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EQUIP Healthcare: An overview of a multi-component intervention to enhance equity-oriented care in primary… Browne, Annette J; Varcoe, Colleen; Ford-Gilboe, Marilyn; Wathen, C. N Dec 14, 2015

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STUDY PROTOCOL Open AccessEQUIP Healthcare: An overview of amulti-component intervention to enhanceequity-oriented care in primary health caresettingsAnnette J. Browne1*, Colleen Varcoe1, Marilyn Ford-Gilboe2, C. Nadine Wathen3 on behalf of theEQUIP Research TeamAbstractBackground: The primary health care (PHC) sector is increasingly relevant as a site for population healthinterventions, particularly in relation to marginalized groups, where the greatest gains in health status can beachieved. The purpose of this paper is to provide an overview of an innovative multi-component, organizational-level intervention designed to enhance the capacity of PHC clinics to provide equity-oriented care, particularly formarginalized populations. The intervention, known as EQUIP, is being implemented in Canada in four diverse PHCclinics serving populations who are impacted by structural inequities. These PHC clinics serve as case studies for theimplementation and evaluation of the EQUIP intervention. We discuss the evidence and theory that provide thebasis for the intervention, describe the intervention components, and discuss the methods used to evaluate theimplementation and impact of the intervention in diverse contexts.Design and methods: Research and theory related to equity-oriented care, and complexity theory, are central tothe design of the EQUIP intervention. The intervention aims to enhance capacity for equity-oriented care at thestaff level, and at the organizational level (i.e., policy and operations) and is novel in its dual focus on:(a) Staff education: using standardized educational models and integration strategies to enhance staff knowledge,attitudes and practices related to equity-oriented care in general, and cultural safety, and trauma- and violence-informed care in particular, and;(b) Organizational integration and tailoring: using a participatory approach, practice facilitation, and catalyst grantsto foster shifts in organizational structures, practices and policies to enhance the capacity to deliver equity-oriented care, improve processes of care, and shift key client outcomes.Using a mixed methods, multiple case-study design, we are examining the impact of the intervention in enhancingstaff knowledge, attitudes and practices; improving processes of care; shifting organizational policies and structures;and improving selected client outcomes.(Continued on next page)* Correspondence: annette.browne@ubc.ca1School of Nursing, The University of British Columbia, T201 – 2211Wesbrook Mall, Vancouver, BC V6T 2B5, CanadaFull list of author information is available at the end of the article© 2015 Browne et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. 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.Browne et al. International Journal for Equity in Health  (2015) 14:152 DOI 10.1186/s12939-015-0271-y(Continued from previous page)Discussion: The multiple case study design provides an ideal opportunity to study the contextual factors shapingthe implementation, uptake and impact of our tailored intervention within diverse PHC settings. The EQUIPintervention illustrates the complexities involved in enhancing the PHC sector's capacity to provide equity-orientedcare in real world clinical contexts.Keywords: Health equity, Health inequities, Intervention research, Case study, Trauma- and violence-informedcare, Cultural safety, Primary health care, Primary care, Indigenous populations, Marginalized populations,Structural violenceBackground: Why enhance capacity forequity-oriented PHC services?Research shows that the primary health care1 (PHC) sectoris increasingly relevant as a site for population health inter-ventions, particularly in relation to marginalized 2 groups,where the greatest gains in health status can be achieved[1–8]. Broad-based PHC interventions – that integrate ac-cessible, high quality services with structural and/or policychanges to improve people’s access to the social determi-nants of health – may be one of the most effective meansof achieving health equity for marginalized populations [1,9]. However, few such interventions have been developedand tested, particularly in the Canadian context.Despite Canada’s national health care program, healthand health care inequities are increasing in the contextof oppressive neoliberal health and social policies [10–12]. Health inequities can be understood as socially con-structed, unjust, and avoidable differences in health andwell-being between and within groups of people [13].These inequities structure patterns of individual ill healthand population-level morbidity and mortality rates [14].Equity in health is, therefore, a social justice goal focusedon pursuing the highest