Assessing the readiness and feasibility to implement a model of care for spine disorders and related disability in Cross Lake, an Indigenous community in northern Manitoba, Canada: A research protocol

Assessing the readiness and feasibility to implement a model of care for spine disorders and related disability in Cross Lake, an Indigenous community in northern Manitoba, Canada: A research protocol | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Study protocol Assessing the readiness and feasibility to implement a model of care for spine disorders and related disability in Cross Lake, an Indigenous community in northern Manitoba, Canada: A research protocol André Bussières, Steven Passmore, Deborah Kopansky-Giles, Patricia Tavares, and 16 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4959958/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 13 Mar, 2025 Read the published version in Chiropractic & Manual Therapies → Version 1 posted 4 You are reading this latest preprint version Abstract Background Since the 1990s, spine disorders have remained the leading cause of global disability, disproportionately affecting economically marginalized individuals, rural populations, women, and older people. Back pain related disability is projected to increase the most in remote regions where lifestyle and work are increasingly sedentary, yet resources and access to comprehensive healthcare is generally limited. To help tackle this worldwide health problem, World Spine Care Canada, and the Global Spine Care Initiative (GSCI) launched a four-phase project aiming to address the profound gap between evidence-based spine care and routine care delivered to people with spine symptoms or concerns in communities that are medically underserved. Phase 1 conclusions and recommendations led to the development of a model of care that included a triaging system and spine care pathways that could be implemented and scaled in underserved communities around the world. Methods The current research protocol describes a site-specific customization and pre-implementation study (Phase 2), as well as a feasibility study (Phase 3) to be conducted in Cross Lake, an Indigenous community in northern Manitoba, Canada. Design : Observational pre-post design using a participatory mixed-methods approach. Relationship building with the community established through regular site visits will enable pre- and post-implementation data collection about the model of spine care and provisionally selected implementation strategies using a community health survey, chart reviews, qualitative interviews, and adoption surveys with key partners at the meso (community leaders) and micro (clinicians, patients, community residents) levels. Recruitment started in March 2023 and will end in March 2026. Surveys will be analyzed descriptively and interviews thematically. Findings will inform co-tailoring of implementation support strategies with project partners prior to evaluating the feasibility of the new spine care program. Discussion Knowledge generated from this study will provide essential guidance for scaling up, sustainability and impact (Phase 4) in other northern Canada regions and sites around the globe. It is hoped that implementing the GSCI model of care in Cross Lake will help to reduce the burden of spine problems and related healthcare costs for the local community, and serve as a scalable model for programs in other settings. Participatory mixed-methods Spine care Value-based healthcare Implementation science Medically underserved area Vulnerable population Protocol Chiropractic Indigenous Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Musculoskeletal disorders affect over 1.71 billion people worldwide, [1] and are the leading contributor to disability. Disability is amplified in remote communities and low-middle income countries (LMICs) where access to care and health resources are limited. [2, 3] Among musculoskeletal disorders, spine pain remains the leading cause of global disability since 1990, [4-6] and is one of the most common complaints seen by primary care clinicians [7]. Moreover, spine pain accounts for nearly 50% of all opioid prescriptions. [7, 8] Spine disorders disproportionately affect economically marginalized individuals, rural populations, women, and older people. [4, 5] Because of population growth and ageing, the number of people living with spine pain and associated disability is rapidly increasing with projections of 843 million people living with low back pain [4] and 269 million people having neck pain by 2050. [9] Hence, spine pain is expected to place an ever-increasing demand on health systems that are already challenged to support appropriate and timely treatment for spine pain and disability. [2, 10, 11] Despite musculoskeletal disorders posing significant burdens to individuals, communities and economies, they have received minimal attention from global and national policy makers. [12, 13] To tackle the world-wide problem of spine disorders, World Spine Care (WSC), a multinational, not-for-profit, charitable organization, has been delivering spine services for the past 15 years in Botswana, the Dominican Republic, India, and Ghana in collaboration with the local community and with governmental support. [14] The WSC program has been recognized by the World Health Organization (WHO) Integrated, People-Centred Health Services (IPCHS) program as a global promising practice. [15] In 2018, the WSC’s Global Spine Care Initiative (GSCI) published a series of papers describing a new model of spine care (MoC) with the flexibility to be implemented in any region of the world. [16-29] The MoC outlines the most up to date evidence-based spine care and services for a person or a population group as they progress through the stages of a condition, injury or event to ensure “ that people get access to care and get the right care, at the right time , by the right team, and in the right place " and helps guide policy makers to transform care in order to address a specific health concern. [29, 30] The activities and initiatives of WSC and the GSCI are consistent with the United Nations’ Sustainable Development Goals (SDG) as they help to mitigate the impact of spine conditions on peoples’ health (SDG Target 3.4), and promote healthy lives and well-being for all (Goal 3) [31] However, the MoC needs to be rigorously tested with a focus on implementation, sustainability, scalability, and impact on individuals, their families, and healthcare systems, particularly in underserved communities. Implementation requires addressing important contextual factors to accessing healthcare interventions, such as clinician and patient attitudes, traditional beliefs, socio-cultural norms and behavior. System level barriers include lack of support or interest from government ministries, human resource shortages, high patient out-of-pocket costs, lack of conveniently located facilities, gender discrimination, or cultural values and preferences of communities. [32-36] Context Both in Canada and internationally, colonization has been recognized as a having a fundamental impact on the health of Indigenous peoples. [37, 38] Examples of discrimination in health care against Indigenous peoples in Canada are well documented, and often involve the mismanagement of pain, [39-41] with for instance, opioid-related overdose events more likely to occur among First Nations people in Western Canada than their non–First Nations counterparts. [42] Comprehensive care for Indigenous peoples includes access to family, community, traditions and ceremonies, all of which are central to healing. Yet many Indigenous persons, especially those who live in rural or remote communities, are often required to travel long distances to receive services, leading to removal from their community and/or family support system, and high costs. These issues may also be compounded by language barriers and difficulty in accessing culturally safe and meaningful health care services. [43] Promising and emerging responses aligning with the Truth and Reconciliation Commission of Canada, [44] include Indigenous directed health and health related services, efforts to increase the number of Indigenous health care providers, cultural safety training and trauma-informed care, and interventions addressing implicit (unconscious, pro-settler) bias of care providers to reduce health inequities and provide the best care. [45] Setting and site selection Indigenous populations in Manitoba, especially those in the northern communities, bear an excessive burden of injury, and acute and chronic diseases compared with the Canadian population as a whole. These groups have limited access to health care, and serious illnesses require patients to fly to southern Manitoba for care. [43, 46] A GSCI team member (JW), an Indigenous chiropractor with over 20 years’ experience delivering spine care near The Pas on Opaskwayak Cree Nation, in northern Manitoba, was instrumental in engaging community leaders of Cross Lake Band/Pimicikamak Cree Nation (https://crosslakeband.ca/), an Indigenous community committed to increasing healthcare services. Since its first site tream visit in April 2022, and in accordance with the University of Manitoba Framework for Research Engagement with First Nation, Metis, and Inuit Peoples, members of the GSCI have developed a strong partnership with Cross Lake community where the GSCI MoC will be implemented. Cross Lake is located 786 km north of Winnipeg, the capital of Manitoba. Cross Lake has an on-reserve population of 6,734 and an off-reserve population of 2,715. [47] Inhabitants include First Nations peoples, Métis, and people of non-Indigenous origin. The majority of the population maintain treaty status and the Indigenous language most commonly spoken locally is Cree. Global aims To mitigate the increasing burden of spine pain in communities that are underserved, WSC developed a four-phase project. In Phase 1 (completed in 2018), the GSCI developed an evidence-based model of spine care (MoC) encompassing a triaging system and care pathways that can be cutumized and implemented in underserved communities. [15-29] This protocol describes a site-specific customization and pre-implementation study ( Phase 2 ), as well as a feasibility study ( Phase 3 ) in Cross Lake. Knowledge generated will provide essential guidance for the Phase 4 scaling up, sustainability, and impact study in other underserved communities in northern Canada and around the globe. Specific objectives Phase 2. Site-specific customization and pre-implementation 1. Confirm the nature of, and extent to which, spinal disorders impact individuals within the underserved community. 2. Measure the perceived value of, and intention to adopt, the MoC triaging system and tailored care approach. Engage with community partners to identify factors that may impact MoC implementation. 3. Estimate the extent of: I) community partners support and engagement throughout the pre-implementation phase; II) local clinicians and caregivers adoption and application of the MoC as intended; and III) people with spine symptoms would utilize the MoC. Phase 3. Feasibility to implement the GSCI MoC 1. Identify, estimate, and understand the extent to which: i) pain and related disability outcomes are important to people with spine symptoms or concerns; and ii) if and how the MoC can be integrated into new or existing community-based programs. 