Table 1 Sample of summary of quotes for each identified theme

Recognizing the need for enhanced institutional cultural competency

Navigating systemic racism among Indigenous communities

P007: Encourage Indigenous kids to go into the health field because we need to break down that systemic racism and those issues that are happening in our healthcare system

P007:Reinstate the coverage for Indigenous people under their current insurance provider is not insured health benefits so it's NIHB be that's a program delivered through health Canada. And they used to have coverage for chiropractic for Indigenous people that was probably up until the 90 s, at some point, and then in the 90 s, with all the cuts, with the Conservative Government, chiropractic was not a surprise that it was slashed

P002: No, I do not think chiropractic as a profession has figured this out yet. It's predominantly a white profession. It predominantly treats white people

The need for advocacy to reduce systemic barriers

P013: Well, certainly a better funding for a chiropractor, of course, would be a better issue or improved insurance benefits to relieve financial barriers, for those who have to have insurance

P007: So, for example, the [Canadian Chiropractic Association] has a mandate that chiropractors, will be on everybody's healthcare team, by the year 2023, when most of the people that I’ve spoken to up here in northern Manitoba never even heard of a chiropractor, that's not going to happen by 2023 if we don't start moving towards building education in these communities to show how we can help, how we can work with them, how we can help them, how we can better their health care services

P014: I think, this is a call on the advocacy groups, this is a call on the national regulatory bodies now to say listen, we need to help you I can give you the skills to give to your members, in order for them to help identify what biases that they have

P002: I would then ensure that we have a policy on you know, diversity, equity and inclusion I would, I would ensure that as a clinic were going and doing outreach to some of these communities and yeah. Just being more involved right, more hands on in the community and providing services and support

Strengthening DEI competencies in professional training

P03: Yeah if someone, for some people pain is part of life, and then they just seek relief to be able to achieve their daily activities. And that's kind of easier because their expectations are more realistic. Some other people if for them pain is something that should be avoided, and that is not normal and that they shouldn't not feel, then usually for them, it means that they need a lot more education and explanation about what's going on things like that, so they can have, they can bring down their expectation sometime people expect like one or two visits they'll get pain free but they've been in pain for months and so those people need to be reassured that pain is normal and you know to an extent, like it's normal to feel pain that it takes time to get better things like that. Much more education for that group of people that want to avoid pain at all costs that don't think it's normal

P002: Just to create this level of awareness on racism and systemic discrimination and culture, and all of these things. But we have a long way to go, I think it needs to infiltrate our curriculum, more needs to infiltrate, so that you know people are trained on it right from the beginning, so when they graduate they're like oh yeah I'm good with this, I already know this right

Advancing equity though diverse representation

P013: Chiropractic is predominantly a Western health care system and the chiropractic colleges, are going to be North America, Australia, many in Europe now that are serving Western European languages. I suppose that as people from cultural groups are coming to Canada, many, there are some who will choose to go into chiropractic and that will eventually in a generation or so increase the number of ethnically or ethnically minority-oriented practitioners. So, it's going to be a while, for that to catch up

P012: And then also just internal privileges that some people are afforded to them. I had to have both my parents cosign for me and so their entire credit rating was looked at right, so if your parents aren't in a position to be you know co-signing and I guess the jig is up right. So, and there really wasn't any financial aid to speak of that I was aware of at least when I was going through, so I would imagine that that creates that big divide

P002: We do not have good representation, even forget color, women just women in leadership is low, so you've got you know more than 50% of students in chiropractic colleges are female, yet they have no female role models and leadership, so what would encourage them to become leaders in the profession, if they don't see anybody that looks like them at the top. So, I think it's really important that these young people are able to visualize what they could be

P011: You're creating a culture where those people are welcome isn't even the right word. Sought out right because right now it's like, oh, anyone can go into healthcare, and it's like, but can they like, think about the barriers that they have to pursuing higher education, the trauma they may have experienced, the low income they have to work their way through school. Whereas you know us rich white kids just gets paid, tuition gets paid by our parents, and we just get to the school and get straight A's because we're sleeping at night, you know what I mean

Fostering a culturally responsive clinical practice

Increased cultural awareness and sensitivity

P011: “But to patients who are from [Non-Western] cultures and, particularly, who have been marginalized and who have been traumatized in the colonized system that we have, those are greater indicators of positive outcomes than anything that comes out of your mouth or anything you teach them to do, because if they don't trust you, they won't actually tell you what's going on and they won't believe anything you say, and they will be afraid because without that trauma-informed lens on you know you don't know if they've had a bad experience with a chiropractor or a doctor.”