possible standard of health andhealth care for all people, paying special attention to thoseat greatest risk of poor health, and taking into accountbroader socio-political and economic influences on healthand access to care [14, 15].Research on PHC delivery at the population level high-lights two persistent problems: (a) inverse care (i.e.,those who are most marginalized and have the greatesthealth problems have the least access to care); and (b)fragmentation and under-resourcing of care for margin-alized populations, even in high income countries [1].There are significant gaps in knowledge concerning: how tomake services as responsive as possible for marginalizedpopulations by more adequately addressing the health ef-fects of structural inequities; how to make PHC servicesmore socially relevant; and how to create policy and fund-ing environments to support these aims [1, 16, 17]. Initia-tives that focus solely on changing the knowledge orpractices of individual practitioners are likely to havelimited success unless they also consider the organizationalcontexts in which practitioners provide health care.However, the inherent complexity involved in developingand evaluating organizational-level interventions to pro-mote equity-oriented care presents many challenges.The purpose of this paper is to provide an overview ofan innovative multi-component, organizational-level inter-vention designed to enhance the capacity of PHC clinicsto provide equity-oriented care, particularly for marginal-ized populations. The intervention, known as EQUIP (theshort name for Research to Equip Primary Healthcare forEquity) is being implemented and evaluated in four di-verse PHC clinics in Canada. These clinics are located intwo of the most highly populated provinces in Canada(Ontario [ON] and British Columbia [BC]), and serve ascase studies for the implementation and evaluation of theEQUIP intervention. The clinics provide a wide range ofinterdisciplinary team-based services to populations ran-ging from 1300 to 6000 clients per clinic. The majority ofclients are significantly affected by structural inequities andmany experience major challenges accessing care. Clientsinclude, for example, people with chronic health problems,chronic mental health and/or substance use problems,those experiencing systemic racism and discrimination in-cluding Indigenous people and racialized new immigrants,and women experiencing various forms of violence.We begin the paper with an overview of the EQUIPintervention, starting with the evidence and theory thatprovide the basis for the inter-related intervention compo-nents, and a discussion of the expected impacts. We thendescribe the methods we are using to understand theprocess of implementing the intervention across diversesettings and to examine its effects. We conclude with abrief discussion of the integrated knowledge translationand exchange (KTE) activities designed to link the know-ledge gained from this study with knowledge users anddecision-makers who have the potential to influence up-take of equity-oriented care in PHC settings. Our aim isnot to provide detailed protocols for implementing andmeasuring the impacts of the EQUIP intervention. Rather,by providing an overview of the intervention and our ap-proach to evaluation, we hope to illustrate the complex-ities involved in attempting to enhance the health caresector's capacity to provide equity-oriented care in “realworld” clinical contexts.Browne et al. International Journal for Equity in Health  (2015) 14:152 Page 2 of 11Design and methods: Overview of the EQUIPinterventionThe EQUIP intervention was designed to enhance the cap-acity of PHC organizations to be as responsive as possible tothe diverse needs of populations whose health is influencedby intersecting forms of structural inequities. Using a com-bination of staff education and practice facilitation to sup-port practice and policy changes at the organizational level,EQUIP provides a flexible structure in which both the gen-eral content and processes of the intervention are tailored tofit with the most salient issues and priorities at each clinic.Grounding the EQUIP intervention in evidence and theoryThe EQUIP intervention is both evidence based and the-oretically informed. Although many bodies of knowledgehave informed the development of this intervention, re-search and theory related to equity-oriented care andcomplexity theory are particularly central to the design.The content of the EQUIP intervention is based on anevolving conceptualization of equity-oriented care. Specific-ally, in previous research developed and conducted in part-nership with PHC clinics and other organizations servingmarginalized populations, we identified evidence- andtheory-informed key dimensions of PHC services thatposition equity as an explicit goal [8, 18, 19]. Through theprior empirical work, we developed a framework identifying(a) four key dimensions of equity-oriented PHC services,which are particularly relevant when working