EQUIP emergency: Can interventions to reduce racism, discrimination and stigma in EDs improve outcomes?
Open accessAbstract
BACKGROUND: Despite a publicly funded system, health care in Canada has been shown to be deeply inequitable, particularly toward Indigenous people. Based on research identifying key dimensions of equity-oriented health care as being cultural safety, harm reduction and trauma- and violence-informed care, an intervention to promote equity at the organizational level was tested in primary health care, refined and adapted, and tested in Emergency Departments (EDs). METHODS: In partnership with clinical, community and Indigenous leaders in three diverse EDs in one Canadian province, we supported direct care staff to tailor and implement the intervention. Intervention activities varied in type and intensity at each site. Survey data were collected pre- and post-intervention from every consecutive patient over age 18 presenting to the EDs (n = 4771) with 3315 completing post-visit questions in 4 waves at two sites and 3 waves (due to pandemic constraints) at the third. Administrative data were collected for 12 months pre- and 12 months post-intervention. RESULTS: Throughout the study period, the participating EDs were dealing with a worsening epidemic of overdoses and deaths related to a toxic drug supply, and the COVID 19 pandemic curtailed both intervention activities and data collection. Despite these constraints, staff at two of the EDs mounted equity-oriented intervention strategies; the other site was experiencing continued, significant staff shortages and leadership changeover. Longitudinal analysis using multiple regression showed non-significant but encouraging trends in patient perceptions of quality of care and patient experiences of discrimination in the ED. Subgroup analysis showed that specific groups of patients experienced care in significantly different ways at each site. An interrupted time series of administrative data showed no significant change in staff sick time, but showed a significant decrease in the percentage of patients who left without care being completed at the site with the most robust intervention activities. CONCLUSIONS: The trends in patient perceptions and the significant decrease in the percentage of patients who left without care being completed suggest potential for impact. Realization of this potential will depend on readiness, commitment and resources at the organizational and systems levels. TRIAL REGISTRATION: Clinical Trials.gov #NCT03369678 (registration date November 18, 2017).
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PHC settings and EDs are critical contexts for addressing health equity, particularly with reductions in community-level primary care and increasing pressures on EDs.
“PHC settings and EDs are critical contexts within which issues of health equity and inequities must be addressed, particularly in light of ongoing reductions in community-level primary care services in most jurisdictions in Canada, with concomitant and increasing pressures on EDs to bridge the gaps in care [5, 10, 24, 49].”
From Using a health equity lens to measure patient experiences of care in diverse health care settings (2024) · cites this paper as [24]
Ratings of quality of care in the SMH sample were high, with an average of 8.11 (SD 2.14) on a 0-10 scale.
“ratings of quality of care in our sample were high, with an average of 8.11 (SD 2.14) on a scale of 0–10, as measured by an item from the British Columbia Emergency Department Patient Experiences of Care scale [10, 24, 36, 77].”
From Using a health equity lens to measure patient experiences of care in diverse health care settings (2024) · cites this paper as [24]
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“Abbreviations BCEDPEC: British Columbia Emergency Department Patient Experiences of Care; EOHC: Equity-Oriented Health Care; EQUIP: PHC EQUIP Primary Health Care; EDI: Equity, Diversity, Inclusion; FLO: Front-Line Ownership; ITS: Interrupted Time Series; LWCC : Left Without Care Complete; PHC: Primary Health Care; SMH…”
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“Abbreviations BCEDPEC: British Columbia Emergency Department Patient Experiences of Care; EOHC: Equity-Oriented Health Care; EQUIP: PHC EQUIP Primary Health Care; EDI: Equity, Diversity, Inclusion; FLO: Front-Line Ownership; ITS: Interrupted Time Series; LWCC : Left Without Care Complete; PHC: Primary Health Care; SMH…”
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“Further, because we were not able to collect data on presenting diagnoses, we were not able to study primary care sensitive conditions [86, 87], which may have permitted a more nuanced analysis of those leaving without care completed.”
