Table 3 Themes with Participant Quotes

Theme #1: Quality Clinics Utilize Structures and Processes that Support Health Equity

Recognize and address historical trauma, structural racism, and SDOH

 “Clinics and clinicians should be prepared to treat the person as a “whole person”. That means that many patients have issues that make the specific disease almost non-important. For example, a patient’s dilemma is that her child is sick, but she also has another baby to take care of, her rent is not paid, her partner is “being snarky”, she does not know how to navigate the system and would take more time to learn. How can a patient find an advocate to help her through her many struggles?” (LGBTQTS)

 “If a clinic has all the resources in terms of housing, employment, or legal information—such as domestic violence, I can get help getting a restraining order—or if there is a person to refer me (and) at the same time (tell me), ‘We will care for your health, and this (resource) will relieve your pain and stress’, it’s very important to me and the Hmong community because we don’t know the language, (the) knowledge, so we don’t know where the information is.” (Hmong)

 “One of the current issues for (the) Latino community is deportation, which has ripple effects: (the) deportation of one person could affect an entire group of people, from his children who will be unable to see their father at all, to a wife who will be suddenly a single mother. ...A clinic providing (connections) for those people with resources in the community, the entire group of people could find relief: churches, low-fee attorneys, organizations helping Latinos, food pantries, school counselors, county workers.” (Latino/a/x)

 “We see being healthy as a right – it was written as a right into our treaties, and we see this in our (Native) teachings, but…because of trauma, I think Native communities struggle with feeling worthy of being healthy.” (Native American)

 “You know sometimes when people who just recently arrived, they have been through so much trauma. Like my grandma for example, when she came in, she said ‘I have body aches’ and later we ended up going to a therapist ... Understanding what these people went through helps so much. So, it is important for doctors to have background knowledge about what the person dealt with.” (Somali)

 “A primary care visit, to me, it’s not just I’m treating you right now, today, it’s we’re treating your overall health and we understand that’s something bothering you today that’s why you’re coming in, but let’s take an overall view of your health, whether it is diabetes, asthma, addiction. Maybe there’s some mental health challenges or some social and economic challenges that is greatly affecting this person’s overall health.” (White)

Have real representation by patients and community members

 “In order to build trust, patients need (to) receive treatment from personnel who represent their own groups or from someone who is culturally competent in their language and culture. I heard a patient who was struggling with economic issues say, ‘The doctor is telling me I have to eat a healthy, balanced meal, with fruits and vegetables. How am I going to tell my wife that, since we hardly have enough money to get some food?’ When I asked the patient why he didn’t tell the doctor the truth, he explained that it was embarrassing enough to have to tell the non-Latino doctor, but that the Spanish interpreter also would hear it.” (Latino/a/x)

 “Clinic leadership should hire people who are Somali. For example, if the clinic is in neighborhood where Somalis live, they should hire interpreters from the community, but how much better (it would be) if they hired people from the community to provide services and to lead the clinic.” (Somali)

Report on health disparity data, goals, and efforts

 “In order to make a complaint, patients have to feel empowered, feel safe and not worried that clinics or staff will retaliate.  In native communities, they often don’t feel empowered enough to even complain at an official level. […]Can the clinic help people effectively complain? Because their voices collectively matter. How do we tell communities that their voices and experiences matter? This is how we can get the system to listen to them. We may have to craft our own creative ways to collect that.” (Native American)

Improve access to care through solutions to barriers and integrated services

 “(At some clinics) I don’t think they really explain what’s going on, I mean, when you’re at the community clinic…they don’t explain anything. They just move you through, and after sitting (there for) 2-3 hours, you just want to leave…and after spending the money for the bus to get there (in time for) your appointment, and you are going to try to get back (on time), but they sit you there for 2 hours. They’ll get you checked in, but you’re sitting there for 2 hours. Now my bus pass is (expired) and I’m going to have to walk home.” (LGBTQTS)

Support healthcare system navigation

 “To build trust, (clinics should) have (a) liaison to help patients feel comfortable, have conversation to show support for the patient, (and) have a team that collaborates so that patients don’t have to repeat themselves because it is tiresome. (…) When a family doesn’t feel empowered to be their child’s advocate, you need to encourage them to ask questions and help them be empowered to be their own advocates.” (Native American)

Create welcoming, private, and safe clinic environments

 “Make sure that staff is trained in HIPPA. Privacy is important. Do not leave my private information for others to see. We do not trust doctors and we do not trust people with our information. Talk in a low voice instead of screaming. There are always people behind who can hear. ... Information should be private and treated with respect. This way I will come back to this clinic.” (Black/African American)

 “What is it like when you go into the clinic, is it all straight, white people?….What’s the literature in the waiting room? Are there gay magazines, are there people of color on them? And around bathrooms and bathroom management…are there single stall bathrooms available? How has the clinic chosen to label the bathrooms? How do I fit within the physicality of the clinic – do I see myself represented?” (LGBTQTS)

 “Showing respect can be as easy as asking for permission. For instance, when a doctor needs to examine a Hmong elder’s head, the doctor should ask for permission ahead of time. This act demonstrates that the doctor acknowledges and respects the patient’s control for their personal space and body. Small gestures like asking for permission contribute to building a trusting relationship between patients, doctors and staff.” (Hmong)

