Margalized Women Discussion Post

J Clin Nurs. 2019;28:3459–3469. wileyonlinelibrary.com/journal/jocn  |  3459© 2019 John Wiley & Sons Ltd

Received: 15 April 2018  | Revised: 22 April 2019  | Accepted: 26 May 2019 DOI: 10.1111/jocn.14937

O R I G I N A L A R T I C L E

Exploring women's health care experiences through an equity lens: Findings from a community clinic serving marginalised women

Natasha Prodan‐Bhalla DNP, MN/NP (A), BScN, Nurse Practitioner1  | Annette J. Browne PhD, RN, Professor & Distinguished University Scholar2

1BC Women's Hospital and Health Centre, Vancouver, British Columbia, Canada 2School of Nursing, University of British Columbia, Vancouver, British Columbia, Canada

Correspondence Natasha Prodan‐Bhalla, 2385 West 13th Ave, Vancouver, BC V6K 2S5, Canada. Email: nprodanbhalla@cw.bc.ca

Abstract Aims and objectives: To explore how marginalised women perceive and rate equity‐ oriented health care at a primary care clinic using items that evaluate patients' experi‐ ences of care. Background: Despite an increased recognition of the importance of health care that is equity‐oriented, and that understands the patient within the context of the broader social determinants of health, inequities in health remain prevalent around the world. Design: Items from the “EQUIP Primary Health Care" research programme were used to explore patients' experiences of equity‐oriented health care. Women were invited to complete the questionnaire with the explicit aim of gaining their input to improve quality of care at the clinic. The Strengthening the Reporting of Observational Studies in Epidemiology Statement was followed for the study. Methods: Sixty‐seven women who experienced significant health and social inequi‐ ties, and were seeking care at a women's only nurse practitioner primary health care clinic in Canada, were invited to complete the questionnaire. For quality improvement purposes, correlational analyses were used to explore women's experiences of care. Results: Women's responses showed that Promote Emotional Safety and Trust and Overall Quality of Care were the most highly correlated domains, indicating the im‐ portance of the health care team in establishing trusting relationships, particularly for women who experience stigma and negative judgement when seeking care. Conclusion: Seeking feedback from patients on their experiences of care using items developed to explicitly tap into equity issues is useful in understanding how patients experience equity‐oriented health care. Responses from the women highlight the im‐ portance of understanding not only the what of equity‐oriented care but also the how. Relevance to clinical practice: The results of this study illustrate the importance of es‐ tablishing trusting relationships, tailoring care, and using a nondiscriminatory approach when working with women who experience negative judgements when seeking care.

K E Y W O R D S

marginalised women, vulnerable populations, health equity, inequalities in health, nurse practitioners, primary care, therapeutic relationships, women's health

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1   |   I N T R O D U C T I O N

Health inequities refer to disparities or inequalities in health that are grounded in social stratification, social exclusion, power imbalances and policy development that reinforce these structurally unjust dif‐ ferences among and between groups (Marmot & Allen, 2014; Wyatt, Laderman, Botwinick, Mate, & Whittington, 2016). The Rio Political Declaration on Social Determinants of Health reports that health in‐ equities are worsening as global wealth increases, confirming that these inequities are a direct result of inadequate social and economic policies as well as exclusionary politics (Kokkinen, Shankardass, O'Campo, & Muntaner, 2017). Women are often vulnerable to health inequities for a variety of reasons including discrimination and unjust structural policies (Alyaemni, Theobald, Faragher, Jehan, & Tolhurst, 2013; Bungay, 2013; Raphael, 2016; Raphael, Curry‐Stevens, & Bryant, 2008; Short, Yang, & Jenkins, 2013). Such structural ineq‐ uities include policies that negatively influence access to childcare, eldercare, maternity leave, legal aid and child support agreements, which result in women earning lower incomes, experiencing higher unemployment rates, lagging behind in education, finding less em‐ ployment opportunity, and lone parenting more often than men (Hankivsky, Varcoe, & Morrow, 2007; Pederson, Greaves, & Poole, 2015).

Women who have experienced marginalisation—which in this context, refers to the social, economic and historical circumstances that create inequities in health and not a characteristic that is in‐ herent in any specific population—experience further social inequity related to a lack of adequate or nutritious food, inadequate housing, general poverty and societal exclusion (Daniel, Bornstein, & Kane, 2018; Wyatt et al., 2016). These social conditions are reflected in worse health outcomes than those experienced by nonmarginalised women. Structural inequities, in turn, result in health inequities, in‐ cluding depression rates twice as high as men, higher rates of psychi‐ atric disorders, HIV and a variety of chronic diseases such as chronic pain and hypertension (Krieger, 2014). As a result, women who are marginalised—single mothers, women experiencing mental illness and substance use disorder, and women living in poverty—are at an even greater risk for health inequities (Krieger, 2011).

