Conceptually, the four key dimensions provide a framework for understanding the essential elements of equity-oriented PHC services when working with marginalized populations. The dimensions are interrelated and overlapping, and include:
The operationalization of these key dimensions is identified in this paper as strategies that intersect to optimize the effectiveness of 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 [37, 41]. As shown in Figure 1, both patients and providers directly linked these specific strategies to short-term outcomes such as an increase in patients’ capacities to manage their own health, and increased access to resources essential to support health. Both also identified longer-term improvements in health and quality of life, with the potential for reducing health inequities at the population level. These 10 overlapping strategies are discussed below to illustrate their relevance at three inter-related levels: organizational, clinical programming, and patient-provider interactions. These are proposed as principles of equity-oriented services, recognizing that PHC organizations, agencies and practices will have to tailor the extent to which they can implement each strategy in their local context.
Ten strategies to guide organizations in enhancing capacity for equity-oriented services
Explicitly articulate the commitment to equity in the mission, vision and other organizational policy statements
When PHC organizations acknowledge the impact of health and social inequities on health, illness and access to health care, the possibility of organizing and delivering services that foster equity for vulnerable patients and populations is promoted. Key to positioning equity as an explicit mandate is the articulation of related commitments in governance, mission statements, and organizational-level policy statements. This requires strong leadership within the organization, and the continual reflection of mission statements in job postings, staff orientations, staff performance reviews, and related documents and activities. The activities of the organizational leaders are important in reinforcing the organization’s commitment to equity, including for example, the kinds of advocacy and social justice or policy work that leaders engage in within the wider community. One of the Centres’ administrative leaders commented:
"Trying to articulate what our mission and vision and values are….I mean it’s a big piece of work. So you don’t just ignore it once you’ve produced the document. We agonized over those. So we darn well better make sure it’s entrenched in what we do."
At the organizational level, hiring practices need to ensure a match between staff and the organization values, philosophy, and the approaches to care that represent the operationalization of the mission statement. Declaring an organizational commitment to fostering equity can contribute to solidifying an organization’s identity and can serve to attract employees who share similar values regarding PHC and social justice, as noted by this physician: “it’s not a hidden agenda – it’s right out there…it’s part of what you’re getting into.” Working within a PHC organization distinguished by an explicit, organizational commitment to equity can represent a defining feature of practice for direct service providers, as this staff member discussed:
"I think to have it [a commitment to equity] as a shared value is very central to what we do…That’s what’s different, if you’ve ever worked anywhere where people don’t really talk about these things, never mind work on them and try to make it a central core."
At the level of direct clinical care, mission and vision statements also provide a sense of perspective and purpose when progress toward achieving improved health for particular patient-groups is slow or ostensibly backsliding, 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’s the ninth time you’ve seen them in a month and you’re not getting anywhere. She or he [the organizational leader] is a person who can take you back to the vision and can take you back to, you know, how to see the bigger picture."
Commitments to equity, however, cannot be enacted and will not be sustainable without supportive funding and policy environments.
Develop and advocate for structures, policies, and processes to support the enactment of equity
Funding and policy environments that are supportive of equity-oriented aims are needed. This means that leaders must develop appropriate structures, policies and processes within their organizations and advocate within larger contexts for the conditions necessary to achieve these aims. Within the Centres, leaders created an organizational culture that supported interdisciplinary team meetings and the active participation of all team members in planning care, programs, and case management. These activities need to be supported by stable funding arrangements to enhance the ability of the organization to enact a philosophical commitment to equity, and by social policy that enhances access to social determinants of health. Thus, Centre leaders were active at local community, city, provincial and federal levels advocating for adequate social housing, better access to income supports, and allocation of health care funding within their own and other health care organizations (to support, for example, methadone programs and other harm reduction activities).
Efforts to create conditions to support the enactment of equity were also influenced by factors beyond the Centres. For example, leaders negotiated for physicians to be paid by salary rather than fee-for-service to enable their participation beyond direct patient care in interdisciplinary meetings and case conferences; however, such meetings were constantly under threat due to fiscal pressures and questions raised by funders about how clinical staff were using time – pressures that varied with the degree of independence each Centre had in relation to their funding bodies. The Centres varied in the extent to which their contractual funding arrangements permitted them to enact the strategies of equity-oriented care. For example, block-funding arrangements with longer terms permitted greater flexibility at one Centre, whereas at the other, year-to-year and fragmented funding and chronic underfunding limited the range of services in place to address the complexities associated with violence, poverty, homelessness, or substance use. Funding is also needed to provide counselling or debriefing for staff who are dealing with the vicarious effects of structural violence and trauma, as discussed further in strategy eight. A manager explained:
"[Our funders were]…micro managing…telling you what your priorities were going to be…telling us almost on a day-to-day or week-to-week basis what you’re going to be doing with your time and those kinds of things. We just kind of said, “No! No, that’s not the way it works.” And to some extent that worked. But they still control the purse strings and as such they still have a lot of kind of ‘leverage over’ – because they can always say, if you’re not going to behave the way we want you to, we’ll find another agency that will."