with margin-alized populations, and (b) following from those key dimen-sions, 10 strategies to guide organizations in enhancingtheir capacity for equity-oriented services, as detailedelsewhere [8]. Ongoing refinement of this framework led usto re-conceptualize inequity-responsive care as the over-arching aim, and as foundational to supporting health andwell-being through the provision of culturally safe care,trauma- and violence-informed care, and contextuallytailored care (Fig. 1). Below, we briefly describe these keydimensions of equity-oriented services, which provide thebasis for the EQUIP intervention components.Increasingly, the concept of trauma is used to frame thehealth, social, and psychological effects of interpersonalviolence [18, 20, 21–33]. Trauma-informed care (TIC) pri-oritizes the need to create an emotionally safe environ-ment based on an understanding of the health effects oftrauma. The insertion of violence into the notion of TICis intentional to emphasize that (a) interpersonal andstructural forms of violence (e.g., poverty, racism) inter-sect and (b) such forms of violence are often ongoing asFig. 1 Key dimensions of equity-oriented PHC servicesBrowne et al. International Journal for Equity in Health  (2015) 14:152 Page 3 of 11well as historical, compounding the negative impacts.Trauma- and violence-informed care (TVIC) involvesoperating from the recognition that people impacted by socialinequities often experience multiple forms of violence; thestructural conditions of their lives often place them at greaterrisk of interpersonal violence, and of experiencing challengesin accessing supports to improve their physical and emotionalsafety. The emphasis on violence-informed care also mitigatesthe potential to locate ‘the problem’ of trauma primarily inthe psyche of those who have experienced violence, ratherthan also in the acts of structural violence and the conditionsthat support those acts [34]. In contrast to more specialized‘trauma therapy and trauma treatment’ such as psychother-apy, TVIC is a more general approach which aims to mitigatethe potential harms and traumatizing effects of seeking healthcare or other services by creating safe and trusting environ-ments [19, 21, 28–30, 35–37].The concept of cultural safety, originally developed inNew Zealand by Maori nurse-leaders, was intended tomove nursing and health care practices beyond conven-tional cultural sensitivity training to more explicitly ad-dress inequitable power relations, institutionalized andinterpersonal racism and other forms of discrimination,and the ongoing impacts of historical injustices onhealth and health care [38–41]. Cultural safety differsfrom the notion of cultural sensitivity, and aims to shiftattention away from “cultural differences” as the sourceof the problem, and onto the culture of health care asthe site for transformation [42–44]. Over the past twodecades, cultural safety has been taken up internationallyin diverse health care settings as a means of addressingpersistent health and health care inequities [42–50]. InCanada and Australia, for example, cultural safety isoften featured as an essential element of health care in-volving Indigenous and non-Indigenous people, and inNew Zealand, is legislated as a basic requirement ofnursing and medical professional education [51].Contextually tailored care expands the notion ofclient-centred care to include services that are explicitlytailored to the populations served and to local contexts.This includes tailoring practices and/or organizationalpolicies and clinical guidelines/protocols to optimallyaddress the most pressing needs of local populations,and the social and community realities that often shiftdepending on local politics, epidemiological trends, etc.At the organizational level, contextually tailored carerequires understanding the local community and con-text, along with mechanisms for developing and updat-ing this knowledge continuously.Complexity theory, an emerging approach in a rangeof disciplines including population health [52–55], wasused to inform our thinking about the interventionstructure and implementation process. Complexity the-ory is particularly useful for understanding health careorganizations as complex adaptive systems with uniquehistories, structures, ways of operating, and communityand funding contexts that shape how the intervention istaken up and its impacts. Rather than conceptualizing in-terventions with a ‘one-size-fits-all’ approach [56], or atightly controlled design using standardized interventions[57], Hawe and others recommend that researchers: (a)expand their notions of interventions to make them adap-tive; (b) broaden definitions of intervention success; (c)allow for strategic redirection during implementation; and(d) expand understandings of the effects on health out-comes [52–54, 58]. Complexity theory, therefore, chal-lenges researchers to design interventions that can bestandardized in terms of the overall purpose, and tai-lored to meet