main-tenance tasks, and offering suggestions for how to makethe physical space safer and more welcoming for womenand children. Engaging in meaningful work-related activ-ities through volunteer and temporary or occasional em-ployment opportunities can be health promoting byenhancing people’s sense of self-efficacy, self-worth, andcapacity to manage their health [55], as this patientdescribed:[I have] a paid position where I’m on call [forjanitorial work]. And that helped me, kept me busy.It kept me from locking myself up and gettingdepressed. . .I’ve got something, like I’m doingsomething and I’m being responsible. . .If I didn’t havethe volunteering I would have been lost. . .I wouldhave just given up. . .Pay didn’t matter. It was justsomewhere to go and know that I was needed, that’swhat I needed, that’s kept me going.Given the significance of participatory engagement,PHC organizations are well-justified in seeking or allo-cating funds to support volunteers or peer supportworkers. It is equally critical for PHC organizations toseek the input of patients at regular intervals so thattheir feedback is part of quality assurance, and to remainaccountable to both local community and patient repre-sentatives by ensuring that the organization is welcom-ing and responsive to local populations. Organizationscan build such approaches through policy. For example,one Centre requires that research conducted there in-clude meaningful patient consultation and involvementin the research process, including employment (e.g., asresearch assistants or facilitators) when possible.8. Tailor care, programs and services to the populations’individual and group histories, with an emphasis ontrauma- and violence-informed careThis strategy is based on the premise that it is criticalto tailor programs and services to people’s individual andgroup histories. Because trauma and violence are inter-twined with inequities, recognizing the significance ofpeople’s histories means that PHC services must takeinto account the fact that most people affected by sys-temic inequities and structural violence have experiencedvarying forms of trauma. Additionally, because peoplewith trauma histories often experience mistrust, buildingtrust is critical to sustaining connections and a sense ofpersonal safety in PHC [56]. As this patient elaborated:We’re not just a number. . .That’s life saving, lifechanging, literally it’s that valuable, it’s life changingbecause when I was out there [on the street] it wasBrowne et al. International Journal for Equity in Health 2012, 11:59 Page 10 of 15http://www.equityhealthj.com/content/11/1/59not good. It was always for something, you know, youwere selling your body or you’re giving up a piece ofyourself daily. And then to have somebody want to dosomething for you, just to help you, like oh my god. . ..It gives you a whole new perspective, it really helps.Trauma- and violence-informed care is not about elicit-ing trauma histories; it is about creating a safe environ-ment based on an understanding of the effects of trauma,so that health care encounters are safe, affirming and val-idating [24,29]. For example, PHC organizations servinghigh numbers of Aboriginal patients must recognize thatmany people have experienced the inter-generationaleffects of systemic and individual discrimination and ra-cism, which can be conceptualized as one feature of his-torical trauma [21,22,57]. This conceptualization oftrauma has implications for other groups of people, forexample, refugees and in some contexts, new immi-grants. In PHC contexts, such services are constituted byrespectful, empowerment practices, not ‘trauma treat-ment’ such as psychotherapy (though referrals may bemade for specific trauma therapy). For example, in recog-nition of the devaluing of Aboriginal culture as a resultof Canada’s colonial history, one of the Centres featuredsignage in a local Indigenous dialect to convey a valuingof Aboriginal identity; in the other, a residential schoolhealing program was implemented to support patientsand their families.The effects of trauma often are manifested in healthand behavioural issues that initially appear to be unre-lated [24]. Interpersonal violence experienced by women,for instance, is associated with acute and chronic issuessuch as: chronic pain (e.g., headache, migraine, backpain, pelvic pain, inflammatory bowel disease), arthritis,hypertension, higher rates of mental health problems,higher rates of substance use and dependence, andsymptoms consistent with posttraumatic stress disorder(PTSD) [25,58]. Because these are common healthissues, health services may fall short in integratingunderstandings of the long-term impact of trauma, andinadvertently fail to create an environment that validatespatient experiences [24,25,30]. Trauma and violence-informed care, therefore, requires that PHC organiza-tions integrate comprehensive and continuing educationfor all staff (including receptionists, direct care providersand management) about the health effects of trauma andthe principles of trauma- and violence-informed care[59], and about strategies for actively minimizing the riskof re-traumatization in the everyday