Importantly, funding arrangements varied in terms of how professional time could be flexibly deployed, for instance, for patient care, team meetings and collaborative case management. Revisioning the use of time was a critical strategy.
Revision use of time to meet the needs of client populations
Time and its use are crucial considerations, in terms of expectations regarding ‘how long’ it should take to see health improvements, and how providers use time. Working with populations whose health is so closely linked with social and economic conditions can seem slow or stagnant with respect to improvements in short- and long-term outcomes. Rather than constructing patients as ‘non-compliant’ or as failing to achieve goals, the Centre’s providers recognized how broader contexts influenced people’s health trajectories and decisions. The collective expertise of staff and interdisciplinary teams was used to determine when to support or ‘push’ patients to go a step further in moving toward their potential. This was particularly evident in relation to substance use and addictions issues, adhering to anti-retroviral treatments, safe-guarding against interpersonal violence, or working toward healthy parenting skills. Staff sought patient’s input about goals, discerning the patients’ readiness and supporting steps to prepare for change – a process that required long-term strategies and commitment. A patient described the impact of not “approaching me too fast”:
"What this place did for me was, actually, it really did help me out. Because it gave me a sense of security, a sense of trust with these people. And for me that’s a hard thing to do, just to trust people. Especially managers and staff members of any type….And staff members don’t approach me too fast, too hard and too quick, which is important, I believe. So, it’s, let me sort of come to you. And because it’s hard for me to ask for things…it’s hard for me to ask for help. So the staff here are patient with that. And I think they understand that, which is important."
Revisioning the use of time also refers to cultivating health care relationships over time. Time is required for participatory engagement of patients, and is fostered by adopting clinic structures that encourage ‘patient activation’, such as patient-initiated appointments scheduled on a drop-in or pre-booked basis. Such scheduling structures need to be creative, fluid, and innovative to accommodate people’s rapidly shifting priorities and concerns, as this provider explained:
"So someone might come in and you think that they are going to be here for their ear infection. But then, you get to know them on a broader level, so you can say like, "how are things going at home?” And to really be able to see people in an ongoing way, and say like, "so where are you living now? And you know and how’s it going?"… So then you can have the opportunity and the time and the resources to address those issues."
Revisioning time also means recognizing the complexity of the work involved in providing PHC to marginalized populations. Organizationally, this required recog nizing the need (and scheduling time) for interdisciplinary meetings; putting in place adequate time and processes to support staff to provide care to people who are highly traumatized; and providing flexibility in scheduling so that patients with greater needs are provided more time. This strategy in turn requires collaborative decision-making.
Engage in decision-making on the basis of critical analyses of power differentials, flattened hierarchies within interdisciplinary teams, and shared leadership approaches
To address the health effects of persistent power inequities, stigma, everyday social exclusion, and systemic discrimination experienced by many marginalized patients, organizations must first reflect critically, and purposefully, on power relations within their organization – in relation to interactions with patients, staff, management, the wider community, and other sectors and organizations. For service providers including receptionists, professional staff, and management, this requires critical self-reflection on how power differentials are managed, particularly with patients who may find it challenging to relate with or trust people in positions of authority [20, 51]. A physician with years of experience working at one of the Centres described this process:
"You’re trying to reflect on, you know, check my attitude: was I being condescending? And I’m sure many times I am, because you know, like, you slip into that role right? You’re the doctor."
Another physician described the approach she takes to engage in critical reflexivity:
"You have to look at the privileges that you gained as a consequence [of your professional status and social location], and that’s very uncomfortable for people."
At the organizational level, attention must be paid to power inequities that often shape staff dynamics. For example, engaging in team meetings and sharing leadership in ways that intentionally aim to flatten professional hierarchies among staff are critical and prerequisite to addressing power differentials in relation to patient populations. Team meetings or case conferences can be conducted in ways to signal all staff input is important – including reception staff who often have the most frequent contact with patients and play an influential role in shaping access to services. Scheduling team meetings at regular intervals also is essential to foster interdisciplinarity and comprehensiveness of services – and is critical to developing synergy among staff and within the organization about how to maintain equity-oriented strategies.