the needs of the different contexts inwhich they are implemented without compromisingintervention integrity [52, 53]. This redefinition ofstandardization has the potential to increase theeffectiveness of the intervention by improving the fitbetween the intervention and the local cultural orsocial environment in which it is implemented.EQUIP intervention componentsThe EQUIP intervention aims to enhance capacity for equity-oriented care at the staff level (i.e., knowledge, confidence andpractices), and at the organizational level (i.e., policy and oper-ations). The EQUIP intervention is novel in its dual focus on:(a)Staff education: using standardized educationalmodels and integration strategies to enhance staffknowledge, attitudes and practices related to equity-oriented care in general, and cultural safety, andtrauma- and violence-informed care in particular, and;(b)Organizational integration and tailoring: using aparticipatory approach, practice facilitation, andcatalyst grants to foster shifts in organizationalstructures, practices and policies to enhance thecapacity to deliver equity-oriented care, improveprocesses of care, and shift key client outcomes.The theoretical model of the intervention is depicted inFig. 2.Based on a view of health care organizations as complexadaptive systems, the EQUIP intervention was developedusing core concepts and strategies that can be tailored tolocal contexts [52, 54, 58]. Given the goals of the interven-tion, and the fact that implementation depends on supportand participation of administrators and staff working in busyclinical settings, we planned the intervention so that it couldbe delivered in phases over a 12 to 24 month timeframe.Given the focus on change at both staff andorganizational levels, we designed intervention activitiesto be appropriate for all staff, regardless of their specificroles, by taking varied learning styles and expertise intoBrowne et al. International Journal for Equity in Health  (2015) 14:152 Page 4 of 11account. Within the intervention, three inter-related stan-dardized educational components, described below, weredelivered in ways which were tailored to local contextsand specific populations served, enhancing the relevanceof the intervention [52, 54, 58]. A practice consultant,trained by the research team, facilitated implementationof the intervention within each setting by delivering thespecific components, working with staff to integrate learn-ing from the educational components, and serving as anongoing resource for staff and the organizations as theyworked through the intervention activities. Consistent withthe participatory and integrated knowledge translation ap-proaches used in this research program, our practice part-ners actively participated in developing the interventionand the study design, and provided ongoing input into therealities of implementing this kind of intervention.Staff education - Three componentsHealth professional education has only recently includedconcepts from a health equity and population health ap-proach, and rarely addresses the health consequences ofviolence, trauma, discrimination and racism [59]. As such,education is one pathway for building staff capacity withinorganizations – to better understand and respond moreeffectively to people impacted by structural inequities andstructural violence. While didactic educational strategiesby themselves tend to not be drivers of behaviour change,the tailored educational and integration strategies offeredthrough EQUIP created catalysts for change in each of thesites [60, 61].Component 1: Orientation to key dimensions of equity-oriented PHC servicesTwo-hour workshops were offered to all staff at each siteto provide an overview of the key dimensions of equity-oriented PHC and 10 strategies for enhancing capacityfor equity-oriented services as shown in Fig. 1 above.Using interactive learning activities, these sessions drewon staff experience and knowledge. Throughout theintervention, the practice consultant was available to re-visit and discuss this content with staff with a view toFig. 2 EQUIP intervention theoryBrowne et al. International Journal for Equity in Health  (2015) 14:152 Page 5 of 11integrating these ideas in relation to Components 2 and3 specific to each setting.Component 2: Orientation to cultural safetyThe primary content of Component 2 was an existingonline, 8-hour, self-directed program known in Canadaas the Indigenous Cultural Competency (ICC) program3.It includes interactive activities facilitated online byskilled adult educators and features content and casesinvolving Indigenous people in the Canadian context.The theoretical foundations of the ICC program includeanti-racist pedagogy, critical race theory, and trans-formative learning principles, all of which align with cul-tural safety, which is also explicitly used. The goals ofthe ICC program are to stimulate positive changes inknowledge and attitudes about Indigenous people thatare also generalizable across diverse