The association between the social determinants of health, so‐ cial inequities and poor health outcomes is evident. Four out of five victims of intimate partner violence are women, resulting in an in‐ creased incidence of lifetime dysthymia, alcohol dependence, drug abuse and binge eating disorder (Lacey, Sears, Matsuko, & Jackson, 2015; Sinha, 2012). Women who use crack cocaine experience sig‐ nificantly more health problems and are more socially isolated, lim‐ iting access to harm reduction services (Bungay, Johnson, Varcoe, & Boyd, 2010). Substance use disorder is another example of how the associated harms, including overdose, HIV and malnutrition, in‐ crease when women are also facing poverty, a lack of food security or inadequate housing. Due to ongoing and historical inequities in Canada, Indigenous women have a life expectancy of 79 years com‐ pared to 83 years for the general population, experience higher rates

of diabetes, die more often as a result of intimate partner violence and have increased rates of smoking, disability and suicide (Statistics Canada, 2017). For the purposes of this paper, the term Indigenous refers to those who identify as the original inhabitants of the land, and within Canada, Indigenous peoples include First Nations, Metis and Inuit people (Browne et al., 2016).

The first point of contact for a large number of marginalised women is within primary health care clinics where nurse practi‐ tioners (NPs) play a pivotal role as primary care providers in this important moment in the patients' journey, developing a feeling of trust, safety and nondiscrimination such that they will return for care (Harvey, Hynes, & Pichora, 2016). However, marginalised women are often reluctant to present to primary health care clinics for multi‐ ple reasons. Commonly cited reasons include the following: lack of trust in health care professionals, feeling dismissed, lack of flexibil‐ ity in the health system and long wait lists (Browne & Fiske, 2001; Browne et al., 2016; Salmon, 2009; Tu et al., 2013; Varcoe et al., 2017). Despite reasonable attempts to accommodate marginalised populations at primary health care clinics, the women's persistent avoidance and associated obstacles are poorly understood.

Simply increasing the number of primary health care teams with a focus on mental health and substance use is not the answer. It is also important to note that NPs are experts in the delivery of pri‐ mary health care that encompasses both care to the individual and population and public health principles as opposed to simply provid‐ ing care to the individual. Exploring the reasons why women avoid seeking out primary health care within the context of health ineq‐ uity can offer clinicians a richer understanding of their patients, their ongoing primary health care needs and strategies for how profes‐ sionals might improve equity‐responsive health care, which is more likely to result in better long‐term health outcomes. The frustration of attempting to provide conventional biomedically driven care for marginalised women who are hesitant, for a variety of reasons, to engage consistently with health services combined with the need to better understand the experiences of such women and the barriers

What does this paper contribute to the wider global community? • An overview of the importance of understanding health inequities in marginalised women in particular.

• An analysis of how nurse practitioners and other pri‐ mary care providers can evaluate patients' perceptions of equity‐oriented care with a view to improve the qual‐ ity of their practice overall.

• A practical approach to understanding how women per‐ ceive equity‐oriented care in primary health care clinics.

• Important insights about equity oriented health care practices, which are essential to improving health equity overall.

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they experience in accessing health care became the impetus for this exploratory study.

It can be frustrating for NPs to care for marginalised popula‐ tions who experience health inequities on a daily basis, while feel‐ ing powerless and futile to effect change by relying on traditional approaches to care. For example, measuring a patient's blood sugar according to guidelines is unlikely to provide meaningful benefit to a patient who does not have access to proper food; however, facilitat‐ ing food security is much more challenging and often not included as an indicator of quality health care. Referring a patient to a special‐ ist is relatively straightforward compared to following up on why a patient may not actually show up to an appointment, or advocating that patients ought to be seen by specialists even if they have missed prior appointments. Compounding this complexity are funding mod‐ els that often do not allow clinicians the time or space to provide equity‐oriented care (i.e. client needs may not be well served by tra‐ ditional 10‐min appointments or clinics may not be available within the patient's community).

The purpose of this paper is to explore how women, who are seen by NPs at a primary health care clinic, perceive and rate equity‐ori‐ ented health care practices. This project was undertaken as part of continuous quality improvement (CQI), with a view to gaining valuable information regarding quality of care from the women's perspectives. Drawing on theory and methods developed as part of a larger research programme titled “Equip Primary Health Care for Equity” (known as “EQUIP”), equity‐oriented health care (EOHC) is defined as “an ap‐ proach that aims to reduce the effects of structural inequities, the im‐ pact of multiple and intersecting forms of racism, discrimination and stigma, and the frequent mismatches between dominant approaches to care” (Browne et al., 2018, p. 2). The larger EQUIP research pro‐ gramme involved a multiple‐case study design focused on examin‐ ing the process and impacts of implementing an organizational‐level health equity intervention in primary health care clinics (Browne et al., 2018; Browne, Varcoe, Ford‐Gilboe, & Wathen, 2015; Ford‐Gilboe et al., 2018). The EQUIP research programme was particularly focused on tapping into the perspectives of marginalised patients to inform strategies for enhancing the capacity of clinics and health care organi‐ sations to provide EOHC—and the results of the EQUIP study are pub‐ lished elsewhere (Browne et al., 2018; Ford‐Gilboe et al., 2018; Lavoie, Varcoe, Wathen, Ford‐Gilboe, & Browne, 2018). For purposes of the CQI project discussed in the current paper, EOHC was explored using items developed as part of the EQUIP research programme to explore patients' experiences of care, and adapted for use in a women's only primary health care clinic serving marginalised women. Specifically, as discussed below, 30 items from a larger set of items developed by the EQUIP research team were adapted for use in a women's only primary health care clinic in Canada.