Tailor care, programs and services to the context of people’s lives (e.g., cultural, social, gender, and demographic contexts)
This strategy rests on the premise that PHC services need to be meaningful to the patient-population served. The notion of ‘tailoring’ builds on and extends the notion of patient-centred care, and refers to the adaptations that can occur when the social and cultural contexts of local patient-populations are taken into account in the process of delivering care. These adaptations are significant when working with patient-populations who, in the process of seeking health care, often encounter dismissiveness, stereotyping and negative assumptions related to poverty, racism, substance use and mental illness [19, 20].
Depending on the local community context, and the populations served, tailoring that attends to the social and cultural context of people’s lives could include: attention to styles of communication (both verbal and non-verbal); efforts to provide services (where possible) in local languages; and adapting clinical practice guidelines in ways that align with the priorities of patients’ lives (which can be chaotic or stable at various times). Most often, responsiveness to social contexts requires interdisciplinary team-based responses; at the organizational level, this means ensuring that staffing levels are adequate to assist patients with, for example, completing lengthy disability forms, liaising with social-services, child protection services and other state authorities, and coordinating with other health care organizations.
At the level of patient-provider interactions, tailoring is essential to draw in, rather than limit access to care by marginalized patient-populations. For example, what might be seen as excellent interpersonal communication in one cultural context might be seen as discriminatory or alienating in another. At the two PHC Centres, initial greetings among people who identify as Aboriginal often incorporate the phrase, “where are you from?” to signal an awareness of the importance of place and community of origin as an essential aspect 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 histories of trauma who are at high risk of experiencing re-traumatization during physical assessments, offering choices and easing into health care encounters can offer high impact ways of recognizing people’s vulnerability and foster trust as an essential component of access to PHC.
Openly discussing various approaches to harm reduction, including how to manage opiate prescribing practices when there are high rates of substance use among the patient population, is an example of tailoring that can take place at organizational and provider levels. These organizational-level discussions are critical when working with client populations with high rates of substance use or chronic addictions combined with multiple forms of discrimination; conveying acceptance and non-judgmental approaches are imperative to supporting people’s access to PHC services. As one patient explained:
"The whole thing of addiction is having people listen and not judging. And most doctors, I know, except for the select few that are here, they are all judging, very judgmental of addicts."
Organizational policies can be tailored to meet the needs of individual patients by implementing clinical practice guidelines that are flexible, dynamic and can be adapted to the person’s life context, personal circumstances, and highest priorities. For example, rather than beginning with their substance use issues per se
, staff at the Centres working with mothers who use substances often began with the women’s top priorities – supporting women to increase contact with children apprehended by state authorities, or supporting women to parent their children to prevent child apprehension. As one provider explained:
Actively counter the impact of intersecting oppressions on health, access to care, and quality of life
"From a care provider perspective…if I can help you keep your five-year-old daughter from going to foster care, you know, that is very rewarding for me, if I could be part of that solution – and very meaningful for her, and more so for the five-year-old."
PHC providers and organizations need to be aware of how marginalizing practices and social exclusion operate in structures and institutions, including health care, thereby shaping people’s health care experiences and access to services; then, they can actively implement strategies to counter these barriers. Our data aligns with the growing body of evidence showing that disempowerment and alienation of marginalized groups in society are major obstacles to achieving health equity [1, 22, 40, 52]. The positive impact of actively conveying respect and acceptance to individuals – and attending to power differentials, is highly significant, particularly for people who experience social exclusion on an everyday basis. A woman who is a patient shared the impact:
"Because a person doesn’t have that courage, you know, they’ll sit there on the street thinking, it’ll be [such a huge thing to go in for health care]…That’s why I come – because they’ll let everyone in…You’re missing so much on that connection – not connected to anybody…Those kinds of just simple gestures…just that little bit of, you know, good human touch, once in a blue moon, can really help somebody get to the next step, right? Good human interaction and connections."
