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Enhancing health care equity with Indigenous populations: evidence-based strategies from an ethnographic… Browne, Annette J; Varcoe, Colleen; Lavoie, Josée; Smye, Victoria; Wong, Sabrina T; Krause, Murry; Tu, David; Godwin, Olive; Khan, Koushambhi; Fridkin, Alycia Oct 4, 2016

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RESEARCH ARTICLE Open AccessEnhancing health care equity withIndigenous populations: evidence-basedstrategies from an ethnographic studyAnnette J. Browne1*, Colleen Varcoe1, Josée Lavoie2, Victoria Smye3, Sabrina T. Wong4, Murry Krause5, David Tu6,Olive Godwin7, Koushambhi Khan1 and Alycia Fridkin8AbstractBackground: Structural violence shapes the health of Indigenous peoples globally, and is deeply embedded inhistory, individual and institutional racism, and inequitable social policies and practices. Many Indigenouscommunities have flourished, however, the impact of colonialism continues to have profound health effects forIndigenous peoples in Canada and internationally. Despite increasing evidence of health status inequities affectingIndigenous populations, health services often fail to address health and social inequities as routine aspects ofhealth care delivery. In this paper, we discuss an evidence-based framework and specific strategies for promotinghealth care equity for Indigenous populations.Methods: Using an ethnographic design and mixed methods, this study was conducted at two Urban AboriginalHealth Centres located in two inner cities in Canada, which serve a combined patient population of 5,500. Datacollection included in-depth interviews with a total of 114 patients and staff (n = 73 patients; n = 41 staff), and over900 h of participant observation focused on staff members’ interactions and patterns of relating with patients.Results: Four key dimensions of equity-oriented health services are foundational to supporting the health andwell-being of Indigenous peoples: inequity-responsive care, culturally safe care, trauma- and violence-informedcare, and contextually tailored care. Partnerships with Indigenous leaders, agencies, and communities are requiredto operationalize and tailor these key dimensions to local contexts. We discuss 10 strategies that intersect tooptimize effectiveness of health care services for Indigenous peoples, and provide examples of how they canbe implemented in a variety of health care settings.Conclusions: While the key dimensions of equity-oriented care and 10 strategies may be most optimallyoperationalized in the context of interdisciplinary teamwork, they also serve as health equity guidelines fororganizations and providers working in various settings, including individual primary care practices.These strategies provide a basis for organizational-level interventions to promote the provision of more equitable,responsive, and respectful PHC services for Indigenous populations. Given the similarities in colonizing processesand Indigenous peoples’ experiences of such processes in many countries, these strategies have internationalapplicability.Keywords: Indigenous people, Health services, Health equity, Health disparities, Canada, Racism, Discrimination,Cultural safety, Structural violence, Trauma informed care, Trauma- and violence-informed care* Correspondence: annette.browne@ubc.ca1School of Nursing, The University of British Columbia, T201 – 2211Wesbrook Mall, Vancouver, British Columbia V6T 2B5, CanadaFull list of author information is available at the end of the article© 2016 The Author(s). 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. BMC Health Services Research  (2016) 16:544 DOI 10.1186/s12913-016-1707-9BackgroundDespite Canada’s commitment to primary health care(PHC)1 and principles of social justice, health inequitiesremain a pressing national concern [1]. In Canada andother nations, PHC renewal continues to be identified asa key pathway to achieve health equity, with particularimplications for marginalized2 populations. Substantialevidence shows that PHC enhancements can lead to im-proved population health outcomes, including reducedacute and chronic conditions, reduced use of emergencyservices, shorter hospital stays, and lower overall healthcare utilization [2–5].In a prior publication [6], we identified four keydimensions of equity-oriented PHC services, whichprovide a framework for understanding the essentialelements of promoting equity among marginalizedpopulations: trauma- and violence-informed care, cul-turally competent care, contextually tailored care, andinequity-responsive care. Since that publication, ouranalysis has focused more explicitly on the effects ofstructural violence and inequities on Indigenous peo-ples’3 health. This paper presents our refined des-cription of the key dimensions of equity-orientedcare and specific strategies to use in PHC settings topromote health equity with Indigenous peoples. Usingresearch at two long-established Indigenous health centresin Canada, we illustrate the relevance of these strategiesfor PHC practices, agencies, and organizations. Althoughthe research we report on in this paper was conducted inthe Canadian context, the health of Indigenous peoplesthroughout the world is shaped by common global colo-nial and neocolonial forces. Given the similarities in col-onizing processes and Indigenous peoples’ experiences ofsuch processes in many countries, these strategies willhave applicability internationally.Indigenous peoples’ healthMany Indigenous communities have flourished despite co-lonial forces, however, ongoing social inequities continueto have negative health effects for Indigenous peoples [7–15]. Structural violence is increasingly understood in popu-lation and public health as a major determinant of the dis-tribution and outcomes of social and health inequities.Structural violence refers to the disadvantage and sufferingthat stems from the creation and perpetuation of struc-tures, policies and institutional practices that are innatelyunjust; because systemic exclusion and disadvantage arebuilt into everyday social patterns and institutional pro-cesses, structural violence creates the conditions whichsustain the proliferation of health and social inequities [16].Structural violence can be “static, insidious, silent,taken-for-granted, and hidden” [17] (p. 258), leadingmany to “interpret disparities in health and income andgood fortune as ‘the way things are’" [18] (p. 5).Structural violence shapes the health of Indigenouspeoples and communities globally, and is deeply embed-ded in history, individual and institutional racism, andinequitable social policies and practices. These continueto exert their effects in the present. For example, inCanada, both the creation of reserve lands with re-sources inadequate for sustenance, and the apprehensionof Indigenous children by the state, initially to residentialschools and subsequently to foster homes, have had pro-found detrimental effects over multiple generations [10,11, 19]. In Australia, similar attempts at assimilationwere implemented through the forced removal of chil-dren from Aboriginal and Torres Strait Islander com-munities. Across colonial contexts, these forcedremovals are often referred to as the ‘stolen generation’,and evidence of the harmful health and social impactscontinues to mount [14]. Today, the legacy of colonialism,and systemic racism and other forms of discrimination,contribute to the current lack of employment opportun-ities, limited access to education, inadequate housing, andhigh levels of poverty experienced by many Indigenouspeoples in Canada, Australia, and other colonized countriesthroughout the world [10, 20, 21].Gaps in health services: the need for strategies to addressthe health effects of structural violenceThe historical and ongoing forms of structural violence ex-perienced by Indigenous peoples have unfolded against thebroader context of neoliberal economic reforms and socialspending cuts over the past three decades. Canada has be-come second only to the USA in its growing levels of in-come inequality [22]. The lack of affordable housing inmany parts of Canada, and the loss of community-basedsocial and health services disproportionately burden Indigen-ous peoples. Within this context, the health and wellbeing ofIndigenous peoples continues to lag behind that of the over-all Canadian population on virtually every measure [7, 9, 10,20, 23–27]. For example, it is estimated that by 2017, themean life expectancy of Indigenous men will be 70.3 yearscompared to 79 years for all Canadian men, and 77 for Indi-genous women compared to 83 for all Canadian women[28]. Throughout Canada, infant mortality rates among Indi-genous populations are dramatically higher compared toother Canadians [23, 29]. Today, Indigenous children repre-sent an alarmingly high percentage of the children in gov-ernment care4, reflecting the current state surveillance ofIndigenous women, families, and communities [30, 31].Research