Closing the health equity gap: evidence-based strategies for primary health care organizations
Closing the health equity gap: evidence-based strategies for primary health care organizations
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DOI：
10.1186/1475-9276-11-59
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发表时间：
2012-10-13
影响因子：
4.8
通讯作者：
Lennox, Scott
中科院分区：
文献类型：
--
作者：
Browne, Annette J.;Varcoe, Colleen M.;Lennox, Scott
导言：国际证据表明，加强对弱势群体的初级卫生保健(PHC)服务对于减少卫生和卫生保健不平等至关重要。然而，关于如何在组织一级加强公共卫生部门内部的公平，人们知之甚少。本文通过对加拿大两个为边缘人群提供服务的PHC中心的研究，探讨了(A)面向公平的服务以指导PHC组织的关键维度，以及(B)面向公平的PHC服务的运作策略，特别是针对边缘人群。数据收集采用人种志设计的混合方法，包括：(A)对114名参与者(73名患者；41名工作人员)的深入访谈；(B)超过900小时的参与者观察；以及(C)对关键组织文件的分析，这些文件揭示了政策和资金环境。结果：通过我们的分析，我们确定了面向公平的PHC服务的四个关键维度：不平等反应护理；创伤和暴力知情护理；根据具体情况量身定做的护理；以及符合文化能力的护理。这些关键方面的运作被确定为10个相互交叉的战略，以优化PHC服务的有效性，特别是通过改善护理质量、改善人们的需求和服务之间的“匹配”、加强患者的信任和参与，以及从以危机为导向的护理向连续性护理的转变。使用数据中的说明性例子，这些策略被讨论以阐明它们在三个相互关联的层面上的相关性：组织、临床规划和患者-提供者互动。结论：这些基于证据和理论的关键维度和策略为PHC组织提供了方向，旨在纠正人口群体中日益严重的健康和医疗保健不平等。研究结果提供了一个框架，用于在与边缘化人口合作时构思和实施面向公平的初级保健服务的基本要素，并将广泛应用于各种环境、背景和司法管辖区。未来需要进行研究，将这些战略与可量化的过程和结果衡量标准联系起来，并测试它们在不同的PHC环境中的影响。
Introduction: International evidence shows that enhancement of primary health care (PHC) services for disadvantaged populations is essential to reducing health and health care inequities. However, little is known about how to enhance equity at the organizational level within the PHC sector. Drawing on research conducted at two PHC Centres in Canada whose explicit mandates are to provide services to marginalized populations, the purpose of this paper is to discuss (a) the key dimensions of equity-oriented services to guide PHC organizations, and (b) strategies for operationalizing equity-oriented PHC services, particularly for marginalized populations.Methods: The PHC Centres are located in two cities within urban neighborhoods recognized as among the poorest in Canada. Using a mixed methods ethnographic design, data were collected through intensive immersion in the Centres, and included: (a) in-depth interviews with a total of 114 participants (73 patients; 41 staff), (b) over 900 hours of participant observation, and (c) an analysis of key organizational documents, which shed light on the policy and funding environments.Results: Through our analysis, we identified four key dimensions of equity-oriented PHC services: inequity-responsive care; trauma-and violence-informed care; contextually-tailored care; and culturally-competent care. The operationalization of these key dimensions are identified as 10 strategies that intersect to optimize the effectiveness of PHC services, particularly through improvements in the quality of care, an improved 'fit' between people's needs and services, enhanced trust and engagement by patients, and a shift from crisis-oriented care to continuity of care. Using illustrative examples from the data, these strategies are discussed to illuminate their relevance at three inter-related levels: organizational, clinical programming, and patient-provider interactions.Conclusions: These evidence-and theoretically-informed key dimensions and strategies provide direction for PHC organizations aiming to redress the increasing levels of health and health care inequities across population groups. The findings provide a framework for conceptualizing and operationalizing the essential elements of equity-oriented PHC services when working with marginalized populations, and will have broad application to a wide range of settings, contexts and jurisdictions. Future research is needed to link these strategies to quantifiable process and outcome measures, and to test their impact in diverse PHC settings.