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Cited by 17Patient Satisfaction in HealthcareCultural Competency in Health CareHealthcare Quality and Satisfaction

Using a health equity lens to measure patient experiences of care in diverse health care settings

Open access
Browne, Annette J., Varcoe, Colleen, Ford-Gilboe, Marilyn, Wathen, C. Nadine, Wilson, Erin, Bungay, Vicky, Perrin, Nancy·2024·PLOS ONE
DOI 10.1371/journal.pone.0297721PMC PMC11156339
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Abstract

People who are structurally disadvantaged and marginalized often report poor health care experiences, such as inequitable treatment, due to intersecting forms of stigma and discrimination. There are many measures of patient experiences of care, however, few are designed to measure equity-oriented health care. In alignment with ongoing calls to integrate actions in support of health equity, we report on the development and testing of patient-reported experience measures that explicitly use a health equity and intersectional lens. Our analysis focuses on two different scales: the Equity-Oriented Health Care Scale—Ongoing, which was evaluated in primary health care settings where patients have an ongoing relationship with providers over time, and the Equity-Oriented Health Care Scale—Episodic, which was tested in an emergency department where care is provided on an episodic basis. Item Response Theory was used to develop and refine the scales. The psychometric properties of each scale were also evaluated. The Equity-Oriented Health Care Scale—Ongoing was first tested with a cohort of 567 patients. The Equity-Oriented Health Care Scale—Episodic was subsequently tested in an emergency department setting with 284 patients. Results of the Item Response Theory analysis for each scale yielded a brief index that captured the level of equity-oriented care when care is ongoing (12 items) or episodic (9 items). Both scales showed evidence of internal consistency and concurrent validity, based on a high correlation with quality of care. They are brief, easy-to-administer patient-reported experience measures that can support organizations to monitor quality of care. Their availability enhances the possibility of measuring equity-oriented health care in diverse contexts and can provide nuanced understandings of quality of care through an intersectional and equity lens.

AI snapshot

Written from the paper’s full text.

TL;DR

The paper reports the development and psychometric testing of two patient-reported experience measures using a health equity and intersectional lens: the 12-item Equity-Oriented Health Care Scale–Ongoing for primary health care and the 9-item Equity-Oriented Health Care Scale–Episodic for emergency department care. Both brief scales showed evidence of internal consistency and concurrent validity with quality of care.

Key findings

  • The EOHCS–Ongoing was tested with 567 patients across four Canadian primary health care clinics; after confirmatory factor analysis and item response theory, it was reduced to 12 items across five domains, with overall internal consistency of .92 and domain alphas from .65 to .82.
  • The EOHCS–Ongoing total score correlated with overall quality of care (r = .602) and fit of care with needs (r = .599); prior longitudinal analysis reported in the paper showed that more equity-oriented health care predicted improvements in patient health outcomes 18 months later.
  • The EOHCS–Episodic was tested with 284 emergency department patients at Surrey Memorial Hospital; one item was dropped due to poor discrimination (0.99), leaving 9 items, with Cronbach’s alpha of 0.82 and concurrent validity with quality of care of r = 0.61.
  • EOHCS–Episodic scores were lower among patients who self-identified as Indigenous (mean 5.10 vs. 7.14, p < .001), had a recent shelter stay (5.00 vs. 7.02, p = .029), reported greater financial strain (6.66 vs. 7.28, p = .028), had English as a first language (6.70 vs. 7.29, p = .044), or were unemployed (6.37 vs. 7.05, p = .034); scores did not vary by age or gender.

Methods

  • Scale development drew on prior qualitative interviews with 68 patients experiencing marginalization, an initial pool of 52 items, cognitive interviews with five patients, and retention of 32 items for psychometric testing; the EOHCS–Episodic was adapted from the ongoing scale for episodic care using 10 binary yes/no items.
  • The EOHCS–Ongoing was evaluated with 567 patients in four primary health care clinics over two years using confirmatory factor analysis in MPLUS and item response theory in STATA 16.0; the EOHCS–Episodic was tested with 284 emergency department patients using a two-parameter item response theory model in STATA 15.0.
  • Analyses included internal consistency, concurrent validity correlations with quality of care and fit of care, and t-tests of EOHCS–Episodic score differences by age, gender, financial situation, Indigenous identity, and employment status.

Limitations

  • Stated: the EOHCS–Episodic could not be administered at two other emergency department sites because of COVID-19 pandemic restrictions, so it was tested at only one site; the paper also states that further testing is needed for acceptability, feasibility, reliability, and validation in diverse settings.
  • Stated: patient-reported experience measures commonly show ceiling effects, and the EOHCS–Ongoing had highly skewed scores with limited variability before item response theory was used to improve discrimination.
  • Evident: the EOHCS–Ongoing sample came from four primary health care clinics mandated to serve people experiencing major structural disadvantages and marginalization, so findings may not generalize to other primary care populations; the EOHCS–Episodic validation reported concurrent but not longitudinal predictive validity.