also shows that the high rates of HIV infectionamong Indigenous women [32–34] and the disproportionatelikelihood of violence against Indigenous women and girlsare explained by the unique experiences of colonization ofIndigenous peoples in Canada, founded on ongoing racismand discrimination [9–11, 35–38].Browne et al. BMC Health Services Research  (2016) 16:544 Page 2 of 17Internationally, the traumatic, negative impacts of historicaland ongoing colonialism on Indigenous peoples’ health andwell-being are immense. Globally, Indigenous peoples experi-ence significantly higher rates of ill health and have dramatic-ally shorter life expectancies than other groups living in thesame countries [39, 40]. In Australia, life expectancy at birthfor Indigenous peoples is estimated to be 19–21 years lowerthan their non-Indigenous counterparts [40]. In parts of Cen-tral and South America, infant mortality rates are extremelyhigh for Indigenous peoples, reflecting limited economic op-portunities, poor access to social services, and high levels ofpublic insecurity [40]. Throughout theworld, Indigenous peo-ples experience disproportionately high levels of maternal andinfant mortality, malnutrition, cardiovascular illnesses, HIV/AIDS and other infectious diseases, such asmalaria and tuber-culosis [39]. These morbidity and mortality patterns arestrongly connected to histories of colonization, the disposses-sion of lands and cultural and economic resources, and theongoing lack of access to the social determinants of health. Asemphasized in the report of the United Nations Special Rap-porteur, these health status disparities are compounded by thepersistent and multifaceted forms of racial discrimination ex-perienced by Indigenous peoples globally: “such discrimin-ation is intimately interconnected and mutually reinforcingwith the spectrum of violations experienced by Indigenouspeoples” [39] (p. 10). Research in Australia, for example, con-tinues to show that ineffective, insensitive and inappropriatecare contributes to Aboriginal peoples’ experiences of sham-ing,misunderstanding and stereotyping [41].Discrimination in health care is continuous with experi-ences of discrimination in people’s everyday lives. Racial dis-crimination is further amplified in the contexts of poverty,substance use, or stigmatizing conditions such as chronicpain, mental health issues, and HIV [42–50]. Research con-firms that Indigenous peoples experience individual andsystemic discrimination when seeking health care [6, 11, 27,44, 51–53], despite efforts within the health care sector topromote cultural sensitivity and cultural safety. For ex-ample, despite long-standing evidence of lower per capitaalcohol consumption by Indigenous peoples compared withthe general population, one of the most common publicperceptions in Canada reflects racialized assumptions aboutIndigenous peoples being prone to alcohol or substance use[11, 54]. The colonizing image of the ‘drunk Indian’ is oneof the most harmful stereotypes operating in health caresettings [55]. These assumptions intersect with messagesin the media, public venues and everyday conversations inCanada to undermine Indigenous land claims, rights, andentitlements, and in health care contexts, shape decisionsabout which patients are credible and deserving of care [6,44, 52, 53, 56]. Thus racism and discrimination must beconsidered determinants of health for Indigenous peoples,and strategies are required to mitigate the negative im-pacts on health [11, 25].Health services, however, are not typically designed totake into account the experiences of Indigenous peoples[10, 25, 57, 58]. For example, despite extensive evidencelinking trauma and violence to multiple health problems,including chronic pain, depression, anxiety and substanceuse [57, 59–62], these dynamics are rarely considered inthe design and delivery of health care for Indigenouspeoples [7, 63–69]. A decolonizing lens is useful foraddressing this complex interplay of factors [66, 70, 71],by directing attention to the root causes of people’shealth and social issues. In this paper, we offer a frame-work and specific strategies for promoting equity-oriented care that takes into account the colonial historyand ongoing subjugation of Indigenous peoples, and thatsupports Indigenous peoples’ agency and resistance tosuch subjugation.MethodsThe findings discussed in this paper resulted from alarger study that: (a) examined how PHC services areprovided to address the health needs of Indigenous andnon-Indigenous peoples experiencing the health effectsof systemic inequities; (b) identified the key dimensionsof equity-oriented PHC services for marginalized popu-lations; and (c) developed a set of PHC indicators to ac-count for the quality, process, and outcomes of carewhen marginalized populations are explicitly targeted.This four-year study used a mixed-methods, ethno-graphic design and was conducted in partnership withtwo urban Aboriginal health centres located in two innercities in Canada. The research team was guided by an In-digenous community advisory committee (CAC) includingleaders in Indigenous health services, patient representa-tives, and people recognized as Indigenous Elders. TheCAC was regularly consulted about methods, the inter-pretation of research findings, and strategies for discussingthe implications with Indigenous peoples and health careleaders. All aspects of our research process received eth-ics approval by two ethics review boards.This study was informed by critical theoretical per-spectives and Indigenous epistemologies. Critical theor-ies are useful for drawing attention to the political andmoral concerns arising from the legacy of colonialism,and how this shapes people's everyday experiences[72–74]. A central methodological concern is that indi-vidual experiences, including those in health care, needto be interpreted and understood within the context ofbroader social, political, and historical relations. Indi-genous epistemologies provide a broad vantage pointfrom which to understand the complex “web ofrelations” [75] that are encountered in health care.Although Indigenous epistemologies encompass arange of diverse ideas, they converge on the idea thatknowledge is underpinned by a world view that reflectsBrowne et al. BMC Health Services Research  (2016) 16:544 Page 3 of 17interconnectedness, relational values, and the pursuitof knowledge about relationships among people, theland, and community [76–78]. Critical perspectives andIndigenous scholarship are committed to challengingEurocentric assumptions and value structures in bothacademia and society at large.A detailed description of the research methods is pro-vided in an earlier publication [6] and summarized here.The two health centres that served as sites for this studywere established in the early 1990s in western Canada asurban PHC clinics with an explicit mandate to provideinterdisciplinary team-based services to Indigenous andnon-Indigenous peoples experiencing significant healthand social inequities. The clinics serve a combined pa-tient population of 5,500, the majority of whom identifyas Indigenous. Many of the patients live on less than$1,000/month (far below Canada’s poverty line), and dueto a lack of affordable housing, live in unstable or unsafehousing, or in shelters or single-room occupancy hotels.A high proportion have histories that include adversechildhood experiences [79–81] (including, for example,being removed by the state from the care of their par-ents, child abuse of all forms, and the death of familymembers), and many face interpersonal and structuralviolence in their everyday lives as adults, including on-going discrimination and stigma related to systemic ra-cism, mental health issues, and substance use. Torespond to people’s overlapping health and social needs,both clinics provide team-based care by nurses, physi-cians, social workers, counsellors, outreach workers,and pharmacists, among others, and to varying degrees,access to Indigenous Elders who provide support for bothIndigenous and non-Indigenous patients.Data were collected by the principal investigators duringintensive immersion at the clinics. We conducted in-depthinterviews with a total of 114 patients and staff (n = 73 pa-tients; n = 41 staff ), including: (a) individual interviews with62 patients, and three focus groups with a total of 11patients; and (b) individual interviews with 33 staff, and anadditional eight staff who participated in focus groups. Weconducted over 900 h of intensive participant observationfocused on staff members’ interactions and patterns ofrelating with patients and other staff during clinicalencounters and in waiting rooms, staff meetings and case-management discussions.Of the patients who participated (n = 73), 52 % werewomen, 45 % were men, and 3 % identified as trans-gender. Seventy-seven percent self-identified as Indi-genous, 22 % as Euro-Canadian, and 1 % as members ofa visible minority5 [82]. Ages ranged