cultural and socialgroups, and heightened sensitivity to racism and stereo-typing generally. To foster integration of the ICC pro-gram’s content in relation to the diverse localpopulations served by the four PHC clinics, the practiceconsultant facilitated ‘integration sessions’ with staff ateach clinic to consider implications for enacting culturalsafety and countering discrimination in their local con-texts. These sessions created opportunities to extend be-yond what is often taken up as superficial attention tocultural practices in more standard cultural sensitivityand cultural competence training programs.Component 3: Orientation to trauma- and violence-informed careThe third component of staff education addressed keyapproaches to TVIC, as defined above. Building on exist-ing curriculum on trauma-informed practice developedin Canada [62, 63], the EQUIP TVIC curriculum was de-veloped to focus explicitly on: (a) ongoing structural andinterpersonal violence, as well as historical and intergen-erational trauma; (b) how these factors intersect withpoverty, racism, chronic pain, mental health problemsand substance use, especially in the context of PHC; and(c) how action is required at all levels including prac-tices, organizational approaches and policy. The TVICtraining included eight hours of face-to-face workshop-style content with opportunities for small-group discus-sion and applied learning via case studies. Congruentwith complexity theory, the training included common,standardized training modules, with discussions andclinical examples tailored to the key priorities identifiedby staff at each clinic.Organizational integration and tailoring (OIT) of interventionThe EQUIP intervention is grounded in the assump-tion that changes in staff knowledge, attitudes andpractices are unlikely to result in significant shifts inequity-oriented processes of care unless attention is di-rected toward: (a) supporting staff to integrate learningfrom each of the three components in the context ofpractice (integration); and (b) creating locally relevantstructures and processes within each organization to sup-port such change (tailoring). As described above, theprocess of integrating personal learning into practice wasinitiated during staff education and continued throughoutimplementation of the intervention. To facilitate the OITprocess, each site received a $10,000 catalyst grant to beused within a 12-month period. These grants provided theimpetus for clinics to identify and address short-termgoals and strategies to further the delivery of equity-oriented care, recognizing that change is an ongoingprocess that will continue to evolve beyond the study’stime parameters.Within each site, the OIT processes were initiated bythe clinical administrative leaders/managers in consult-ation with experienced clinicians and staff who engagedin the following steps:1. Assessing the strengths, weaknesses and opportunitiesfor enhancing equity-oriented PHC on three levels:(a) their individual interactions with clients; (b) teamprocesses and practices, including types of programsoffered and/or ways of delivering specific programs(e.g., communication, documentation, managingreferrals); and (c) organizational structures andpolicies that direct how services are delivered (e.g.,policies about missed appointments, waiting lists,outreach activities, physical set up);2. Reviewing clinic profiles prepared by the EQUIPteam, including selected health and social statusindicators (e.g., trauma symptoms, depressionsymptoms, languages spoken, income) for theirclients compared to local, regional and nationalpopulation norms to identify foci for change;3. Selecting 3–5 priorities for organizational changebased on the assessment;4. Developing a detailed plan for addressing each priority,specifying goals, strategies, timelines and responsibilities,and a proposed budget for the catalyst grant;5. Implementing and evaluating the proposed changeswithin a 12-month period.OIT activities at the four PHC clinics include, for ex-ample: adapting the waiting room environment to bemore welcoming for families caring for young children;developing and integrating harm reduction strategiesinto clinical programming and care; developing supportsto address vicarious trauma experienced by staff whenresponding to the needs of clients experiencing violence;and expanding the approaches used to assess and re-spond to clients’ experiences of chronic pain, amongBrowne et al. International Journal for Equity in Health  (2015) 14:152 Page 6 of 11others. In each site, the practice consultant was availableto help problem-solve issues during implementation,reinforce the principles of equity-oriented care, and assiststaff to evaluate the impact of their efforts and adjust theplan as needed.Expected impacts of the interventionFigure 2, above, illustrates the proposed ways in whichthe EQUIP intervention could theoretically lead to a re-duction in health inequities at the population level. Wepropose that engagement