Health Equity Implementation Framework to Understand Patient Experiences of Health Inequities in Practice

Background and Purpose: Notable inequities in patient experiences exist in the healthcare system. Communities with a large concentration of blacks and immigrants are often marginalized rather than centralized in the healthcare system. These inequities may fuel distrust and exacerbate adverse outcomes, thereby widening the health gap. To address health inequities, a consortium of academic institutions, patient advocacy councils, community stakeholders, and healthcare safety net institutions who serve Central Brooklyn partnered to develop the Brooklyn Health Equity Index (BKHI), tailored to the needs and experiences of residents of Central Brooklyn. The BKHI comprises three phases: (1) community-driven qualitative data collection, (2) development of the BKHI prototype and pilot testing, and (3) wide dissemination. In Phase one, we evaluated patient experiences in Central Brooklyn, providing opportunities for community hospitals to discover quality improvement initiatives so they may provide better patient care and improve patient outcomes. We report on the first phase of the Brooklyn Health Equity Index.

Methods: Using the Health equity implementation framework and a review of the literature, we developed separate guides(protocol) in advance for conducting focus groups (FGs) and key informant interviews. The guides were developed based on the following a priori themes: addressing disparities, discrimination in health care, trust/medical mistrust, implicit bias, provider responsiveness, cultural sensitivity, structural competency, social health determinants, and patient safety. In this qualitative study, we used a purposive sampling method to recruit 62 participants aged 21–76 years from 10 focus groups (FGs) and 18 key informant interviews with stakeholders across Central Brooklyn. The ten FGs ranging from 4-8 members for patients, community patient advocates, and medical students, and the 18 key informant interviews with hospital administrators, health care providers, and community patient advocates. Interpretative phenomenological analysis (IPA) was used as the guiding approach to explore the participants’ lived experiences.

Findings: Three major themes emerged from the qualitative data: trust, discrimination, and social determinants of health (SDOHs). Participants widely recognize that there is a lack of trust, and that discrimination exists between providers and patients. According to both providers and patients, trust-building is fostered not only on race concordance but also on empathy and respectful communication. Among our key informants who worked in safety net settings, there was a heightened awareness of institutional racism and social determinants of health. The findings of this qualitative study informed the development of the eleven items of the BKHI instrument in phase 11.

Conclusion and Implications for Policy or Practice: The healthcare system urgently needs changes that give patients a voice to combat disparities in healthcare. Implementing health system improvements based on feedback from patients on their unique experiences seeking care is an important step toward a more equitable health system.