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“Abbreviations BCEDPEC: British Columbia Emergency Department Patient Experiences of Care; EOHC: Equity-Oriented Health Care; EQUIP: PHC EQUIP Primary Health Care; EDI: Equity, Diversity, Inclusion; FLO: Front-Line Ownership; ITS: Interrupted Time Series; LWCC : Left Without Care Complete; PHC: Primary Health Care; SMH…”
MethodFeasibility of using emergency department patient experience surveys as a proxy for equity of care.
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“[68], which compared the BCEDPEC sample to a sample collected inperson, our sample was more diverse in terms of having greater representation from Indigenous people and those less likely to have a usual primary care home (meaning access to an identified physician or nurse practitioner as their regular health care prov…”
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“Further, because we were not able to collect data on presenting diagnoses, we were not able to study primary care sensitive conditions [86, 87], which may have permitted a more nuanced analysis of those leaving without care completed.”
BackgroundVariations in Resource Intensity and Cost Among High Users of the Emergency Department
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“Patient populations overrepresented among those who LWCC include those with mental health issues/psychiatric needs [83, 84], substance use health problems [82, 83, 85], chronic pain [7], unstable/low income housing [82, 85] and frequent use of the ED [84, 85].”
BackgroundBufalino, V. J., Bleser, W. K., Singletary, E. A., Granger, B. B., O'Brien, E. C., Elkind, M. S. V., Lopez, M. H., Saunders, R. S., McClellan, M., & Brown, N. (2020) · Circulation Cardiovascular Quality and Outcomes · doi:10.1161/circoutcomes.120.006780 · Cited by 7 · cited 1× · see citing works
“Interventions to promote equity are often aimed at improving health care access and care for individuals and studied within the context of specific health issues such as diabetes [20], stroke [21], cancer screening [22], or organ transplant [23].”
BackgroundAn ED paradox: patients who arrive by ambulance and then leave without consulting an ED provider
Doupe, M. B., Day, S., Palatnick, W., Chochinov, A., Chateau, D. G., Snider, C., de Faria, R. L., Weldon, E., & Derksen, S. A. (2016) · Emergency Medicine Journal · doi:10.1136/emermed-2015-205165 · Cited by 5 · cited 8× · see citing works
“Abbreviations BCEDPEC: British Columbia Emergency Department Patient Experiences of Care; EOHC: Equity-Oriented Health Care; EQUIP: PHC EQUIP Primary Health Care; EDI: Equity, Diversity, Inclusion; FLO: Front-Line Ownership; ITS: Interrupted Time Series; LWCC : Left Without Care Complete; PHC: Primary Health Care; SMH…”
BackgroundInfluentialThe Role of Discrimination Experiences in Postrape Adjustment Among Racial and Ethnic Minority Women
Walsh, K., Gilmore, A. K., Barr, S. C., Frazier, P. A., Ledray, L. E., Acierno, R. E., Ruggiero, K. J., Kilpatrick, D. G., & Resnick, H. S. (2021) · Journal of Interpersonal Violence · doi:10.1177/08862605211028006 · Cited by 5 · cited 1× · see citing works
“These findings aligned with historical and ongoing evidence of inequitable treatment in EDs for Indigenous people [4, 7, 33, 34], people experiencing violence [35, 36], and those presenting with histories of mental illness [37], substance use and/or homelessness [38, 39].”
BackgroundWright, P. C. (2020) · cIRcle (University of British Columbia) · doi:10.14288/1.0394782 · Cited by 4 · see citing works
Surviving influenza: lived experiences of health inequity and pandemic disease in Canada
Jones, E. W. (2020) · Canadian Medical Association Journal · doi:10.1503/cmaj.201074 · Cited by 3 · see citing works
Flagged first, then by citations
1 of the 72 references couldn’t be matched to a known paper.