from 20 to 72(mean = 45 years). Of the clinics' staff who participated(n = 41), 24 % were nurses or nurse practitioners, 22 %were physicians, 22 % were medical office assistantsand office managers, 10 % were in administrativeleadership positions, 7 % were social workers, 5 % weresubstance use counsellors, and 10 % were other staff in-cluding an Elder, an outreach worker, a support worker,and a pharmacist.We conducted an interpretative thematic analysis[83] using NVivo to assist with organizing and codingthe interview and observational data. As data werecollected and analyzed, coding categories were re-fined. In the final stages, the analysis shifted to amore abstract and conceptual representation ofthemes and key dimensions of equity-oriented care.The credibility of our analysis, as a criterion forrigour in qualitative research, was assessed throughregular meetings with the Indigenous CAC anddiscussion sessions with patients at both clinics.These stakeholders confirmed that the identifiedthemes reflected their experiences and interpretations,and that the framework and strategies we proposecapture those features of PHC services that are neces-sary to optimize care in partnership with Indigenouspopulations.Results and discussionWe previously identified key dimensions of equity-oriented PHC services which are particularly relevantwhen working with diverse groups of marginalized pop-ulations [6]. In the case of Indigenous peoples, these keydimensions need to be conceptualized in ways that takeinto account the historical and ongoing forms of dis-crimination and structural violence that continue toshape Indigenous peoples’ health, well-being, and ac-cess to resources. In Fig. 1, the four key dimensionsare operationalized using four general approaches and10 strategies that intersect to optimize the effective-ness of services. These can be locally tailored in part-nership with Indigenous communities.Key dimensions of equity-oriented PHC revisitedAs shown in Fig. 1, inequity-responsive care is founda-tional to supporting health and well-being, and requiresexplicit attention to the provision of culturally safe care,trauma- and violence-informed care, and contextuallytailored care. These are explained briefly below:Culturally safe careCultural safety was originally developed in New Zealandby Māori nurse leaders in consultation with Māoricommunities as a pragmatic tool for moving nursingand health care practices beyond the notion of culturalsensitivity to more actively address inequitable powerrelations, discrimination and racism, and the ongoingimpacts of historical injustices on health and healthcare [84]. Cultural safety has the potential for shapinghealth care practices, organizations, and policies byBrowne et al. BMC Health Services Research  (2016) 16:544 Page 4 of 17identifying social justice goals as integral to health care,and by shifting attention away from cultural differences asthe source of the ‘problem’ and onto the culture of healthcare as the site for transformation. Increasingly inCanada, the USA and Australia, cultural safety is fea-tured as an essential element of health care involvingIndigenous peoples [85–87]. In New Zealand, culturalsafety is legislated as a basic requirement of nursingand medical professional education [88].Trauma- and violence-informed care (TVIC)The concept of trauma is used increasingly to informcare provided to people who are marginalized by socialand structural inequities [57, 61, 62, 89, 90]. The termtrauma can be problematic in part because it signifiesboth traumatic events (often presumed to have occurredonly in the past) and the responses to such events (oftenpresumed to be only psychological). Indigenous andnon-Indigenous scholars [62] critique this ‘trauma trend’because it both obscures the impact of ongoing struc-tural violence and is often used to pathologize Indigen-ous peoples. We share these concerns and endorse thecall for using a decolonizing lens when discussingtrauma in relation to Indigenous peoples [62]. Integrat-ing attention to violence when discussing trauma keepsthe focus on violence (both historic and ongoing), andreduces the likelihood of locating the ‘problem’ only inrelation to the psychological impacts for those who haveexperienced violence, rather than also on structural vio-lence and the conditions that support it [62].Our understanding of TVIC draws on previous workon trauma-informed care, but is founded on the assump-tion that people disadvantaged by systemic inequities ex-perience varying forms of violence that have traumaticimpacts on an ongoing basis. These impacts include awide range of symptoms and health problems such aschronic pain, mental health issues and substance use.TVIC involves providing care that is respectful andaffirming, and requires all staff within any givenorganization to (a) recognize the intersecting healtheffects of structural and individual violence, and otherforms of inequity; (b) understand people’s health andsocial issues in context; and (c) work to reduce re-traumatization. Importantly, TVIC is not about elicit-ing trauma histories; rather, the goal is to create asafe environment for all based on an understandingof the traumatic effects of historical and ongoing vio-lence and discrimination.Contextually tailored careExpanding the concept of patient- and family-centredcare, contextually tailored care includes services that areexplicitly tailored to the local communities and popula-tions served. This may include tailoring practices and/ororganizational policies and clinical guidelines to addressthe needs of local population demographics, and socialand community realities that often shift depending onlocal politics, epidemiological trends, and economic con-ditions. For example, depending on need, some popula-tions might benefit from mental health support forFig. 1 Essential Elements of Equity-Oriented Primary Health Care with Indigenous PeoplesBrowne et al. BMC Health Services Research  (2016) 16:544 Page 5 of 17families dealing with the intergenerational effects of resi-dential schools, support for women raising young chil-dren, or home visits for isolated seniors. Individualsworking in health care cannot enact these strategies with-out supportive organizational strategies and policies, orwithout an awareness of the multiple contexts that shapeboth Indigenous peoples’ health and the broader sociopo-litical environment in which health care is provided. Weemphasize the following four general approaches as abasis from which to enact strategies to operationalize thekey dimensions of equity-oriented care for Indigenouspopulations.Four general approachesDevelop partnerships with Indigenous peoplesPartnerships with Indigenous peoples and/or leaders,agencies, and communities are required to operationalizeand tailor these key dimensions to local contexts. Thesepartnerships can begin in small ways and develop overtime [91, 92]. For example, in Canada, partnerships couldbe developed through consultations with local Elders,Friendship Centre6 staff, local First Nations, Metis andInuit organizations, and/or by structuring Boards orother governance bodies to include Indigenous peoplesor representatives.Take action at all levelsThe practices of individual health care providers are im-portant, but insufficient to achieving health equity. Actionis required (a) at the intrapersonal level among all levels ofstaff involved in health care organizations and systems,with an emphasis on people's values, beliefs and assump-tions, and their capacity for reflexivity; (b) at the interper-sonal level to optimize the interactions among providersand patients, among staff, and between different healthand social service organizations; and (c) at the contextuallevel, including efforts by staff, managers, and leaders toaffect change within health care organizations and thewider community.Attend to local and global historiesWhile the approaches and strategies in this paper areintended to promote equity in PHC for Indigenous peo-ples, we are explicitly not advocating a pan-Indigenousunderstanding. That is, in full recognition of the diversityof Indigenous peoples, an understanding of local history isessential. Although Indigenous peoples may have someshared experiences of historical and ongoing colonization,these histories are diverse, as are the cultures, languages,and traditions of the people involved. Promotinghealth equity requires understanding the erosion of Indi-genous peoples’ power and resources as purposeful inthe service of historical and contemporary colonialconquest.Attend to the unintended and potentially harmfulconsequences of each strategyWe emphasize caution to pre-empt potentially harmfuluptake of the 10 strategies outlined below, given pre-dominant assumptions, policies, and practices that cur-rently drive health care systems. Hence, we identify howto avoid, for example, the potential for culturalism7 oressentialism to seep into the interpretation of these strat-egies. Describing what