It is important for primary health care providers to reflect and gather patients' experiences with a view to improve the quality of care provided at clinics. Marginalised populations are often not in‐ cluded in research, and it is essential to hear their perspective when providing care to ensure appropriate services are meeting the needs of the population attending the clinic. This increase in understanding

with a view to improve the quality of care overall in an attempt to mitigate health inequity will allow primary health care providers to gain further competence providing such care, leading to an increase in job satisfaction and a decrease in moral distress (Wyatt et al., 2016). The insights from this study will assist nurses, NPs and other primary health care providers to build on and provide care that is ac‐ cessible, trauma‐ and violence‐informed and welcoming for women who face many barriers to health and accessing care.

2   |   B A C K G R O U N D

2.1 | Theoretical perspectives

Equity‐oriented care acknowledges that health inequities are poor outcomes that occur for certain populations as a result of unfair and potentially remediable practices and policies that are unjust (Marmot & Allen, 2014). In Canada and the USA, large proportions of women experience significant health and social inequities due to multiple factors including gender discrimination, poverty, lack of affordable housing and increased exposure to violence and trauma (Bungay, 2013). These structural inequities in turn perpetuate poor health outcomes that often include higher rates of HIV, depression and other stigmatising diseases that lead to varying levels of morbid‐ ity and disability.

The key dimensions of EOHC provided the theoretical frame‐ work for this study (Browne et al., 2015, 2016). These dimensions have been identified in prior publications based on research at primary health care centres in Canada that serve marginalised populations (Browne et al., 2015, 2016, 2012). These key dimen‐ sions of equity‐informed care include the provision of trauma‐ and violence‐informed care, contextually tailored care, culturally safe care and inequity‐responsive care, and have been discussed previously (Browne et al., 2015). In addition, ten strategies have also been identified to provide a guide for organisations to en‐ hance their capacity for equity‐oriented services, including the following: making an explicit commitment to equity, taking mea‐ sures to counteract discrimination, and optimising the use of place and space (Browne et al., 2018). The delivery of equity‐respon‐ sive care requires funding models that provide clinicians the time and space to explore highly sensitive issues with their patients such as trauma, violence, and systemic racism and discrimination. Recognising the key dimensions of EOHC encourages health care providers to work within a framework of social determinants and act as advocates for housing and food security in addition to pro‐ viding basic health care.

2.2 | Methods

2.2.1 | Design

Consistent with the purpose of this paper, descriptive statistics provided baseline information about women's perspectives regard‐ ing the women's experiences of EOHC. A subsequent correlational

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analysis using the Spearman correlation coefficient was performed to examine relationships between dimensions. A particular focus on the dimensions of Promote Emotional Safety and Trust and Non‐Discriminatory Posture and Promote Emotional Safety and Trust and Overall Quality of Care was included. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement was followed for the study (see Appendix S1).

2.2.2 | Setting

The study discussed in this paper was conducted in a primary health care clinic for women in a Western Canadian inner city, where the incomes, living standards and education levels are the lowest in Canada (Salmon, 2009). A group of NPs started working in the clinic to address the lack of fit between traditional primary health care models and underserved, marginalised women in this part of the city. The clinic is located within a nonprofit women's resource centre whose mandate is to help women with housing, income, food security, health care and other resources. The NPs are salaried providers funded through the local health authority that receives funding from the provincial government for NP roles. The centre provides a safe place for women who may be seeking refuge from various types of violence (Lazarus, Chettiar, Deering, Nabess, & Shannon, 2011). In addition to the primary health care clinic, which operates Monday to Friday with drop‐in and sched‐ uled 30‐min appointments, women are able to access computers, coffee, couches and televisions at no cost. Volunteers manage the site and greet and register the clients when they arrive for appointments.

Many of the clients who attend the clinic live in extreme poverty, and have mental health and substance use issues, and most would be considered marginalised, living on the fringes of society (British Columbia Women's Hospital & Health Centre, 2014). Many of these women are survival sex trade workers who provide sex for money to survive, and very often live with boyfriends who act as pimps and supply them with meagre housing, food, and drugs to maintain their reliance on substances, which involves significant harm. Other than managing depression, mental illness and substance use issues, the most common reasons for client visits include treatment for sex‐ ually transmitted infections, scabies, bedbug infestations and skin infections from methicillin‐resistant staphylococcus aureus (British Columbia Women's Hospital & Health Centre, 2014). Patient data re‐ veal that the majority of client visits to the clinic are for gynaecological examinations, screening for STI testing, contraceptive advice and de‐ pression (British Columbia Women's Hospital & Health Centre, 2014).

2.2.3 | Recruitment and sample

Participants were recruited at the primary health care clinic previ‐ ously described. Inclusion criteria were age greater than 19 years, ability to speak and understand English, and attendance at the clinic within the previous 6 months. During the three‐month recruitment

period, a total of 94 women were identified as eligible and invited to participate in the study. Twenty‐six women declined; the most common reason cited was lack of time. One woman did not sign the consent, leaving a total of 67 participants.

The majority of the women were younger than 36 years (56%), born in Canada (75%), identified as Caucasian (58%) and reported an annual income less than $20,000 (57%). Sixteen per cent of the participants identified as an Indigenous person, and 21% of the sample was unemployed (see Table 1 for the details of participant characteristics).