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Integrity signals

Registry

Crossref · 10.1371/journal.pone.0297721

Cites

70 of 70 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 84 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    Within each domain, item factor loadings ranged from .47 to .91.

    “Within each domain, item factor loadings ranged from .47 to .91.”
    Quote in the paperSubstantial claim
  • Findingown data

    IRT analysis yielded a brief index capturing level of EOHC: 12 items for ongoing care and 9 items for episodic care.

    “Results of the Item Response Theory analysis for each scale yielded a brief index that captured the level of equity-oriented care when care is ongoing (12 items) or episodic (9 items).”
    Quote in the paperSubstantial claim
  • Findingown data

    Qualitative interviews with 68 marginalized patients accessing PHC in urban Indigenous clinics identified five domains of EOHC: WCM, ARB, TIC, EST, NDP.

    “Analysis of our qualitative interviews with 68 patients experiencing marginalization and accessing PHC in urban Indigenous clinics identified five domains: (1) create a welcoming, comfortable milieu (WCM); (2) promote accessibility and reduce barriers (ARB); (3) tailor care to individual context, history and experience (TIC); (4) promote emotional safety and trust (EST); and (5) convey a non-discr”
    Quote in the paperSubstantial claim
  • Findingown data

    Eight items were identified for deletion, resulting in 24 items remaining.

    “we identified eight items for deletion (at least one from each domain), resulting in 24 items remaining.”
    Quote in the paperSubstantial claim
  • Findingown data

    Recruitment resulted in a sample diverse and generally representative of populations served by SMH.

    “The recruitment efforts resulted in a sample that was diverse and was generally representative of the populations served by SMH.”
    Quote in the paperNot a substantial claim
  • Classified as probably not a substantial claim. 26
  • May combine two claims. 36

  • Classified as probably not a substantial claim.

    Findingreasoning

    Stakeholder review suggested a five-point scale would require discernment not easily made during episodic care, so response options were changed to yes/no.

    “A review by diverse stakeholders suggested that using a five-point scale would require a level of discernment not easily made during an episodic, and often brief, health care encounter; consequently, we changed the response option to a simple yes/no.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Results of the IRT analysis for the final 12 items in the EOHCS-Ongoing scale are shown in Table 2, with items organized from least to most difficult.

    “Results of the IRT analysis for the final 12 items in the scale are shown in Table 2, with items organized in descending order from least to most difficult.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingcitation

    In the SMH sample, 50.2% of respondents reported at least somewhat or very difficult financial strain as measured by the Financial Strain Index.

    “In addition, 50.2% of the respondents reported at least somewhat or very difficult financial strain as measured by the Financial Strain Index (Table 4) [75].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [75] J Ali, 1997, Employment transitions and psychological distress: The contrasting experiences of single and married mothers., J Health Soc Behav source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Findingnone given

    The EOHCS-Ongoing comprises 12 items reflecting five domains of EOHC.

    “The EOHCS–Ongoing is comprised of 12 items that reflect five domains of EOHC.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    In the SMH sample, 48.4% of respondents reported they were not born in Canada.

    “The sample collected at SMH included 48.4% of respondents who reported they were not born in Canada, and 42.3% who reported a first language other than English.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingreasoning

    Ten adapted items were used with binary response options for initial testing in EQUIP Emergency.

    “Ten adapted items were used with the binary response option for our initial testing in EQUIP Emergency, as shown in Table 3.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    The final 12-item pool includes nine of 10 core items and three additional items, with 10 positively worded and two negatively worded items.

    “This item pool includes nine out of 10 core items and three additional items, with 10 positively-worded and two negatively-worded items.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The distribution of scores was highly skewed with limited variability.

    “the distribution of scores was highly skewed with limited variability.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The five patients concurred on clarity and relevance of items and were uniformly positive about patients being invited to respond.

    “They concurred with regard to the clarity and relevance of items, and were uniformly positive about the prospect of patients being invited to respond to these items.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Three of five domains (ARB, EST, TIC) overlapped more than expected, with correlations .92-.96, suggesting redundancy remained.

    “three of the five domains (ARB, EST, TIC) overlapped more than expected (correlations .92-.96), suggesting that redundancy remained.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    EOHCS-Ongoing total scores correlated with overall quality of care (r=.602) and fit of care with needs (r=.599), providing evidence of concurrent validity.

    “Total scores correlated with single-item measures of overall quality of care (r = .602) and fit of care with needs (r = .599), providing evidence of concurrent validity.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Compared to provincial trends, sample had greater representation from people born outside Canada, non-English first language, and Indigenous.

    “Compared to provincial population trends, the sample tended to be more diverse in terms of having greater representation from those born outside of Canada, people who did not have English as their first language, as well as greater representation from people who self-identified as Indigenous.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    With 32 items in five domains, the Chi-square test for the overall model was significant.

    “With 32 items in the model arranged into five domains, the Chi-square test for the overall model was significant (see Table 1).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    In the SMH sample, 42.3% of respondents reported a first language other than English.