2. Estimate key parameters to inform a future Phase 4 (upscaling) project. Ethics approval Following established principles to guide ethical research within Canadian Indigenous communities, [48] team members completed recommended training (Tri-Council Policy Statement (TCPS 2), First Nations Principles of OCAP, Personal Health Information Act) prior to obtaining ethics approval from the University of Manitoba’s Research Ethics Board for each study component. The 3-year project will be conducted and reported in accordance with the requirements of the Standards for Reporting Implementation Studies (StaRI) Statement. [49] Methods/ Design Using participatory, sequential mixed-methods approaches, [50, 51] the research team will actively engage local partners and Knowledge Keepers throughout the study at the meso- (community leaders, health administrators), and the micro-levels (local clinicians, people with spine problems, community residents), and collect quantitative followed by qualitative information (Figure 1). Participatory research involves the co-production of knowledge that is relevant to policy and practice, with an explicit focus on end users’ concerns, participation, and outcomes to enable practice change by empowering those most likely to use the new knowledge. [52, 53] Fig 1. Mixed-method sequential exploratory design flow chart We acknowledge the inherent differences between Western methods and Indigenous ways of knowing and the risks in trying to integrate these approaches (e.g., generalizing Indigenous traditions by taking them out of context; denying cultural differences in order to find commonality; assimilating Indigenous knowledge in a way that it becomes invisible). [54] To address power imbalances and philosophical differences, the team will seek to understand, with humility and respect, Indigenous knowledges and ways of knowing. Through discussion, we will select Indigenous-Western knowledge linking frameworks (principles and methods), [55] such as Etuaptmumk (Two-Eyed Seeing), [56] considering specific context (history, place, distinct character, and beliefs of the Indigenous community), and seek to adopt seven principles found in Indigenous and Western science (Relationality, Reciprocity, Reflexivity, Respect, Reverence, Responsivity, and Responsibility), helping political, academic and other actors fulfill their obligations to both truth and reconciliation and gender-based analysis plus policies and practices. [55] Phase 2. Site-specific customization and pre-implementation Quantitative and qualitative methods will be used to gather insights from our partners pertaining to the implementation of the GSCI MoC: Quantitative studies (community health survey, chart review) will be conducted to understand our partners’ needs and priorities, and the perceived impact of spine problems. Qualitative studies (individual interviews and focus groups) will be conducted to explore partners intentions to adopt and implement MOC, focusing on understanding the local context and potential implementation challenges and facilitators, and the meaning and values of select clinical outcomes (pain level, pain medication used, function, disability, and quality of life). Phase 3. Feasibility study We will use an observational pre-post design, using mixed-methods research. Mixed-methods research uses quantitative and qualitative research integration to develop contextual understanding of complex multi-level systems. [50] Quantitative studies (adoption survey, chart review, clinical outcomes) will be conducted to assess partners’ perceived acceptability, appropriateness, and feasibility to implement the MoC and related implementation support strategies, and care delivery process (GSCI triaging, care pathways) for people seeking care for spine symptoms, and its potential clinical impact (pain, medication used, function, disability, quality of life). Qualitative studies will be conducted toward the end of the study to explore our partners’ experiences with the new services, and intentions to maintain the MoC and related support strategies. Study participants Community health survey, new clinical service and community movement program All adults 18 years and older with spine symptoms (pain, disability) or concerns (e.g., prior problems with their neck or back) residing in Cross Lake, Manitoba, will be eligible for inclusion. Translation will be used with adults who prefer to communicate in Cree. Chart reviews Clinical records of consenting consecutive adult patients presenting at the Cross Lake Nursing Station run by Health Canada over a 12-month period will be accessed and information will be de-identified. Adoption questionnaire, qualitative interviews or focus groups Partners likely to influence implementation of the MoC including the Chief and community Band council members, community Elders and knowledge keepers, as well as Directors of Cross Lake Health Services, representatives of the local government, and all licensed local care providers (e.g., medical doctors, nurses, allied health care providers) and local community health workers (paid or volunteer CHWs), exercise therapists, massage therapists, and traditional healers will be eligible for inclusion. Recruitment Participants recruitment started in March 2023 (chart review) and will end in March 2026 (clinical service) Implementation blueprint With our partners, we will co-create an implementation blueprint to support high value-based spine care (i.e., safe, timely, effective, efficient, equitable, patient-centred). [57] The 8-step process will be underpinned by implementation science frameworks that consider the multilevel and dynamic interactions between the interventions, the perspective and characteristics of diverse recipients (leaders, clinicians, patients, residents), the infrastructure, and the external environment (e.g., clinical guidelines): [12, 58, 59] 1. Engaging local partners Relationship-building with the community is essential for sustainable development. [60] Prior to launching the study, a structured site visit of WSC and GSCI members (n=5) took place to engage with the community leadership and an Elder. A research agreement was signed on July 7, 2022 between Cross Lake Band/Pimicikamak Cree Nation, World Spine Care, University of Manitoba, and Université du Québec à Trois-Rivières, and a data transfer agreement (GSCI, Health and Welfare Canada Cross Lake Nursing Station in collaboration with the Department of Indigenous Services Canada/Government of Canada) was signed on August 22, 2022 to determine data collection, storage and ownership. Periodic site visits will be planned during the 3-year study period to i) assess organizational issues (infrastructure requirements, partners and researchers roles and responsibilities, understand intake and flow of patients with spine symptoms, including GSCI MoC fit and acceptability); ii) monitor service implementation and research activities and co-identify viable solutions with community partners; and iii) assess how best to sustain the MoC and related support strategies. 2. Local context and population needs In Canada, healthcare for Indigenous persons living on reserve in northern communities is managed federally. Under the universal healthcare plan, coverage for basic hospital and medical care at no charge to patients, but each province creates its own health insurance plan with some degree of variability across provinces. [61] In Manitoba, up to seven visits per year to a chiropractor are partially covered under the provincial health plan, but not under the federal health plan. Outpatient physical therapy is covered through an individual’s employment benefits. Both chiropractic care and physical therapy are healthcare services covered by Manitoba Public Insurance (motor vehicle accident injuries), and the Workers Compensation Board of Manitoba (workplace injury). Cross Lake Nursing Station is managed by Health Canada, with resident nurses and general practitioner physicians as fly-in staff, providing essential care to community members. It has limited access to allied health care focused on spinal problems. Those in need of spine care must travel to nearby cities. Both The Pas (a 401 km drive) and Thompson (a 255 km drive) have hospitals with access to telehealth for specialized services available in Winnipeg, including orthopedic spine surgeons. More serious illnesses and spine care needs require residents to fly to Winnipeg (520 km). 3. Selecting spine care model and interventions to meet needs The GSCI MoC is a person- and people-centered, classification system and care pathway which considers the influence of cultural, economic, and healthcare system design elements. It identifies the resources needed to support the model’s delivery of care (Figure 2). [16, 29, 62] This MoC provides a triage system and care pathways grouped into four specific categories of spine care aligned with high quality clinical practice guidelines: [63-66] community-based (e.g., education, reassurance, exercise programs, self-care); primary care (community-based health care, providing screening for serious conditions, and ongoing accessible, comprehensive, evidence-based coordinated care); secondary care (acute trauma and emergency care, imaging and diagnostic testing, surgical interventions); and tertiary care (specialized medical and surgical care for complex spine problems). These categories of care are to be integrated into the available healthcare system in partnership with local communities, existing healthcare facilities/providers, patients, and health policy makers (Additional file 1, Appendix 1. Implementation toolkit). Fig 2. GSCI model of care and levels of spine care 4. Gathering program materials Two logic models or road maps will be used to plan, execute, report, and synthesize the current implementation project: The administrative logic model provides an overview of the activities, output, and outcomes of the study (Additional file 1, Appendix 2); while the Implementation Research Logic Model (Figure 3) presents the shared relationships among context, implementation strategies and process, service and clinical outcomes, allowing for the comprehensive specification of all introduced and present implementation strategies, as well as their changes (adaptations, additions, discontinuations) during the project. [67] Fig. 3. Logic framework (phase 2 and 3 studies) 5. Identifying implementation support strategies Multifaceted strategies implemented in communities that are underserved and LMICs targeting infrastructure, supervision, other management techniques, training combined with group problem-solving can result in moderate to large practice changes. [68] Strategies targeting healthcare providers (e.g., educational training with clinician reminders and group problem-solving, practice facilitation, outreach visits, and input from local opinion leaders) and healthcare recipients (e.g., mass media interventions, self-management support, behavioural interventions and mobile phone text messaging) are generally effective in improving care. [68, 69] Increasing the frequency and the duration of strategies are likely to result in greater success and sustained practice change and better patient low back pain outcomes. [70] 6. Comparing existing programs and culturally adapt processes Additional file 1, Appendix 3 provides a detailed description of implementation support strategies. Following the Effective Practice for Organizational Change (EPOC) taxonomy of health systems interventions to expand equitable access to spine care, [71] we have provisionally selected eight implementation support strategies, along with 29 sub-strategies, targeting stakeholders across all levels to promote and sustain local interest in implementing the GSCI MoC (Table 2). Table 2 Provisionally selected implementation support strategies and sub-strategies Context-specific strategies are required for successful evidence implementation, and a number of common barriers