the strategy ‘is not’ is particularlyimportant in today’s health care climate where decisionsabout efficiencies and performance management may haveserious implications for deepening, rather than ameliorat-ing, health inequities among Indigenous populations.Ten strategies to guide equity-oriented services withIndigenous peoplesUsing illustrative examples from our datasets, the 10 strat-egies are discussed in relation to health care involving In-digenous peoples. Depending on the type of PHCorganization involved (e.g., individual physician practices,or team-based agencies offering wrap-around services),aspects of these 10 strategies will be more relevant ormore feasible at particular points in time. Consistent withinterpretive inquiry, literature is integrated into the dis-cussion of findings to form linkages among the empiricaldata and relevant theoretical perspectives.1. Explicitly commit to fostering health equity in partnershipwith Indigenous peoples in mission, vision, or otherfoundational policy statementsOperationalizing an organization’s or unit’s commitmentto health equity begins with attention to values, and anintention to work toward shared values at the level ofindividual health care providers, and in relation toorganizational structures, policies, and processes. Asemphasized by this physician about the clinic in whichhe worked: “It’s a bigger place for values, shared values…We do try and understand, you know, the historical con-text. We try and understand where people are comingfrom… the things that are impacting their health”.Throughout Canada, health care organizations servediverse communities and populations. We have arguedelsewhere that it is important for health care organiza-tions to develop strategies for fostering health equity inways that will result in overall improvements in care [6,42, 44]. However, in Canada, because the most extremehealth inequities persist in relation to Indigenous peo-ples, and because racism toward Indigenous peoples isso pervasive, it is morally imperative to articulate anexplicit commitment to foster health equity in relationto Indigenous peoples in mission or vision statementsand in documents outlining strategic directions or aims.As emphasized above, partnerships with Indigenouspeoples are integral to this strategy, and as we discussBrowne et al. BMC Health Services Research  (2016) 16:544 Page 6 of 17further, the strategies have the potential to positively in-fluence health services more widely.2. Develop organizational structures, policies, and processesto support the commitment to health equityWhile setting the intention is a first step, supportiveinfrastructure is required. Individual health care pro-viders, managers, and funders must be supportive ofthe structures, policies, and processes that will fosterequity for Indigenous peoples through the 10 strat-egies. This means every staff member must examinetheir values, assumptions, and privileges. Structures,policies, and processes related to hiring, performanceevaluation, recognition, rewards and compensation,continuing education, and staff meetings all must beviewed with respect to equity. For example, staffwhose values align with the commitment to equitymust be recruited, hired and retained. This meansthat organizations need to invest time to recruit bothIndigenous and non-Indigenous staff members whosevalues and motivations for working with Indigenouspopulations align with the social justice orientationunderlying the key dimensions of equity-orientedcare and the 10 strategies. Given health human re-source shortages, and the relatively few nurses andphysicians who are of Indigenous descent in the Canadianworkforce, it remains challenging to recruit staff memberswho identify as Indigenous. As one First Nations staffmember in our study described, although the goal is tohire Indigenous staff, it is not always possible; however, itis critical that staff demonstrate a commitment to valuesthat align with a social justice and health equitymandate:It doesn’t always have to be Aboriginal people thatrun an Aboriginal agency. The values just have to bethere entrenched in the policies, being able to look atservice delivery, those kinds of things… it can be verydifficult if somebody comes to work here who maynot have the same values.Further, staff whose commitments are not aligned can-not be retained. In both clinics, staff members were askedto leave, or decided to leave with the remaining staff ex-pressing consensus that there was a mismatch between thevalues of the organization and the particular person. Thiscan be challenging in both unionized and non-unionizedenvironments for different reasons, including both legalreasons and community opinions. For example, employeesat the clinics who were well-known in the wider commu-nity were asked to leave because of mismatches, but thereasons for dismissal could not be shared, causing tensions.In some cases considerable human resource and legal workwas required to affect dismissal.Importantly, staff members whose values do alignwith those of the organization must be supported towork effectively in their roles. Organizational sup-ports, including access to support for vicarioustrauma, are needed for all staff working with patientswho experience the effects of structural violence on adaily basis. It is particularly essential for organizationsto implement strategies to support Indigenous healthcare providers and other staff who have also beensubjected to structural or other forms of violence andtrauma in their lives, and who are caring for patientsexposed to such trauma. In this study, staff membersat both clinics provided care to people experiencingextreme forms of structural violence, but without ad-equate support for dealing with vicarious trauma, asthis program manager emphasized:In the last fourteen years we’ve lost about twentyAboriginal staff…. And, of course, we don’t haveany type of psychology services or EAP [employeeassistance program]. What we have are eachother… we can’t just hire Aboriginal people andnot realize how this workplace can re-trigger… andre-traumatize… I’m saying we need experiencedpeople. We make it a policy to hire Aboriginalpeople however when we hire people, we can’t justhire on the basis of being Aboriginal. You can’t justthrow a new grad in and say “go to work”. Youcan’t.3. Optimize use of place and space to create awelcomingmilieuUnderpinning all 10 strategies is a commitment tocreating spaces and places where people feel welcomewhen they come for health care, as described by thispatient:You don’t have to sit in a room, like in a doctor’soffice, and be real square, you know, be really uptight.Here, it's like you see people walking back and forth,conversations happening all the time. It's like you’rea piece of this place, you're not just a number. It’slike a home.This is especially significant given the patterns of dis-missal that many Indigenous peoples experience. AsWendt and Gone [93] and others [53, 94] have argued,when people experience dismissal, invisibility, or con-versely, are hyper-visible, it is especially important tocreate settings in which people feel they are deserving,understood, recognized, and accepted. As found inWendt and Gone's [93] study of urban-Indigenoustherapeutic landscapes, patients at the clinics reiteratedtheir view of these places as crucial urban spaces oftenidentified as home:Browne et al. BMC Health Services Research  (2016) 16:544 Page 7 of 17Like at other places, you don’t have a personalrelationship with the staff… Here, like, you chat withthe staff and they offer support for other things inyour life that you need. It's more personal here.4. Re-vision the use of timeRe-visioning the use of time in providing care is anessential feature of equity-oriented care. Flexibility is re-quired to foster trust with people who are often dis-missed or mistreated within the health care system. Forexample, in this study, both clinics’ scheduling systemswere continuously revised (balancing drop-in withscheduled visits) to be as responsive as possible to whatpatients perceived as their highest priorities, as thiswoman described:If we’re in a bad situation, we can more likely justpop in to see [one of the staff]. You know, and get itout of your system. It’s good to know that there’repeople here that will actually listen to you.Developing and allocating time for follow-up actionsfor those who might otherwise ‘fall through the cracks’is especially important for patients whose social supportsystems are limited. This conveys to patients that staff areconcerned about their well-being beyond the boundariesof the clinic’s physical space. This woman, a patient at oneof the clinics, described the significance of such follow-up:They record if I don’t come to the doctor, so thatmakes me feel good because, uh [pause], because Iknow that if something should happen to me outsideof the clinic, and if I don’t come here, they’re going todefinitely acknowledge that. Because they know howimportant