title: Enhancing measurement of primary health care indicators using an equity lens: An ethnographic study.
abstract: BACKGROUND
  One important goal of strengthening and renewal in primary healthcare (PHC) is achieving health equity, particularly for vulnerable populations. There has been a flurry of international activity toward the establishment of indicators relevant to measuring and monitoring PHC. Yet, little attention has been paid to whether current indicators: 1) are sensitive enough to detect inequities in processes or outcomes of care, particularly in relation to the health needs of vulnerable groups or 2) adequately capture the complexity of delivering PHC services across diverse groups. The purpose of this paper is to contribute to the discourse regarding what ought to be considered a PHC indicator and to provide some concrete examples illustrating the need for modification and development of new indicators given the goal of PHC achieving health equity.
  
  
  METHODS
  Within the context of a larger study of PHC delivery at two Health Centers serving people facing multiple disadvantages, a mixed methods ethnographic design was used. Three sets of data collected included: (a) participant observation data focused on the processes of PHC delivery, (b) interviews with Health Center staff, and (c) interviews with patients.
  
  
  RESULTS
  Thematic analysis suggests there is a disjuncture between clinical work addressing the complex needs of patients facing multiple vulnerabilities such as extreme levels of poverty, multiple chronic conditions, and lack of housing and extant indicators and how they are measured. Items could better measure and monitor performance at the management level including, what is delivered (e.g., focus on social determinants of health) and how services are delivered to socially disadvantaged populations (e.g., effective use of space, expectation for all staff to have welcoming and mutually respectful interactions). New indicators must be developed to capture inputs (e.g., stability of funding sources) and outputs (e.g., whole person care) in ways that better align with care provided to marginalized populations.
  
  
  CONCLUSIONS
  The current emphasis on achieving greater equity through PHC, the continued calls for the renewal and strengthening of PHC, and the use of monitoring and performance indicators highlight the relevance of ensuring that there are more accurate methods to capture the complex work of PHC organizations.
authors: University of British Columbia (UBC) School of Nursing, Critical Research in Health and Health care Inequities, 2211 Wesbrook Mall, Vancouver, British Columbia, V6T-2B5, Canada. sabrina.wong@nursing.ubc.ca.
authors: Sabrina T
authors: ST
authors: Wong
authors: Annette J
authors: AJ
authors: Browne
authors: Colleen
authors: C
authors: Varcoe
authors: Josée
authors: J
authors: Lavoie
authors: Victoria
authors: V
authors: Smye
authors: Olive
authors: O
authors: Godwin
authors: Doreen
authors: D
authors: Littlejohn
authors: David
authors: D
authors: Tu