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      Diverse community leaders’ perspectives about quality primary healthcare and healthcare measurement: Qualitative community-based participatory research

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          Abstract

          Background

          Healthcare quality measurements in the United States illustrate disparities by racial/ethnic group, socio-economic class, and geographic location. Redressing healthcare inequities, including measurement of and reimbursement for healthcare quality, requires partnering with communities historically excluded from decision-making. Quality healthcare is measured according to insurers, professional organizations and government agencies, with little input from diverse communities. This community-based participatory research study aimed to amplify the voices of community leaders from seven diverse urban communities in Minneapolis-Saint Paul Minnesota, view quality healthcare and financial reimbursement based on quality metric scores.

          Methods

          A Community Engagement Team consisting of one community member from each of seven urban communities —Black/African American, Lesbian-Gay-Bisexual-Transgender-Queer-Two Spirit, Hmong, Latino/a/x, Native American, Somali, and White—and two community-based researchers conducted listening sessions with 20 community leaders about quality primary healthcare. Transcripts were inductively analyzed and major themes were identified.

          Results

          Listening sessions produced three major themes, with recommended actions for primary care clinics.

          #1: Quality Clinics Utilize Structures and Processes that Support Healthcare Equity.

          #2: Quality Clinics Offer Effective Relationships, Education, and Health Promotion.

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

          Conclusion

          Community leaders identified ideal characteristics of quality primary healthcare, most of which are not currently measured. They expressed concern that linking clinic payment with quality metrics without considering social and structural determinants of health perpetuates social injustice in healthcare.

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          Most cited references42

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          Structural racism and health inequities in the USA: evidence and interventions

          The Lancet, 389(10077), 1453-1463
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            Racism as a Determinant of Health: A Systematic Review and Meta-Analysis

            Despite a growing body of epidemiological evidence in recent years documenting the health impacts of racism, the cumulative evidence base has yet to be synthesized in a comprehensive meta-analysis focused specifically on racism as a determinant of health. This meta-analysis reviewed the literature focusing on the relationship between reported racism and mental and physical health outcomes. Data from 293 studies reported in 333 articles published between 1983 and 2013, and conducted predominately in the U.S., were analysed using random effects models and mean weighted effect sizes. Racism was associated with poorer mental health (negative mental health: r = -.23, 95% CI [-.24,-.21], k = 227; positive mental health: r = -.13, 95% CI [-.16,-.10], k = 113), including depression, anxiety, psychological stress and various other outcomes. Racism was also associated with poorer general health (r = -.13 (95% CI [-.18,-.09], k = 30), and poorer physical health (r = -.09, 95% CI [-.12,-.06], k = 50). Moderation effects were found for some outcomes with regard to study and exposure characteristics. Effect sizes of racism on mental health were stronger in cross-sectional compared with longitudinal data and in non-representative samples compared with representative samples. Age, sex, birthplace and education level did not moderate the effects of racism on health. Ethnicity significantly moderated the effect of racism on negative mental health and physical health: the association between racism and negative mental health was significantly stronger for Asian American and Latino(a) American participants compared with African American participants, and the association between racism and physical health was significantly stronger for Latino(a) American participants compared with African American participants. Protocol PROSPERO registration number: CRD42013005464.
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              What can “thematic analysis” offer health and wellbeing researchers?