to me my health is… and so they woulddefinitely try to track me down through my family andso on… So, that’s one main reason that I come here.In the context of providing care to Indigenous peoples,re-visioning the use of time is not founded on culturalistassumptions about time being differently understood byIndigenous peoples. Rather, this is a strategy and meansof providing services that are consistent with the keydimensions of equity-oriented health care. Taking thetime required to provide good care is important, not asa ‘cultural’ value, but because colonial processes have beenand continue to be so harmful. Re-visioning time does notnecessarily require spending more time with people. Ra-ther, time is used differently, for example, to validate andrecognize that people are making their best efforts to dealwith often overwhelming situations and environments.Health and healing are recognized as life-long processesthat require providers to develop relationships with pa-tients over time. Whereas in some health care settings,patients are ‘banned’ or ‘fired’ when they do not adhereto recommended treatments or advice, understandingthe effects of structural violence and discriminationleads providers committed to equity to never ‘give up’on or abandon patients.Fostering genuine partnerships with communities orcommunity leaders, and seeking their input into pro-grams or policies, also requires flexible use of time toensure meaningful involvement of all stakeholders [95].Performance indicators and quality assurance measuresare typically not designed to account for these kinds ofinvestments in time. At both clinics, administrators andstaff were frequently required by the Health Authorityand funders to justify their regular interdisciplinary teammeetings, which were essential to engaging in team-based case management, developing consistent ap-proaches to care, and forming community partnerships.This highlights the need for measures and indicatorsthat can capture the value of these activities, so that theseaspects of service delivery are legitimized and made visibleas essential components of equity-oriented health care[96, 97].5. Continuously attend to power differentialsGiven the historical and ongoing abuses of power to-ward Indigenous peoples in Canadian society and inhealth care, underpinning all other strategies is theinvestment required at all levels of the organizationto continuously attend to power differentials. Workingto mitigate power differentials requires attention tolanguage and discourses in health care that sustaininequities. For example, given the pervasiveness ofindividualist ideology in health care, and how oftenindividualism is used as a framework to blame Indi-genous peoples for their circumstances, health carestaff need to actively develop diverse strategies tomitigate the myriad ways that judgments about‘personal responsibility’ are conveyed in verbal andnon-verbal interactions with patients. For example,providers at both clinics described how they hadlearned to respond to people in their professional andsocial networks who expressed judgements about In-digenous peoples as being responsible for their ownsuffering or having some genetic predisposition tohealth or social problems (such as substance use).Similarly, egalitarian discourses that advocate ‘treatingeveryone the same’ de-historicize and de-politicize thecomplex factors that underpin social suffering, anddivert attention away from the structural inequitiesthat influence health and access to health care [52].Attending to power differentials in the context ofproviding health care to Indigenous peoples requiresrecognizing that the dominant ideological doctrine of‘treating everyone the same’ can actually reproduceBrowne et al. BMC Health Services Research  (2016) 16:544 Page 8 of 17inequities by blinding health care providers to theirrelative privilege and biases, to the unequal power re-lationships between patients and providers, and to thesocial inequities that differentially shape people’shealth. As these staff members explained:So, it’s almost like you’re counteracting that. Like,I’m counteracting those things as a professional.And to be able to be aware of the reality ofsomebody who lives in the core [inner city] area,who is poor… I want to make this person feel thateven though I’m a [provider], I am at the samelevel as they are. I don’t place myself above themor anything like that. There is no status of powerwhen I work with people. I try to keep that asminimal as possible.We try as much as possible, I believe, to be not asjudgmental. The way people, the patients, have toldus, how they feel when they go to emergency or theother government bodies is that they feel kind ofjudged and discriminated against. I think we areall here to try to be non-judgmental and to treateverybody with respect and, you know, I think thatpays off.People who experience inequities and marginalizationoften experience dismissal and/or stigma when acces-sing health care or community services. As researchcontinues to show, such power inequities are fre-quently magnified for Indigenous peoples in Canada[6, 30, 44, 53, 98]. Experiences of discrimination anddismissal, and the consequent lack of trust in healthcare systems, underpin people’s efforts to avoid con-tact with the health care sector. Health care providersand organizations need to anticipate and expect thatmany people, based on their own and others’ histor-ies, will feel mistrustful of the health system’s abilityto offer help, with further isolating effects. As one ofthe patients said of herself and others attending theclinic: “They don’t trust, and to gain their trust isto… kind of listen to them [patients], and it willcome back”.The significance of earning patients’ trust in the faceof long-standing experiences of mistrust was describedby another woman, who discussed her process ofworking with staff as she tapered herself off what sheperceived to be an unhealthy, long-term dependenceon benzodiazepines:I’ve encountered so many people here [at the clinic],and nobody lies to me… But you know what: if itwasn’t for this place, I wouldn’t have been who I amtoday. Seriously. That is not a lie… They helped mefind myself… They helped me with the trust. And alot of people can’t trust a clinic, you know.Attending to power differentials requires all staff torealize that how one is perceived as a member of thehealth care system cannot be separated from one’sposition in broader socio-historical relations. Even if astaff member does not intend to act in a ‘power over’or discriminatory manner, his or her social location asa member of the health care system can be seen bypatients to imply that power inequities will be main-tained and shape their access to services [52].Countering power differentials in organizations in-volves adapting clinic procedures in ways that conveyrespect and preserve people's dignity. For example, bothclinics explicitly decided not to staff waiting rooms withsecurity guards. Rather, patients' expressions of anger orfrustration were met with respectful responses, especiallyby medical office assistants. Our field notes reflected therelatively rare occurrences of aggressive or violent be-haviour in the clinics in comparison to our field workobservations in Emergency Units, where security guardswere present.6. Tailor care, programs, and services to local contexts,Indigenous cultures, and knowledge systemsExperiences of colonization have important similaritiesfor many Indigenous peoples, and these similarities arethe basis for many of the proposed strategies; however,the diverse and particular histories, cultures, and know-ledge systems of the people served must be used as thefoundation for tailoring care. This requires all staff (andboard members if applicable) to learn about the specificpre-colonial and colonial histories of local communi-ties. This can be supported by managers and leadersthrough staff orientation and continuing education,and by integrating Indigenous knowledges, languagesand concepts into care. These efforts can be promotedthrough partnerships with knowledge keepers, Elders,and other Indigenous leaders. This approach is in dir-ect opposition to the more common efforts by healthcare organizations to address the needs of Indigenouspeoples through ‘cultural sensitivity training’. Althoughattention to culture is important, this is often done inisolation from other fundamental concepts and frame-works, such as social determinants of health, advocacy,and social justice [99, 100]. Cultural sensitivity trainingcan also reinforce potentially stigmatizing notions ofIndigenous identity, inadvertently resulting in‘othering’ practices [99, 100]. Health care providers andorganizations working with Indigenous populations,therefore, need to guard against the culturalist tenden-cies pervasive in health care, which reinforce popular-ized, stereotyped notions of culture as the primaryBrowne et al. BMC Health Services Research  (2016) 16:544 Page 9 of 