Disclosures: Dr. Colleen Varcoe: Co-led the EQUIP research team and oversaw the design of the EQUIP toolkit and related knowledge mobilization. Mitigating Potential Bias: Only published trial data is presented. Dr. Heather Smith: Worked at the clinic with the EQUIP research team at the time of data collection and was involved in the designing of components of the EQUIP toolkit as well as beta testing the final website and tools. Mitigating Potential Bias: Only published trial data is presented.
What I did before
Since graduating from family medicine residency in 2010, I have practiced in a number of clinics. Much of the practice I have done has served First Nations people, people living with harmful substance use, people living close to, or on, the street and people who were incarcerated. Often, the work I did left me frustrated – with the patients I served, with the systems I worked within and with the institutions that oversaw this work. I often found it hard to balance patient needs and expectations with workload; institutional policies and overburdened systems simply intensified that difficulty. I knew I wasn’t always giving patients the kind of care that was meeting their needs, but I didn’t know how to align the care I was able to offer with the things I knew were important and would be valued by patients – the intangibles that bring joy to your work and help smooth over the frustrations in practice.
What changed my practice
In 2013, one of the clinics I work at was offered an opportunity to be part of a multi-centre study: the EQUIP Primary Health Care Study. The EQUIP PHC Study grew out of previous work done with our clinic in response to calls for health care organizations to contribute to health equity1-3. The research looked at social determinants of health and how the clinic successfully provided care to people marginalized by poverty, racism and other forms of discrimination and stigma4, 5. Importantly, the EQUIP research has shown that equity oriented care actually predicts better health outcomes, including lower pain disability, lower depressive symptoms, fewer trauma symptoms and better quality of life!6
San’yas Indigenous Cultural Safety training was offered as part of the intervention within the EQUIP Study. The premise was that as we were a culturally diverse group working in a primarily First Nations clinic, the San’yas training would position us on a common base of understanding as we moved forward with the study and its resultant interventions.
The Indigenous Cultural Safety (ICS) training is a “unique, facilitated online training program designed to increase knowledge, enhance self-awareness, and strengthen the skills of those who work both directly and indirectly with Aboriginal people. The goal of the ICS training is to further develop individual competencies and promote positive partnerships. Skilled facilitators guide and support each participant through dynamic and interactive learning modules. Participants will learn about terminology; diversity; aspects of colonial history such as Indian residential schools and Indian Hospitals, time line of historical events; and contexts for understanding social disparities and inequities. Through interactive activities participants examine culture, stereotyping, and the consequences and legacies of colonization.” (http://www.sanyas.ca/training)
As the EQUIP study progressed and data were released, the EQUIP team helped to design strategies and tools based on clinic specific data as well as the more global findings from the study. These strategies, or interventions, were implemented and further assessment was done to assess the impact of the interventions on patients and practitioner in the realms of cultural safety, trauma- and violence-informed care, and later in the study, harm reduction.
What I do now
Health equity-oriented care is now part of my daily practice; the tools created with, and provided by, the EQUIP study have helped to make health care inequity an issue that I can screen for and offer options for management.
The EQUIP Toolkit offers a suite of evidence based, practical tools that can used by individuals and organizations to shift their practices, and clinic spaces, towards equity. I worked with the team to design a tool to support the residents I now train to speak to people in ways that limit erroneous assumptions and are safer, particularly for people who have trauma histories. For example, to prevent the harms associated with unintentionally conveying negative stereotypes about certain groups and alcohol consumption, I train residents to open with the question “do you drink alcohol?” instead of “how much do you drink?” Instead of telling patients “there’s nothing wrong with you”, I recommend that practitioners frame negative test results as indicating the “good news is that there is nothing dangerous or life-threatening”, while still acknowledging troubling symptoms. These tools offer practical tips, talking points and pathways to make clinics more welcoming and supportive to people experiencing violence or struggling with addiction. Drawing on equity indicators7, the toolkit also offers “walk throughs” and measurement tools to assess what is currently happening in your workplace.