Research works printed but not linked: 3
- [13]Mate K, Wyatt R. Health equity must be a strategic priority. NEJMCatalyst. 2017. https://catalyst.nejm.org/doi/full/10.1056/CAT.17.0556. · DOI
- [70]Kulik CT Roberson L Diversity initative effectiveness: What organizations can (and cannot) expect from diversity recruitment, diversity training, and formal mentoring programs. Diversity at Work 2010 Cambridge Cambridge University Press 265 317
- [78]Palis H, Bélair M-A, Hu K, Tu A, Buxton J, Slaunwhite A. Overdose deaths and the COVID-19 pandemic in British Columbia, Canada. Drug Alcohol Rev; 2021. 34908203
Cited by
Sorted by citations
Trauma- and Violence-Informed Care: Orienting Intimate Partner Violence Interventions to Equity
Wathen, C. N., & Mantler, T. (2022) · Current Epidemiology Reports · doi:10.1007/s40471-022-00307-7 · Cited by 132 · see citing works
Emergency department care experiences among people who use substances: a qualitative study
Rajab, D., Fujioka, J. K., Walker, M., Bartels, S. A., MacKenzie, M., & Purkey, E. (2023) · International Journal for Equity in Health · doi:10.1186/s12939-023-02050-x · Cited by 20 · see citing works
“This intervention has been tested in EDs and primary healthcare settings in Canada and shown improvements in self-reported patient outcomes, and enhanced staff comfort and confidence in providing EOHC [29, 30, 45, 46].”
BackgroundUsing a health equity lens to measure patient experiences of care in diverse health care settings
Browne, A. J., Varcoe, C., Ford-Gilboe, M., Wathen, C. N., Wilson, E., Bungay, V., & Perrin, N. (2024) · PLOS ONE · doi:10.1371/journal.pone.0297721 · Cited by 17 · see citing works
“…to understand experiences of care in a more nuanced way, and in light of deepening health care inequities in Canada [26, 78, 79], the larger EQUIP Emergency survey also sought to understand patients’ experiences of discrimination, both in their everyday life and during their ED visit [10, 24, 36].”
BackgroundMethodResultInfluentialSelf-citationFrom Subversion to Hard-Wiring Equity
Slemon, A., Bungay, V., Varcoe, C., & Garneau, A. B. (2023) · Advances in Nursing Science · doi:10.1097/ans.0000000000000517 · Cited by 10 · see citing works
“41 Toward similar aims, institutions can engage nurses, other health care providers, and patients in identifying meaningful strategies for shifting current normative practices and discourses toward equity, in what Chin 42(pp356-357) describes as “a culture of equity in which the whole organization…”
Self-citationBringing an Equity Lens to Participant Observation in Critical Ethnographic Health Research
Horrill, T. C., Varcoe, C., Brown, H. J., Stajduhar, K., & Browne, A. J. (2024) · International Journal of Qualitative Methods · doi:10.1177/16094069241270397 · Cited by 10 · see citing works
“…et al., 2019), primary health care (Browne et al., 2011b, 2016; Browne et al., 2011a), care in the emergency department (ED) (Tang et al., 2015; Varcoe et al., 2019, 2022a, 2022b), maternity care for rural Indigenous women (Brown et al., 2011; Varcoe et al., 2013) and the health and…”
Self-citationHorrill, T. C., Crawford, J., Beck, S., Bourgeois, A., Kaur, J., Lambert, L. K., McKenzie, M., Stajduhar, K., & Browne, A. J. (2025) · International Journal for Equity in Health · doi:10.1186/s12939-025-02554-8 · Cited by 7 · see citing works
“The effectiveness of these approaches to equity-oriented healthcare have been studied in Canadian primary care and emergency departments settings [37, 39–41] and have been identified as relevant and applicable for implementation in the cancer care sector [36].”
Reconceptualizing Advocacy: A Novel Model for Nursing Theory and Practice
Pitcher, C. F., Slemon, A., & Danda, M. C. (2025) · Nursing Inquiry · doi:10.1111/nin.70036 · Cited by 6 · see citing works
“Such an approach enables nurses to meaningfully grapple with the realities of a health care system that has been shown to perpetuate harms as a result of stigma and discrimination (Ford ‐ Gilboe et al. 2018; Kitching et al. 2020; Varcoe et al. 2022).”
Hearn, F., Biggs, L. J., Brown, S., Krastev, A. H., Szwarc, J., & Riggs, E. (2023) · Trauma Care · doi:10.3390/traumacare3030016 · Cited by 6 · see citing works
Social Justice in Nursing: A Critical Interpretive Synthesis
Slemon, A., Handlovsky, I., & Schmied, S. (2025) · Nursing Philosophy · doi:10.1111/nup.70045 · Cited by 8 · see citing works
“…towards embedding equity in specific primary care and emergency health services settings, demonstrating how such microcosms of equity enhance healthcare providers' capacity to enact social justice practices and reduce patients' experiences of discrimination (Browne et al. 2018; Varcoe et al. 2022).”