 “My aunt has diabetes. I went with her to see a doctor and the doctor didn’t see her as she is. She’s an elderly woman and has never been educated. He told her how to manage her diabetes, but she didn’t understand the whole scope of it or why. He told her “no more tea” and didn’t discuss it further with her. He doesn’t understand how tea is part of our culture. If he understood our culture, he could treat her well and he could reach her. Now she constantly goes to the ER instead of going to her doctor. She needs education and help to learn how she can eat.” (Somali)

 “Having a calming, healing environment (is important). I know that (my clinic) has a chaotic environment, and with anxiety, sometimes, I have trouble being in the waiting area (because) you’re in everybody’s business. I think it doesn’t really respect patients’ confidentiality and privacy. (White)

Theme #2: Quality Clinics Provide Respectful, Trusting, and Effective Relationships with Patients and Communities

Support effective and longitudinal clinician-patient relationships

 “People do not want to share a lot earlier in the relationship. The relationship must be built to have trust. Some clinics develop trust faster than others. If you trust the clinic you will be able to share more, your whole experience.” (Black/ African American)

 “For those with drug and alcohol problem, if you don’t have a supportive environment, it’s easy to slip back into using again. Creating the supports for long-term health is really important. Like mental health, one thing is to have a regular schedule with a provider. If you can only get it once a month, it’s hard to follow up with the positive that you’re getting from it. Sometimes that relationship ends when you decide you can only go so far with a therapist or the therapist thinks they need to end the working relationship. (White)

Provide training for staff to improve cultural-responsiveness and be attuned to unconscious bias

 “Respect for elders, how the staff in the clinic acknowledge you, instead of calling you by your first name….I know that this is not the culture, but treating a client as Mr., and Mrs. first is respectful and you may give permission to call you by your first name.” (Black/ African American)

 “For me, when we go to the clinic, we are scared and when we get there, we are constantly thinking that they (staff/doctors) might not know our language, maybe they’ll have an interpreter. ‘Is the interpreter going to interpret correctly or not? Will they understand me?’ When people need interpreters, then they need more time, not only to interpret, but there is also a cultural piece. Hmong are relationship people--we need more time to build relationships with providers and explain things fully so we don’t get embarrassed.” (Hmong)

 “Cultural training must be available to the clinic staff at all levels. Clinics can even invite patients to talk about ways to improve services so the services fit with patients’ culture desires and needs. My aunt has diabetes. I went with her to see a doctor and the doctor didn’t see her as she is. She is an elderly woman and has never been educated. He told her how to manage her diabetes but she didn’t understand the whole scope of it or why. He told her ‘no more tea’ and didn’t discuss it further with her. He doesn’t understand how tea is a part of our culture. If he understood our culture, he could treat her well, and he could reach her. Now she constantly goes to the ER instead of going to her doctor. She needs education and help to learn how she can eat.” (Somali)

Provide culturally-relevant patient education

 “Adopting healthy lifestyles is key to addressing many health issues in our community. However, there are many issues that block this useful tool to reaching many people in the community. From lack of healthcare access due to education and financial constraints to health system design, communities use the health system when they are sick or as a ‘last resort’ rather than as a tool to stay healthy and prevent diseases. … They need culturally and linguistically appropriate education and information about health promotion, so people can understand and can institute healthy lifestyles.” (Latino/a/x)

Integrate family and community-based strategies for health promotion and education

 “Family members could provide important information about the patient. Latino patients are used to going to their doctor’s appointment with their spouse, children, in-laws, godmother. Often times, these family members could provide information that is useful for the provider, to give better service to the patient.” (Latino/a/x)

Theme #3: Funding Based on Current Quality Measures Perpetuates Health Inequities

 “Regarding diabetes treatment, if patients continue to smoke, (then) the clinic automatically fails, (and) doesn’t get their funding…but that (smoking) is a trauma thing, you know?” (LGBTQTS)

 “The current system for reimbursement is not the best practice for communities like ours. I don’t think that a clinic (in suburbia with better quality scores) is doing any better job than a clinic in Minneapolis that is dealing with other factors. We know that only 10% of clinical factors contribute to health, and the rest is related to social factors, so social factors are a bigger component of dealing with health problems and getting the results that would rank a clinic or provider higher or lower on the current scale.” (Somali)

 “I agree, I don’t think it (payment) should be tied to it (services), because the community you are serving should be the community you are focused on, and you cannot talk about the Somali community without addressing housing issue, food issue, income issue, transportation issue. There are people that can’t even come to seek services because they are dealing with those. I think this whole rating system is deeply flawed and it seems like it benefits white people more than it benefits people of color and I think maybe the whole thing should just be scrapped and a new system should be approached based on our input. What I’m hearing is that the people most in need, those in clinic serving them could be reimbursed at a lower rate than ...other people and to me. that sounds really bad. It (financial remuneration) should be based on the people they are serving--what services do you provide and how are the people you are serving receiving the services you provide?” (Somali)