17analytical lens for understanding people’s health issues.For example, both clinics have worked hard to integrateculture into their health services, and regularly integratesmudging8 and teachings by Elders, as described by thisstaff member:We have Elders here… and we have the smudgeceremony during our meetings… At one pointsomeone [would] come in twice a week to dosmudges with the clients and they would do thedrum and sit out there [in the waiting room] and…would talk to people… There was much more of acalmer atmosphere when he was here… It reallychanged the dynamics of the waiting room… It’slike an innovative idea but it’s actually quite, insome ways I guess, common sense, but you don’toften think of putting someone who’s going tobring some healing words and energy into thewaiting room.These cultural practices are integral to both clinics,but alone are insufficient for equitable care. Rather, tai-loring requires meaningful partnerships, integration ofunderstandings of local history, and integration ofIndigenous knowledges, as discussed by this physician:I like to think that I use some of the bigger principlesas in… taking the narrative and the stories frompeople and listening… They’re principles that kind ofhelp me in keeping a more open view of the situationso I don’t get stuck on a medical model… It’s beyondthat. It's the spiritual aspect and the family aspect andthat historical aspect, because I mean history is everyday in the clinic. There’s history that’s hugelysignificant in the work I’m doing there.Organizations that are planning to tailor programs tolocal Indigenous contexts need to be flexible in howfunds are allocated [101]. Indigenous knowledge can beintegrated in a variety of ways through partnerships inthe local community, and the process can have power-ful impacts within an organization. These approachesshould be locally-determined given that Indigenousknowledge is grounded in local contexts, communities,histories and protocols [102, 103].7. Actively counter systemic and individual experiences ofracism and intersecting forms of discriminationGiven the high proportion of Indigenous peoples inCanada who experience racism and discrimination, coun-teracting people's experiences of discrimination at an indi-vidual level requires that health care providers convey anunderstanding of history and context. As this patientdescribed, these dynamics routinely shape many Indigen-ous peoples’ health care experiences:Toward Native people, you know, if you go to adifferent organization, you know, you get all the looks,and you know, like, “what are you doing here?”, thatkind of service. Just to get some kind of service, youhave to really act good.Conveying knowledge, genuine interest, and willing-ness to listen to people in an unhurried manner can cre-ate space for people to feel more fully understood, asdescribed by this patient:Like when you go to a regular doctor, they don’t sitand ask you how you’ve been, you know what I mean?So, they know your whole situation. I go to [anotherdoctor] and he’ll just feed me pills.Repeatedly, staff and patients identified that the impactof such efforts was often powerful. This physician de-scribed how supported his patient reported feeling afterinquiring about the impact that residential schoolinghad on the patient's health:I had discussions about the residential school, and Ididn’t remember even ever talking about [it] andhadn’t documented much in the chart. Yet he thoughtthat, or he felt that he’d been incredibly supported inhis experiences through residential school and thetraumas that he had there. So somehow, whateverhe’d brought up, and whatever I did, he felt like hewas validated. But I didn’t even think it wassignificant. So he was getting benefit that I didn’teven acknowledge or realize.Countering racism and discrimination, which is linkedto addressing unequal power relations, demands thathealth care providers have an acute awareness of howracism intersects with gendered inequities, classism, andother forms of discrimination, as this staff memberexplained:Listening to somebody talk about how they wentsomewhere [within the health care system] and howthey waited and how the doctors treated themdifferently. And then, it could be as simple as saying,“well I’m sorry that happened to you,” being able tovalidate how they feel rather than saying, “oh well,that’s the system and you have to work through it.”And it’s just really small little things. And it is peoplecoming back and saying, “well, that really helped me.”And you may not even remember saying that or youmay not even remember doing those kinds of things.Browne et al. BMC Health Services Research  (2016) 16:544 Page 10 of 17Organizations that develop strategies to counter ra-cism and discrimination need to push back againstdominant, neoliberal discourses that reinforce miscon-ceptions about people having equal access to healthcare and resources [52, 53, 98, 104]. The significanceof ensuring that people feel welcome in health carespaces cannot be overemphasized. Repeatedly, patientsexplained the significance:You see the people that walk in here, I mean, they’renot always nice looking characters. But you’re alwayswelcome. They always treat you like you’re just asgood as the next person.Actively counteracting discrimination in organizationsrequires that claims of discrimination be considered ser-iously, regardless of intention. Often patients who expressconcern about being disrespected are assumed to beoverly sensitive, reactive, or attempting to gain unfair ad-vantage by making such claims, and research shows thatpeople who experience discrimination on a daily basismay not be able to distinguish intentional from uninten-tional unfairness [44, 45, 47]. At the organizationallevel, it is therefore imperative to provide mandatory,explicit, anti-racist training for staff at all levels, in-cluding administrators, managers, receptionists, anddirect service providers. Recurring training is requiredto revisit strategies for countering the persistent po-tential for Indigenous peoples to be treated in inequit-able ways within the health care sector.8. Ensure opportunities for meaningful engagement of patientsand community leaders in strategic planning decisionsAs discussed in the first strategy, addressing the rootcauses of health, social, and health care inequities requirespartnerships with Indigenous peoples and communitymembers. Engagement can take many forms, dependingon organizational context, governance structures, and pa-tient populations. Patients involved in this study, forexample, reiterated the significance of being asked forinput or volunteering their time to assist with seem-ingly mundane tasks related to upkeep of the clinic’spremises. As this patient explained:When I sit out here [in the clinic’s waiting room], Isee different skills of people… So I’m thinking, when Igo back to my reserve, I want to give back. Everybodyhas that. I want to give back. Look at how much I’vetaken from my family. Everyone down here has thatfeeling. Even when they have nothing they want togive back.In some settings, the formation of a Community Ad-visory Committee or an Elders Committee may beinstrumental in ensuring that integration of Indigenousknowledge aligns with culturally safe intentions, and toavoid the appropriation of knowledge. In other set-tings, opportunities for employing patients as peersupport workers or volunteers may be feasible, and canhave significant impacts on the quality of life for thoseinvolved, as this patient described:I want to help people, I want to do stuff in this worldfor people and this is one of… why I’m doing this [asa] positive prevention peer support worker.Finding opportunities for community members to bemeaningfully involved in some aspect of the clinic orprogramming also provides a means for acknowledgingand drawing on the strengths, capacity, and agency ofcommunity partners.9. Tailor care, programs, and services to address interrelatedforms of violenceHealth care providers need to recognize that some Indi-genous people may be survivors of multiple forms ofviolence with traumatic effects, while still experiencingcurrent and ongoing interpersonal violence (including ra-cial violence and intimate partner violence), and ongoingstructural violence (such as systemic and organizationalracism, absolute poverty, etc.) [11, 105–107]. Tailoringcare, therefore, means offering comprehensive care thatsimultaneously addresses the multiple consequences ofinterrelated forms of violence.TVIC is one way of respectfully tailoring care to theimpact of history, specifically histories of violence, onpeople’s lives. At the individual level, this includes ac-knowledging the impact of social injustices and struc-tural violence on people's sense of agency, that is, theconstraints and possibilities for health and well-being inany individual's life. Thus, the strategy of re-visioningtime intersects with this strategy in that the ‘pace’ ofhealing will be influenced by each