can be addressed simultaneously using locally available, low-cost resources. [72] Guided by adaptation frameworks, [73-75] and in accordance with initial study findings and input from our partners, proposed support strategies will be modified, refined and culturally adapt to overcome implementation barriers or abandon. [53, 76] 7. Adapting material for new context and monitoring Prior to study onset, all relevant study documentation (GSCI triage system and care pathways, information, instructions, training materials, and measures) will be translated and culturally adapted following a 4-step process prior to being administered: i) questionnaire adaptation/creation; ii) expert team, partners, and local PIs (AB, SP) review; iii) pre-testing of measures for readability and understandability; and iv) data collection. [77-79] 8. Co-refining the GSCI MoC and related support strategies with community partners Using appreciative inquiry, [80] an affirmative approach to project evaluation shifting away from deficits-oriented evaluation methods towards a strengths-based or “desire-based” inquiry, [96, 97] we will engage with community partners to discuss pre- and post-implementation study findings and promote self-determining further adaptions of the GSCI MoC and proposed implementation support strategies. We will deliberately choose to initially focus on factors that contribute to positive health care encounters through the discussion of experiences and best practices, and using that positive potential within participants, the community, and the wider system to create positive changes and commit to a way forward. [80] Procedures, Data Collection, Evaluation Table 3 outlines the project phases, methods for data collection and designated timelines. Study instruments are available upon request. Phase 2. Customization and pre-implementation (Year 1) Quantitative data At the onset of the study, we will conduct a community health survey and a retrospective chart review to confirm the nature of and extent to which spinal disorders impact individuals within selected underserved communities. Community health survey : Through in-person interviews, team members will administer the health survey in either in English or Cree language based on participant preference, in randomly selected households. The survey questionnaire contains 154 questions derived from the 2020 Canadian Community Health Survey [81] and the Global Burden of Disease [82], covering socio-demographics, general health, spine pain and related disability, chronic comorbid conditions, self-care, spine care received, and satisfaction with care. Chart review: De-identified data on consecutive charts from adult community members seeking musculoskeletal care within the preceding year at Cross Lake Nursing Station will be reviewed to access spine-related health care utilization. Qualitative data Qualitative methodology will be used to explore and understand partner’s perspectives and experiences about the GSCI MoC and related implementation strategies. [83] Using in-person semi-structured interviews , we will identify perceived individual, organizational, and contextual factors shaping the uptake of MoC within the community, and better understand perceptions about spine care needs, what is culturally safe and acceptable spine care, as well as meaningful clinical outcomes to use in patients with spine symptoms. Focus groups or individual in-person or online interviews of local clinicians and CHWs will serve to better understand the intention and readiness to adopt the MoC and explore implementation barriers. The interview guides will be informed by the Theoretical Domain Framework (TDF) [84], offering an ecological lens in which to consider multi-level influences on behavior change. [85] The TDF has been widely used across health disciplines, health conditions and settings. The framework will guide the data collection, coding, analysis, and reporting of findings to gain a comprehensive understanding of relevant modifiable determinants, to facilitate the design of implementation strategies that will address them. [86] Table 3 Description of project phases, Timing, Data Collection Phase 3. Feasibility study (Year 2-3) 1) Implementation (Year 2) Phase 3 will begin after baseline data collection, the MoC and related implementation strategies have been refined, culturally adapted, and prepared for initiating the implementation. Local clinicians will have been trained to apply the GSCI triage and care pathways on patients with spine symptoms or concerns (Additional file 1, Appendix 4, Tables 1-3). In parallel, we will prepare and launch the new spine care service and community movement program (Additional file 1, Appendix 5). 2) Post-implementation (Year 3) Quantitative data We will administer adoption survey questionnaires to meso- and micro-level partners 6 months after initiating implementation of the MoC, inquiring about the perceived acceptability, appropriateness, and feasibility to implement the MoC and related implementation support strategies. These three brief measures will be collected after implementation of the new clinical service and community movement program as users need to first experience the MoC (triage and care pathways) and implementation strategies (e.g., educational training modules, self-care tools) and have initiated the use of the MoC prior to completing these questionnaires. The same measures will be administered again 2-3 months before the study ends. A second chart review will be conducted 9-12 months post-implementation to estimate and understand the extent to which: i) local clinicians and caregivers accepted, adopted, and applied the GSCI MoC as intended; and ii) people with spine symptoms have accepted recommended care. Service and clinical outcomes : Consecutive, consenting adult patients who agreed to participate in the project and meet inclusion criteria will be inducted into the study. At the end of each patient care episode for a complaint of spine symptoms, patient charts will be reviewed to determine the care delivered (i.e., process through which patients with spine condition are diagnosed, treated, referred or managed over time) along with the patient’s self-reported outcome measures. Validated patient reported health outcome questionnaires (pain, function, disability, quality of life) will be administered before and after care over a 2-month period. The results from the patient health outcome measures will be used to estimate key parameters such as effect sizes to inform the selection of a primary outcome and to calculate the sample size for a future study. Qualitative data We will conduct a second series of in-person TDF-guided interviews and focus groups [83] among the same partners 9-12 months after initiating implementation, to understand if and how the MoC was implemented, gather information on local clinicians’ and CHWs’ intentions to continue use of the MoC, community leaders’ willingness to maintain the new clinical service and community movement program, and community leaders’ priority toward helping scale up this project in other communities. Data Sources The aforementioned objectives will be addressed using the following data sources (Table 4) as described in the project timelines (Figure 4). Table 4 Summary of data collection Fig 4. Project timelines Implementation, Service and Clinical outcomes The study outcomes were selected to reflect the hypothesized mechanism of effect of the proposed implementation support strategies of the MoC, while considering the need to minimize respondent burden and maintain participant confidentiality. The measures have established psychometric properties, and can be compared when the MoC is implemented in other settings. [87-92] Drawing on the RE-AIM evaluation framework, study outcomes will focus on reach, adoption, implementation, and maintenance. [93-95] The Proctor et al. [96] and Lewis et al. [97] taxonomies will serve to further characterize selected primary process outcomes, downstream service, and clinical outcomes measures. Further, we will use appreciative inquiry [80] involving a four phase cycle (i.e., Discovery ‘ valuing the best of what is’ , Dream ‘envisioning what might be’ , Design ‘dialoguing what should be’ , and Delivery/Destiny ‘innovating what will be’ ) [98, 99] to reflect on the extent to which the proposed GSCI MoC and services align with key concepts of the Indigenous Healthcare Quality Framework. [99] This framework represents the person-centered perspectives and the requirements of healthcare systems and provider factors that are required for the achievement and sustainability of health care for Indigenous people that is high quality, culturally safe and free of racism. It also considers the continuous cycles experienced throughout the lives of Indigenous people, and the vital connection to the land held by First Nations, Inuit, and Metis peoples. 1. Primary implementation outcomes Reach can be defined as “…the integration of a practice within a service setting and its subsystems”. [96] We will adapt the THET-Partnership-Health-Check-Tool to evaluate stakeholders engagement [100] using quantitative methods (e.g. administrative data such as support letters, formal memoranda of understanding, meeting attendance, and partners adoption survey). [101] Adoption relating to the readiness for implementation [102] will be gathered using validated 4-item measures of acceptability of intervention measure (AIM), intervention appropriateness measure (IAM), and feasibility of intervention measure (FIM). [103, 104] Acceptability is the perception among stakeholders that the intervention is agreeable, palatable, and satisfactory. Appropriateness is the perceived fit, relevance, or compatibility of the innovation for a given setting, provider, or consumer. Feasibility is the extent to which the intervention can be successfully carried out within the given setting. [105] The implementation measures are scored with a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree), with higher average scores indicating greater readiness for implementation. These measures have demonstrated strong psychometric properties, and readability is at the 5th grade level. [103] Implementation ( adaptability , fidelity) is the consistency at which the different parts of the GSCI triage and care pathways are implemented across settings, clinicians, and patients, and at what cost, and how was the program adapted. [95] Adaptability can be defined as “the degree to which an intervention can be adapted, tailored, refined, or reinvented to meet local needs”, while Fidelity “the degree to which an intervention was implemented as intended”. [96] An Adaptation framework will capture adaptations made during the study. An Implementation Status Report will collect clinical and implementation activities. Maintenance is the extent to which the MoC triaging and care pathways become part of routine practice. Constructs explored with stakeholders will pertain to leadership engagement, intention to continue to use MoC and the community program, environmental context, planning, relative advantage and available resources. Cost are the resources (personnel, material) utilized by the strategies and their costs, [106] including the delivery of the new services, staff/clinician training, patients’ external referrals for advanced imaging and medical specialist consultation, and travels. 