Our findings showed how countering racism, discrimination, stigmatization, and social exclusion can be achieved by conveying unconditional positive regard for patients regardless of their circumstances, and fostering the human dignity of all persons even in informal interactions in waiting rooms, at reception desks, over the telephone, or during clinical encounters. Affirming approaches can be ostensibly ‘small’ gestures, achieved through non-verbal communication, tone of voice, and other types of communication, as one provider described:
"I’ll stop and have a small conversation with the person, or I’ll say, you know, I’m really happy to see you here today, to let them know that they’re appreciated. Because other than that, people never see them [as people]."
Creating an accepting, non-judgmental PHC environment also manifests in the ways staff respond to patients’ expressions of frustrations or anger. This requires that staff continually reflect on the personal and social contexts which give rise to patients’ expressions of anger, 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 and HIV care, and she started out really hostile, but she kept coming back. And then, after a year…she’s like, “no, I wouldn’t go anywhere else” and, “I’m so thankful for being here.” I just needed to accept that…she might be angry and hostile for a while but…eventually…the real person will emerge…"
At an organizational level, actively countering the impact of intersecting oppressions requires policies that support a low barrier health care environment wherein patients are, as one staff member described, “just allowed to be.” They do not have to transform themselves into something else to be seen as legitimate or credible.
One indicator of accessibility, especially for people who are marginalized or ‘hard to reach’, is when patients drop in or hang out at a Centre, without a specific appointment. 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 feel comfortable coming here, and like I said, because I see a lot of my people here. And a lot of the staff, you know, talk to you…Like I said there are times where I don’t even need to be here, but I come here to talk to a friend or have a coffee, you know, and just go home."
Our observational data showed that these strategies had a visible impact; expressions of frustration or hostility by patients were infrequent, despite sometimes long wait times in waiting rooms, and despite some people being visibly under the influence of substances. On occasion, when some people’s behaviours approached a disruptive level, staff (usually receptionists) respectfully used communication styles to diffuse tensions and set limits, which were usually respected. This contrasted with our prior research in emergency departments where we observed security guards routinely deal with behaviours in ways that often resulted in escalating frustration and aggressive behaviours, and ended in dismissal or banning of patients and police involvement [19, 20, 53].
PHC organizations can also exercise leadership within their communities by increasing awareness of how racialization and discrimination operate in health care settings such as emergency departments, and in the wider community, and by working to counter such oppression. For example, a nurse at one of the Centres informed the media about methadone dispensing pharmacies that were exploiting vulnerable patients for economic gain; this action contributed to an investigation and policy changes to prevent such exploitation in the future.
Create opportunities to promote and foster engagement with community and other sectors, including participatory engagement by patients
Enhancing equity-capacity within PHC organizations ideally will involve engagement and collaboration with various sectors in the local community and beyond to maximize opportunities to address the social contexts of patients’ lives. For example, tailoring care, programs and services to the contexts of patients’ lives could involve liaising with child welfare agencies to develop ways to support women at risk of having their children apprehended. Actively countering discrimination could involve hosting an in-service at the emergency departments known to be frequented by patients to discuss possible anti-racist approaches. Recognizing that not all PHC organizations or staff have the flexibility to engage in these ways, this strategy is held out as an ideal to work towards, and as a starting point for meaningful dialogues within and between a range of health and social sectors. Such engagement also requires action at the level of policy, so that values related to equity can be effectively and democratically operationalized . Following our example above, liaising with child welfare agencies to develop ways to support women would include, for instance, working on health policies related to child health assessments and social policies related to income support.
Participatory engagement of patients can take many forms and PHC organizations can play a role in providing a sense of meaningful belongingness, for example, by providing paid or volunteer opportunities including peer support programs. These experiences offer powerful points of connection for people marginalized by social and structural inequities, who often experience social exclusion. Having a meaningful focus and daily routine is particularly relevant for patients who are homeless or living in shelters, or who are unemployed or unable to be employed due to persistent chronic physical or mental illness, or substance use issues. At both Centres, for example, patients are periodically hired on a part-time basis (according to the availability of funds) to assist with peer support activities, focus groups, and women’s or men’s wellness programs. In one of the Centres, research funds for a self-management HIV program were used to hire patients as peer interviewers and research assistants. Patients often expressed a sense of ownership and responsibility in relation to ‘their’ Centre. In many cases, patients who used the Centres regularly played a role in shaping the physical and social milieu by voluntarily making coffee and replenishing supplies in the waiting areas, voluntarily helping with janitorial or maintenance tasks, and offering suggestions for how to make the physical space safer and more welcoming for women and children. Engaging in meaningful work-related activities through volunteer and temporary or occasional employment opportunities can be health promoting by enhancing people’s sense of self-efficacy, self-worth, and capacity to manage their health , as this patient described:
"[I have] a paid position where I’m on call [for janitorial work]. And that helped me, kept me busy. It kept me from locking myself up and getting depressed…I’ve got something, like I’m doing something and I’m being responsible…If I didn’t have the volunteering I would have been lost…I would have just given up…Pay didn’t matter. It was just somewhere to go and know that I was needed, that’s what I needed, that’s kept me going."