individual’s history. Atthe organizational and provider levels, tailoring to ad-dress interrelated forms of violence involves developingstrategies to acknowledge that dispossession fromIndigenous lands, territories, cultures and languages is afundamental determinant of health and form of struc-tural violence that is often at the root of people's mentalhealth and substance use issues [21, 108].Research shows that organizations informed by under-standings of TVIC recognize that issues of substance use,chronic pain, and histories of trauma are integrally inter-connected for people experiencing structural violence [11,25, 37, 58, 89, 105, 109–111]. Such organizations alsorecognize that people who present with these intertwiningissues frequently mistrust health care services. Therefore,for example, services must simultaneously addressBrowne et al. BMC Health Services Research  (2016) 16:544 Page 11 of 17substance use, and the health consequences of violenceand trauma, including post-traumatic stress disorder,chronic pain, and sleep problems according to thepatients' priorities. As in most PHC settings, pain wasone of the most common presenting concerns amongpatients in this study, as this provider explained:Managing pain in this environment is exceedinglychallenging because people do have emotional painand they do have physical pain and there is a grayarea and they overlap.Addressing the consequences of interrelated formsof violence includes being responsive to the multi-faceted nature of pain, and developing strategies foraddressing pain from a trauma- and violence-in-formed perspective. Similarly, substance use issuesmust be addressed by taking chronic pain and traumahistories into account. This requires adapting conven-tional guidelines for treating chronic pain, mentalhealth issuses, and substance use in ways thatrecognize the effects of trauma and violence onhealth, and that extend beyond the often tense nego-tiations for prescription drugs.Elsewhere we have described the experiences of Indi-genous peoples who express concerns about beingviewed as ‘drug seeking’ when they were seeking helpfor what they perceived to be legitimate pain issues [44,53, 112]. Similarly, in this study patients argued for:… a lot more doctors with compassion for Aboriginalpeople, instead of just looking at them like they’redrug addicts or alcoholics, and not helping with thereal pain, which all of us do have real pain.Without a broader understanding of the intertwiningnature of trauma, pain, and substance use, negativejudgments conveyed to patients, particularly those whoexperience problematic substance use, can have harm-ful consequences, as this patient described:The whole thing of addiction is having people listen,and not judging. And most doctors I know, except forthe select few that are here, they are all judging, veryjudgmental of addicts [sic]. Especially at the hospital.I would rather go through severe pain than go tothe hospital.At an organizational level, training about providingcare for patients who have experienced violence, and theintersecting health and social impacts, has been shownto increase clinicians’ confidence, knowledge, and effi-cacy [113–115]. Such training is essential to integrateunderstandings of the long-term impact of trauma intopractices and policies, and to avoid inadvertently creat-ing an invalidating environment [61, 90, 116]. This pro-vider explained the growing integration of TVIC attheir PHC clinic:… critically thinking how we provide care andalways going back to those core things of wherethat person has come from. So now when we talk[at staff meetings], we don’t just talk about[patients] needing this or that, we go to a muchdeeper level. It’s very interesting to see the switchthat’s happened with staff because they’re nowtalking about, you know, that’s really re-traumatizing or do you realize the level of traumathis person comes from? Or do you realize howdifficult it is for that person to walk through thatdoor? Or do you realize how difficult it was forthat person to actually bring up their concern to you?…And so we, we now are getting into conversationsaround our table about power imbalances andabout how our interactions can really affect this.So I’ve seen our place come from being just a placeof, you know, a safe place to come to, but it’s nowcome to a place where I can see staff graspingthese ideas and talking to each other.Given the high rates of state apprehensions of Indigen-ous children [10] and growing evidence of the benefits ofsupporting women to care for their own children [117,118], it is critical for PHC organizations and individualproviders to develop strategies for building trusting rela-tionships with women and families. Strategies includeworking with social workers and other team members tosupport parents’ access to visitations with children re-moved from their care. At an organizational level, thesekinds of efforts could be framed as part of a largerstrategy to support both men and women. PHC pro-viders can contribute to interrupting the intergenera-tional effects of residential school by recognizing thecontinuities between residential school and contem-porary child protection practices, and supporting In-digenous peoples to parent their own children. Forexample, in one of the clinics, support for pregnantand post-partum women who were under surveillanceby state authorities involved working in partnershipwith child protection workers, social workers, andother social services staff to develop shared-casemanagement plans.10. Tailor care to address the social determinants of healthfor Indigenous peoplesIncreasing access to the social determinants of healthis important for all people who experience health in-equities. Due to welfare state colonialism, economicBrowne et al. BMC Health Services Research  (2016) 16:544 Page 12 of 17constraints on reserves, and discriminatory policies,this strategy requires intensive effort in relation to In-digenous peoples.At a provider level, health issues must be continu-ally understood and addressed within the context ofthe social determinants and how they are specificallyconstrained by myriad colonial policies for Indigenouspeoples. For example, access to stable housing is con-strained by the consequences of the reserve system inCanada, by shifting policies that determine who has‘status’ and by discrimination in housing, employment,and education. As this physician explained, the socialdeterminants of inequities for Indigenous peoples mustcontinuously inform clinical care:It does shape diagnostic and therapeutic decisions…If their housing is unstable… those kinds of thingsare all very pertinent to making therapeutic plansthat are going to be more likely to succeed… I’mgenuinely interested in who they [patients] are asindividuals. I think that can be only expressed byhaving those types of conversations and asking thefollow up questions: “so did you get in touch withyour daughter, how’d that work out? How’s thehousing situation coming along, any luck, any leads?"At a minimum, people’s social circumstances and therestrictions that these circumstances place on healthmust be understood and acknowledged. Further, practicalsteps can be taken, as this provider explained:… there’s a water cooler [in the waiting room] andsometimes there’s leftover food… andwe’ve hadtoothbrushes and toothpaste, and samples of stuff becausewe recognize…Well, nobody has even two dollars to buythat stuff…And so I think there’s that level of recognitionof the degree of need, and the poverty that [some are]living in. And it’s understood and not judged.At an organizational level, structures and time allocationmust support providers to address people’s socio-economicneeds, either through partnership arrangements with otheragencies or by creating a network of multi-disciplinary teammembers to whom patients can be referred. This requiresreconsidering priorities given the local organizational con-text, as this administrator explained:Well when you sit back and think about it, there’s aneed for so many things that are non-medical thatultimately come to bear upon people’s medicalconditions. Like housing, and like even education…and those kinds of things. And you know, we’renot able to pay enough attention to thoseparticular areas.While PHC organizations can acknowledge people’scircumstances, create networks, and facilitate access tothe social determinants of health, ultimately broadersocial change is required to achieve health equity. Healthcare providers and health care organizations must par-ticipate in broader democratic processes and social ad-vocacy, bringing their unique vantage points to bear onpublic decision-making.ConclusionsThe key dimensions of equity-oriented care and 10strategies discussed in this paper may be mostoptimally operationalized in the context of interdis-ciplinary teamwork, however, they also serve as healthequity guidelines for organizations and providersworking in various settings, including individual