2. Secondary outcomes Service outcomes refers to local clinicians delivering care during clinical encounters, people with spine symptoms applying advice on self-care (e.g., home exercise), and community members attending activities (e.g., community movement program). Service outcomes may be determined by an observer with some professional training or self-reported using the MoC fidelity checklist. Clinical outcomes are considered secondary outcomes as the aim is to determine whether questionnaires can be routinely collected as planned. When a patient attends for consultation, socio-demographic, baseline and follow-up measures will be obtained using validated questionnaires: a) Numeric rating scale (NRS) to assess pain; b) WHODAS 2.0 (WHO Disability Assessment Schedule 2.0) to measure ability; c) Patient Specific Functional Scale for function; and d) EuroQol (EQ-5D 3L) for health-related quality of life. We recognize however the need to discuss with our partners the selection of culturally adapted outcome measures. [107] For instance. Indigenous perspectives of pain are often more holistic, encompassing mental, spiritual, emotional, and physical hurt. [108] S tudy sample Community Health Survey (CHS): 50 homes in the community will be randomly selected using a household list available from the community’s urban planning. A trained local RA (MS) will orally administer the CHS at the study onset to up to three adults living in these households (total of 150 surveys). Chart reviews: Chart reviews will be conducted pre- and post-implementation on 50 consecutive charts (or until data saturation) by team members (JW, PT). They will extract data from charts in the local clinic in the community or in households visited in the case where it is customary for the patient to keep their chart at home. A total of 100 charts will be extracted during the study period. Semi-structured interviews and focus groups: All interviews will be conducted pre- and post-implementation by the co-authors (AB, JL) in English or a local RA (MS) with patients in the local language at the study onset and again at the end of the study: i) Semi-structured interviews: Using maximum variability principles, a purposive sample of 10-13 individuals will be drawn among community leaders (n=10), respondents of the chart review (n=2-3) and community health survey (n=4-5) to seek respondents across a spectrum (spread of age, gender, occupation, pain duration, disability level) to ensure that all viewpoints would be adequately represented; ii) A focus group or semi-structured interviews will be conducted with 6-8 local clinicians and 1-2 CHWs representing a wide range in years in practice and health disciplines. Adoption surveys : Between 4 to 8 participants per partner group (decision-makers/local leaders; local clinicians/CHWs, people with spine symptoms, community residents) will complete 3 short implementation surveys pre- and post-implementation, either paper-based or orally administered by RAs. MoC Fidelity checklists: GSCI primary spine care clinicians will complete the fidelity checklists while observing 4-6-consecutive clinical encounters between the local clinicians and CHWs (n=6-8 per setting) and people seeking spine care 3 and 6 months after online and in-person training. Clinical outcomes: Clinical outcomes will be collected on consecutive patients before and after care at two time points. Analysis Using appreciative inquiry, [80] we will seek input from our partners in the interpretation of the findings and dissemination and implementation of the research results. Where available, analyses will consider sex, gender and age-related differences and patterns in the data. We will complete yearly implementation status reports, including a model of care matrix, partner’s analysis table, and implementation strategy plan. Quantitative Data Analysis Statistical analyses will be conducted using SAS Analytics Software (SAS Institute). Data from the Community health survey (CHS), chart reviews (CR), and implementation measures will be analyzed descriptively. Frequency distributions and proportions will be generated for categorical variables, and means, standard deviations, and medians with interquartile ranges will be computed for continuous variables. For the CHS, we will analyze three self-reported measures of in-community spine symptoms in the 12 months prior to the survey: i) whether the respondent reduced their participation or level of activity as a result of spine symptoms and related co-morbidities, ii) whether the respondent consulted someone for their spine problem, and if so, the type of care received, satisfaction with community-based care, and self-management strategies used, and iii) reported general health status, and community activities and gatherings. The CR will provide an understanding of the type of spine care received (pharmaceutical and non-pharmaceutical care, referrals for imaging or treatment) in the 12 months prior to data collection. Pre- and post-implementation results will be contrasted to highlight any trends observed in spine care delivery. Implementation outcomes: Reach will be reported descriptively as the proportion of partners (community leaders, residents) that engage with each of the implementation support sub-strategies, and local clinicians completing training and adopting the MoC and care pathway. Adoption : Descriptive statistics will be used to summarize data related to demographics, and AIM, IAM and FIM total scores. Associations of AIM, IAM, and FIM with other measures, such as characteristics, will be assessed via Spearman rank correlations for continuous measures and Wilcoxon rank sum tests or Kruskal-Wallis tests for categorical measures. [105] Adaptations to the implementation support strategies will be reported descriptively, with adaptations summarized using a modified version of a consistent coding framework of adaptations (FRAME) [109]. Fidelity will be reported as the number of people seeking spine care, provided each of the steps involved in triaging and/or using the spine care pathway were administered. The overall fidelity score will be calculated based on the number of people with spine symptoms seeking care across communities appropriately triaged based on the GSCI MoC. Costing will be reported descriptively as costs of providing the new clinical service and community movement program, training material, MRI and CT scan costs, visits to medical specialists, and related travelling expenses. Qualitative Data Analysis All interviews and focus groups will be audio recorded and transcribed verbatim. Coding and analysis will be managed using NVivo (QSR International, Version 12). Qualitative data analysis will be conducted through an interpretivist lens, [110] exploring participants’ experiences and thoughts. Two PhD students (NR, EB) will independently code each transcript guided by a mutual understanding of the TDF domain definitions and constructs within a domain, [84] and will meet weekly to review coding and achieve consensus. Two senior authors (AB, SM) familiar with the TDF will review the coded transcripts to solve any disagreements from the original coders to increase the reliability of coding (crystallization). Data will be analyzed using a combination of deductive and inductive coding. Deductive codes will be derived from the TDF domains, following a coding guideline to ensure consistency between coders. Data analysis will be carried out by pairs of trained RAs and two senior authors who will independently code the same subset of transcripts. [111] Coders will then meet after every 3-4 transcripts to discuss and reach consensus on code allocation, and the coding schemes will be refined and amended via an iterative process. The emergent coding tree will reflect both deductive and inductive codes. [84, 111] Key modifiable barriers identified will be mapped onto behavior change intervention techniques to inform the development and refinement of culturally acceptable implementation support strategies designed to support or change the health system to increase adoption of the evidence-based practice of the GSCI MoC into usual care. [111, 112] Study risk and risk mitigation strategies, and knowledge management and dissemination plans are presented in Additional files 1, Appendices 6 and 7 respectively. Discussion Spine pain is a highly prevalent and disabling, yet invisible condition. Major international clinical guidelines recognize that the vast majority of people with spine pain can be effectively managed with physical and psychosocial interventions, and discourage use of pain medication, steroid injections and spinal surgery. [ 63 – 66 ] However, the undertreatment of pain is systematically reported in the literature, particularly in marginalized populations. [ 39 – 41 , 113 – 115 ] In addition, many health systems globally are not designed to support non-phamacological spine care approaches, with inadequate payment systems favouring medical care over patients’ self-management and rehabilitation, deep-rooted medical traditions and beliefs about care for spine pain, [ 116 ] and difficulty in accessing culturally safe and meaningful health care services for Indigenous peoples. [ 43 ] Promising solutions, practices and policies include providing accessible and culturally acceptable high-value spine care services, cultural safety training and trauma-informed care, addressing care providers’ biaises, and incentives to increase the number of Indigenous health care providers [ 44 , 45 , 116 ] Results from this project are expected to further advance our understanding on the experiences and challenges of accessing spine care in a remote northern Indigenous community, and inform planning of a study aiming to determine the most effective means of sustaining and scaling the GSCI MoC to larger communities and to determine its personal, social and economic impact on underserved communities. To maximize the fit between the proposed spine care services, practice settings, and the broader ecological system, we will regularly engage with key partners and work toward reaching a mutual understanding throughout the project, seek to continually learn and problem solve, co-adapt implementation strategies with a primary focus on ongoing improvement considering multi-level contexts (e.g., culture, support, time, resources, funding). [ 117 – 119 ] Conclusion Implementing the GSCI Model of Care in Cross Lake is expected to help reduce the burden of spine problems and related healthcare costs for the local community and serve as a scalable model for programs in other northern Canada regions and sites around the globe. Abbreviations CHS Community Health Survey CHW Community Health Worker CR Chart Review EPOC Effective Practice for Organizational Change GSCI Global Spine Care Initiative: https://www.globalspinecareinitiative.org/ IPCHS Integrated, People-Centred Health Services LMICs Low- and Middle-Income Countries MoC Model of Care MRC Medical Research Council MSK Musculoskeletal RA Research Assistant REB Research Ethics Board SDG Sustainable Development Goals TDF Theoretical Domain Framework UK United Kingdom WHO World Health Organization WSC World Spine Care: https://www.worldspinecare.org/ WSCC World Spine Care Canada: https://www.worldspinecare.org/canada Declarations Ethics approval and consent to participate Following established principles to guide ethical research within Canadian Indigenous communities, [49] team members completed recommended training (Tri-Council Policy Statement (TCPS 2), First Nations Principles of OCAP, Personal Health Information Act) prior to obtaining ethics approval from the University of Manitoba’s Research Ethics Board for each study component: Qualitative (#HE2022-0248); Chart review: (HE2022-0249), Community health survey (HE2022-0250), Adoption survey (HE2022-0394), Community movement program (HE2023-0017), and Care pathway (HE2023-0144). Consent for publication Not applicable Availability of data and materials Not applicable Competing interests