in the EQUIP interventionmay enhance staff knowledge, confidence and practices,and shift policies, structures and operations in the clinicsto better align with the principles of equity-orientedcare, leading to enhanced delivery of care. As care be-comes more responsive to client priorities and prefer-ences, positive short-term changes for clients mayinclude: improved access to health services and commu-nity resources; enhanced emotional safety and sense ofrespect during health care encounters; increased capacityto seek help to address health priorities; and an im-proved overall fit of care with needs. Longer term, accessto equity-oriented care may lead to improvements inoverall health outcomes and quality of life.Given that PHC is delivered within complex adaptivesystems, we argue that multiple factors shape how equity-oriented PHC is taken up within organizations. These in-clude: (a) the characteristics of the population; (b) thecharacteristics of the staff; (c) the organizational milieu,including formal and informal power structures, policies,and funding; (d) the political, policy and economic con-texts, particularly government directives that affect healthcare delivery and factors influencing the broader determi-nants of health; and (e) the historical and geographic con-text, specifically, the physical location of organizations invaried rural and urban locations, and the social conditionslinked to those locations. As we discuss below, themethods we are using to evaluate the implementation andimpacts of the intervention permit us to pay close atten-tion to these contextual factors.Evaluating the implementation and impact of theEQUIP interventionUsing a mixed methods, multiple case-study design, weare currently examining the impacts of the EQUIP inter-vention in enhancing staff knowledge, confidence, atti-tudes and practices; improving processes of care; shiftingorganizational policies and structures; and improving se-lected client outcomes. A multiple case study is a compre-hensive research strategy useful in exploring, describing,explaining, and evaluating causal links in real world inter-ventions that are too complex to be assessed by survey orexperimental strategies alone [64, 65]. This researchdesign is also useful for describing the process ofimplementing EQUIP, including how the context shapesuptake of this intervention in diverse PHC settings.Although we are assessing the impacts of the inter-vention on clients, staff and the organization, thePHC site is the primary unit of analysis. Drawing onmultiple sources of quantitative and qualitative data,our goal is to generate a detailed understanding ofeach case and a more generalized understanding ofcommonalities across cases [65].Within Canada’s publicly funded health care system,PHC is a provincial responsibility, resulting in diversemodels of care and funding arrangements. Given thegoal of understanding how context shapes the deliveryand impact of EQUIP, we purposefully selected PHCclinics that would provide variation across five dimen-sions of context noted in the intervention theory (Fig. 2).Although the context of each clinic differs, the fourclinics share some important features. Each has an expli-cit mandate to provide PHC and programming that is asaccessible as possible given their local populations, andeach offers team-based care from a mix of providers,such as primary care physicians, nurse practitioners, reg-istered nurses, social workers, counsellors and other staffmembers, although the team composition varies by site.The clinics are located in diverse geographic areas in-cluding rural, regional and inner city settings, and havedifferent histories (e.g., longstanding versus newer clinics).These important differences provide sufficiently rich caseexamples for both within-site and across-site analyses re-lated to temporal changes in outcomes, and the influenceof context on processes and outcomes. This will allow usto draw inferences regarding common and site-specificfactors shaping the implementation and impact across thefour sites.Quantitative assessments of impact of the interventionQuantitative assessments of the impact of the EQUIPintervention on staff are being conducted at three pointsin time (at baseline, midway through the intervention,and following the completion of OIT) using an onlinesurvey designed to assess knowledge, attitudes and con-fidence in enacting practices related to the three compo-nents of staff education. We are examining changes overtime in staff knowledge, attitudes, confidence and prac-tices using statistical approaches appropriate to the levelof measurement.Quantitative assessments of temporal changes in pro-cesses of care and client outcomes are being conductedusing data collected through a client survey at four pointsin time (at baseline, early in the intervention, midwaythrough the intervention, and following). At baseline, asample of 120–160 clients was recruited from each site,comprising a longitudinal cohort of 567 clients followedover 