Nolen, S., Wilson, T. T., Jacka, B. P., Li, Y., Beaudoin, F. L., & Marshall, B. D. L. (2023) · Addictive Behaviors Reports · doi:10.1016/j.abrep.2023.100496 · Cited by 5 · see citing works
“Additional operational and policy changes can help sustain these practices and also standardize care (Varcoe et al., 2022).”
BackgroundImproving Indigenous health equity within the emergency department: a global review of interventions
Marchand, T., Squires, K., Daodu, O. O., & Brindle, M. E. (2024) · Canadian Journal of Emergency Medicine · doi:10.1007/s43678-024-00687-3 · Cited by 4 · see citing works
“Four papers discussed the importance of integrating Indigenous ways of knowing, doing and being into healthcare [16, 26–28].”
BackgroundMethodInfluentialWalker, M., MacKenzie, M., Douglas, S. L., Collier, A., Pritchard, J., Hoffe, S., Norman, P. A., Purkey, E., Messenger, D. W., & Bartels, S. A. (2024) · Frontiers in Disaster and Emergency Medicine · doi:10.3389/femer.2024.1397597 · Cited by 3 · see citing works
Edalati, H., Katan, C., & Taha, S. A. (2024) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2024.1425514 · Cited by 3 · see citing works
Björklund, S., Hagell, P. L., Hagell, P., Persson, M., & Holmberg, M. (2024) · International Emergency Nursing · doi:10.1016/j.ienj.2024.101451 · Cited by 3 · see citing works
Adu, J., Wong, J. P., Boakye, P. N., Gyamfi, S., Etowa, E. B., & Owusu, M. F. (2025) · JMIR Research Protocols · doi:10.2196/66851 · Cited by 3 · see citing works
“While several studies have examined mental health and mental illness–related stigma among Black people in Canada [17,34,69], very few have attempted to co-design a contextual framework to deal with the growing mental health disparities in Black communities [70,71].”
Cater, C., Browne, A. J., Varcoe, C., Hirani, S. S., & Wilson, E. (2025) · Nursing Inquiry · doi:10.1111/nin.70049 · Cited by 2 · see citing works
“…study employs a structural lens guided by critical theoretical perspectives to investigate the organizational and structural factors that extend beyond individual behaviors of patients and staff, or their interactions (Browne and Reimer ‐ Kirkham 2014; Kirkham and Browne 2006; Varcoe et al. 2022).”
InfluentialSelf-citationOperationalizing the Quintuple Aim of Health System Improvement Through Equity-Oriented Health Care
Wathen, C. N., Browne, A. J., Wilson, E., Bungay, V., & Varcoe, C. (2025) · Health Services Insights · doi:10.1177/11786329251381442 · Cited by 2 · see citing works
“…doing so, they found that the site that managed, during the COVID-19 pandemic and other disruptions, 44 to implement EOHC most robustly demonstrated significant reductions in their rate of patients leaving without their care completed, 45 a key indicator used in ED, 46 including Lean-ED, studies.”
Self-citationInterventions to improve equity in emergency departments for Indigenous people: A scoping review
MacLean, D., Curtin, K. D., Barnabe, C. C. M., Bill, L., Healy, B. A., Holroyd, B. R., Khangura, J. K., & McLane, P. (2024) · Academic Emergency Medicine · doi:10.1111/acem.14987 · Cited by 2 · see citing works
“37 The Dalarinji/Flexiclinic model of care was described as having Indigenous patients seen by a dedicated senior clinician/Aboriginal Health Care Worker team, with the ability to leave and return to ED visits as needed and having their care resumed without duplication of the triage process or…”
InfluentialDu, A. L., Macias, A. A., Burton, B. N., & Gabriel, R. A. (2025) · Journal of Intensive Care Medicine · doi:10.1177/08850666251337399 · Cited by 1 · see citing works
“42 Additional evidence supports a systems-based approach, such as fi nancial incentives to treat a broader ethnic mix of patients.”