    “The sample collected at SMH included 48.4% of respondents who reported they were not born in Canada, and 42.3% who reported a first language other than English.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    A new CFA with 24 items in five domains revealed substantially improved model fit and supported a good fit between the five-domain structure and the item pool.

    “Results of a new CFA conducted with these 24 items (organized into the same five domains) revealed substantially improved model fit and supported a good fit between the five-domain structure of the scale and the item pool.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Sample included representation from people over 65, Indigenous peoples, precarious housing, born outside Canada, and difficulty living on income.

    “This included representation from people over 65, Indigenous peoples, people experiencing precarious housing, people born outside of Canada, and people who found it difficult to live on their income (Table 4).”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingreasoning

    Two items eliminated from EOHCS-Ongoing in development of EOHCS-Episodic were "ask about basic resources that affect your health" and "have a negative attitude toward people using services because of mental health concerns".

    “Two items eliminated from the EOHCS–Ongoing in the development of the EOHCS–Episodic were “ask about basic resources that affect your health” and “have a negative attitude toward people using services because of mental health concerns”.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Internal consistency was .92 for the overall EOHCS-Ongoing scale and .65 to .82 for each domain.

    “Internal consistency was .92 for the overall scale and .65 to .82 for each domain.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Both scales showed evidence of internal consistency and concurrent validity based on a high correlation with quality of care.

    “Both scales showed evidence of internal consistency and concurrent validity, based on a high correlation with quality of care.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    EOHCS-Episodic scores did not vary by age or gender.

    “Scores did not vary by age or gender.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingreasoning

    Through this research, the authors developed two scales that serve as PREMs: one for ongoing or longitudinal care relationships, such as primary care, and another for episodic care, such as EDs, walk-in clinics, urgent care centers, and outpatient departments.

    “Through our research, we have developed two scales that serve as PREMs: one for use in settings where the care relationship is ongoing or longitudinal, such as in primary care, and another for use in settings where care is episodic, such as in EDs, walk-in clinics, urgent care centers, outpatient departments, among others.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: There are strong calls to integrate attention to equity in health care provision and emerging evidence of positive impacts for patients, providers, and organizations.
    • Rests on an assumption: Organizations lack access to brief and reliable ways of measuring whether equity-enhancing innovations have the intended impacts and for whom, and therefore face significant challenges justifying and funding such initiatives.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    During EQUIP Emergency data collection, respondents commented comparing the challenges they experienced accessing care in their countries of origin.

    “In the course of data collection in EQUIP Emergency, respondents commented comparing the challenges they experienced accessing care in their countries of origin.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    People who are structurally disadvantaged experience poorer outcomes on many measures of health and report poorer health care experiences.

    “people who are structurally disadvantaged experience poorer outcomes on many measures of health and report poorer health care experiences [4–7].”
    Quote in the paperSubstantial claim0 of 4 sources checked
    • cites [4] P McLane, 2021, First Nations members’ emergency department experiences in Alberta: A qualitative study., CJEM. source

      Not checked in the free run.

    • cites [5] AJ Browne, 2011, Access to primary care from the perspective of Aboriginal patients at an urban emergency department. Qual Health Res.

      Not checked in the free run.

    • cites [6] C Gilmer, 2020, Homeless patients associate clinician bias with suboptimal care for mental illness, addictions, and chronic pain, J Prim Care Community Health source

      Not checked in the free run.

    • cites [7] SA Bartels, 2023, Emergency department care experiences among members of equity-deserving groups: Quantitative results from a cross-sectional mixed methods study., BMC Emergency Medicine source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable).

    Premisecitation

    Intersectionality offers a perspective for understanding how multiple forms of social inequity interact to produce relative advantages or disadvantages.

    “Intersectionality offers a perspective for understanding how multiple forms of social inequity interact and interrelate to produce relative advantages or disadvantages [22, 23].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [22] Patricia Hill Collins, 2019

      Not checked in the free run.

    • cites [23] PH Collins, 2022, Black feminist thought: 30th anniversary edition: Knowledge, consciousness, and the politics of empowerment: Routledge source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    People avoid seeking care or leave without being seen due to fear of being negatively judged or treated dismissively.

    “In many cases, people avoid seeking care or leave without being seen, due to fear of being negatively judged or treated in a dismissive manner [5, 24, 27–29].”
    Quote in the paperSubstantial claim0 of 5 sources checked
    • cites [5] AJ Browne, 2011, Access to primary care from the perspective of Aboriginal patients at an urban emergency department. Qual Health Res.

      Not checked in the free run.

    • cites [24] C Varcoe, 2022, EQUIP emergency: Can interventions to reduce racism, discrimination and stigma in EDs improve outcomes?, BMC Health Serv Res source

      Not checked in the free run.

    • cites [27] AJ Browne, 2022, Addressing anti-Indigenous racism in Canadian health systems: Multi-tiered approaches are required, Can J Pub Health source

      Not checked in the free run.

    • cites [28] M. Greenwood, 2021, An open invitation to address anti-Indigenous systemic racism, Lancet source

      Not checked in the free run.

