Table 1. Core set of Health Equity Indicators for PHC Organizations After Modified Delphi Consultation.
Original Indicator | Round 1 Mean (SD) | Round 2 Mean (SD) | Final Indicator | Relevant Key Dimensions of Equity-Oriented PHC Services | Potential Data Source | |
Practice/Clinic Context | ||||||
1. | Funding is allocated to support ongoing training (including orientation) of all staff re: (a) cultural competence as it applies to the local context (b) inequity-responsive care (e.g. social determinants of health), (c) trauma-informed care | 8.3 (1.2) Modified | 8.2 (1.3) | Provide ongoing training for all staff to support achieving the clinic's mandate to promote equity | Inequity-responsive care, Contextually-tailored care, Culturally-safe care, Trauma/violence-informed care | Organizational Survey |
2. | All team members are working to full scope of practice | 8.3 (0.9) Same | 8.2 (1.2) | Ensure staff work to their full scope of practice to optimize the clinic's capacity to provide equity-oriented care or services | Inequity-responsive care, Culturally-safe care | Staff Survey, Organizational Survey |
3. | Vision/mission statement acknowledges that addressing inequity, trauma, and cultural competence are explicit mandates | 7.8 (1.8) Modified | 8.1 (1.3) | Include an explicit statement regarding commitment to foster health equity in Vision and Mission Statements | Inequity-responsive care, Trauma/violence-informed care, Culturally-safe care | Organizational Survey |
4. | Funding is allocated for programs or strategies to support staff who work with populations with high prevalence of trauma | 8.0 (1.1) Modified | 8.1 (1.1) | Provide strategies to support staff to deal with the emotional impact of working with patients who experience trauma including interpersonal and structural forms of violence1 | Trauma/violence-informed care | Organizational Survey, Staff Survey, Reflexive practice/self-assessment, Peer review |
Treatment/Processes of Care/Outputs | ||||||
5. | Staff demonstrate culturally safe care (checking assumptions, taking historical context into consideration, acknowledging and addressing context such as language, religion, spirituality) | 8.4 (1.0) Same | 8.4 (1.1) | Provide culturally safe care and practices as evidenced by, for example, staff questioning their assumptions about ‘culture’, taking sociopolitical and historical contexts into consideration, acknowledging and addressing contexts such as language, religion, sexual orientation, age, geography, spirituality, etc | Culturally-safe care | Observational Survey, Staff Survey, Reflexive practice/self-assessment, Peer review |
6. | Patients report experiencing increased trust in provider and respectful relations | 8.5 (0.7) Modified | 8.4 (1.0) | Assess patients' level of trust in staff | Inequity-responsive care, Culturally-safe care, Trauma/violence-informed care | Patient Survey |
7. | Interprofessional collaboration is a routine part of the services and care provided | 8.1 (1.0) Same | 8.3 (1.2) | Engage in interprofessional collaboration as a routine aspect of care and services provided | Inequity-responsive care, Contextually-tailored care | Organizational Survey, Staff Survey |
8. | Services at the clinic support patients' access to various types of social assistance services (e.g. income, housing, food assistance, residential school programs, disability) | 8.5 (0.9) Modified | 8.2 (1.1) | Engage and coordinate with community services, and government and non-governmental organizations, in planning and providing care for patients, including for example: Housing services; Social welfare services; Child welfare services and support services for parents; Counseling services for trauma or other mental health issues; Services for substance use issues; Elders, traditional healers, Aboriginal support workers; Acupuncturists or physiotherapists, if needed | Inequity-responsive care, Contextually-tailored care | Organizational Survey |
9. | Intersectoral advocacy activities occur such as educational collaborative activities with other health agencies/institutes such as hospitals | 7.7 (1.1) Modified | 8.2 (1.0) | Engage and collaborate with other health departments, organizations and social service agencies regarding how to tailor services, programs and approaches to better meet the needs of marginalized populations (e.g., with emergency departments, pharmacies, hospital units, walk in clinics, shelters, etc.) | Inequity-responsive care, Contextually-tailored care | Organizational Survey, Staff Survey, External partner survey (e.g. ministry stakeholders) |
