How Equity-Oriented Health Care Affects Health: Key Mechanisms and Implications for Primary Health Care Practice and Policy.
How Equity-Oriented Health Care Affects Health: Key Mechanisms and Implications for Primary Health Care Practice and Policy.
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DOI：
10.1111/1468-0009.12349
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发表时间：
2018-12
期刊：
影响因子：
--
通讯作者：
Browne For The Equip Research Program AJ
中科院分区：
文献类型：
--
作者：
Ford-Gilboe M;Wathen CN;Varcoe C;Herbert C;Jackson BE;Lavoie JG;Pauly BB;Perrin NA;Smye V;Wallace B;Wong ST;Browne For The Equip Research Program AJ
关于需要引导卫生系统解决不平等问题的共识正在形成，其中大部分讨论针对人口卫生干预措施和指标。我们对将这些方法应用于初级卫生保健知之甚少。本研究实证表明，在初级卫生保健中提供更多以公平为导向的卫生保健（EOHC），包括了解创伤和暴力、文化安全以及根据具体情况量身定制的护理，可以预测生活在边缘化条件下的人们长期改善的健康状况。这是通过增强患者对其护理的舒适和信心以及他们自己对预防和管理健康问题的信心来实现的。这一有希望的新证据表明，在护理点上以公平为导向的干预措施可以开始改变那些最需要的人在卫生结果方面的不平等。人们对解决人口健康和系统层面的卫生不公平现象给予了极大的关注，但在确定通过临床护理减少卫生不平等现象的方法方面，特别是在初级卫生保健方面，进展甚微。虽然人们普遍认为公平导向的医疗保健（EOHC）可以改善患者的健康状况，但很少有经验证据支持这一说法。为了解决这个问题，我们测试了更多的EOHC是否预示着更积极的患者健康结果，并确定了这种关系的选定中介。我们的分析使用了从4个初级卫生保健诊所招募的395名患者的纵向数据，这些诊所为生活在边缘化条件下的人提供服务。参与者在2年的时间里完成了4次结构化访谈，包括自我报告和调查问题。利用通径分析技术，我们测试了一个假设的过程模型，通过该过程，患者对EOHC的感知导致自我报告的健康结果（生活质量、慢性疼痛残疾、创伤后应激障碍和抑郁症状）的改善，包括健康结果的特定协变量（年龄、性别、经济压力、歧视经历）。在24个月的时间里，较高的EOHC水平预示着患者对所接受的医疗保健的舒适度和信心，从而增加了预防和管理健康问题的信心，进而改善了健康结果（抑郁症状、创伤后应激障碍症状、慢性疼痛和生活质量）。此外，经济压力和遭受歧视的经历对所有健康结果都产生了重大的负面影响。这项研究是第一个从经验上证明，随着时间的推移，提供更多的EOHC可以预测更好的患者健康结果的研究。在政策层面，本研究支持在以公平为重点的组织和提供者层面的初级卫生保健过程中进行投资，以此作为改善患者健康的一种手段，特别是那些生活在边缘化条件下的患者。这些结果是否在不同的患者群体和更广泛的卫生保健环境中是可靠的，需要进一步研究。
A consensus regarding the need to orient health systems to address inequities is emerging, with much of this discussion targeting population health interventions and indicators. We know less about applying these approaches to primary health care. This study empirically demonstrates that providing more equity‐oriented health care (EOHC) in primary health care, including trauma‐ and violence‐informed, culturally safe, and contextually tailored care, predicts improved health outcomes across time for people living in marginalizing conditions. This is achieved by enhancing patients’ comfort and confidence in their care and their own confidence in preventing and managing health problems. This promising new evidence suggests that equity‐oriented interventions at the point of care can begin to shift inequities in health outcomes for those with the greatest need. Significant attention has been directed toward addressing health inequities at the population health and systems levels, yet little progress has been made in identifying approaches to reduce health inequities through clinical care, particularly in a primary health care context. Although the provision of equity‐oriented health care (EOHC) is widely assumed to lead to improvements in patients’ health outcomes, little empirical evidence supports this claim. To remedy this, we tested whether more EOHC predicts more positive patient health outcomes and identified selected mediators of this relationship. Our analysis uses longitudinal data from 395 patients recruited from 4 primary health care clinics serving people living in marginalizing conditions. The participants completed 4 structured interviews composed of self‐report measures and survey questions over a 2‐year period. Using path analysis techniques, we tested a hypothesized model of the process through which patients’ perceptions of EOHC led to improvements in self‐reported health outcomes (quality of life, chronic pain disability, and posttraumatic stress [PTSD] and depressive symptoms), including particular covariates of health outcomes (age, gender, financial strain, experiences of discrimination). Over a 24‐month period, higher levels of EOHC predicted greater patient comfort and confidence in the health care patients received, leading to increased confidence to prevent and manage their health problems, which, in turn, improved health outcomes (depressive symptoms, PTSD symptoms, chronic pain, and quality of life). In addition, financial strain and experiences of discrimination had significant negative effects on all health outcomes. This study is among the first to demonstrate empirically that providing more EOHC predicts better patient health outcomes over time. At a policy level, this research supports investments in equity‐focused organizational and provider‐level processes in primary health care as a means of improving patients’ health, particularly for those living in marginalizing conditions. Whether these results are robust in different patient groups and across a broader range of health care contexts requires further study.
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