    • cites [29] AJ Browne, 2016, Enhancing health care equity with Indigenous populations: Evidence-based strategies from an ethnographic study., BMC Health Serv Res

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Experiences of care are bound up with factors such as feeling treated respectfully and that care is tailored to needs.

    “Experiences of care are bound up with numerous factors such as feeling that one has been treated in a respectful manner (particularly for people who have had past negative experiences), and that care has been tailored to meet their particular needs and priorities [11, 19, 20].”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [11] AJ Browne, 2018, Disruption as opportunity: Impacts of an organizational health equity intervention in primary care clinics., Int J Equity Health source

      Not checked in the free run.

    • cites [19] M Ford-Gilboe, 2018, How equity-oriented health care affects health: Key mechanisms and implications for primary health care practice and policy., Milbank Q source

      Not checked in the free run.

    • cites [20] AJ Browne, 2022

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    CIHI PREMs for in-patient care were developed to measure experiences without explicit attention to stigma and discrimination, limiting focus to involvement in decision-making and treatment options.

    “the Canadian Institute for Health Information’s (CIHI) PREMs for in-patient care [12] were developed to measure experiences without explicit attention to stigma and discrimination [13], limiting the focus of PREMs to involvement in decision-making and treatment options [14].”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [12] Canadian Institute for Health Information, 2022

      Not checked in the free run.

    • cites [13] S Hadibhai, 2018, Developing the first pan-Canadian acute care patient experiences survey., Patient Exp J source

      Not checked in the free run.

    • cites [14] Canadian Institute for Health Information, 2022

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Structurally disadvantaged groups reported significantly more discrimination in EDs and rated their care more poorly than other groups.

    “structurally disadvantaged groups of people reported significantly more discrimination in EDs, and rated their care more poorly than other groups [10].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [10] C Varcoe, 2022, Through an equity lens: Illuminating the relationships among social inequities, stigma and discrimination, and patient experiences of emergency health care., Int J Health Serv source

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductown data

    Research assistants trained in equity-oriented approaches conducted surveys and gathered patient feedback on clarity, meaning, and response options.

    “Research Assistants, trained in equity-oriented approaches including strategies for working respectfully with people who experience significant inequities (and are thus often not included in research), conducted the surveys and gathered patients’ feedback on the clarity, meaning, and response options to the items.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisereasoning

    Ceiling effects occur because many patients rate providers at top levels possibly due to respect or social desirability, and are problematic because they disguise important differences in experiences of care.

    “Ceiling effects occur because many patients rate providers at the top levels possibly because of respect or social desirability, and are problematic because they tend to disguise important differences in experiences of care, including when care is sub-optimal and in need of improvement.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    Many items in EOHCS-Ongoing would be relevant to measuring patient-reported experiences of care in episodic settings.

    “we considered that many of the items in the EOHCS–Ongoing would be relevant to measuring patient’s reported experiences of care.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    The scales are brief, easy-to-administer patient-reported experience measures that can support organizations to monitor quality of care.

    “They are brief, easy-to-administer patient-reported experience measures that can support organizations to monitor quality of care.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    Response options and time frame needed to be adapted to reflect experiences during a single episodic visit.

    “the response options and time frame needed to be adapted to reflect their experiences during a single, episodic visit.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    SMH is the largest ED in British Columbia and serves diverse suburban communities including high proportions of newcomers.

    “SMH is the largest ED in the Canadian province of British Columbia, and serves diverse suburban communities, including high proportions of newcomers, with many who speak a language other than Canada’s two official languages, English or French, at home [67, 68].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [67] K Thomas, 2021, Media framing of emergency departments: A call to action for nurses and other health care providers., BMC Nursing. source

      Not checked in the free run.

    • cites [68] Statistics Canada, 2022, While English and French are still the main languages spoken in Canada, the country’s linguistic diversity continues to grow., Ottawa, ON

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Longitudinal analysis showed that providing more EOHC predicted improvements in important patient health outcomes 18 months later, supporting predictive validity of EOHCS-Ongoing.

    “using path analysis techniques, longitudinal analysis with the EOHCS–Ongoing showed that providing more EOHC predicted improvements in important patient health outcomes 18 months later, supporting predictive validity of the EOHCS–Ongoing.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [19] M Ford-Gilboe, 2018, How equity-oriented health care affects health: Key mechanisms and implications for primary health care practice and policy., Milbank Q source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Structurally disadvantaged groups were significantly less likely to have regular primary care access and significantly more likely to have repeat ED visits, lower acuity presentations, and chronic health problems.

    “structurally disadvantaged groups of people were significantly less likely to have regular primary care access, and significantly more likely to have repeat ED visits, to present to EDs with health issues that were rated as lower acuity, and to present with chronic health problems [10].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [10] C Varcoe, 2022, Through an equity lens: Illuminating the relationships among social inequities, stigma and discrimination, and patient experiences of emergency health care., Int J Health Serv source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    The construct of EOHC and theoretical approach underlying EQUIP PHC and EQUIP Emergency were consistent.