provision of ser-vices, as one health care provider explains:So, [in case conferences and team meetings] we talkabout. . .the level of trauma that this person comesfrom. . .Or how difficult it is for that person to walkthrough that door. . .Or how difficult it was for thatperson to actually bring up their concern toyou. . .getting into conversations around our tableabout power imbalances and about how ourinteractions [with patients] can really affect this.Equally critical are supports for staff who may be deal-ing with vicarious trauma when working with patientpopulations who have significant trauma histories. Asdescribed by one health care provider:She [was] a staff member that was not only in moraldistress from what she was seeing in this communityand taking it on but from also never resolving herown background trauma and seeing how it triggeredher to work with the clients. . .but not having anemployee assistance program [EAP] to refer her tofor counseling [was hard]. . .I’ve lost about twenty[staff]. . .I’ve lost them. . .when they couldn’t take thestress. . .we don’t have any type of psychology servicesor EAP. . .Thus, tailoring and an emphasis on trauma- andviolence-informed care must take into account theeffects of working with highly traumatized patients,and as identified in strategy two, funding must beavailable to provide staff with adequate support. Giventhe correlation between trauma and all forms of in-equity, trauma- and violence-informed care is alsoclosely related to strategies to address social determi-nants of health.9. Enhance access to resources that address the socialdeterminants of health with an emphasis onadvocacy and inter-sectoral collaborationsAddressing the social determinants of health isrecognized as essential to PHC [7,38,39,40,60]; there-fore, this strategy involves explicitly working to addressthese issues as legitimate and routine aspects of healthcare, often as the main priority. Maintaining or im-proving health is dependent on access to adequate safehousing, adequate nutrition, and meaningful activities.For example, mental health or well-being (especially inthe face of PTSD and depression associated with allforms of trauma) is challenging to achieve in the con-text of inadequate social housing rife with rodent or in-sect infestations; physical health is challenging toachieve without a place to refrigerate food or medica-tions [61]. At the individual level, this involves workingwith patients to facilitate access to social housing,food, and clothing, or supporting efforts toward paidemployment. Our data repeatedly documented the im-pact of addressing people’s social needs as fundamentalBrowne et al. International Journal for Equity in Health 2012, 11:59 Page 11 of 15http://www.equityhealthj.com/content/11/1/59to maintaining or improving health, as this patientdescribed:I got the subsidy from them [the nurse and socialworker at the Centre] for housing and I got the kidsback now. . .I knew that I wanted to go to rehab [toaddress substance use issues]. I’ve been thinking aboutit for a whole year since I got the subsidy. . .That reallymade me look in the mirror at myself. . .[The subsidy]is like winning a lottery to me. . .[With] the subsidy, Ithought, I’ve really got to smarten up, pull up my socksand start really watching the company I keep and startgetting my life on track. And it’s getting there. . ..Fostering connections with individuals, groups andresources is critical, because many people experiencingmarginalization are disconnected from their families orhome communities by policies, poverty and violence.Supporting connections to possible employment is criticalbecause most people served cannot afford phones orcomputers, and thus have no way of being contacted.At the organizational level, addressing this strategyinvolves leaders and staff within PHC agencies taking onadvocacy roles and inter-sectoral collaboration in theirwider communities to influence policies, such as work-ing with housing organizations to maximize the avail-ability of social housing; working with child welfareauthorities to increase parents’ access to children andvisitation rights; looking at ways to mitigate the rootcauses of homelessness; or advocating for more servicesfor people with mental health problems. This attentionto socio-political and economic environments must beextended to more immediate social and physicalenvironments.10. Optimize use of place/space to meet the needs ofclient populationsIncreasingly, the socio-spatial environments of healthcare are being conceptualized as relational spaces that canbe intentionally designed to support people’s subjectivitiesand experiences [62]. The notion of ‘therapeutic environ-ments’ highlights the ways that socio-spatial environmentscan be transformed to foster people’s sense of agency andentitlement (or deservedness) when seeking PHC services.This has significant implications for patient-populationswho experience discrimination and social exclusion intheir everyday lives. A patient explained:They make you feel welcome and they know you byname. And that means something to you, likesomebody knows me, and it just makes me feel like acertain kind of