              The field of health and wellbeing scholarship has a strong tradition of qualitative research—and rightly so. Qualitative research offers rich and compelling insights into the real worlds, experiences, and perspectives of patients and health care professionals in ways that are completely different to, but also sometimes complimentary to, the knowledge we can obtain through quantitative methods. There is a strong tradition of the use of grounded theory within the field—right from its very origins studying dying in hospital (Glaser & Strauss, 1965)—and this covers the epistemological spectrum from more positivist forms (Glaser, 1992, 1978) through to the constructivist approaches developed by Charmaz (2006) in, for instance, her compelling study of the loss of self in chronic illness (Charmaz, 1983). Similarly, narrative approaches (Riessman, 2007) have been used to provide rich and detailed accounts of the social formations shaping subjective experiences of health and well-being (e.g., Riessman, 2000). Phenomenological and hermeneutic approaches, including the more recently developed interpretative phenomenological analysis (Smith, Flowers, & Larkin, 2009), are similarly regularly used in health and wellbeing research, and they suit it well, oriented as they are to the experiential and interpretative realities of the participants themselves (e.g., Smith & Osborn, 2007). Thematic analysis (TA) has a less coherent developmental history. It appeared as a “method” in the 1970s but was often variably and inconsistently used. Good specification and guidelines were laid out by Boyatzis (1998) in a key text focused around “coding and theme development” that moved away from the embrace of grounded theory. But “thematic analysis” as a named, claimed, and widely used approach really “took off” within the social and health sciences following the publication of our paper Using thematic analysis in psychology in 2006 (Braun & Clarke, 2006; see also Braun & Clarke, 2012, 2013; Braun, Clarke, & Rance, 2014; Braun, Clarke, & Terry, 2014; Clarke & Braun, 2014a, 2014b). The “in psychology” part of the title has been widely disregarded, and the paper is used extensively across a multitude of disciplines, many of which often include a health focus. As tends to be the case when analytic approaches “mature,” different variations of TA have appeared: ours offer a theoretically flexible approach; others (e.g., Boyatzis, 1998; Guest, MacQueen, & Namey, 2012; Joffe, 2011) locate TA implicitly or explicitly within more realist/post-positivist paradigms. They do so through, for instance, advocating the development of coding frames, which facilitate the generation of measures like inter-rater reliability, a concept we find problematic in relation to qualitative research (see Braun & Clarke, 2013). Part of this difference results from the broad framework within which qualitative research is conducted: a “Big Q” qualitative framework, or a “small q” more traditional, positivist/quantitative framework (see Kidder & Fine, 1987). Qualitative health and wellbeing researchers will be researching across these research traditions—making TA a method well-suited to the varying needs and requirements of a wide variety of research projects. Despite the widespread uptake of TA as a formalised method within the qualitative analysis canon, and within health and wellbeing research, we often get emails from researchers saying they have been queried about the validity of TA as a method, or as a method suitable for their particular research project. For instance, we get emails from doctoral students or potential doctoral students, who have been told that “TA isn't sophisticated enough for a doctoral project” or emails from researchers who have been told that TA is only a descriptive or positivist method that requires no interpretative analysis. We get emails from people asking how to respond to reviewer queries on articles submitted for publication, where the validity of TA has been raised. We get so many emails, that we've created a website with answers to many of the questions we get: www.psych.auckland.ac.nz/thematicanalysis. The queries or critiques often reveal a lack of understanding about the potential of TA, and also about the variability and flexibility of the method. They often seem to assume a realist, descriptive method, and a method that lacks nuance, subtlety, or interpretative depth. This is incorrect. TA can be used in a realist or descriptive way, but it is not limited to that. The version of TA we've developed provides a robust, systematic framework for coding qualitative data, and for then using that coding to identify patterns across the dataset in relation to the research question. The questions of what level patterns are sought at, and what interpretations are made of those patterns, are left to the researcher. This is because the techniques are separate from the theoretical orientation of the research. TA can be done poorly, or it can be done within theoretical frameworks you might disagree with, but those are not reasons to reject the whole approach outright. TA offers a really useful qualitative approach for those doing more applied research, which some health research is, or when doing research that steps outside of academia, such as into the policy or practice arenas. TA offers a toolkit for researchers who want to do robust and even sophisticated analyses of qualitative data, but yet focus and present them in a way which is readily accessible to those who aren't part of academic communities. And, as a comparatively easy to learn qualitative analytic approach, without deep theoretical commitments, it works well for research teams where some are more and some are less qualitatively experienced. Ultimately, choice of analytic approach will depend on a cluster of factors, including what topic the research explores, what the research question is, who conducts the research, what their research experience is, who makes up the intended audience(s) of the research, the theoretical location(s) of the research, the research context, and many others. Some of these are somewhat fluid, some are more fixed. Ultimately, we advocate for an approach to qualitative research which is deliberative, reflective, and thorough. TA provides a tool that can serve these purposes well, but it doesn't serve every purpose. It can be used widely for health and wellbeing research, but it also needs to be used wisely. Virginia Braun School of Psychology, The University of AucklandPrivate Bag 92019, Auckland Mail Centre 1142Auckland, New ZealandEmail: v.braun@auckland.ac.nz Victoria Clarke Department of Health and Social Sciences, University of the West of EnglandBristol BS16 1QY, UK
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                Author and article information

                Contributors
                kpera@mncare.org
                spergament@mncare.org
                yang0858@umn.edu
                patt0346@d.umn.edu
                naciimad@gmail.com
                ckaigama@mncare.org
                Mrsoto12@smumn.edu
                mscandrett@msstrat.com
                thaom@uwosh.edu
                sati0003@umn.edu
                Journal
                Int J Equity Health
                Int J Equity Health
                International Journal for Equity in Health
                BioMed Central (London )
                1475-9276
                18 October 2021
                18 October 2021
                2021
                : 20
                : 226
                Affiliations
                [1 ]Minnesota Community Care, Inc., 895 E 7th, St. Saint Paul, MN 55106 USA
                [2 ]GRID grid.17635.36, ISNI 0000000419368657, Program in Health Disparities Research, , University of Minnesota, ; 717 Delaware St. SE, Minneapolis, MN 55414 USA
                [3 ]GRID grid.17635.36, ISNI 0000000419368657, Department of Family and Community Medicine, , University of Minnesota, ; 420 Delaware Street SE, Minneapolis, MN 55455 USA
                [4 ]Minnesota Health Care Safety Net Coalition, 1113 East Franklin Ave #202B, Minneapolis, MN 55404 USA
                [5 ]GRID grid.267474.4, ISNI 0000 0001 0674 4543, Department of Anthropology, Global Religions and Cultures, , University of Wisconsin-Oshkosh, ; 800 Algoma Blvd, Oshkosh, WI 54901 USA
                Author information
                http://orcid.org/0000-0001-9560-1260
                Article
                1558
                10.1186/s12939-021-01558-4
                8521261
                34663330
                a1499a37-dd81-41ff-b940-0276cf1f7bc3
                © The Author(s) 2021

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

                History
                : 25 June 2021
                : 23 September 2021
                Funding
                Funded by: Minnesota Department of Health
                Funded by: FundRef http://dx.doi.org/10.13039/100000968, American Heart Association;
                Funded by: Minnesota Community Care
                Categories
                Research
                Custom metadata
                © The Author(s) 2021

                Health & Social care
                primary care quality metrics,healthcare inequities,pay-for-performance,value-based payments,community-based participatory research (cbpr)

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