    “The construct of EOHC underpinning EQUIP PHC, and EQUIP Emergency, and the theoretical approach underlying these studies were consistent [24, 36].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [24] C Varcoe, 2022, EQUIP emergency: Can interventions to reduce racism, discrimination and stigma in EDs improve outcomes?, BMC Health Serv Res source

      Not checked in the free run.

    • cites [36] C Varcoe, 2019, EQUIP Emergency: Study protocol for an organizational intervention to promote equity in health care., BMC Health Serv Res source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Study protocol was approved by listed research ethics boards.

    “The study protocol was approved by the research ethics boards of the University of British Columbia, the University of Northern British Columbia, and the research ethics boards of Fraser Health Authority, Northern Health Authority, and Providence Health Care (approval #s H16-03397, H17-01548, and H18-01423).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Interpretationreasoning

    Their availability enhances the possibility of measuring equity-oriented health care in diverse contexts and can provide nuanced understandings of quality of care through an intersectional and equity lens.

    “Their availability enhances the possibility of measuring equity-oriented health care in diverse contexts and can provide nuanced understandings of quality of care through an intersectional and equity lens.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    People who anticipate poor treatment report preparing for health care encounters carefully and engaging with staff with vigilance and distrust, shaping those encounters.

    “people who anticipate poor treatment report preparing for health care encounters as carefully as they can, and engaging with health care staff with vigilance and distrust, undoubtedly shaping those encounters [5, 16, 30].”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [5] AJ Browne, 2011, Access to primary care from the perspective of Aboriginal patients at an urban emergency department. Qual Health Res.

      Not checked in the free run.

    • cites [16] AJ Browne, 2013, Can ethnicity data collected at an organizational level be useful in addressing health and healthcare inequities?, Ethn Health source

      Not checked in the free run.

    • cites [30] C Varcoe, 2009, Harms and benefits: Collecting ethnicity data in a clinical context., Soc Sci Med source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The hospital serves the largest urban Indigenous population among municipalities in BC, with 2.16% (16,300 people) self-identifying as First Nations, Métis, or Inuit.

    “The hospital also serves the largest urban Indigenous population among municipalities in BC, with 2.16% (16,300 people) of the population self-identifying as First Nations, Métis, or Inuit [70–73].”
    Quote in the paperNot a substantial claim0 of 4 sources checked
    • cites [70] Surrey Urban Indigenous Leadership Committee., 2022, Finding our way home: Research on Indigenous homelessness in Surrey., Surrey, BC

      Not checked in the free run.

    • cites [71] Surrey Urban Indigenous Leadership Committee, 2023, Indigenous people in Surrey: Highlights from the census., Surrey, BC

      Not checked in the free run.

    • cites [72] Surrey Urban Indigenous Leadership Committee, 2022, Skookum housing solutions: Our roadmap for change., Surrey, BC

      Not checked in the free run.

    • cites [73] Statistics Canada, 2022, Table 98-10-0266-01 Indigenous identity by Registered or Treaty Indian status: Canada, provinces and territories, census divisions and census subdivisions Ottawa, ON.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Consent was documented on signed consent forms for all participants.

    “Consent was documented on signed consent forms for all participants.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    In health services research, fit between care provided and alignment with patients' needs are considered important features of quality of care.

    “In health services research, the fit between care provided, and the alignment of such care with patients’ needs in the context of their lives, are considered important features of quality of care [66].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [66] M Kunneman, 2023, Making care fit manifesto, BMJ Evidence-Based Medicine source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    EOHCS-Ongoing is a promising measure of EOHC useful for assessing impacts of interventions or monitoring care delivery in PHC.

    “Collectively, psychometric evaluation suggests that the EOHCS–Ongoing is a promising measure of EOHC that may be useful in assessing the possible impacts of interventions to enhance EOHC in PHC settings or in monitoring care delivery as part of Continuous Quality Improvement (CQI).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    Conventional psychometric testing supported validity and reliability of EOHCS-Ongoing, but a different approach was needed to simplify the scale and improve discrimination.

    “while these analyses supported the validity and reliability of the EOHCS–Ongoing based on conventional psychometric testing, we recognized that a different approach was needed to further simplify the scale and improve its ability to capture variation in perceptions of EOHC in order to be useful in research, quality improvement, or decision-making contexts.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    People who experience significant health and social inequities face the greatest challenges accessing primary care, and consequently people increasingly access care in EDs for needs that could be addressed in PHC.

    “The literature confirms that people who experience significant health and social inequities face the greatest challenges accessing primary care; consequently, people are increasingly accessing care in EDs for needs that, if resources were available, could be addressed in the PHC sector [4–6, 26, 50–52].”
    Quote in the paperSubstantial claim0 of 7 sources checked
    • cites [4] P McLane, 2021, First Nations members’ emergency department experiences in Alberta: A qualitative study., CJEM. source

      Not checked in the free run.

    • cites [5] AJ Browne, 2011, Access to primary care from the perspective of Aboriginal patients at an urban emergency department. Qual Health Res.