Given the significance of participatory engagement, PHC organizations are well-justified in seeking or allocating funds to support volunteers or peer support workers. It is equally critical for PHC organizations to seek the input of patients at regular intervals so that their feedback is part of quality assurance, and to remain accountable to both local community and patient representatives by ensuring that the organization is welcoming and responsive to local populations. Organizations can build such approaches through policy. For example, one Centre requires that research conducted there include meaningful patient consultation and involvement in the research process, including employment (e.g., as research assistants or facilitators) when possible.
Tailor care, programs and services to the populations’ individual and group histories, with an emphasis on trauma- and violence-informed care
This strategy is based on the premise that it is critical to tailor programs and services to people’s individual and group histories. Because trauma and violence are intertwined with inequities, recognizing the significance of people’s histories means that PHC services must take into account the fact that most people affected by systemic inequities and structural violence have experienced varying forms of trauma. Additionally, because people with trauma histories often experience mistrust, building trust is critical to sustaining connections and a sense of personal safety in PHC . As this patient elaborated:
"We’re not just a number…That’s life saving, life changing, literally it’s that valuable, it’s life changing because when I was out there [on the street] it was not good. It was always
something, you know, you were selling your body or you’re giving up a piece of yourself daily. And then to have somebody want to do something 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 eliciting trauma histories; it is about creating a safe environment based on an understanding of the effects of trauma, so that health care encounters are safe, affirming and validating [24, 29]. For example, PHC organizations serving high numbers of Aboriginal patients must recognize that many people have experienced the inter-generational effects of systemic and individual discrimination and racism, which can be conceptualized as one feature of historical trauma [21, 22, 57]. This conceptualization of trauma has implications for other groups of people, for example, refugees and in some contexts, new immigrants. In PHC contexts, such services are constituted by respectful, empowerment practices, not ‘trauma treatment’ such as psychotherapy (though referrals may be made for specific trauma therapy). For example, in recognition of the devaluing of Aboriginal culture as a result of Canada’s colonial history, one of the Centres featured signage in a local Indigenous dialect to convey a valuing of Aboriginal identity; in the other, a residential school healing program was implemented to support patients and their families.
The effects of trauma often are manifested in health and behavioural issues that initially appear to be unrelated . Interpersonal violence experienced by women, for instance, is associated with acute and chronic issues such as: chronic pain (e.g., headache, migraine, back pain, pelvic pain, inflammatory bowel disease), arthritis, hypertension, higher rates of mental health problems, higher rates of substance use and dependence, and symptoms consistent with posttraumatic stress disorder (PTSD) [25, 58]. Because these are common health issues, health services may fall short in integrating understandings of the long-term impact of trauma, and inadvertently fail to create an environment that validates patient experiences [24, 25, 30]. Trauma and violence-informed care, therefore, requires that PHC organizations integrate comprehensive and continuing education for all staff (including receptionists, direct care providers and management) about the health effects of trauma and the principles of trauma- and violence-informed care , and about strategies for actively minimizing the risk of re-traumatization in the everyday provision of services, as one health care provider explains:
"So, [in case conferences and team meetings] we talk about…the level of trauma that this person comes from…Or how difficult it is for that person to walk through that door…Or how difficult it was for that person to actually bring up their concern to you…getting into conversations around our table about power imbalances and about how our interactions [with patients] can really affect this."
Equally critical are supports for staff who may be dealing with vicarious trauma when working with patient populations who have significant trauma histories. As described by one health care provider:
"She [was] a staff member that was not only in moral distress from what she was seeing in this community and taking it on but from also never resolving her own background trauma and seeing how it triggered her to work with the clients…but not having an employee assistance program [EAP] to refer her to for counseling [was hard]…I’ve lost about twenty [staff]…I’ve lost them…when they couldn’t take the stress…we don’t have any type of psychology services or EAP…"
Thus, tailoring and an emphasis on trauma- and violence-informed care must take into account the effects of working with highly traumatized patients, and as identified in strategy two, funding must be available to provide staff with adequate support. Given the correlation between trauma and all forms of inequity, trauma- and violence-informed care is also closely related to strategies to address social determinants of health.