pride inside you – like who you areand where you come from.At the organizational level, this could translate into anagency’s commitment to create a low barrier and accept-ing environment, as a receptionist described:They come in and they’re cold and we welcome themwith a warm coffee, and tell them they’re welcome tosit and chat, and sort of see how they are doing,where they slept, if they slept.This contrasts with the atmosphere in conventionalwaiting rooms, as described by a physician:You know what [typical] waiting rooms feel like. . .thatquietness, and contained-ness. . .Everybody sits intheir little world. That is so foreign to our clients thatthey feel really out of place.Essential to creating a therapeutic space are receptionstaff who play an active role in setting the tone in waitingrooms, during phone interactions, and during informalconversations with patients. This has implications for thekinds of training that staff receive, and requires their ac-tive involvement within organizational and decision-making structures. Creating supportive social spaceswithin PHC settings can involve, for example, havingphones available for patients, a computer with internetaccess, and freely available coffee and tea. To fully addressa population’s needs, providers may need to extend theirinfluence beyond the boundaries of the physical PHCspace by providing care in other spaces (i.e., shelters, peo-ple’s homes, single-room occupancy hotels, outreach ser-vices on the streets, etc.). Building on earlier strategies,patients can be integral partners in planning and creatingsuch spaces and outreach processes.In summary, these findings are based on a rigorousanalysis of a large set of ethnographic data as the foun-dation for identifying the essential elements of equity-oriented PHC services when working with marginalizedpatient-populations, and will have broad application to awide range of settings, contexts and jurisdictions. Onelimitation of this study is that the data collected werebased on research conducted in only two PHC Centresin Canada. As well, the findings reflect team-based careas the primary mechanism for delivery of PHC services,and salaried versus fee-for-service compensation ar-rangements for physicians and other staff. Further re-search will be needed to examine the relevance andoperationalization of these key dimensions and strategieswhen other models of service delivery are used, and inother jurisdictions and national contexts.ConclusionsA commitment to equity and social justice in PHCrequires recognition of the particular health and socialBrowne et al. International Journal for Equity in Health 2012, 11:59 Page 12 of 15http://www.equityhealthj.com/content/11/1/59needs of people subject to systematic discriminationand relatively little power [63]. If the PHC sector is tobecome optimally relevant as a site for populationhealth interventions, PHC organizations will need toprioritize locally-relevant strategies that are explicitlyoriented to working with these groups, where it isexpected that the greatest gains can be achieved.If equity-oriented PHC organizations are to flourish, theywill require support by inter-sectoral government policiesand flexible funding models that recognize the essential roleof community-based organizations in fostering healthequity. The four key dimensions and 10 strategies for en-hancing capacity for equity-oriented PHC services are im-portant to hold out as ideals, given the persistence andincreasing levels of health and health care inequities acrosspopulation groups in Canada and other nations.Recognizing that a wide range of models are currentlyused to address the health needs of vulnerable popula-tions, consideration needs to be given to which aspects ofthe framework outlined in Figure 1 will be most relevantand feasible in particular contexts. The four key dimen-sions of equity-oriented PHC services are broad enoughto be relevant as principles for guiding organizations andindividual clinicians in primary care practices. Eachorganization, agency or practice can prioritize their start-ing point, given that the 10 strategies can be implemen-ted incrementally, and in seemingly ‘small’ ways that donot require additional costs. For example, even at an in-dividual physician’s practice, changing the manner withwhich receptionists answer phone calls or scheduleappointments can have powerful effects on patients; insome settings, that kind of adjustment will signify thatefforts are being made to counter the ongoing dismissalthat many patients experience, thus addressing strategysix. Finding ways to address any aspect of the 10 strat-egies will have a synergistic and compounding effectbecause they overlap and intersect. The 10 strategiesalso can serve as a stimulus, for example, for develop-ing new inter-sectoral collaborations; arguing for differ-ent funding models; expanding one’s referral patterns(e.g., to social service agencies, trauma-counsellors,etc.); and engaging in advocacy work or communityservice activities. Although some of the strategies mayseem to run counter to dominant trends in health carethat emphasize the rapid processing of patients, our re-search shows that