      Not checked in the free run.

    • cites [6] C Gilmer, 2020, Homeless patients associate clinician bias with suboptimal care for mental illness, addictions, and chronic pain, J Prim Care Community Health source

      Not checked in the free run.

    • cites [26] Public Health Agency of Canada, 2019

      Not checked in the free run.

    • cites [50] E Purkey, 2020, Experience of emergency department use among persons with a history of adverse childhood experiences., BMC Health Serv Res. source

      Not checked in the free run.

    • cites [51] National Collaborating Centre for Indigenous Health, 2019, Access to health services as a social determinant of First nations, Inuit and Métis health Prince George, BC: National Collaborating Centre for Aboriginal Health

      Not checked in the free run.

    • cites [52] TI Shah, 2020, Geographic accessibility to primary care providers: Comparing rural and urban areas in Southwestern Ontario., Can Geogr source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    The use of these scales can highlight how peoples' intersecting social locations impact their experiences of care.

    “The use of these scales can highlight how peoples’ intersecting social locations impact their experiences of care.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Interpretationreasoning

    Both scales are potentially useful in identifying areas of care redesign to prioritize for improvements, and for monitoring the impact of actions to improve care, particularly for patients most impacted by health and social inequities.

    “Both scales are potentially useful in identifying areas of care redesign to prioritize for improvements, and for monitoring the impact of actions to improve care, particularly for patients most impacted by health and social inequities.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Organizations lack access to brief and reliable ways of measuring whether equity-enhancing innovations have the intended impacts and for whom, and therefore face significant challenges justifying and funding such initiatives.

  • May combine two claims.

    Premisecitation

    High proportions of Indigenous peoples face multiple forms of discrimination and stigma when accessing health care, impacting their experience of care.

    “With regard to the lower EOHCS–Episodic scores experienced by Indigenous peoples, these findings are not surprising in the Canadian context and align with ongoing research demonstrating the extent to which high proportions of Indigenous peoples face multiple forms of discrimination and stigma when accessing health care, impacting their experience of care [4, 5, 8, 68, 86].”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [4] P McLane, 2021, First Nations members’ emergency department experiences in Alberta: A qualitative study., CJEM. source

      Not checked in the free run.

    • cites [5] AJ Browne, 2011, Access to primary care from the perspective of Aboriginal patients at an urban emergency department. Qual Health Res.

      Not checked in the free run.

    • cites [8] P McLane, 2022, First Nations status and emergency department triage scores in Alberta: A retrospective cohort study., Can Med Assoc J source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Interpretationreasoning

    While the EOHCS-Ongoing was developed for use in PHC care settings delivering team-based care, it may be appropriate in settings where care is provided by individual providers over time with a roster of patients.

    “While the EOHCS–Ongoing was developed for use in PHC care settings delivering team-based care, it may be appropriate in settings where care is provided by individual providers, for example, physicians or nurse practitioners, where the goal is to provide care over time with a roster of patients.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductcitation

    The authors systematically used an equity lens to study people's experiences of care, identified the key dimensions of EOHC, and derived items to measure experiences that align with those key dimensions.

    “We have systematically used an equity lens to study people’s experiences of care, and from that identified the key dimensions of EOHC, and derived items to measure experiences that align with those key dimensions [11, 19].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [11] AJ Browne, 2018, Disruption as opportunity: Impacts of an organizational health equity intervention in primary care clinics., Int J Equity Health source

      Not checked in the free run.

    • cites [19] M Ford-Gilboe, 2018, How equity-oriented health care affects health: Key mechanisms and implications for primary health care practice and policy., Milbank Q source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    Both the EOHCS-Ongoing and EOHCS-Episodic are brief, easy-to-administer patient self-report scales that can support organizations to effectively monitor quality of care using an intersectional equity lens.

    “Both the EOHCS–Ongoing and EOHCS–Episodic are brief, easy-to-administer patient self-report scales that can support organizations to effectively monitor quality of care using an intersectional equity lens.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Organizations lack access to brief and reliable ways of measuring whether equity-enhancing innovations have the intended impacts and for whom, and therefore face significant challenges justifying and funding such initiatives.

  • Classified as probably not a substantial claim.

    Study design and conductreasoning

    The items in both scales focus on experiences of care in varied settings.

    “Given that the items in both scales focus on experiences of care in varied settings, we have also explored the use of these measures beyond health care services.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    Given ongoing constraints in Canadian health care sectors, diminishing opportunities for continuity of care, and increasing shifts toward episodic health care delivery, the availability of both scales makes it possible to measure EOHC in a wide range of contexts.

    “In view of ongoing constraints in Canadian health care sectors, diminishing opportunities for continuity of care, and increasing shifts toward episodic health care delivery, the availability of both scales makes it possible to measure EOHC in a wide range of contexts.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Organizations lack access to brief and reliable ways of measuring whether equity-enhancing innovations have the intended impacts and for whom, and therefore face significant challenges justifying and funding such initiatives.

  • May combine two claims.