Enhance access to resources that address the social determinants of health with an emphasis on advocacy and inter-sectoral collaborations
Addressing the social determinants of health is recognized as essential to PHC [7, 38–40, 60]; therefore, this strategy involves explicitly working to address these issues as legitimate and routine aspects of health care, often as the main priority. Maintaining or improving health is dependent on access to adequate safe housing, adequate nutrition, and meaningful activities. For example, mental health or well-being (especially in the face of PTSD and depression associated with all forms of trauma) is challenging to achieve in the context of inadequate social housing rife with rodent or insect infestations; physical health is challenging to achieve without a place to refrigerate food or medications . At the individual level, this involves working with patients to facilitate access to social housing, food, and clothing, or supporting efforts toward paid employment. Our data repeatedly documented the impact of addressing people’s social needs as fundamental to maintaining or improving health, as this patient described:
"I got the subsidy from them [the nurse and social worker at the Centre] for housing and I got the kids back now…I knew that I wanted to go to rehab [to address substance use issues]. I’ve been thinking about it for a whole year since I got the subsidy…That really made me look in the mirror at myself…[The subsidy] is like winning a lottery to me…[With] the subsidy, I thought, I’ve really got to smarten up, pull up my socks and start really watching the company I keep and start getting my life on track. And it’s getting there…."
Fostering connections with individuals, groups and resources is critical, because many people experiencing marginalization are disconnected from their families or home communities by policies, poverty and violence. Supporting connections to possible employment is critical because most people served cannot afford phones or computers, and thus have no way of being contacted.
At the organizational level, addressing this strategy involves leaders and staff within PHC agencies taking on advocacy roles and inter-sectoral collaboration in their wider communities to influence policies, such as working with housing organizations to maximize the availability of social housing; working with child welfare authorities to increase parents’ access to children and visitation rights; looking at ways to mitigate the root causes of homelessness; or advocating for more services for people with mental health problems. This attention to socio-political and economic environments must be extended to more immediate social and physical environments.
Optimize use of place/space to meet the needs of client populations
Increasingly, the socio-spatial environments of health care are being conceptualized as relational spaces that can be intentionally designed to support people’s subjectivities and experiences . The notion of ‘therapeutic environments’ highlights the ways that socio-spatial environments can be transformed to foster people’s sense of agency and entitlement (or deservedness) when seeking PHC services. This has significant implications for patient-populations who experience discrimination and social exclusion in their everyday lives. A patient explained:
"They make you feel welcome and they know you by name. And that means something to you, like somebody knows me, and it just makes me feel like a certain kind of pride inside you – like who you are and where you come from."
At the organizational level, this could translate into an agency’s commitment to create a low barrier and accepting environment, as a receptionist described:
"They come in and they’re cold and we welcome them with a warm coffee, and tell them they’re welcome to sit and chat, and sort of see how they are doing, where they slept, if they slept."
This contrasts with the atmosphere in conventional waiting rooms, as described by a physician:
"You know what [typical] waiting rooms feel like…that quietness, and contained-ness…Everybody sits in their little world. That is so foreign to our clients that they feel really out of place."
Essential to creating a therapeutic space are reception staff who play an active role in setting the tone in waiting rooms, during phone interactions, and during informal conversations with patients. This has implications for the kinds of training that staff receive, and requires their active involvement within organizational and decision-making structures. Creating supportive social spaces within PHC settings can involve, for example, having phones available for patients, a computer with internet access, and freely available coffee and tea. To fully address a population’s needs, providers may need to extend their influence beyond the boundaries of the physical PHC space by providing care in other spaces (i.e., shelters, people’s homes, single-room occupancy hotels, outreach services on the streets, etc.). Building on earlier strategies, patients can be integral partners in planning and creating such spaces and outreach processes.
In summary, these findings are based on a rigorous analysis of a large set of ethnographic data as the foundation for identifying the essential elements of equity-oriented PHC services when working with marginalized patient-populations, and will have broad application to a wide range of settings, contexts and jurisdictions. One limitation of this study is that the data collected were based on research conducted in only two PHC Centres in Canada. As well, the findings reflect team-based care as the primary mechanism for delivery of PHC services, and salaried versus fee-for-service compensation arrangements for physicians and other staff. Further research will be needed to examine the relevance and operationalization of these key dimensions and strategies when other models of service delivery are used, and in other jurisdictions and national contexts.