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Int J Equity Health. 2018 Sep 27;17(1):154. doi: 10.1186/s12939-018-0820-2.

Disruption as opportunity: Impacts of an organizational health equity intervention in primary care clinics.

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School of Nursing, The University of British Columbia, T201-2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada.
School of Nursing, The University of British Columbia, T201-2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada.
Arthur Labatt Family School of Nursing, Western University, FIMS & Nursing Building, London, ON, N6A 5B9, Canada.
Faculty of Information & Media Studies, Western University, FIMS & Nursing Building, London, ON, N6A 5B9, Canada.
Public Health Agency of Canada, 785 Carling Avenue, AL 6809B, Ottawa, ON, K1A 0K9, Canada.
School of Social Work, University of Victoria, PO Box 1700, STN CSC, Victoria, BC, V8W 2Y2, Canada.
Canadian Institute for Substance Use Research, and School of Nursing, University of Victoria, Victoria, BC, V8W 2Y2, Canada.
School of Population and Public Health, The University of British Columbia, and Centre for Studies in Family Medicine, The Western Centre for Public Health and Family Medicine, Western University, London, ON, N6A 3K7, Canada.
Department of Community Health Sciences and Ongomiizwin - Research, Indigenous Institute of Health and Healing, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, MB R3E 3P5, Canada.
Centre for Health Services and Policy Research and School of Nursing, University of British Columbia, T201-2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada.
Faculty of Nursing, Universite de Montreal, PO Box 6128, Centre-ville Station, Montreal, QC, H3C 3J7, Canada.



The health care sector has a significant role to play in fostering equity in the context of widening global social and health inequities. The purpose of this paper is to illustrate the process and impacts of implementing an organizational-level health equity intervention aimed at enhancing capacity to provide equity-oriented health care.


The theoretically-informed and evidence-based intervention known as 'EQUIP' included educational components for staff, and the integration of three key dimensions of equity-oriented care: cultural safety, trauma- and violence-informed care, and tailoring to context. The intervention was implemented at four Canadian primary health care clinics committed to serving marginalized populations including people living in poverty, those facing homelessness, and people living with high levels of trauma, including Indigenous peoples, recent immigrants and refugees. A mixed methods design was used to examine the impacts of the intervention on the clinics' organizational processes and priorities, and on staff.


Engagement with the EQUIP intervention prompted increased awareness and confidence related to equity-oriented health care among staff. Importantly, the EQUIP intervention surfaced tensions that mirrored those in the wider community, including those related to racism, the impacts of violence and trauma, and substance use issues. Surfacing these tensions was disruptive but led to focused organizational strategies, for example: working to address structural and interpersonal racism; improving waiting room environments; and changing organizational policies and practices to support harm reduction. The impact of the intervention was enhanced by involving staff from all job categories, developing narratives about the socio-historical context of the communities and populations served, and feeding data back to the clinics about key health issues in the patient population (e.g., levels of depression, trauma symptoms, and chronic pain). However, in line with critiques of complex interventions, EQUIP may not have been maximally disruptive. Organizational characteristics (e.g., funding and leadership) and characteristics of intervention delivery (e.g., timeframe and who delivered the intervention components) shaped the process and impact.


This analysis suggests that organizations should anticipate and plan for various types of disruptions, while maximizing opportunities for ownership of the intervention by those within the organization. Our findings further suggest that equity-oriented interventions be paced for intense delivery over a relatively short time frame, be evaluated, particularly with data that can be made available on an ongoing basis, and explicitly include a harm reduction lens.


Attitude of health personnel; Harm reduction; Health care disparities; Health equity; Health services accessibility; Health services research; Indigenous populations; Primary care; Structural violence; Trauma informed care; Trauma- and violence-informed care; Vulnerable populations

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