    Premisecitation

    Research shows that once newcomers are able to access care, they tend to rate their care received in Canada highly and report high levels of trust in their providers.

    “Research shows that once newcomers are able to access care, they tend to rate their care received in Canada highly and report high levels of trust in their providers [81–84].”
    Quote in the paperNot a substantial claim0 of 4 sources checked
    • cites [81] N Carter, 2022, Adult newcomers’ perceptions of access to care and differences in health systems after relocation from Syria., Confl Health source

      Not checked in the free run.

    • cites [82] A Zghal, 2021, Exploring the impact of health care provider cultural competence on new immigrant health-related quality of life: A cross-sectional study of Canadian newcomers., J Transcult Nurs source

      Not checked in the free run.

    • cites [83] T-Y Lee, 2014, A descriptive phenomenology study of newcomers’ experience of maternity care services: Chinese women’s perspectives., BMC Health Serv Res source

      Not checked in the free run.

    • cites [84] R Whitley, 2017, Mental health status, health care utilisation, and service satisfaction among immigrants in Montreal: An epidemiological comparison, Can J Psychiatry source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    Both scales have the capacity to shed light on experiences of care using an intersectional lens, providing a more nuanced understanding of EOHC in contrast to focusing on a single dimension.

    “Both scales have the capacity to shed light on experiences of care using an intersectional lens–providing a more nuanced understanding of EOHC–in contrast to focusing on a single dimension.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    The EOHCS-Episodic items reflected the key dimensions of EOHC.

    “The EOHCS–Episodic items reflected the key dimensions of EOHC as discussed above.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationcitation

    The lower EOHCS-Episodic scores experienced by Indigenous peoples are not surprising in the Canadian context and align with ongoing research on discrimination and stigma in health care.

    “With regard to the lower EOHCS–Episodic scores experienced by Indigenous peoples, these findings are not surprising in the Canadian context and align with ongoing research demonstrating the extent to which high proportions of Indigenous peoples face multiple forms of discrimination and stigma when accessing health care, impacting their experience of care [4, 5, 8, 68, 86].”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [4] P McLane, 2021, First Nations members’ emergency department experiences in Alberta: A qualitative study., CJEM. source

      Not checked in the free run.

    • cites [5] AJ Browne, 2011, Access to primary care from the perspective of Aboriginal patients at an urban emergency department. Qual Health Res.

      Not checked in the free run.

    • cites [8] P McLane, 2022, First Nations status and emergency department triage scores in Alberta: A retrospective cohort study., Can Med Assoc J source

      Not checked in the free run.

58 of 58

  • The authors state this as an assumption.

    In PHC contexts, there is an ongoing relationship between patients and a health care setting.

    “The EOHCS–Ongoing was developed in PHC contexts delivering team-based care, in which there is an assumption of an ongoing relationship between patients and a health care setting.”

  • The paper relies on this without support.

    There are strong calls to integrate attention to equity in health care provision and emerging evidence of positive impacts for patients, providers, and organizations.

    “There continues to be strong calls to integrate attention to equity in health care provision, and emerging evidence of positive impacts for patients, providers, and organizations.”

  • The paper relies on this without support.

    Organizations lack access to brief and reliable ways of measuring whether equity-enhancing innovations have the intended impacts and for whom, and therefore face significant challenges justifying and funding such initiatives.

    “However, without access to brief and reliable ways of measuring whether equity-enhancing innovations have the intended impacts, and for whom, organizations will continue to face significant challenges justifying and funding such initiatives.”
3 of 3

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Overall, participants in this study did not experience involuntary psychiatric admission and treatment under the MH Act in ways that are consistent with the principles of equity-oriented care (i.e., care experienced as safe, destigmatizing, trauma- and violence-informed, culturally-safe, harm reduction-oriented, anti-racist, and gender-affirming).

    “In summary, our findings demonstrate that, overall, participants in this study did not experience involuntary psychiatric admission and treatment under the MH Act in ways that are consistent with the principles of equity-oriented care (i.e., care experienced as safe, destigmatizing, trauma- and violence-informed, culturally-safe, harm reduction-oriented, anti-racist, and gender-affirming) [25,26].”

    From “Backed into a Corner”: Lived experiences of receiving and providing involuntary psychiatric treatment under British Columbia’s Mental Health Act (2026) · cites this paper as [26]

    The Background (page unavailable) defines equity-oriented care in terms of trauma- and violence-informed care, culturally safe care, harm reduction, reducing stigma, and antiracism. It does not identify gender-affirming care as a dimension. The finding about participants’ experiences of involuntary psychiatric admission is the citing authors’ own conclusion, not a finding attributed to this source. (LLM, conf=0.84)

    Experimental — accuracy not yet measured

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • ED-visit counts exceed the stated sample size

    Minor

    The table is labeled as describing 284 patients, but its ED-visit categories contain 793 and 834 patients, totaling 1,627. These counts cannot describe the stated sample.

  • CFA result is called a good fit despite missing the stated cutoff

    Minor

    The paper defines a good CFI fit as at least .95, but the 24-item model's CFI is .934. Its RMSEA of .06 also falls in the paper's stated "fair fit" range, rather than its "close fit" range.