2.2.4 | Data collection

Items from the larger EQUIP study reflect the key dimensions of equity‐oriented health care as identified by the EQUIP research team and were modified for use in the NP clinic to explore women's experiences of EOHC, including 30 Likert‐based items as outlined in Table 2 (Browne et al., 2018, 2015; Ford‐Gilboe et al., 2018). As outlined above, the larger set of items were developed by the EQUIP team based on a comprehensive literature review of a va‐ riety of different scales and analyses related to equity‐based care (Browne et al., 2018, 2015; Ford‐Gilboe et al., 2018; ). The larger set of items were developed from item response theory using pa‐ tient cohort data (n = 567) for the larger EQUIP study (Browne et al., 2018, 2015; Ford‐Gilboe et al., 2018; ). The development of those items is discussed in detail in a prior publication and is sum‐ marised below (Ford‐Gilboe et al., 2018).

Briefly, as part of EQUIP, items for the EQUIP questionnaire were developed to tap aspects of EOHC amenable to patients’ self‐reports and then refined using cognitive interviews with a sample of patients (Ford‐Gilboe et al., 2018). Patients were asked to rate how often in the previous 6 months their health care pro‐ viders had engaged in each action on a 5‐point scale ranging from “never” to “always.” Sample items included “try to make you feel as comfortable as possible”; “seem open to talking about sensi‐ tive issues such as grief, mental health problems, substance use, or abuse experiences”; “ask you about basic resources that affect your health, such as food, clothing, or shelter”; “help you work on any barriers you have to accessing health care”; “give you advice that is suitable for your everyday life”; “have a negative attitude toward you because of mental health concerns.” Scores on these items reflect the degree or level of EOHC, from the patient's per‐ spective, from lower to higher. The larger set of items have since been further refined and published as a 12‐item scale known as the Equity‐oriented Health Care Scale (E‐HoCS), which is now publically available at https ://equip healt hcare.ca/toolkit (Ford‐ Gilboe et al., 2018). For the study discussed in this paper, items from the larger set developed for the EQUIP research programme were used for CQI purposes to tap into women's perspectives on the quality of their care. As we argue, these items are relevant and useful for orienting clinicians to the how of equity‐oriented care—as experienced from the patients' perspective.

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The NPs and the directors at the women's primary health care clinic provided input into the modification of these items to enhance their alignment with the clinic's organisation (e.g. front staff are not

employed, but rather volunteers who welcome and register patients). An Indigenous advisor from the community was also consulted and provided feedback about the 30 selected questions. Basic demo‐ graphic questions were also included. Similar to the larger set of items used in the EQUIP research programme, EOHC items are organised around six domains reflecting the constructs they were designed to evaluate including Promote Accessibility and Reduce Barriers; Welcoming, Comfortable Environment; Promote Emotional Safety and Trust; Non‐Discriminatory Posture; Tailor Care to Individual Context, History and Experience; and Overall Quality of care.

Six volunteers from the clinic assisted with data collection for the study. These volunteers were trained in privacy and confidentiality protocols, as well as de‐escalation, re‐directing and sensitivity training relevant to this client population. Volunteers offered participants the choice to complete the questionnaire on paper or iPad, depending on the preference of the participant. The participants were also given the choice of answering the questionnaire privately or with the assistance of a research volunteer. For those who chose privacy, volunteers were available outside the study room where participants completed the questionnaire, in case they required clarification of any questions.

The researcher flagged potential and eligible participants on the booked appointments each day before the clinic opened. Then, at check‐in, a volunteer asked the eligible client if she was willing to speak to a research volunteer to learn about the study. The women were assured both verbally and in writing that participation was not man‐ datory and that if they chose to participate, their answers would not affect the care they received. The researcher was onsite for all study days and confirmed participant eligibility for the drop‐in patients at the clinic and for any other women using the space. The researcher did not approach potential participants directly due to research ethics board guidelines, but had volunteers work in tandem to recruit participants and administer the survey questionnaire.

All study volunteers were trained with the use of a script in their re‐ cruitment role and reviewed and obtained signed consent from willing participants and immediately gave it to the researcher. The researcher placed the consent in a locked drawer in her office and assigned a study ID number to the participant to assure anonymity on all paper and electronic forms. All files were secured with password and firewall protection. Participants were informed they could skip any questions they felt uncomfortable answering. The questionnaire responses were

T A B L E 1  Participant characteristics

Characteristic Frequency (%)

Gender—female 67 (100)

Age years

19–25 15 (22)

26–35 23 (34)

36–45 7 (10)

46–55 10 (15)

>55 12 (18)

Clinic referral

Friend or family 29 (43)

Flyer/brochure 2 (3)

Just walking by 22 (33)

Internet 14 (21)

Ethno‐cultural background

Caucasian 33 (58)

Indigenous 9 (16)

Other/mixed 15 (26)

Education

No formal school 1 (1)

Elementary school 2 (3)

Incomplete high school 4 (6)

High school graduation 8 (12)

Incomplete technical or college 7 (10)

Technical or college graduation 14 (21)

Incomplete university 12 (18)

University degree(s) 19 (28)

Employment status

Full‐time work or self‐employed 20 (30)

Part‐time work or self‐employed 12 (18)

Unemployed 14 (21)

Sick leave or disability 8 (12)

Student 10 (15)

Homemaker 3 (4)

Main source of income

Employment 28 (42)

Unemployment benefits 1 (1)

Disability benefits 8 (12)

Income assistance 14 (21)

Canada pension plan 3 (4)

Partner/family support 9 (13)

Savings/investments 2 (3)

Other 2 (3)

Serious financial difficulty in the last 6 months 30 (46)

Characteristic Frequency (%)

Household income before taxa

No income 3 (5)

<$12,000 19 (30)

$12,000–$19,000 14 (22)

$20,000–$39,000 13 (21)

$40,000–$59,000 11 (17)

$60,000–79,000 3 (5)

aStatistics Canada Low Income Measure (Poverty Line) for one adult in Canada is $18,000 (Statistics Canada, 2018).