van der Breggen, A., Leske, S., Dean, J. A., Sanjida, S., Wallace, J., Lee, N., & Ward, J. S. (2026) · International Journal for Quality in Health Care · doi:10.1093/intqhc/mzag057 · Cited by 2 · see citing works
Roland, H. B., McGuire, C. M., Baskin, M. L., Esposito, M. H., Baker, E., & Brown, E. (2024) · Cancer · doi:10.1002/cncr.35512
“19 Thus, measuring net influences on health may require data capturing structural racism at multiple spatial levels.”
House-Kokan, M., Jetha, F., & Silveira, A. (2025) · Science Talks · doi:10.1016/j.sctalk.2025.100448
Fürer, N., Giacobbe, E., & Ress, E. (2026) · Journal of Emergency Nursing · doi:10.1016/j.jen.2025.12.006
Horrill, T. C., Crawford, J., Beck, S. M., Bourgeois, A., Kaur, J., Lambert, L. K., McKenzie, M. R., Stajduhar, K., & Browne, A. J. (2026) · Frontiers in Oncology · doi:10.3389/fonc.2026.1676594
“…and emergency department settings (19 – 22), these approaches are relevant to cancer care (15), and care grounded in cultural safety, trauma-and violence-informed approaches, and harm reduction philosophies is critical to improving access to cancer care and patient experiences of care (9, 21, 24).”
Varcoe, C., Browne, A. J., Bungay, V., Wathen, C. N., Wilson, E., Byres, D., Stones, C., Dolan, S., Slemon, A., Black, A., et al. (2026) · BMC Health Services Research · doi:10.1186/s12913-026-14919-y
“Analyses of the impact of the EQUIP ED intervention are reported elsewhere [21, 22].”
Self-citationDeering, K., King, D., Thompson, C., Zhou, H., & Shannon, K. (2026) · Journal of the International Association of Providers of AIDS Care (JIAPAC) · doi:10.1177/23259582261447934
“39 Extensive work has been undertaken to disseminate knowledge and recommendations of a toolkit outlining the Women-Centered HIV Care model, which includes core components of both person-centered and trauma-and violence-aware care.”
Oster, R. T., Listener, L., Young, D., Saddleback, M., Lightning, P., Bill, L., Chow-Horn, W., Gray, M., Bedard, J. R., & Bell, R. C. (2026) · Frontiers in Public Health · doi:10.3389/fpubh.2026.1823280
- Authors
- Varcoe, C., Browne, A. J., Perrin, N., Wilson, E., Bungay, V., Byres, D., Wathen, N., Stones, C., Liao, C., & Price, E. R.
- Affiliations
- University of British Columbia (CA)
- Johns Hopkins University (US)
- University of Northern British Columbia (CA)
- Provincial Health Services Authority (CA)
- Corresponding author
- Varcoe, Colleen
- Venue
- BMC Health Services Research
- Published
- 2022-09-02
- Volume
- 22
- Issue
- 1
- Pages
- 1113-1113
- ISSN
- 1472-6963 (ISSN-L)
- PMC
- PMC9436447
- OpenAlex
- W4294119542
- Cited by
- 27
- References
- 72
- Citations by year
- 2026: 6 · 2025: 8 · 2024: 8 · 2023: 4 · 2022: 1
- FWCI
- 7.55
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Locations
- BMC Health Services Research (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- cIRcle (University of British Columbia) (submittedVersion, cc-by)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Funders
- Canadian Institutes of Health Research (PJT148832)
- Topics
- Social Sciences › Sociology and Political Science › Cultural Competency in Health Care
- Social Sciences › Health › Indigenous Health, Education, and Rights
- Health Sciences › Medicine › Emergency Medicine › Emergency and Acute Care Studies
- Keywords
- health equity, emergency department, Indigenous health, racism in healthcare, discrimination, stigma, cultural safety, harm reduction, organizational interventions, drug overdose, COVID-19 pandemic
- MeSH terms
- COVID-19, Adolescent, Canada, Delivery of Health Care, Emergency Service, Hospital, Humans, Violence, Racism
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