The “Equipping for Equity” modules presents a digestible way to explore the idea of equity-oriented healthcare for practitioners who are new to the idea or who wish to broaden the areas in which they feel under resourced. Broad areas such as trauma and violence informed care, cultural safety and harm reduction are distilled into tools, templates and action-oriented strategies; the scholarly papers and base reading are available for those who wish to do a deeper exploration, but busy practitioners can simply focus on acquiring tools that will help deliver care that is effective and acceptable for “complex” clients while leaving the practitioner more satisfied with their work.
The Poverty Intervention Tool, developed initially in Ontario and then reworked for BC now has a toolkit specific to each province and territory. It encourages practitioners to screen for poverty with all their patients and then offers a roadmap that can be customized for each patient with a “positive” screen.
Equity-oriented health care allows me to shape individual patient encounters – ensuring medications that I offer are on the patient’s drug plan, asking specifically if a therapy fits within a patient’s budget before I “prescribe” and considering alternatives if it doesn’t, greeting the patient in their traditional language and asking them about where they are from. I have changed some of the language I use (e.g. ‘Do you drink alcohol?’ instead of ‘How much alcohol do you drink?’), and I actively screen for poverty by asking patients if they “ever have trouble making ends meet at the end of the month (sensitivity 98%, specificity 40% for living below the poverty line)”. I have also swapped out my boilerplate treatment agreement with one that still meets my needs, and those of my College, but does so through a health equity lens (e.g. Equity Oriented Opiate Treatment Agreements).
Outside of my clinic interactions, health equity focused care can be applied to patients receiving specialist care as well. My knowledge of my patient gives me insight into areas my specialty colleagues may not have. In practical terms, this may look like a patient who is in unstable or shelter housing, who requires a colonoscopy, being admitted to detox or hospital overnight to ensure they have privacy and the ability to complete their colonoscopy preparation and are better able to attend the appointment. It may be a line in the referral note letting the specialist know what additional services the patient may need to facilitate the best outcome.
If wanting to shift from frustrations to (more) satisfaction in your workday life resonates, start with the Equipping for Equity modules. These short vignettes and practical and actionable practices are a launching point for a practice that provides health-equity oriented care. From there, look at your practice, your clinic, and your hospital to see what areas you see yourself starting to apply tools from the toolkit and let it snowball from there.
Links to Tools and Training
- San’yas Indigenous Cultural Safety Training – http://www.sanyas.ca/home
- EQUIP Tool kit – https://equiphealthcare.ca/toolkit/
- Equipping for Equity Modules – https://equiphealthcare.ca/modules/
- Poverty Intervention Tool – http://www.cfpc.ca/Poverty_Tools/
- Treatment Agreement – https://equiphealthcare.ca/toolkit/opiate-agreement/
- Wyatt R, Laderman M, Botwinick L, Mate K, J. W. Achieving Health Equity: A Guide for Health Care Organizations. Cambridge, MA: Institute for Healthcare Improvement; 2016. (available at ihi.org)
- Institute for Health Care Improvement. IHI triple aim measures. Cambridge, MA: Institute for Health Care Improvement; 2015. (view)
- Institute for Health Care Improvement. How to improve. Cambridge, MA: Institute for Health Care Improvement; 2015. (view)
- Browne AJ, Varcoe C, Wong S, et al. Closing the health equity gap: Evidence-based strategies for primary healthcare organizations. International Journal for Equity in Health. 2012;11(15). doi: 10.1186/1475-9276-11-59 (view)
- Browne AJ, Varcoe C, Lavoie J, et al. Enhancing health care equity with Indigenous populations: Evidence-based strategies from an ethnographic study. BMC Health Services Research. 2016;16(544):1-17. doi: 10.1186/s12913-016-1707-9 (view)
- Ford-Gilboe M, Wathen CN, Browne AJ, et al. How Equity-Oriented Health Care Impacts Health: Key Mechanisms and Implications for Primary Health Care Practice and Policy. Millbank Quarterly. In press.
- Wong S, Browne AJ, Varcoe C, et al. Enhancing Measurement of Primary Health Care Indicators Using an Equity Lens. International Journal for Equity in Health. 2011;5(10):38. doi: 10.1186/1475-9276-10-38 (view)