T A B L E 1   (Continued)

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T A B L E 2   Items used to assess women's experiences of equity‐oriented health care adapted for use in a women's primary health care clinic

Domain Questions

Promote accessibility and reduce barriers

In the past 6 months, how often did the Nurse Practitioners at this clinic: Encourage you to come see them or call when you need to? 0 = Never, 1 = Rarely, 2 = Sometimes, 3 = Usually, 4 = Always Try to be flexible in meeting your health care needs? 0 = Never, 1 = Rarely, 2 = Sometimes, 3 = Usually, 4 = Always Help you to work on any barriers you have accessing health care (e.g., costs of medications or services, problems with transportation or childcare, problems getting a referral, etc.)? 0 = Never, 1 = Rarely, 2 = Sometimes, 3 = Usually, 4 = Always Try to help you get health care you needed that was not offered at the clinic, such as contact with medical specialists, tests to diagnose health problems, dentists or counseling? 0 = Never, 1 = Rarely, 2 = Sometimes, 3 = Usually, 4 = Always Try to help you to get services that are not offered at this clinic (such as social assistance, disability benefits, housing, or parenting support)? 0 = Never, 1 = Rarely, 2 = Sometimes, 3 = Usually, 4 = Always Support you to talk about stressful experiences? 0 = Never, 1 = Rarely, 2 = Sometimes, 3 = Usually, 4 = Always How often did you feel that you had enough time with your health care provider? 0 = Never, 1 = Rarely, 2 = Sometimes, 3 = Usually, 4 = Always

Welcoming, comfort‐ able environment

In the past 6 months: How often did the volunteersa welcome you when you came for care? 0 = Never, 1 = Rarely, 2 = Sometimes, 3 = Usually, 4 = Always How often were the volunteers and other clinic staff rude to you? 0 = Never, 1 = Rarely, 2 = Sometimes, 3 = Usually, 4 = Always How often did volunteers and other clinic staff treat you with courtesy and respect? 0 = Never, 1 = Rarely, 2 = Sometimes, 3 = Usually, 4 = Always How helpful do you find the volunteers at the clinic? 0 = Not at all, 1 = Not very, 2 = Somewhat, 3 = Moderately, 4 = Very

Promote emotional safety and trust

In the past 6 months, how often did the Nurse Practitioners at this clinic: Try to make you feel as comfortable as possible? 0 = Never, 1 = Rarely, 2 = Sometimes, 3 = Usually, 4 = Always Explain what they would like to do before taking action (e.g., ordering a test, recommending certain treatments, refer‐ ring you to another provider)? 0 = Never, 1 = Rarely, 2 = Sometimes, 3 = Usually, 4 = Always Ask your permission before touching or examining you? 0 = Never, 1 = Rarely, 2 = Sometimes, 3 = Usually, 4 = Always Seem open to talking about sensitive issues (e.g., grief, mental health problems, substance use, or abuse experiences)? 0 = Never, 1 = Rarely, 2 = Sometimes, 3 = Usually, 4 = Always

Non‐discriminatory posture

In the past 6 months, how often did the Nurse Practitioners at this clinic: Accept you for who you are? 0 = Never, 1 = Rarely, 2 = Sometimes, 3 = Usually, 4 = Always Have a negative attitude toward patients because of drug or alcohol abuse? 0 = Never, 1 = Rarely, 2 = Sometimes, 3 = Usually, 4 = Always Have a negative attitude toward patients because of mental health concerns? 0 = Never, 1 = Rarely, 2 = Sometimes, 3 = Usually, 4 = Always In the past 6 months, how often have you felt discriminated against by staff at this clinic, including the Nurse Practitioners, volunteers and others? 0 = Never, 1 = Rarely, 2 = Sometimes, 3 = Usually, 4 = Always In the past 6 months, how often did the staff talk down to you at this clinic, including the Nurse Practitioners, volun‐ teers, and others? 0 = Never, 1 = Rarely, 2 = Sometimes, 3 = Usually, 4 = Always

(Continues)

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stored on REDCap, a secure online program approved by the Local Institutional Review Board (IRB).

2.2.5 | Data analysis

Data collected from responses to the questionnaire were im‐ ported from the REDCap database into a statistical program for analysis. Descriptive and correlational statistics were conducted. Correlational analysis was used to assess the strength between the domains of Promote Emotional Safety and Trust and Non‐ Discriminatory Posture and Promote Emotional Safety and Trust and Overall Quality of Care. Based on an anticipated moderate to large correlation coefficient (r = 0.4), 46 participants were needed to detect a significant effect with a power of 0.80 and an alpha of 0.05 (Cohen, 1977). Ninety‐four women were recruited as it was anticipated the consent rate would be low which was not the case in the end. The overall purpose of the paper was to gain insight into the perceptions women had about approaches to EOHC in the clinic in an effort to improve the overall quality of care provided, rather than to refine the questionnaire or items.