10. | Systems are in place to identify and follow up with patients who are at risk of “falling through the cracks” (e.g., patients who repeatedly miss appointments, or who don't follow through referrals, or who don't come in to pick up their meds, etc.) | 8.5 (0.9) Same | 8.1 (1.2) | Create processes to identify and follow-up with patients who are at risk of “falling through the cracks” (e.g., patients who repeatedly miss appointments or do not follow through referrals, etc.) | Inequity-responsive care, Contextually tailored care, | Organizational Survey |
11. | Services and programs are available and tailored to meet the health and healthcare needs of the local populations served, for example: outreach and homecare services; in-patient visits; meal programs; child care; assistance with transportation; gender-specific services such as women's groups; trauma-specific services; assistance with accessing housing, income and food | 8.3 (1.0) Same | 8.1 (1.0) | Tailor services and programs to meet the health and healthcare needs of local populations served. (e.g., outreach services; in-patient visits; assistance with child care; assistance with transportation; gender-specific services such as women's or men's groups; trauma-specific services; assistance with accessing housing, income and food) | Inequity-responsive care, Contextually-tailored care, Culturally-safe care | Organizational Survey |
12. | All staff demonstrate reflexive practice | 8.3 (1.0) Modified | 8.1 (1.2) | Regularly examine how staff members' verbal and non-verbal interactions impact patients | Inequity-responsive care, Culturally-safe care, Trauma/violence-informed care | Staff Survey, Reflexive practice/self-assessment, Peer review |
13. | Regular team meetings involve all staff to address complex health and healthcare issues | 8.3 (1.3) Modified | 8.0 (1.2) | Develop mechanisms to integrate input from all staff members to address patients' complex health and health care issues (e.g., team meetings, case conferences, care teams) | Inequity-responsive care Contextually-tailored care, Culturally-safe care, Trauma/violence-informed care | Organizational Survey |
Treatment Outcomes/Immediate Outcomes of PHC | ||||||
14. | Patients report improved quality of life | 8.4 (0.9) Modified | 8.3 (1.0) | Assess levels of improvements in patients' quality of life (as a result of receiving care at the clinic) | Inequity-responsive care | Patient Survey, Patient Interviews |
15. | Providers have increased knowledge and skills in working with the health effects of trauma and related symptoms | 8.3 (0.9) Modified | 8.2 (1.0) | Provide ongoing training on (a) the health effects of trauma, violence and related symptoms, and (b) the development of knowledge, skills, and confidence to work with patients affected by trauma and violence | Trauma/violence-informed care | Organizational Survey, Staff Survey |
16. | The clinic is able to track whether the patient-population has fewer unmet health care needs | 8.0 (1.3) Modified | 8.2 (1.1) | Assess whether patients report that they health and healthcare needs have been met | Inequity-responsive care, Culturally-safe care, Trauma/violence-informed care | Patient surveys, Patient Interviews |
17. | Patient “activation” is monitored | 8.3 (0.8) Modified | 7.6 (1.3) | Assess patients' levels of confidence in managing their health and health care needs (e.g., asking staff for help, making appointments, following through with appointments, etc.) | Inequity-responsive care, Contextually-tailored care | Patient survey, Patient Interviews |
Note. Participants rated the importance of each indicator on a 9-point scale where 1 = not important and 9 = very important. A higher score = more importance. Indicators were modified or kept the same between Round 1 and Round 2.
Trauma- and violence-informed care is a relative new concept in most health sectors, despite evidence confirming the high rates of trauma and violence experienced by people experiencing the negative health effects of health, social and structural inequities. Trauma- and violence informed care requires all staff in an organization, including receptionists to direct care providers and management, to understand the intersecting health effects of trauma, structural and individual violence, and other forms of inequity, so that health care encounters are affirming, and the possibility of re-traumatization is reduced. Trauma- and violence informed care is not about eliciting trauma histories; rather it is about creating a safe environment based on an understanding of trauma effects.