2 of 2

Cites

Flagged first, then by citations

1 of the 71 references couldn’t be matched to a known paper.

Research works printed but not linked: 23

  1. K. Mate, 2022, On the quintuple aim: Why expand beyond the triple aim?
  2. Canadian Institute for Health Information, 2022, Looking at PREMs through the lens of health equity
  3. AJ Browne, 2022, Taking action at the organizational level: Creating a context for implementing trauma- and violence-informed care in health care and other sectors., 1953
  4. Public Health Agency of Canada, 2019, Addressing stigma: Towards a more inclusive health system
  5. University of Toronto, 2022, Women’s health in Canada: Challenges of Intersectionality
  6. Panel on Research Ethics, 2022, TCPS 2 (2022)–Chapter 9: Research involving the First Nations, Inuit, and Métis Peoples of Canada: Government of Canada;
  7. C Varcoe, 2024, Fourth Canadian Edition ed
  8. EQUIP Health Care, 2022, Substance use health
  9. Community Addictions Peer Support Association, 2021, Understanding substance use health: A matter of equity
  10. Emergency Department (ED) visits: Volumes and median length of stay by triage level, 2014, visit disposition, and main problem
  11. National Collaborating Centre for Indigenous Health, 2019, Access to health services as a social determinant of First nations, Inuit and Métis health Prince George, BC: National Collaborating Centre for Aboriginal Health
  12. C Varcoe, 2023, Implementing trauma- and violence-informed care: A handbook for health and social services, 25
  13. LK Muthén, 2006, Mplus user’s guide: Statistical analysis with latent variables: User’s guide
  14. Statistics Canada, 2022, While English and French are still the main languages spoken in Canada, the country’s linguistic diversity continues to grow., Ottawa, ON
  15. Statistics Canada, 2010, Canada’s ethnocultural mosaic, 2006 census: Definitions Ottawa, ON.
  16. Surrey Urban Indigenous Leadership Committee., 2022, Finding our way home: Research on Indigenous homelessness in Surrey., Surrey, BC
  17. Surrey Urban Indigenous Leadership Committee, 2023, Indigenous people in Surrey: Highlights from the census., Surrey, BC
  18. Surrey Urban Indigenous Leadership Committee, 2022, Skookum housing solutions: Our roadmap for change., Surrey, BC
  19. Statistics Canada, 2022, Table 98-10-0266-01 Indigenous identity by Registered or Treaty Indian status: Canada, provinces and territories, census divisions and census subdivisions Ottawa, ON.
  20. Statistics Canada, 2017, British Columbia [province] and Canada [country] (table) Ottawa, ON: Statistics Canada Catalogue no. 98-316-X2016001
  21. Population Data BC, 2019, Patient centered measurement data—The emergency department 2018 survey
  22. Public Health Agency of Canada, 2020, From risk to resilience: An equity approach to COVID-19
  23. Statistics Canada, 2022, Census profile., Ottawa, ON.

Cited by

Sorted by citations

Related

Authors
Browne, A. J., Varcoe, C., Ford-Gilboe, M., Wathen, C. N., Wilson, E., Bungay, V., & Perrin, N.
Affiliations
  • University of British Columbia (CA)
  • Western University (CA)
  • University of Northern British Columbia (CA)
  • Johns Hopkins University (US)
Corresponding author
Browne, Annette J.
ORCID
Venue
PLOS ONE
Publisher
Public Library of Science (PLoS)
Published
2024-06-06
Volume
19
Issue
6
Pages
e0297721
ISSN
1932-6203 (ISSN-L)
DOI
10.1371/journal.pone.0297721
PMC
PMC11156339
OpenAlex
W4399394180
Semantic Scholar
1002784f4613a70438ecf96f2cd2c103c3bf1659
Cited by
17
References
71
Citations by year
2026: 9 · 2025: 8
FWCI
9.92
Type
journal article
Language
en
Open access
Licence
Locations
  • PLoS ONE (publishedVersion, cc-by)
  • medRxiv (acceptedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
Funders
  • Canadian Institutes of Health Research (#PJT148832)
  • SSHRC (Tier 1) Canada Research Chair
  • Women's Health Research Chair in Rural Health
Topics
  • Health Sciences › Health Professions › General Health Professions › Patient Satisfaction in Healthcare
  • Social Sciences › Sociology and Political Science › Cultural Competency in Health Care
  • Health Sciences › Health Professions › General Health Professions › Healthcare Quality and Satisfaction
Keywords
health equity, patient experience, patient-reported experience measures, intersectionality, structural disadvantage, primary care, emergency department care, scale development, psychometric properties, quality of care monitoring
MeSH terms
Health Equity, Adult, Aged, Emergency Service, Hospital, Female, Humans, Male, Middle Aged, Primary Health Care, Psychometrics, Quality of Health Care, Surveys and Questionnaires, Patient Satisfaction, Healthcare Disparities

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-10.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-10.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

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