3   |   R E S U LT S

Women reported high levels in the domains of Welcoming, Comfortable Environment and Non‐Discriminatory Posture. The re‐ sults suggested that 11 out of 15 correlations were statistically signifi‐ cant and greater than rs = 0.35, p < 0.003. The correlations between the items categorised as Promote Accessibility and Reduce Barriers and Welcoming, Comfortable Environment; Promote Accessibility

and Reduce Barriers and Non‐Discriminatory Posture; Welcoming, Comfortable Environment and Tailor Care to Individual Context, History and Experience; and Non‐Discriminatory Posture and Tailor Care to Individual Context, History and Experience were not statisti‐ cally significant, p > 0.003. This indicated a positive relationship be‐ tween the majority of the domains, which was expected. The strongest correlation was present between Promote Emotional Safety and Trust and Overall Quality of Care (rs = 0.75, p < 0.0001). Non‐discriminatory Posture and Promote Emotional Safety and Trust were also positively correlated, however, not as strongly as the former (rs = 0.37, p = 0.005). The weakest correlation was between Welcoming, Comfortable Environment and Tailor Care to Individual Context, History and Experience (rs = 0.36, p = 0.006). The full analysis is detailed in Table 3.

Scores were calculated as a sum of the subscale scores for all of the items under each of the six domains shown in Table 2. If one of the subscales was missing an answer, the score for that participant was not calculated and was counted as missing. Some items were re‐ verse‐scored (e.g. how often were staff rude to you?). In these cases, the scales were reversed (i.e. 1 = 5, 2 = 4, 3 = 3, 4 = 2 and 5 = 1) to create the score. Four of the questions could be answered as nonap‐ plicable (N/A). For these items, the participants were instructed to leave the question blank and data analysis was performed based on this instruction.

Given that the domain items were not normally distributed, the Pearson's correlation coefficient could not be used; therefore, Spearman's rank correlation coefficient was calculated for all pair‐ wise comparisons. The two assumptions of this test were met: the variables were ordinal level, and there was a monotonic relationship between variables (Gibbons & Chakraborti, 2011). There were 30 items spread across six domains (see Table 2), which resulted in 15

Domain Questions

Tailor care to individ‐ ual context, history and experience

In the past 6 months, how often did the Nurse Practitioners at this clinic: Know about what is important to you? 0 = Never, 1 = Rarely, 2 = Sometimes, 3 = Usually, 4 = Always Ask you about who is important in your life? 0 = Never, 1 = Rarely, 2 = Sometimes, 3 = Usually, 4 = Always Ask for your opinion about what’s happening with your health? 0 = Never, 1 = Rarely, 2 = Sometimes, 3 = Usually, 4 = Always Help you address what is important to you about your health? 0 = Never, 1 = Rarely, 2 = Sometimes, 3 = Usually, 4 = Always Support your decisions about how you manage your health? 0 = Never, 1 = Rarely, 2 = Sometimes, 3 = Usually, 4 = Always Ask about basic resources that affect your health, such as food, clothing or shelter? 0 = Never, 1 = Rarely, 2 = Sometimes, 3 = Usually, 4 = Always Give you advice that is suitable for your everyday life? 0 = Never, 1 = Rarely, 2 = Sometimes, 3 = Usually, 4 = Always

Overall quality of care

Overall, do you have confidence in the Nurse Practitioners you have seen at this clinic? 0 = Not at all, 1 = Yes, to Some Extent, 2 = Yes, Definitely Overall, how would you rate the care you received at the clinic over the last 6 months? 0 = Poor, 1 = Fair, 2 = Good, 3 = Very Good, 4 = Excellent I feel emotionally and physically safe within the clinic? 0 = Strongly Disagree, 1 = Disagree, 2 = Neither Agree or Disagree, 3 = Agree, 4 = Strongly Agree

aAt the women's health clinic, receptionists are not employed: instead, volunteers fulfil some of roles that receptionists would normally fill.

T A B L E 2   (Continued)

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pairwise correlations. Applying a Bonferroni correction to the sig‐ nificance cut‐off (alpha) resulted in an adjusted alpha = 0.003 (Abdi, 2007). Therefore, any p‐values < 0.003 were considered to be statis‐ tically significant. A posterior power analysis determined 80% power to detect correlation coefficients of 0.33 or higher.

A strong positive relationship was found between the domains of Promote Emotional Safety and Trust and Overall Quality of Care. Furthermore, analysis revealed these were the two most strongly correlated domains (rs = 0.74; p < 0.0001). A moderately strong re‐ lationship was found between the domains of Non‐Discriminatory Posture and Promote Emotional Safety and Trust (rs = 0.37, p = 0.005). However, Tailor Care to Individual Context, History and Experience was the domain strongly correlated the most number of times, indicating the importance of this domain, perhaps, over Promote Emotional Safety and Trust.