pri-mary care practices. Although the data were gener-ated from research with two Indigenous PHC clinicsin one province in Canada, our ongoing researchusing the key dimensions and 10 strategies indicatesthat they have broader applicability in a range ofPHC contexts. These strategies can form the basis oforganizational-level interventions to promote equity,and represent viable and “politically possible” [57] (p.90) ways of increasing the provision of more equit-able, responsive, and respectful PHC services for Indi-genous populations. These approaches should not beconceptualized as solely applicable to Indigenous pop-ulations; rather, they have the potential to theprovision of high quality care across populationgroups, moving care closer to the fundamental princi-ples of quality PHC services.Further research is needed to better understand howthese approaches and strategies might intersect andlead to improvements in the overall quality of care,such as: an improved match between people's needsand services, enhanced trust and engagement by pa-tients, a shift from crisis-oriented care to continuity ofcare, and an increase in the use of community-basedservices with potential for decreasing hospital admis-sions, readmission rates, and emergency departmentuse. Studies focusing on the impacts of equity-orientedcare should compare a range of contexts to deepen un-derstanding regarding the appropriateness and applic-ability of these strategies. Future research is alsorequired to measure the impacts of equity-oriented careon staff and organizational practices, patient outcomes,and ultimately on population health.Endnotes1PHC is the principal vehicle for the delivery of healthcare at the most local level of a country's health system,and is the first level of contact for individuals, familiesBrowne et al. BMC Health Services Research  (2016) 16:544 Page 13 of 17and communities, constituting the first element of acontinuing health care process.2Our use of the terms ‘marginalization’ or ‘marginal-ized’ in relation to Indigenous peoples recognizes thatmarginalization is entrenched in the history of relationsbetween Indigenous peoples and the nation-state,resulting in a disproportionate burden of ill health andsocial suffering within Indigenous populations. Margin-alized therefore refers to the conditions that continueto result in structural, social and health inequities. Ouruse of the term is also inclusive of the many strengthsand capacities accumulated in the context of people’shistory and circumstances, and people's agency, resist-ance and resilience.3Consistent with accepted terminology used in land-mark international reports, we use the term Indigenouspeoples to refer to the diversity of populations through-out the world. In Canada, over 1.4 million people of thetotal population of ~ 32.9 million (4.3 %) identify asIndigenous [119], and the term Indigenous peoplesrefers to the original inhabitants of the land [120],including First Nations, Métis, and Inuit people. Theterm Aboriginal is also commonly used, and the colo-nial term ‘Indian’ is still used in federal governmentpolicy documents (e.g., The Indian Act). Approxi-mately 50 % of Indigenous peoples are registered withthe federal Department of Indigenous and NorthernAffairs, and are therefore considered ‘Status’ Indians(First Nations). Thirty percent are Métis, 15 % areunregistered First Nations, and 4 % are Inuit. Thereare currently 617 First Nations ‘bands’ or tribalgroups in Canada representing over 50 culturalgroups [119]. Approximately 78 % of Indigenouspeoples live off-reserve [121].4In British Columbia (BC), Canada, for example, Indi-genous children are 14 times more likely to be taken intothe ‘care’ of the child welfare system than non-Indigenouschildren during their school-aged years [122].5In Canada, visible minority refers to persons whoare identified according to Canada’s EmploymentEquity Act as "persons, other than Aboriginal peoples,who are non-Caucasian... or non-white in colour"[82].6Friendship Centres have formed in many Canadiancities under the auspices of the National Associationof Friendship Centres. Initially, these Centres were de-veloped to provide supports related to employment,housing, health and education. Over the decades, thenumber of Centres and their range of services have in-creased significantly.7Culturalism is a form of stereotyping whereby culture,defined very narrowly and often in stereotypical ways,becomes the primary explanation for why certain groupsof people may be experiencing particular health or socialissues. Research continues to show that healthcare pro-fessionals frequently attribute people’s social problems totheir cultural characteristics, for example, leading themto wrongly assume that violence toward women may beacceptable in particular cultural groups, or that somepeople are more prone to using drugs or alcohol becauseof ‘their culture’.8Smudging is a practice common to many Indigenousgroups in North America. It usually involves ceremonyand using the smoke of sacred herbs, grasses or treebranches to cleanse one’s self and thoughts.AbbreviationsCAC: Community advisory committee; PHC: Primary health care;TVIC: Trauma- and violence-informed careAcknowledgementsWe gratefully thank the research participants for generously sharing theirperspectives and for enabling us to conduct this research. We thank ourteam members whose ideas contributed to the analysis discussed in thispaper: Scott Lennox, Doreen Littlejohn, John O’Neil, and Patricia Rodney.We also thank Patty Belda, Margaret Coyle and Jane Inyallie for participatingin the interpretation of the research results and helping us to understandthe implications.FundingThis research was generously funded by the Canadian Institutes of HealthResearch Grant #173182. The funder had no role in study design, datacollection and analysis, decision to publish, or preparation of the manuscript.Availability of data and materialsThe datasets generated during and/or analysed during the current study arenot publicly available due to anonymity requirements but are available fromthe corresponding author on reasonable request.Authors’ contributionsAJB is the Nominated Principal Investigator and CV, JL, VS and SW areco-Principal Investigators. All authors contributed to the conceptualizationand design of the study. AJB and CV led the development and writing ofthis manuscript, and JL, VS, SW and DT contributed equally to revising andfinalizing the manuscript. MK, OG, KK and AF contributed to the analysisand interpretation of the findings. All authors read and approved thefinal manuscript.Authors’ informationBrowne, Varcoe, Wong and Smye are members of the Critical Research inHealth and Healthcare Inequities Unit at the University of British ColumbiaSchool of Nursing (http://www.crihhi.nursing.ubc.ca). Lavoie is Director of theManitoba First Nations Centre for Aboriginal Health Research. Tu is a primarycare physician and Research and Education Coordinator at the VancouverNative Health Society. Krause is Executive Director of the Central InteriorNative Health Society. Godwin is Executive Director of the Prince GeorgeDivision of Family Practice. Khan was the research manager for this study.Fridkin was a doctoral student trainee during this project.Competing interestsThe authors declare that they have no competing interests.Consent for publicationNot applicable.Ethics approval and consent to participateEthics approval was provided by the University of British ColumbiaBehavioral Research Ethics Board, and the University of Northern BritishColumbia Research Ethics Board. Consent to participate was obtainedfrom all participants involved in this research.Browne et al. BMC Health Services Research  (2016) 16:544 Page 14 of 17Author details1School of Nursing, The University of British Columbia, T201 – 2211Wesbrook Mall, Vancouver, British Columbia V6T 2B5, Canada. 2Manitoba FirstNations Centre for Aboriginal Health Research, 715 John Buhler ResearchCentre, 727 McDermot Ave, Winnipeg, Manitoba R3E 3P5, Canada. 3Facultyof Health Sciences, University of Ontario Institute of Technology, 2000Simcoe Street North, Science building, Room 3000, Oshawa, Ontario L1H7 K4, Canada. 4School of Nursing and the Centre for Health Services andPolicy Research, The University of British Columbia, T201 – 2211 WesbrookMall, Vancouver, British Columbia V6T 2B5, Canada. 5Central Interior NativeHealth Society, 365 George Street, Prince George, British Columbia V2L 1R4,Canada. 6Department of Family Practice, The University of British Columbia,5950 University Boulevard, Vancouver V6T 1Z3, British Columbia, Canada.7Prince George Division of Family Practice, 1302 7 Ave, Prince George, BritishColumbia V2L 3P1, Canada. 8Indigenous Health Program, Provincial HealthServices Authority of British Columbia, 201-601 West Broadway, Vancouver,British Columbia V5Z 4C2, Canada.Received: 12 September 2015 Accepted: 24 August 2016References1. 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