if marginalized populations are to beserved effectively, radically different approaches arerequired and can be legitimized as more efficient.These strategies also have the potential to positively in-fluence PHC services more widely because by enhan-cing equity-competence for marginalized populations,improvements in PHC service delivery can be realizedfor all populations. Contrary to dominant rhetoricabout efficiencies in health care, our data show thatequity-based strategies can result in improved healthoutcomes and quality of life; the next step in researchwill be to link these strategies to quantifiable processand outcome measures.Endnotesa In Canada, the term ‘Aboriginal people’ is used gen-erally to refer to Indigenous groups comprising FirstNations, Métis and Inuit peoples [64]. These threegroups reflect ‘organic political and cultural entities thatstem historically from the original peoples of NorthAmerica, rather than collections of individuals united byso-called ‘racial’ characteristics’ [64](p. xii).b PHC is conceptualized as the principal vehicle forthe delivery of health care at the most local level of acountry's health system, and is the first level of contactfor individuals, families and communities, constitutingthe first element of a continuing health care process.The World Health Organization (WHO) claims thatPHC embodies the principles of universal access, equity,and social justice [6,7]. Further, the WHO claims that ef-fectively operationalizing PHC reform necessitatesachieving universal access and social protection so as toimprove health equity; reorganizing service deliveryaround people’s needs and expectations; securing health-ier communities through better public policies; and re-modeling leadership for health around more effectivegovernment and the active participation of key stake-holders. Implementing PHC is therefore foundational toaddressing inequities, yet little progress has been madeto date in actualizing that implementation.c Health equity is defined as the absence of systematicand potentially remediable differences in one or morecharacteristics of health across populations or popula-tion groups defined socially, economically, demographic-ally, or geographically [7,11].d In Canada, "visible minority" refers to persons whoare identified according to Canada’s Employment EquityAct “as being non-Caucasian...or non-white in colour.Under the Act, Aboriginal persons are not considered tobe members of visible minority groups” [47].Competing interestsThe authors have no competing interests to declare.Authors’ contributionsAJB, CMV, STW, VLS, JL, DL, DT, OG, MK, JO and PR conceived of the study.AJB, CMV, STW, VLS, & JL led all aspects of data collection, literature reviews,and collaboration with our clinical partners, and developed the initial draft ofthis manuscript. All authors participated in the analysis and interpretation ofthe results, and read and approved the final manuscript.Financial disclosureThis research was generously funded by the Canadian Institutes of HealthResearch Grant #173182. The funders had no role in study design, datacollection and analysis, decision to publish, or preparation of the manuscript.Browne et al. International Journal for Equity in Health 2012, 11:59 Page 13 of 15http://www.equityhealthj.com/content/11/1/59AcknowledgmentsOur research team thanks the patients and staff at the PHC Centres for theirgenerous contributions to the analytical insights and framework reflected inthis manuscript. Thank you goes to Dr. Koushambhi Khan for her exemplaryleadership as our Research Manager, Alycia Fridkin and Jacqueline Denison,our Graduate Research Assistants, and to Phoebe Long and Joyce Lui fortheir careful editorial work in preparing the manuscript.Author details1University of British Columbia, School of Nursing, T201 – 2211 WesbrookMall, Vancouver, British Columbia V6T 2B5, Canada. 2University of NorthernBritish Columbia, School of Health Sciences, 3333 University Way, PrinceGeorge, British Columbia, Canada. 3Vancouver Native Health Society, 440 EastHastings Street, Vancouver, British Columbia, Canada. 4Prince George Divisionof Family Practice, Prince George, British Columbia, Canada. 5Central InteriorNative Health Society, 1140 4th Avenue, Prince George, British Columbia,Canada. 6Simon Fraser University, Faculty of Health Sciences, 8888 UniversityDrive, Burnaby, British Columbia, Canada. 7University of British ColumbiaCentre for Health Services and Policy Research, 201-2206 East Mal,Vancouver, British Columbia, Canada.Received: 20 March 2012 Accepted: 6 October 2012Published: 13 October 2012References1. 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Ottawa: RoyalCommission on Aboriginal Peoples; 1996.doi:10.1186/1475-9276-11-59Cite this article as: Browne et al.: Closing the health equity gap:evidence-based strategies for primary health care organizations.International Journal for Equity in Health 2012 11:59.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/submitBrowne et al. International Journal for Equity in Health 2012, 11:59 Page 15 of 15http://www.equityhealthj.com/content/11/1/59

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