4   |   D I S C U S S I O N

Promote Emotional Safety and Trust and Overall Quality of Care were the most highly correlated domains according to our study participants, indicating how important it is for NPs working in pri‐ mary health care settings to establish a trusting relationship with the women at this clinic to deliver high quality of care. The women also rated Tailor Care to Individual Context, History and Experience highly, which was also positively correlated to three other domains: Promote Accessibility and Reduce Barriers, Overall Quality of Care and Promote Emotional Safety and Trust. Tailoring care to the social and cultural context of women's lives demands that NPs develop an understanding of the lived experience of marginalised women and how inadequate housing, food insecurity and financial pressures im‐ pact health. This is underlined by data from the clinic involved in this research, which indicates 60% of the patients present with social is‐ sues, rather than purely medical issues when seen by the NP (British Columbia Women's Hospital & Health Centre, 2014).

Overall, the results of this exploratory study revealed that the women rated the clinic team highly on all questions indicating they were, in fact, practising equity‐oriented primary health care. This is not surprising as the clinic is committed to equity‐responsive care;

however, how the participants rated the various domains of care is significant. The strongest individual domains were Welcoming, Comfortable Environment and Non‐Discriminatory Posture. The high ratings for the Welcoming, Comfortable Environment questions indicate the need for marginalised women to feel respected and part of an egalitarian community if they are to show up for appointments. The weakest individual dimension was Promote Accessibility and Reduce Barriers, which included questions on helping clients find housing and food security. These are perhaps the most challenging aspects of care; for instance, it is more difficult for a provider to assist a client with affordable housing than it is to monitor blood pressure or discuss harm reduction in the context of substance use. Perhaps these barriers and issues are not emphasised enough during consults, and this represents an area for primary health care provid‐ ers to improve. It is also likely that these types of barriers represent the most difficult aspect of delivering health care to marginalised clients in urban centres where housing, employment and substance use are ongoing concerns.

Our results indicate that inviting patients to rate their experiences of EOHC has the capacity to provide a CQI approach and insight into an organisation's approach to care and can be implemented to begin to tackle such complicated issues within the context of the patient's lived experience. Since the project discussed in this paper was con‐ ducted, and as noted above, the items have been further refined and published as the E‐HoCS (Ford‐Gilboe et al., 2018; ). The E‐HoCS explores patients' perceptions of the extent to which the care they receive reflects cultural safety, trauma‐and violence‐ informed care and contextually tailored care. The E‐HoCS is a valuable tool that can be readily used by the health care team to conduct quality improve‐ ment when trying to improve care for marginalised populations and is a good example of how patients can be involved in framing how care is provided. Nurse practitioners are often leaders of CQI initiatives and can be leaders in recognising the importance of equity‐oriented care within interdisciplinary teams. The overall goal is to improve eq‐ uity‐oriented care that ultimately leads to improved health outcomes overall.

Several insights occurred during data collection, which may assist in the effectiveness of future research at the clinic and other compa‐ rable settings. It is possible that the most marginalised clients at this

T A B L E 3  Correlation table

Reduce barriers Welcoming environment Trust Posture Tailored care

Welcoming, Comfortable Environment

0.35, 0.02 – – – –

Promote Emotional Safety and Trust

0.52, 0.0001 0.39, 0.002 – – –

Non‐Discriminatory Posture 0.02, 0.89 0.36, 0.006 0.37, 0.005 – –

Tailor Care to Individual Context, History and Experience

0.69, <0.0001 0.32, 0.01 0.67, <0.0001 0.13, 0.34 –

Overall Quality of Care 0.46, 0.0006 0.42, 0.004 0.75, <0.0001 0.39, 0.002 0.58, <0.0001

Note: Data shown are correlations (r) and the p‐values. Significant correlations are bolded.

     |  3467PRODAN‐BHALLA AND BROWNE

clinic did not feel comfortable completing the questionnaire and inter‐ acting with research volunteers. In addition, what constitutes “margin‐ alised” is also subjective and difficult to measure. Illustrating this is the fact that the respondents were highly educated (49% graduated from university); however, 21% were unemployed and 57% of the sample earned less than $19,000/year. The clinic is a small space and includes a small group of NPs, volunteers and patients, who collectively create a small, connected community of women. For this reason, it was not al‐ ways possible to keep the identification of the researcher undisclosed and at a distance from study participants. In fact, compliance with the ethics protocol and procedures added a layer of formality to the data collection that on occasion seemed to cause some women to decline to participate in the study. This formality is possibly another reason why we believe the sample did not reflect the most marginalised cli‐ ents; managing more paperwork and steps in the research process cre‐ ated more barriers for some women.

The largest unexpected outcome was the strong relationships between the primary health care providers and the volunteer sup‐ port staff that developed as a result of implementing a research study in the clinic space. The researcher gained an appreciation for the contributions that volunteers make to equity‐oriented primary health care and the extent to which they support the overall health of the women seen at the clinic. In this setting, volunteers act as re‐ ceptionists booking appointments, dealing with scheduling conflicts and fielding complaints with little training. At the same time, the vol‐ unteers act as a resource for the women in terms of finding them food, housing, detox beds and numerous other miscellaneous items such as helping them file their taxes and fax documents. In this way, volunteers are alleviating some of the barriers that are essential to equity‐based health care. The women often self‐disclose to the vol‐ unteers about their relationships, stressors and difficult experiences, information which the NP could use to augment care and make more effective treatment plans; however, due to codes of confidentiality, NPs and volunteers cannot share details about patient care. As a result, the need to protect client confidentiality can be a barrier to effective teamwork and equity‐oriented care.