The authors declare that they have no competing interests. The lead author AB (the manuscript’s guarantor) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; and that no important aspects of the study have been omitted. Funding This project received financial support from Health Canada Substance Use and Addictions Program (agreement # 2223 HQ 000126), The Canadian Chiropractic Research Foundation (CCRF), The Canadian Chiropractic Association (CCA), and The Skoll Foundation. Authors' contributions A.B., S.P., D.K.G., P.T., E.L.H., A. D.W., J.W., M.A.G., S.M., and S.H. developed the concept and design with input from all authors. D.A.M., D.Z.M., H.H., M.S., R.S., M.J., and M.F.W. provided needed guidance and context. A.B., wrote the main manuscript text and prepared figures 1, 3, and 4 with input from all authors. D.K.G., P.T., E.L.H., A. D.W., M.N., and S.H. prepared figure 2. All authors critically revised the manuscript for important intellectual content. A.B., S.P., and J.M. provided administrative, technical, or material support. A.B. and S.H. supervised the team. Acknowledgements We thank Cross Lake Band Council members for their guidance and ongoing support, Dr. Simon K Sarpong, and the entire staff at the Health Canada Cross Lake Nursing Station for their assistance with the clinical program, and Dr. Margareta Nordin for her strong leadership, and tireless work ethic and determination to help reduce the global burden of musculoskeletal conditions. References Cieza A, Causey K, Kamenov K, Hanson SW, Chatterji S, Vos T. Global estimates of the need for rehabilitation based on the Global Burden of Disease study 2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2021;396(10267):2006-17. https://doi.org/.10.1016/s0140-6736(20)32340-0. Hoy D, Geere JA, Davatchi F, Meggitt B, Barrero LH. A time for action: Opportunities for preventing the growing burden and disability from musculoskeletal conditions in low- and middle-income countries. Best Pract Res Clin Rheumatol. 2014;28(3):377 – 93. https://doi.org/.10.1016/j.berh.2014.07.006. Briggs AM, Jordan JE, Sharma S, Young JJ, Chua J, Foster HE et al. Context and priorities for health systems strengthening for pain and disability in low- and middle-income countries: a secondary qualitative study and content analysis of health policies. Health Policy Plan. 2022;38(2):129 – 49. https://doi.org/.10.1093/heapol/czac061. Ferreira ML, de Luca K, Haile LM, Steinmetz JD, Culbreth GT, Cross M et al. Global, regional, and national burden of low back pain, 1990–2020, its attributable risk factors, and projections to 2050: a systematic analysis of the Global Burden of Disease Study 2021. Lancet Rheumatol. 2023;5(6):e316-e29. https://doi.org/.10.1016/S2665-9913(23)00098-X. Safiri S, Kolahi A-A, Hoy D, Buchbinder R, Mansournia MA, Bettampadi D et al. Global, regional, and national burden of neck pain in the general population, 1990–2017: systematic analysis of the Global Burden of Disease Study 2017. BMJ. 2020;368:m791. https://doi.org/.10.1136/bmj.m791. Vos Tea. Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020;396(10258):1204-22. https://doi.org/.10.1016/s0140-6736(20)30925-9. Finley CR, Chan DS, Garrison S, Korownyk C, Kolber MR, Campbell S, et al. What are the most common conditions in primary care? Systematic review. Can Fam Physician. 2018;64(11):832–40. Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC clinical practice guideline for prescribing opioids for pain — United States, 2022. MMWR Recomm Rep. 2022;71(No. RR-3):1–95. https://doi.org/.http://dx.doi.org/10.15585/mmwr.rr7103a1 Wu AM, Cross M, Elliott J, Culbreth G, Haile L, Steinmetz J et al. Global, Regional, and National Burden of Neck Pain, 1990 to 2020 and Projections to 2050: A Systematic Analysis of the Global Burden of Disease Study 2021. Lancet. 2024;6(3):E142-E55. https://doi.org/.10.2139/ssrn.4427441. Briggs A, Woolf A, Dreinhöfer K, Homb N, Hoy D, Kopansky-Giles D, et al. Reducing the global burden of musculoskeletal conditions. Bull World Health Organ. 2018;96:366–8. https://doi.org/.http://dx.doi.org/10.2471/BLT.17.204891 . World Health O. Low back pain - Fact sheets 2023 [ https://www.who.int/news-room/fact-sheets/detail/low-back-pain Briggs AM, Shiffman J, Shawar YR, Åkesson K, Ali N, Woolf AD. Global health policy in the 21st century: Challenges and opportunities to arrest the global disability burden from musculoskeletal health conditions. Best Pract Res Clin Rheumatol. 2020;34(5):101549. https://doi.org/.https://doi.org/10.1016/j.berh.2020.101549 . Chhabra HS, Tamai K, Alsebayel H, AlEissa S, Alqahtani Y, Arand M et al. SPINE20 recommendations 2023: One Earth, one family, one future WITHOUT spine DISABILITY. Brain Spine. 2023;3:102688. https://doi.org/.10.1016/j.bas.2023.102688. Haldeman S, Outerbridge G, Eberspaecher S, Brady O, Kopansky-Giles D, Nordin M et al. World Spine Care: A Charity Providing Spine Care in Botswana, Dominican Republic, India and Ghana. ISSLS Book: Lumbar Spine Online Textbook. Section 6, Chap. 1. August, 2018. 2018. Organization WH. Framework for Integrated, People-Centred Health Services. https://www.who.int/health-topics/integrated-people-centered-care#tab=tab_1 Accessed March 26, 2024. 2016. Haldeman S, Nordin M, Chou R, Côté P, Hurwitz EL, Johnson CD et al. The Global Spine Care Initiative: World Spine Care executive summary on reducing spine-related disability in low- and middle-income communities. Eur Spine J. 2018;27(6):776 – 85. https://doi.org/.10.1007/s00586-018-5722-x. Johnson CD, Haldeman S, Nordin M, Chou R, Côté P, Hurwitz EL et al. The Global Spine Care Initiative: methodology, contributors, and disclosures. European Spine Journal. 2018;27(6):786 – 95. https://doi.org/.10.1007/s00586-018-5723-9. Hurwitz EL, Randhawa K, Yu H, Côté P, Haldeman S. The Global Spine Care Initiative: a summary of the global burden of low back and neck pain studies. Eur Spine J. 2018;10.1007/s00586-017-5432-9. https://doi.org/.10.1007/s00586-017-5432-9 Hurwitz EL, Randhawa K, Torres P, Yu H, Verville L, Hartvigsen J et al. The Global Spine Care Initiative: a systematic review of individual and community-based burden of spinal disorders in rural populations in low- and middle-income communities. Eur Spine J. 2018;27(Suppl 6):802 – 15. https://doi.org/.10.1007/s00586-017-5393-z. Green BN, Johnson CD, Haldeman S, Kane EJ, Clay MB, Griffith EA et al. The Global Spine Care Initiative: public health and prevention interventions for common spine disorders in low- and middle-income communities. Eur Spine J. 2018;27(Suppl 6):838 – 50. https://doi.org/.10.1007/s00586-018-5635-8. Nordin M, Randhawa K, Torres P, Yu H, Haldeman S, Brady O et al. The Global Spine Care Initiative: a systematic review for the assessment of spine-related complaints in populations with limited resources and in low- and middle-income communities. Eur Spine J. 2018;27(Suppl 6):816 – 27. https://doi.org/.10.1007/s00586-017-5446-3. Acaroğlu E, Nordin M, Randhawa K, Chou R, Côté P, Mmopelwa T et al. The Global Spine Care Initiative: a summary of guidelines on invasive interventions for the management of persistent and disabling spinal pain in low- and middle-income communities. Eur Spine J. 2018;27(Suppl 6):870-8. https://doi.org/.10.1007/s00586-017-5392-0. Cedraschi C, Nordin M, Haldeman S, Randhawa K, Kopansky-Giles D, Johnson CD et al. The Global Spine Care Initiative: a narrative review of psychological and social issues in back pain in low- and middle-income communities. Eur Spine J. 2018;27(Suppl 6):828 – 37. https://doi.org/.10.1007/s00586-017-5434-7. Acaroğlu E, Mmopelwa T, Yüksel S, Ayhan S, Nordin M, Randhawa K et al. The Global Spine Care Initiative: a consensus process to develop and validate a stratification scheme for surgical care of spinal disorders as a guide for improved resource utilization in low- and middle-income communities. Eur Spine J. 2018;27(Suppl 6):879 – 88. https://doi.org/.10.1007/s00586-017-5332-z. Ameis A, Randhawa K, Yu H, Côté P, Haldeman S, Chou R et al. The Global Spine Care Initiative: a review of reviews and recommendations for the non-invasive management of acute osteoporotic vertebral compression fracture pain in low- and middle-income communities. Eur Spine J. 2018;27(Suppl 6):861-9. https://doi.org/.10.1007/s00586-017-5273-6. Haldeman S, Johnson CD, Chou R, Nordin M, Côté P, Hurwitz EL et al. The Global Spine Care Initiative: classification system for spine-related concerns. Eur Spine J. 2018;27(6):889–900. https://doi.org/.10.1007/s00586-018-5724-8. Haldeman S, Johnson CD, Chou R, Nordin M, Côté P, Hurwitz EL et al. The Global Spine Care Initiative: care pathway for people with spine-related concerns. Eur Spine J. 2018;27(Suppl 6):901 – 14. https://doi.org/.10.1007/s00586-018-5721-y. Kopansky-Giles D, Johnson CD, Haldeman S, Chou R, Côté P, Green BN et al. The Global Spine Care Initiative: resources to implement a spine care program. Eur Spine J. 2018;27(6):915 – 24. https://doi.org/.10.1007/s00586-018-5725-7. Johnson CD, Haldeman S, Chou R, Nordin M, Green BN, Côté P et al. The Global Spine Care Initiative: model of care and implementation. Eur Spine J. 2018;27(Suppl 6):925 – 45. https://doi.org/.10.1007/s00586-018-5720-z. Speerin R, Slater H, Li L, Moore K, Chan M, Dreinhöfer K et al. Moving from evidence to practice: Models of care for the prevention and management of musculoskeletal conditions. Best Pract Res Clin Rheumatol. 2014;28(3):479–515. https://doi.org/.10.1016/j.berh.2014.07.001. United Nations. Sustainable Development Goals (DSDG), Department of Economic and Social Affairs, Sustainable Development. 2019. Dawkins B, Renwick C, Ensor T, Shinkins B, Jayne D, Meads D. What factors affect patients’ ability to access healthcare? An overview of systematic reviews. Trop Med Int Health. 2021;26(10):1177–88. https://doi.org/.https://doi.org/10.1111/tmi.13651 . Peters DH, Tran NT, Adam T. Implementation research in health: a practical guide. Alliance for Health Policy and Systems Research, World Health Organization; 2013. Pati MK, Swaroop N, Kar A, Aggarwal P, Jayanna K, Van Damme W. A narrative review of gaps in the provision of integrated care for noncommunicable diseases in India. Public Health Rev. 2020;41:8. https://doi.org/.10.1186/s40985-020-00128-3. Oosterveer TM, Young TK. Primary health care accessibility challenges in remote indigenous communities in Canada's north. Int J Circumpolar Health. 2015;74:29576. https://doi.org/.10.3402/ijch.v74.29576. Winn CS, Chisholm BA, Hummelbrunner JA. Factors affecting recruitment and retention of rehabilitation professionals in Northern Ontario, Canada: a cross-sectional study. Rural Remote Health. 2014;14:2619. Cunningham M, Chapter V. Health. United Nations, Permanent Forum on Indigenous Issues, State of the world’s Indigenous peoples. New York: United Nations; 2009. pp. 156–87. Mowbray M. Social determinants and Indigenous health: The International experience and its policy implications. Geneva, Switzerland: World Health Organization Commission on Social Determinants of Health; 2007. Wylie L, McConkey S. Insiders’ Insight: Discrimination against Indigenous Peoples through the Eyes of Health Care Professionals. J Racial Ethn Health Disparities. 2019;6(1):37–45. https://doi.org/.10.1007/s40615-018-0495-9. Boyer Y. Healing racism in Canadian health care. CAMJ. 2017;189(46):E1408-E9. https://doi.org/.10.1503/cmaj.171234. Tang SY, Browne AJ. 'Race' matters: racialization and egalitarian discourses involving Aboriginal people in the Canadian health care context. Ethn Health. 