2.5 years. Clients were eligible to participate based onBrowne et al. International Journal for Equity in Health  (2015) 14:152 Page 7 of 11the following inclusion criteria: at least 18 years of age,able to understand and speak English, had made at leastthree visits to one of the clinics in the past 12 months,and intended to continue accessing services for the twoyears following recruitment. Recruitment occurred by in-viting all clients who met the inclusion criteria, and whocame to the clinic on purposively selected days, to partici-pate. To enhance representativeness, both clients who hadscheduled appointments and those who “dropped in” wereinvited to participate.The structured survey is comprised of investigator-developed survey items, standardized self-report mea-sures and open-ended questions designed to measurethe main concepts in our intervention theory, namely:(a) health care experiences, particularly perceptions ofequity-oriented care; (b) short-term client outcomes, suchas access to health services or community resources, cap-acity to address their health priorities, and overall ‘fit’ ofservices; and (c) longer-term outcomes including healthstatus (e.g., chronic pain, depression, symptoms of post-traumatic stress) and quality of life. Demographic infor-mation (e.g., age, gender, employment status, financialstrain, Indigenous identity) was also collected. To enhanceretention, we maintained contact with participants on aregular basis between the waves of data collection, and of-fered honoraria to acknowledge the time and effort re-quired to complete the client interviews. Our retentionrate after four waves of data collection was 77 % acrossthe four clinics.Our initial analysis will focus on characterizing anychanges in the main concepts identified in the inter-vention theory in Fig. 2, using statistical modellingtechniques to allow comparisons of changes withinand across clinic sites, and to model in predictors ofsuch change. We will focus initially on changes inequity-oriented processes of care and short-term cli-ent outcomes, since we expect that these outcomesare more likely to change in the relatively short studytimeframe, while changes in health status and qualityof life will take longer to achieve. Next, we will exam-ine the mechanisms of change suggested in our inter-vention theory by testing a series of causal models.Consistent with our case study design, we expect totest both general models that apply across clinics,and clinic-specific models based on the focus of theirOIT goals and the specific context. For example, in aclinic where OIT focused on introducing improvedguidelines for the management of chronic pain, wemay test a model linking: (a) changes in client per-ceptions of equity-oriented care; (b) overall fit of carewith needs (a short-term outcome); and (c) level ofdisabling chronic pain (a health outcome). The specificmodels to be tested will be informed by our theoreticalframework and earlier analyses of client data, as well asemerging insights gained through the qualitative explor-ation described next. Given the sample size, clinic-specificanalyses will incorporate a limited number of variables inorder to ensure adequate statistical power.Qualitative exploration of processes of change andcontextual influencesQualitative research methods are ideally suited to study-ing both the process and impact of implementing theEQUIP intervention at each site, including how diversecontexts shape the uptake of the intervention. We are:(a) conducting in-depth, open-ended interviews withstaff and administrative leaders; (b) conducting generalobservations of the milieu at each setting, and more de-tailed observations of staff meetings recorded as field-notes; and (c) analyzing policy and contractual fundingdocuments to consider how they both shape and areshaped by engagement with the intervention. The in-depth interviews focus on staff members’ experiences ofengaging with the EQUIP intervention, including chal-lenges and successes, and their perceptions of any effectson their practice, team processes, approaches to care,and organizational policies and structures. Thesemethods of data collection are essential to the multiplecase study design in order to generate both a detailed un-derstanding of each case, and a more generalized under-standing of commonalities that exist across cases.Particular attention will be paid to understanding whichaspects of context best explain differences in the interven-tion’s impacts across the sites. The qualitative findings willalso be essential to contextualize the quantitative analysisof temporal changes described above.Discussion and future directionsOur multiple case study design and use of complexitytheory provides an ideal opportunity to study the con-textual factors shaping the implementation, uptake andimpact of a complex, tailored intervention within diversePHC settings. As our analysis proceeds, findings relatedto the impact of the EQUIP intervention will provideevidence about