P005: I think it's a lack of perspective, I think, maybe you know the rigors of becoming a doctor limit some people's exposure to the world and maybe they don't have experiences that are broad enough to to really understand that you know what they're learning in books may not be true. And you know, depending on what they're reading and what they believe they can have some very damaging ideas

P008: I don't know if we ever have enough cultural knowledge, but I feel comfortable with treating anybody and everybody. I'm always learning. And so I guess I’m just trying to be sensitive and I, you know I feel like I haven't had any alarm bells go off with how I’ve dealt with things, but I feel like I’m always I guess yeah sensitive to me not knowing the right thing to do or say, but at least giving that the safe space to be able to manage it in a you know, whatever humane way so

Developing culturally competent behaviours

P011: We need a culture that says, we get that not everyone has the same playing field and we're going to make it easier for the people for whom it is intrinsically harder, because that is the only way to make it equitable. Equitable doesn't mean the same for everybody, it means that everybody gets what they need, and once we have a culture and a desire and people actually actively deserving out, different perspectives and lived experiences, I think you will see more practitioners, because people will… Barriers will be removed and people will feel included, and it won’t be such an uphill battle and you know people from minority groups need healthcare practitioners from those minority groups, that is the fastest way to build trust and the fastest way to have better health outcomes for patients, when they trust their practitioner. So I mean it's a culture and a system shift and it starts with white wealthy healthcare practitioners getting it through their heads that they're not god's gift to mankind and taking some taking some education and just listening and humbling themselves and being open to the reality that they are privilege

P014: We have portions of our intake form for languages in case they need [other] languages. If they need a form translated, a huge population over here is the Punjabi population, so we do have intake forms that are translated into that right. So, we try our best and in terms of accommodating for language barriers, but also for people that just need additional time for their appointments. […] We create larger appointment times for people with language barriers or people that seem to have more complex cases, that way they're heard to the same extent that a [native] English speaker is heard

Understanding patients’ cultural values

P006: A mainstream North American perspective on health and how you reach those health outcomes, that's not necessarily the same approach or perspective that other people from other cultures and ethnicities view their health

P007: In Indigenous health we practice what's called the medicine wheel, and that includes mind body spirit and emotion and so Western medicine is just getting into mind body medicine. We take that further we take that twice as far we go mind body spirit and emotion and then make sure, that ensures that all aspects of locations well-being are monitored, not just their physical body, but their mental health, their nutrition, and their and their emotions and their responses and we all know that stress pay plays a big role and so by understanding my teaching in indigenous medicines and of the medicine wheel that allows me to apply those principles to my patients and I’ve done this over the years

P003: Pain is not always seen the same for some people part pain is just part of life it's something that is normal, and when it gets too much, when it affects their daily activity they will consult only then. And for some other culture, it seems like pain is something that should be avoided at all costs, like any pain is an issue

Contextual determinants of cultural competence in accessing care

Patients’ socioeconomic status

P011: I find even booking the booking process can sometimes be a challenge for people if they aren't you know middle, upper middle class, you know phones with Internet, very tech savvy. For them online booking is great, but for older generations are people who don't have a lot of technology it's a real problem. And, and the same with follow up in the same, like exercises so again technology […] [Y]ou can send exercises, but again, you need a computer, you need to set up a password, you need to create an account, you need to login, you need to have access

P014: The people working a lot in the area over here just to make ends meet and as a result of that the attendance is poor but also, they don't get better because they have the constant bombardment of what's… The stimuli that's also causing detriment to their house, for example, if they have a working job that's repetitive in nature and their injuries or injury that's a result of a job that's repetitive in nature there in the cyclical pattern of never getting better, even if you provide them with the full course of treatment, for example. You give them the skills and the tools that they need to be successful, to alleviate pain, however, they can’t alleviate that pain, because their bodies are just not designed to work 16 h a day with repetitive motion

Lack of accessibility limiting access to care

P014: So, in terms of equitable patient care, we do have it for physical disabilities type of thing, where we have. Individuals that that we have we make it we have bigger rooms there, so we have smaller rooms, we have bigger and bigger rooms are for those individuals that need that require them more space. we have chairs that are a little bigger in size for obese patients, we have you know assistant devices here that will help individuals that find that they have a little bit of a functional impairment; to get in so we do make provisions for individuals that have that are a little bit of need, in certain ways mentally speaking and cognitive cognitively speaking. We're dealing with stroke victims, we're dealing with patients that may have certain impairments, such as reading or writing etc. We accommodate that by asking right I’m trying to adapt the needs; I can't tell you what the needs are because I don't know until I ask

P007: So having the profession so far away from the [Indigenous] communities is what would be a major barrier

P009: If there's a language barrier then usually I ask if they have somebody there okay to come in to help translate, especially with the beginning stages and then, once we're more comfortable and I go maybe try to learn some phrases in their language to help say too much or pain or things like that they get through

Chiropractors as advocates for patient equity

P004: If they have other health issues outside of the chiropractic practice if they don't have a medical doctor, that's another big problem, the lack of medical doctors, you know, I do try to find them or guide them towards resources that may help them