2008;13(2):109 – 27. https://doi.org/.10.1080/13557850701830307. Belzak L, Halverson J. The opioid crisis in Canada: a national perspective. Health Promot Chronic Dis Prev Can. 2018;38(6):224 – 33. https://doi.org/.10.24095/hpcdp.38.6.02. Canadian Pain Task Force. Working together to better understand, prevent, and manage chronic pain: What we heard. Oct 2020. Health Canada, Ottawa, ON, Canada (Accessed December 26 2023). 2020. Report No.: ISBN: 978-0-660-36395-0. TRC. Truth and Reconciliation Commission of Canada: Calls for Action. Manitoba: Winnipeg; 2015. Allan B, Smylie J. First Peoples, second class treatment: The role of racism in the health and well-being of Indigenous Peoples in Canada. Toronto: Wellesley Institute; 2015. Hudson I, Cohen B. Manitoba inequality update: Low income families left behind. 2018. Report 978-1-77125-394-9. Canada PMoCJT. Supporting and improving Indigenous-led health care for First Nations in British Columbia 2023 [ https://www.pm.gc.ca/en/news/news-releases/2023/04/14/supporting-and-improving-indigenous-led-health-care-first-nations Hayward A, Sjoblom E, Sinclair S, Cidro J. A New Era of Indigenous Research: Community-based Indigenous Research Ethics Protocols in Canada. J Empir Res Hum Res Ethics. 2021;16(4):403 – 17. https://doi.org/.10.1177/15562646211023705. Pinnock H, Barwick M, Carpenter CR, Eldridge S, Grandes G, Griffiths CJ et al. Standards for Reporting Implementation Studies (StaRI): explanation and elaboration document. BMJ Open. 2017;7(4):e013318. https://doi.org/.10.1136/bmjopen-2016-013318. Green CA, Duan N, Gibbons RD, Hoagwood KE, Palinkas LA, Wisdom JP. Approaches to mixed methods dissemination and implementation research: Methods, strengths, caveats, and opportunities. Adm Policy Ment Health. 2015;42(5):508 – 23. https://doi.org/.10.1007/s10488-014-0552-6. Nelson G, Ochocka J, Griffin K, Lord J. Nothing about me, without me: participatory action research with self-help/mutual aid organizations for psychiatric consumer/survivors. Am J Community Psychol. 1998;26(6):881–912. https://doi.org/.10.1023/a:1022298129812. Nguyen T, Graham ID, Mrklas KJ, Bowen S, Cargo M, Estabrooks CA et al. How does integrated knowledge translation (IKT) compare to other collaborative research approaches to generating and translating knowledge? Learning from experts in the field. Health Res Policy Syst. 2020;18(1):35. https://doi.org/.10.1186/s12961-020-0539-6. Abayneh S, Lempp H, Hanlon C. Participatory action research to pilot a model of mental health service user involvement in an Ethiopian rural primary healthcare setting: study protocol. Res Involv Engagem. 2020;6(1):2. https://doi.org/.10.1186/s40900-019-0175-x. Stinson J, Lusis E, Murphy T, Ryan B et al. What are Indigenous and Western ways of knowing? drawn from Levac L, McMurtry L, Stienstra D, Learning across Indigenous and Western Knowledge Systems and Intersectionality: Reconciling Social Science Research Approaches. In: Guelph Uo, editor. 2018. Levac L, McMurtry L, Stienstra D, Baikie G, Hanson C, Mucina D. Learning across Indigenous and Western Knowledge Systems and Intersectionality. Reconciling Social Science Research Approaches. University of Guelph; 2018. p. 40. Roher SIG, Yu Z, Martin DH, Benoit AC. How is Etuaptmumk/Two-Eyed Seeing characterized in Indigenous health research? A scoping review. PLoS One. 2021;16(7):e0254612. https://doi.org/.10.1371/journal.pone.0254612. Smith T. What is value-based care? These are the key elements: JAMA Network, AMA; 2020 [ https://www.ama-assn.org/ Lewis CC, Scott K, Marriott BR. A methodology for generating a tailored implementation blueprint: an exemplar from a youth residential setting. Implementation Sci. 2018;13(1):68. https://doi.org/.10.1186/s13012-018-0761-6. Skivington K, Matthews L, Simpson SA, Craig P, Baird J, Blazeby JM et al. A new framework for developing and evaluating complex interventions: update of Medical Research Council guidance. BMJ. 2021;374:n2061. https://doi.org/.10.1136/bmj.n2061. Mbah MF, Bailey M, Shingruf A. Considerations for relational research methods for use in Indigenous contexts: implications for sustainable development. Int J Soc Res Methodol. 2023;10.1080/13645579.2023.2185345:1–16. https://doi.org/.10.1080/13645579.2023.2185345 Canada Go. Understand how health care works in Canada. https://www.canada.ca/en/immigration-refugees-citizenship/services/new-immigrants/new-life-canada/health-care-card.html (Accessed July 26 2021). 2021. Brady O, Haldeman S, Nordin M, Outerbridge G, Hondras M, Kopansky-Giles D, et al. Global Forum: Spine research in underserved, low income and culturally unique communities. The WSC Charity Research Program – Challenges and Facilitators. J Bone Joint Surg Am. 2016;98:e110. Parikh P, Santaguida P, Macdermid J, Gross A, Eshtiaghi A. Comparison of CPG’s for the diagnosis, prognosis and management of non-specific neck pain: a systematic review. BMC Musculoskelt Disord. 2019;20(1):81. https://doi.org/.10.1186/s12891-019-2441-3. Corp N, Mansell G, Stynes S, Wynne-Jones G, Morsø L, Hill JC et al. Evidence-based treatment recommendations for neck and low back pain across Europe: A systematic review of guidelines. Eur J Pain. 2021;25(2):275 – 95. https://doi.org/.10.1002/ejp.1679. Lin I, Wiles L, Waller R, Goucke R, Nagree Y, Gibberd M et al. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med [Internet]. 2019;10.1136/bjsports-2018-099878. World Health O. WHO guideline for non-surgical management of chronic primary low back pain in adults in primary and community care settings. Geneva: World Health Organization 2023 [ file:///C:/Users/bussiera/Downloads/9789240081789-eng%20(1).pdf Smith JD, Li DH, Rafferty MR. The implementation research logic model: a method for planning, executing, reporting, and synthesizing implementation projects. Implementation Sci. 2020;15(1):84. https://doi.org/.10.1186/s13012-020-01041-8. Rowe AK, Rowe SY, Peters DH, Holloway KA, Ross-Degnan D. The effectiveness of training strategies to improve healthcare provider practices in low-income and middle-income countries. BMJ Glob Health. 2021;6(1). https://doi.org/.10.1136/bmjgh-2020-003229. Pantoja T, Opiyo N, Lewin S, Paulsen E, Ciapponi A, Wiysonge CS et al. Implementation strategies for health systems in low-income countries: an overview of systematic reviews. Cochrane Database Syst Rev. 2017;9(9):CD011086-CD. https://doi.org/.10.1002/14651858.CD011086.pub2. Mesner SA, Foster NE, French SD. Implementation interventions to improve the management of non-specific low back pain: a systematic review. BMC Musculoskelet Disord. 2016;17:258. https://doi.org/.10.1186/s12891-016-1110-z. EPOC. Cochrane-Effective Practice and Organisation of Care (EPOC) taxonomy of health systems interventions. EPOC Resources for review authors. Oslo: Norwegian Knowledge Centre for the Health Services; 2016. https://zenodo.org/records/5105851 . Whitehorn A, Fu L, Porritt K, Lizarondo L, Stephenson M, Marin T et al. Mapping clinical barriers and evidence-based implementation strategies in low-to-middle income countries (LMICs). Worldviews Evid Based Nurs. 2021;18(3):190–200. https://doi.org/.10.1111/wvn.12503. Shayo MJ, Shayo P, Haukila KF, Norman K, Burke C, Ngowi K et al. Expanding access to rehabilitation using mobile health to address musculoskeletal pain and disability. Front Rehabil Sci. 2022;3:982175. https://doi.org/.10.3389/fresc.2022.982175. Williams AB, Wang H, Burgess J, Li X, Danvers K. Cultural adaptation of an evidence-based nursing intervention to improve medication adherence among people living with HIV/AIDS (PLWHA) in China. Int J Nurs Stud. 2013;50(4):487 – 94. https://doi.org/.10.1016/j.ijnurstu.2012.08.018. Card JJ, Solomon J, Cunningham SD. How to adapt effective programs for use in new contexts. Health Promot Pract. 2011;12(1):25–35. https://doi.org/.10.1177/1524839909348592. Chevalier JM, Buckles DJ. Participatory action research: Theory and methods for engaged inquiry (2nd ed.). Routledge. https://doi.org/10.4324/9781351033268 . 2019. Boateng GO, Neilands TB, Frongillo EA, Melgar-Quiñonez HR, Young SL. Best Practices for Developing and Validating Scales for Health, Social, and Behavioral Research: A Primer. Front Public Health. 2018;6(149). https://doi.org/.10.3389/fpubh.2018.00149. Tsang S, Royse CF, Terkawi AS. Guidelines for developing, translating, and validating a questionnaire in perioperative and pain medicine. Saudi J Anaesth. 2017;11(Suppl 1):S80-S9. https://doi.org/.10.4103/sja.SJA_203_17. Beaton D, Bombardier C, Guillemin F, Ferraz M. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine (Phila Pa 1976). 2000;25:3186–91. Murphy L, Kordyl P, Thorne M. Appreciative inquiry: a method for measuring the impact of a project on the well-being of an Indigenous community. Health Promot J Austr. 2004;15(3):211–4. https://doi.org/.https://doi.org/10.1071/HE04211 . Statistic Canada. Canadian Community Health Survey (CCHS). Annual Component – 2020 Questionnaires. Statistic Canada. https://www23.statcan.gc.ca/imdb/p3Instr.pl?Function=assembleInstr&a=1&⟨=en&Item_Id=1262397#qb1262741 (Accessed July 05 2024). 2020. Institute for Health Metrics and Evaluation (IME). Global Burden of Disease (GBD) [Internet]. Seattle, Washington. 2021 May. https://www.healthdata.org/research-analysis/gbd 2021 [. Bradshaw C, Atkinson S, Doody O. Employing a qualitative description approach in health care research. Glob Qual Nurs Res. 2017;4:2333393617742282. https://doi.org/.10.1177/2333393617742282. Cane J, O'Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci. 2012;7(1):37. http://www.implementationscience.com/content/7/1/37 . Norton TC, Rodriguez DC, Willems S. Applying the Theoretical Domains Framework to understand knowledge broker decisions in selecting evidence for knowledge translation in low- and middle-income countries. Health Res Policy Syst. 2019;17(1):60. https://doi.org/.10.1186/s12961-019-0463-9. Michie S, Johnston M, Francis J, Hardeman W, Eccles M. From theory to intervention: mapping theoretically derived behavioural determinants to behaviour change techniques. Appl Psychol. 2008;57. https://doi.org/.10.1111/j.1464-0597.2008.00341.x. Schoenwald SK, Garland AF, Chapman JE, Frazier SL, Sheidow AJ, Southam-Gerow MA. Toward the Effective and Efficient Measurement of Implementation Fidelity. Adm Policy Ment Health and Ment Health Serv Res. 2011;38(1):32–43. https://doi.org/.10.1007/s10488-010-0321-0. Velentgas P, Dreyer N, Nourjah P, Smith S, Torchia M. Developing a Protocol for Observational Comparative Effectiveness Research: A User's Guide. Rockville (MD): Agency for Healthcare Research and Quality (US); 2013 Jan. Publication No.: 12(13)-EHC099. 2013. Willmeroth T, Wesselborg B, Kuske S. Implementation Outcomes and Indicators as a New Challenge in Health Services Research: A Systematic Scoping Review. Inquiry. 2019;56:46958019861257. https://doi.org/.10.1177/0046958019861257. Khadjesari Z, Boufkhed S, Vitoratou S, Schatte L, Ziemann A, Daskalopoulou C et al. Implementation outcome instruments for use in physical healthcare settings: a systematic review. Implement Sci. 2020;15(1):66. https://doi.org/.10.1186/s13012-020-01027-6. Clinton-McHarg T, Yoong SL, Tzelepis F, Regan T, Fielding A, Skelton E et al. Psychometric properties of implementation measures for public health and community settings and mapping of constructs against the Consolidated Framework for Implementation Research: a systematic review. Implementation Sci. 2016;11(1):148. https://doi.org/.10.1186/s13012-016-0512-5. Lewis CC, Fischer S, Weiner BJ, Stanick C, Kim M, Martinez RG. Outcomes for implementation science: an enhanced systematic review of instruments using evidence-based rating criteria. Implementation Sci. 2015;10(1):155. https://doi.org/.10.1186/s13012-015-0342-x. Glasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion interventions: the RE-AIM framework. Am J Public Health. 