Embedding an Intersectional Lens: Measuring and Mobilizing SDOH Data for Equity in Community-Based Primary Care

Background: Health systems worldwide are seeking ways to embed equity and person-centredness into primary care. Yet despite growing awareness of the social determinants of health, many primary care indicators track system averages, making it difficult to see where inequities persist for communities facing social disadvantage.

 

Community Health Centres (CHCs) in Ontario are uniquely positioned to address these inequities through their mandate to serve people facing poverty, racism, gender inequities, disability, and migration-related barriers. Recognizing the potential of CHCs’ rich social determinant data, a new partnership was established between the Alliance for Healthier Communities, academic researchers, and community partners to develop and apply intersectional analytic methods within CHC data systems.

 

Approach: The partnership brings together data infrastructure, analytic expertise, and community knowledge to operationalize intersectionality within the Alliance’s Business Intelligence Reporting Tool (BIRT), a province-wide digital system capturing social, demographic, and health data from CHCs. The initial phase of this collaboration focuses on intersectional data modelling, collaborative interpretation and co-designing knowledge products that can generate actionable, equity-oriented insights for community-based primary care.

 

Stakeholder engagement is foundational to this collaboration. The work is guided by client and community research partners, academic researchers, health system leaders, and policy makers, ensuring that multiple forms of expertise inform each stage of the project. Together, these collaborators are shaping the project’s focus on understanding who remains unattached to primary care, uncovering intersecting inequities in chronic disease management and cancer screening, and ensuring that data interpretation is grounded in community realities rather than purely statistical perspectives.

 

Results: The formation of this partnership represents a significant milestone in advancing equitable community-based primary care analytics in Ontario. Through the early stages of collaboration, the team has established a co-governance structure that balances academic, operational, and community leadership, ensuring shared decision-making and accountability. Partners have collectively developed a framework for embedding intersectionality into Community Health Centre (CHC) performance monitoring and integrating social determinant data into real-time, equity-focused learning cycles.

 

 The partnership has also strengthened both relational and technical capacity across the CHC network, positioning teams to use digital health data for continuous equity improvement. Most importantly, the collaboration has cultivated a shared commitment to using data not only for measurement, but as a tool for transformation in support of person-centred, equitable healthcare delivery.

 

Implications: This emerging partnership demonstrates how co-produced research can bridge the gap between digital health innovation, health services delivery, and health equity within community-based primary care. By embedding intersectional analytics into existing digital data systems, the collaboration directly contributes to achieving the Quintuple Aim.

 

This research also contributes to the broader field of knowledge mobilization by demonstrating how co-produced, intersectional analytics can inform organizational change and policy implementation. Policymakers and funders will gain evidence-based insights into how intersectional analyses can reduce health disparities and ensure that future initiatives achieve equitable attachment across all population groups.