the practice-level changes, and policyand funding contexts needed to enhance capacity to pro-vide equity-oriented care for people who are most im-pacted by structural inequities and structural violence.Integrated KTE activities cut across all aspects of ourintervention research, and involve clinical leaders withinthe sites and knowledge users in policy-making positionscollaborating in planning and delivering the intervention.Describing the site-specific contextual factors and deci-sions regarding how to tailor and implement the interven-tion becomes, de facto, the first step in an evolvingintervention-specific KTE strategy. For example, identifiedenablers and challenges in each context are becoming ‘les-sons learned’ about what works, what does not, and why.Browne et al. International Journal for Equity in Health  (2015) 14:152 Page 8 of 11This is informing our understanding of how the interven-tion (or aspects of it) could be tailored in new jurisdictions.These integrated KTE activities are informing our under-standing of the complex factors that may intersect to influ-ence implementation and the possible impacts in new sitesoutside of this research context. Longer term, this analysiswill enable thinking beyond the specific PHC sites toinform a more policy-oriented approach to equity-oriented interventions, and ultimately, equity-drivensystem transformations.Endnotes1PHC is conceptualized as the principal vehicle for thedelivery of health care at the most local level of a country’shealth system. Primary care is one of PHC’s core servicesbecause it serves as the first point of entry, providesperson-focused care for all but the most uncommon con-ditions, and integrates or co-ordinates care providedelsewhere.2In this research program, the terms ‘marginalization’ or‘marginalized’ refer to the social, political and economicconditions that create structural, social and health inequi-ties in Canada and other nations, versus a characteristicthat can be attributable to any particular population orgroup.3The Indigenous Cultural Competency (ICC) programwas developed in British Columbia (BC), Canada, by theAboriginal Health Division of the BC Provincial HealthServices Authority (PHSA), and has been adapted foruse in other provinces across Canada, and in Australia.Further information about this program can be found at:http://www.culturalcompetency.ca/.AbbreviationsBC: British Columbia, Canada; ICC: Indigenous cultural competency;KTE: Knowledge translation and exchange; OIT: Organizational Integrationand Tailoring; ON: Ontario, Canada; PHC: Primary health care; TIC: Trauma-informed care; TVIC: Trauma- and violence-informed care.Competing interestsNone.Authors’ contributionsAB is the Nominated Principal Investigator for the EQUIP research program,and CV, MFG and NW are co-Principal Investigators. AB, CV, and MFG led theconceptualization and design of the EQUIP research program, withimportant input from NW who subsequently joined our leadership team.AB led the development of this manuscript, and CV, MFG and NW contributedequally to the ongoing development of the final manuscript. The EQUIP ResearchTeam provided input into the overall conceptualization and operationalization ofthis research program. All authors read and approved the final manuscript.AcknowledgementsThe EQUIP Research Team of Co-Investigators, Knowledge Users and ClinicalLeaders includes: Patty Belda, Kathy Bresett, Pat Campbell, Margaret Coyle,Anne Drost, Myrna Fisk, Olive Godwin, Irene Haigh-Gidora, Carol Herbert,Beth Jackson, Colleen Kennelly, Murry Krause, Josée Lavoie, Doreen Littlejohn,Marjorie MacDonald, Wendy McKay, Bernadette Pauly, Tatiana Pyper, VictoriaSmye, David Tu, Leslie Varley, Bruce Wallace, Cheryl Ward, Elizabeth Whynot,and Sabrina Wong. We would like to thank Phoebe Long, Joanne Parker andJoanne Hammerton for their outstanding contributions as research managerson the EQUIP research program, and Kelsey Timler for her work as researchassistant. The EQUIP Research Program is funded through a Canadian Institutesof Health Research Operating Grant: Programmatic Grants to Tackle Health andHealth Equity [#ROH-115210] (www.cihr-irsc.gc.ca).Author details1School of Nursing, The University of British Columbia, T201 – 2211Wesbrook Mall, Vancouver, BC V6T 2B5, Canada. 2Arthur Labatt Family Schoolof Nursing, Western University, H37 Health Sciences Addition, 1151Richmond St., London, ON N6A 5C1, Canada. 3Faculty of Information &Media Studies, Western University, North Campus Building, Room 240, 1151Richmond St., London, ON N6A 5B7, Canada.Received: 24 July 2015 Accepted: 10 November 2015References1. World Health Organization. The World Health Report 2008 - primary health care(Now more than ever). 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New York, NY: Guildford Press; 2006.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitBrowne et al. International Journal for Equity in Health  (2015) 14:152 Page 11 of 11

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