1999;89. Glasgow RE, Harden SM, Gaglio B, Rabin B, Smith ML, Porter GC et al. RE-AIM Planning and Evaluation Framework: Adapting to New Science and Practice With a 20-Year Review. Front Public Health. 2019;7(64). https://doi.org/.10.3389/fpubh.2019.00064. Kwan BM, McGinnes HL, Ory MG, Estabrooks PA, Waxmonsky JA, Glasgow RE. RE-AIM in the Real World: Use of the RE-AIM Framework for Program Planning and Evaluation in Clinical and Community Settings. Front Public Health. 2019;7(345). https://doi.org/.10.3389/fpubh.2019.00345. Proctor E, Silmere H, Raghavan R, Hovmand P, Aarons G, Bunger A et al. Outcomes for implementation research: Conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health and Ment Health Serv Res. 2011;38(2):65–76. https://doi.org/.10.1007/s10488-010-0319-7. Lewis C, Proctor E, Brownson R. Measurement Issues in Dissemination and Implementation Research. In: Ross C. Brownson GAC, and Enola K. Proctor, editor. Dissemination and Implementation Research in Health: Translating Science to Practice. Oxford Scholarship Online. 2017;10.1093/oso/9780190683214.001.0001. https://doi.org/.10.1093/oso/9780190683214.001.0001 Cooperrider D. What is Appreciative Inquiry? 2019 [ https://www.davidcooperrider.com/ai-process/ Indigenous Healthcare Quality Partnership. Indigenous healthcare quality framework. 2022. Gedde M, de Vries E. Accessed July 26, al. TCHe. The International Health Links Manual A guide to starting up and maintaining long term international health partnerships. Tropical Health and Education Trust (THET). https://www.thet.org/wp-content/uploads/2017/08/Links-Manual-In-Full-Low-Res-72dpi.pdf (2021). 2009. Gedde M. Accessed February 14, THET. Partnership for Global Health. The Tropical Health and Education Trust (THET): https://www.thet.org/principles-of-partnership/ (2024). 2009. Glasgow R, Mckay H, Piette J, Reynolds K. The RE-AIM framework for evaluating interventions: what can it tell us about approaches to chronic illness management? Patient Educ Couns. 2001;44:119–27. Weiner BJ, Lewis CC, Stanick C, Powell BJ, Dorsey CN, Clary AS et al. Psychometric assessment of three newly developed implementation outcome measures. Implementation Sci. 2017;12(1):108. https://doi.org/.10.1186/s13012-017-0635-3. McLaughlin M, Duff J, Sutherland R, Campbell E, Wolfenden L, Wiggers J. Protocol for a mixed methods process evaluation of a hybrid implementation-effectiveness trial of a scaled-up whole-school physical activity program for adolescents: Physical Activity 4 Everyone (PA4E1). Trials. 2020;21(1):268. https://doi.org/.10.1186/s13063-020-4187-5. Tarfa A, Sayles H, Bares SH, Havens JP, Fadul N. Acceptability, Feasibility, and Appropriateness of Implementation of Long-acting Injectable Antiretrovirals: A National Survey of Ryan White Clinics in the United States. Open Forum Infect Dis. 2023;10(7):ofad341. https://doi.org/.10.1093/ofid/ofad341. Cidav Z, Mandell D, Pyne J, Beidas R, Curran G, Marcus S. A pragmatic method for costing implementation strategies using time-driven activity-based costing. Implementation Sci. 2020;15(1):28. https://doi.org/.10.1186/s13012-020-00993-1. Julien N, Lacasse A, Labra O, Asselin H. Review of chronic non-cancer pain research among Aboriginal people in Canada. Int J Qual Health Care. 2018;30(3):178 – 85. https://doi.org/.10.1093/intqhc/mzx195. Bailey NGN, Knott R, Grenier G, Craig KD, Kramer JLK. Physical pain among Indigenous Peoples in Canada: a scoping review. Can J Anaesth. 2023;70(6):1047-63. https://doi.org/.10.1007/s12630-023-02461-y. Wiltsey Stirman S, Baumann AA, Miller CJ. The FRAME: an expanded framework for reporting adaptations and modifications to evidence-based interventions. Implementation Sci. 2019;14(1):58. https://doi.org/.10.1186/s13012-019-0898-y. Verhoef M, Mulkins A, Boon H. Integrative health care: How can we determine whether patients benefit? J Altern Comp Med. 2005;11(Suppl 1):57–65. Atkins L, Francis J, Islam R, O’Connor D, Patey A, Ivers N et al. A guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems. Implementation Sci. 2017;12(1):77. https://doi.org/.10.1186/s13012-017-0605-9. Bussières A, Al Zoubi F, Quon J, Ahmed S, Thomas A, Stuber K, et al. Fast tracking the design of theory-based KT interventions through a consensus process. Implement Sci. 2015;10(1):18. Emerson AJ, Hegedus T, Mani R, Baxter GD. Chronic musculoskeletal pain experiences in marginalized populations: a mixed methods study protocol to understand the influence of geopolitical, historical, and societal factors. Phys Ther Rev. 2020;25(4):292–301. https://doi.org/.10.1080/10833196.2020.1807803. Pagé G, Mittinty MM, Gyakye deGraft-Johnson K. Disparities in back pain 2021 [updated July 2021; cited 2024 February 15]. https://www.iasp-pain.org/resources/fact-sheets/disparities-in-back-pain/ Reyes SG, Bajaj PM, Alvandi BA, Kurapaty SS, Patel AA, Divi SN. Impact of Social Determinants of Health in Spine Surgery. Curr Rev Musculoskelet Med. 2023;16(1):24–32. https://doi.org/.10.1007/s12178-022-09811-1. Traeger AC, Buchbinder R, Elshaug AG, Croft PR, Maher CG. Care for low back pain: can health systems deliver? Bull World Health Organ. 2019;97(6):423 – 33. https://doi.org/.10.2471/blt.18.226050. Tricco AC, Ashoor HM, Cardoso R, MacDonald H, Cogo E, Kastner M et al. Sustainability of knowledge translation interventions in healthcare decision-making: a scoping review. Implementation Sci. 2016;11(1):55. https://doi.org/.10.1186/s13012-016-0421-7. Chambers DA, Glasgow RE, Stange KC. The dynamic sustainability framework: addressing the paradox of sustainment amid ongoing change. Implementation Sci. 2013;8(1):117. https://doi.org/.10.1186/1748-5908-8-117. Laur C, Corrado AM, Grimshaw JM, Ivers N. Trialists perspectives on sustaining, spreading, and scaling-up of quality improvement interventions. Implement Sci Commun. 2021;2(1):35. https://doi.org/.10.1186/s43058-021-00137-6. Tables Table 1 Glossary of Terms Acupuncture Provider delivered acupuncture, dry needling, or electro-acupuncture/needling. Bracing Provider directed bracing for treatment of acute, stable vertebral fractures (post-trauma and osteoporotic) Diffusion A passive process by which new evidence is communicated to researchers, educators and educational policy makers using traditional vehicles Dissemination Process by which targeted and tailored information (main messages or key implications) is transmitted to specific relevant audiences to increase the application and uptake of evidence as well as to bridge research-to-practice gaps. Education about spine conditions Health care provider shares information in a report of findings regarding the spine-related concern or condition, including diagnosis, prognosis, therapies, alternatives, and consent. Depending upon the presentation, the provider may reassure individual about the benign and self-limiting nature of the typical course of spinal pain that has no serious pathology, advise patients to remain active and provide information about effective self-care options that address the spinal condition or concern. Episode of Care (EOC) Process through which patients with a particular condition are diagnosed, treated, followed, and managed over time. EOC includes any and all interventions used by the primary, secondary and tertiary practitioners to achieve maximum therapeutic recovery of the spinal disorder that brought the patient to the primary spine clinic or the prevention of a given disorder. EOC may involve multiple care providers for those presenting with multiple conditions or comorbidities. The end goal of care is prevention or resolution of the condition based on outcome measure assessments or the achievement of a “steady state” for chronic conditions which are likely to recur. Heat/cold therapy Recommendation of home use of physical agents. For example, heating pads, heat wraps, hot baths, warm gel packs, ice packs. Implementation Uses robust scientific methods underpinned by theories, models and frameworks to identify research-practice gaps, identify supports and barriers to the uptake of evidence-based innovations, design implementation support strategies to reduce research-practice gaps, evaluate the impact of these strategies on patient care and health outcomes as well as strategies to sustain implementation. Knowledge Translation Planned activities aims at promoting the uptake and application of research evidence to improve patient care and health outcomes. Manual therapy Provider delivered manipulation, mobilization, massage, and/or soft-tissue therapies. Macro Individuals setting policies and priorities at the regional / national level who will enable those resources to be available Meso Individuals involved in organizing service delivery, running clinics, community leaders and Band counselors Micro Individuals delivering the model of care when implemented and those with spinal problems receiving the model of care Mind-body therapies Recommendation for self-directed use of one or more of the following: meditation, yoga, biofeedback, tai chi,qigong, relaxation techniques, hypnosis, guided imagery, stress management, or breathing techniques. Self-care Information about how one can take care of spinal conditions or concerns. Information distributed from published material, the internet, public health sources, or other communications Spine symptoms or concerns Includes back and/or neck pain; spine-related deformity, injury, neurological conditions, pathology and diseases. Episode of Care: The Episode of Care (EOC) according to Hussey et al. (2017) is the process through which patients with a particular condition are diagnosed, treated, followed, and managed over time for each patient. The episode frameworks Hussey et al. have constructed also include the precursor to the episode: the population at risk for developing a given condition or needing a given surgical procedure. The GSCI model includes preventative care of spinal disorders. Here we will define an episode of care to include any and all interventions used by the primary, secondary and tertiary practitioners to achieve maximum therapeutic recovery of the spinal disorder that brought the patient to the primary spine clinic or the prevention of a given disorder. The EOC may involve multiple care providers for those presenting with multiple conditions or comorbidities. The end goal of care is prevention or resolution of the condition based on OM assessments or the achievement of a “steady state” for chronic conditions which are likely to recur. Sustainability To what extent an evidence-based intervention can deliver its intended benefits over an extended period of time after external support from the donor agency is terminated Therapeutic exercise Supervised or prescribed and self-directed exercise regimens aimed at spinal pain or a spinal condition. Table 2 Provisionally selected implementation support strategies and sub-strategies Implementation support strategies (n=8) and sub-strategies (n=29) 1. Health partnerships (year 1-3) [121] 1.1: Partnership agreement signed by health districts or local government executive and local community leader. 1.2: New or existing Local Implementation Team oversees program. 1.3: The local Implementation Team is inclusive of a local clinician champion and community leaders to oversee the program and uses a self-assessment and action plan tool. 1.4: Local implementation team meets weekly; macro level committees meet twice per year. 2. Health workforce capacity development: Local clinicians (year 2) [53, 70, 71, 74, 122-125] 2.1: Group problem solving (with or without formal teams) or collaborative improvement every 2-3 months. 2.2: Pre-service educational training: Local clinicians register and complete the 2 online educational training sessions at the beginning of year 2. 