5   |   L I M I TAT I O N S

Limitations to the study included a small sample size. In addition, de‐ spite assistance, many of the women did not want to use the iPad. Reasons provided to the volunteers were that it would take too much time and it was too much work. It too may have added another ele‐ ment of complexity that was not desired. We noted that in striving to protect marginalised women, the additional protections requested by the ethics review board, in part, further marginalised them. When participants knew they were eligible, they often wanted to proceed in completing the questionnaire immediately instead of being led step by step through the consent process, and then moving to a private room under the guidance of a volunteer. Many participants expressed having no concerns about privacy, but often felt short on time, and as a result were impatient with the inflexibility of the research protocol.

Nonetheless, the willingness of the women to participate was unanticipated. Even though this particular population of margin‐ alised women has been heavily studied by virtue of living in one of Canada's poorest neighbourhoods and are often paid for their participation, not one woman asked about payment for partici‐ pation in this study. Women also heard about the study by word of mouth on the street and would ask to participate even when not eligible, indicating a desire to help the clinic and participate in research.

6   |   F U T U R E R E S E A R C H

Seeking patients' feedback on their experiences of EOHC provides a practical way for NPs and other clinicians to evaluate perceptions of equity‐oriented care within their own settings to better understand individual interactions with marginalised patients at the clinical level and thereby improve equity‐oriented care. Since the research was conducted, the EQUIP team has further refined their understanding of EOHC and how to assess it. The EQUIP team has demonstrated that providing more EOHC in primary health care settings, includ‐ ing 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 enhanc‐ ing patients' comfort and confidence in their care and their own con‐ fidence in preventing and managing health problems" (Ford‐Gilboe et al., 2018, p. 636). In turn, higher levels of confidence predicted improvements in depressive and post‐traumatic stress disorder symptoms, and quality of life, in particular (p. 657). These EOHC measurement tools may also be relevant in other settings and coun‐ tries depending on context, and further research is currently in pro‐ gress to assess their applicability.

There are several interesting ideas for future research that could easily build on this study. Leading the same study at a walk‐in clinic or other primary health care clinic with different funding models as a comparison with these results would allow for a better un‐ derstanding about how this particular clinic and care provided by nurse practitioners fits into the community from an equity‐oriented framework. Certainly, the concept of trust was integral to care in this study. Measuring trust alone and the development of con‐ crete strategies to enhance trusting relationships between clients and the diverse range of interdisciplinary staff that often work in primary health care settings would be useful. Finally, performing research before and after education sessions to the entire team on equity‐oriented care would contribute to the discourse on the practice of equity‐oriented primary health care, and could be used to demonstrate an improvement in key outcomes identified as sen‐ sitive in a marginalised population. Ideally, the ultimate goal of fu‐ ture research would be to demonstrate a link between high levels of equity‐oriented care and improved health outcomes such as levels of depression, substance abuse and chronic disease, which would demonstrate the importance of sustainable funding for health care that is equity‐oriented.

3468  |     PRODAN‐BHALLA AND BROWNE

7   |   C O N C L U S I O N

Inequities in health occur as a result of structural and systemic poli‐ cies that are discriminatory and unfair. Marginalised women are one group who experience a large proportion of health inequities due to gender discrimination and other systemic limiting policies such as a lack of affordable childcare. Primary health care is not only the first point of contact for marginalised women but also the founda‐ tion upon which healthier populations are built. Understanding how women perceive equity‐oriented care in primary health care clinics provides important insights into gaps in equity‐oriented health care practices that are an essential component of improving health equity overall. This paper shared results from one NP clinic working with marginalised women providing a better understanding of how pri‐ mary health care providers can interact with their patients in an at‐ tempt to improve health equity. The use of items designed to tap into EOHC combined with a CQI approach provides hope and renewed direction for clinicians working with marginalised populations by identifying the domains of equity‐based care they are already sup‐ porting, and those areas on which they can improve. Discussing and understanding the what as well as the how to mitigate these inequi‐ ties in health will allow both policy makers and health care profes‐ sionals to fund and practice equity‐oriented care at all levels within the health care system as the path to improve health outcomes over‐ all. Through the improvement of equity‐oriented care, both the NPs and staff volunteers in this study were able to develop a renewed sense of hope and purpose in the care they deliver.

8   |   R E L E VA N C E T O C L I N I C A L P R A C T I C E

The results of this study illustrate the importance of establishing trusting relationships, tailoring care and using a nondiscriminatory approach when working with patients. These approaches can con‐ tribute to enhancing health equity in primary care settings, which, in turn, may lead to better health outcomes overall.

O R C I D

Natasha Prodan‐Bhalla https://orcid. org/0000‐0003‐0053‐0856

Annette J. Browne https://orcid.org/0000‐0002‐6320‐4428

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S U P P O R T I N G I N F O R M AT I O N

Additional supporting information may be found online in the Supporting Information section at the end of the article. 

How to cite this article: Prodan‐Bhalla N, Browne AJ. Exploring women's health care experiences through an equity lens: Findings from a community clinic serving marginalised women. J Clin Nurs. 2019;28:3459–3469. https ://doi. org/10.1111/jocn.14937