2.3: On the job training: interactive workshop to ease knowledge integration, practice facilitation and educational outreach visits by a trained GSCI clinician overseeing patient encounters over 2-3 weeks using the Implementation Toolkit (Appendix 3, Table 1 and 3). 2.4: Local clinician Champion training –1-day of face-to-face training session by trained a GSCI clinician, hosted by Local Implementation Team. 2.5: Peer coaching (improving routine supervision, benchmarking, or audit with feedback) by local champion for 12 months. 2.6: Weekly contact made with GSCI trained clinician via email and/or Zoom. 3. Health workforce capacity development: Community health workers (CHW) (year 2) – Concurrent with item 2 3.1: CHWs’ training –1-day of face-to-face training session hosted by trained GSCI clinician, hosted by Local Implementation Team, and facilitated by the local clinician Champions. Accommodation, meals and transport costs covered by the grant. 3.2: CHWs are trained to 1) recognize serious causes of spine problems via online or paper-based tools; and 2) deliver educational messages (reassurance, advice on self-care such as staying active, and basic exercise) for people with non-complicated spine symptoms/concerns (MoC class classes 1 through 3a, c and 4a) or to refer people with spine problems for further evaluation and treatments to local clinicians (MoC classes 3b, 4b and 5a, b and c). (Appendix 3, Table 2). 3.3: Equipping and motivating CHWs to conduct outreach and referrals process from community to health centers. 3.4: Weekly contact made with in-community local clinician Champion via phone, email and/or face-to-face site visits for 12 months. 4. Educational tools to promote self-management (year 2-3) [124, 126-132] 4.1: Self-administered online and paper format patient screening questionnaire to help make informed decision regarding the need to consult a licensed healthcare provider or to self-manage their spine pain (Appendix 3, Table 2). 4.2: Online and paper format educational and exercise booklet; develop/adapt 1-page information resources (https://www.ccgi-research.com/patient-resources) 4.3: Follow-up contact made by with in-Community Champion via phone, email and/or face-to-face site visits for 12 months. 5. Community Movement Program (year 1-3) [71, 133, 134] 5.1: In-Community Champion training –1-day of face-to-face training session hosted by Local Implementation Team in Term 1: train the trainer on adult yoga-like mind-body classes, whereby Yoga instructors are trained on spine health, who, in turn, will deliver consistent messaging on spine health issues. Accommodation, meals and transport costs covered by the grant. 5.2: Community support (community health education or social marketing of health services): spine health educational messages delivered monthly by CHWs through partnership with local community leaders at social gatherings (e.g., the village market or the church), clinic’s/healthcare centers, on social media platforms (Facebook via cell phones), using the local radio, and/or targeted at schoolchildren via their teachers. 5.3: Co-design and animate locally accepted community activity/exercise program. 5.4: Follow-up contact made by local clinician Champion with in-community Champion via phone, email and/or face-to-face site visits for 12 months. 6. Resources (year 1-3) 6.1: Printed posters outlining MoC Principles, triage system and care pathway to be displayed in the Nursing Station (Implementation Toolkit: Appendix 3, Table 1-2). 6.2: Equipment provided to support the delivery of MoC 6.3: Electronic resources housed on the program website (online) included: overview of program presentation (Microsoft PowerPoint presentation) project milestones to be achieved each term (over 3 years) online quality training (GSCI videos), worksheet, peer observation materials patient personal self-care plan templates recess and lunch resources policy templates examples of community physical activity tips and frequently asked questions 7. Provision of prompts and reminders (year 2-3) [125] 7.1: Weekly emails or phone calls made by the Local Implementation Team to local clinician and in-Community Champions to encourage implementation. 7 .2: Automated or paper-based messages sent each term via the program website or hand delivered to Champions, local clinicians and CHWs to prompt completion of educational training modules/videos/booklet chapters and online (or paper-based) termly performance monitoring and feedback surveys. 8. Implementation performance monitoring and feedback (year 2-3) [135] 8.1 : Champions, local clinicians and CHWs complete all surveys via the program website or paper-based. 8.2: Feedback report sent to Champions, local clinicians and CHWs via email or hand-delivered. Abbreviations: CHW = Community Health Worker; GSCI = Global Spine Care Initiative; MoC = Model of Car Table 3 Description of project phases, Timing, Data Collection Stepwise approach to 1) prepare implementation, assessing the current status of spine care in Cross Lake; identifying potential barriers and facilitators to the uptake of the MoC, and co-designing implementable solutions, and 2) evaluate the feasibility to implement a new spine care clinical service and community movement program supported by tailored strategies. Project phases Duration Activities Customization and pre-implementation (Phase 2) 12 months Build local implementation team Periodic community engagement site visits Secure REB approvals, Memorandum of Understanding, and data sharing agreement Co-create, refine, culturally adapt, and prepare all study material, select patient health outcome measures Design database linkages Train research assistants Recruit study participants for the chart review, Community Health Survey, and qualitative interviews; analyze & interpret data Prepare community movement program; select primary spine care clinicians Online and in-person educational training of local clinicians and community health workers on GSCI triaging and spine care pathways Fidelity & monitoring log (FRAME adaptation framework) Feasibility (Phase 3) - Implementation 10 months Further customize MoC tools and implementation support strategies Implement protocols Launch community education and movement program Launch new clinical service for people with spine symptoms or concerns Collect implementation, service and patient outcomes Implementation adoption survey (AAF tool) MoC Fidelity checklist, feedback, local team meetings Fidelity & monitoring log (FRAME adaptation framework) - Post-implementation 12 months Post-implementation visit Second chart review and qualitative interviews Fidelity & monitoring log (FRAME adaptation framework) Data analysis and interpretation (pre- and post-implementation) 6 months Conduct quantitative and qualitative analyses (pre- and post-implementation) Meet with key stakeholders to help with data interpretation (both pre- and post-implementation data) Fidelity & monitoring log (FRAME adaptation framework) Dissemination plan Prospect for sustainability and GSCI Initiative Phase 4 2 months Meet with health authorities (district, provincial, Federal level) to discuss sustainability of services within the community, and scaling up in other communities. AAF=Acceptability, Appropriateness, Feasibility; REB-Research Review Board Table 4 Summary of data collection Study Aim Level Type of data collected Tools Outcome How it is done Aim A. Confirm the nature of and extent to which spinal disorders impact individuals within Cross Lake, northern Manitoba, Canada Micro level Quantitative Quantitative Community health survey Retrospective chart review Perceived impact Trained research assistants Aim B. Measure the value of, and intention of stakeholders to adopt the GSCI MoC, and identify barriers and facilitators impacting the implementation of this model among stakeholders Meso- and micro level Qualitative Semi-structured interviews or Focus groups Perceived TDF barriers and enablers Project PI, trained research assistants Aim C. Estimate and understand the extent to which (1) stakeholders support and engage throughout the study, and are empowered to drive the identification and refinement of implementation strategies for their own barriers, (2) local clinicians and caregivers accept, adopt, and apply the GSCI MoC as intended, and (3) people with spine symptoms accept recommended care. (1) Meso- and (2, 3) micro level Quantitative Administrative data (support letters, MUC, meeting attendance, THET-Partnership-Health-Check-Tool) Education training attendance Stakeholder adoption surveys Reach Adherence/Fidelity Adoption (Acceptability, Appropriateness, Feasibility (AAF) measures) Local implementation team Online / in-person educational modules Research assistant Aims C and D. Estimate/understand the extent to which (1) what health outcomes are important to people with spine symptoms or concerns, 2) the MoC can potentially be integrated into community-based programs, and (3) the implementation efforts are perceived to have a higher burden leading to added cost) (1, 3) Micro-level (2) Meso- and micro level Qualitative Quantitative Semi-structured interviews Adoption surveys Perceived TDF barriers and enablers Adoption (Acceptability, Appropriateness, Feasibility (AAF) measures) Implementation (Fidelity, Perceived cost) Trained research assistants Online, paper-based, and orally administered Aim E. Estimate key parameters such as effect sizes to inform the selection of a primary outcome and to calculate the sample size for a future Phase 4 implementation study All levels Quantitative Surveys Clinical outcomes Fidelity and context monitoring log and a fidelity checklist. Pain, function, disability, quality of life Co-PIs, statistician AAF=Acceptability, Appropriateness, Feasibility; TDF=Theoretical Domain Framework Additional Declarations Competing interest reported. The authors declare that they have no competing interests. The lead author AB (the manuscript’s guarantor) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; and that no important aspects of the study have been omitted. Supplementary Files Additionalfile1ImplementationToolkitAppendices17.pdf Cite Share Download PDF Status: Published Journal Publication published 13 Mar, 2025 Read the published version in Chiropractic & Manual Therapies → Version 1 posted Editorial decision: Revision requested 26 Aug, 2024 Editor assigned by journal 26 Aug, 2024 Submission checks completed at journal 26 Aug, 2024 First submitted to journal 22 Aug, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4959958","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Study protocol","associatedPublications":[],"authors":[{"id":345387089,"identity":"1ac7f407-4d5b-4826-89c4-1dc6464a66fd","order_by":0,"name":"André Bussières","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9klEQVRIiWNgGAWjYHACAyA+AMSMDSCeHOlajBkYmInWAgGJDYS08M9u3vbhA8OdxPn9hxsfV1TUpW84nn/sA0ONHU4tEneOFc+cwfAsccONxGbDM2cO524485h5BsOxZNzW3MgxZuZhOJy4QYKxTbKx7UDuhhvJzEB/4XadPEjLH6CW+f0H2382/qtLN4BoqcepxQCkhQGopeFAYhtjYwNzAlTLYZxaDG+kFTP2GDwzBvlFsuHYYcOZZx4bMyQcO45Ti9yN5M0MPyruyM7vP/7wY0NNnTzf8cTHDB9qqnF7H+I8FF4CGJEESFU/CkbBKBgFwx0AAKPbW3psWR2lAAAAAElFTkSuQmCC","orcid":"","institution":"Université du Québec à Trois-Rivières","correspondingAuthor":true,"prefix":"","firstName":"André","middleName":"","lastName":"Bussières","suffix":""},{"id":345387090,"identity":"202326f3-4be0-4578-83c6-a68a53c1e2a5","order_by":1,"name":"Steven Passmore","email":"","orcid":"","institution":"University of Manitoba","correspondingAuthor":false,"prefix":"","firstName":"Steven","middleName":"","lastName":"Passmore","suffix":""},{"id":345387091,"identity":"896670bb-23bc-4d5e-9762-ffe222779cd1","order_by":2,"name":"Deborah Kopansky-Giles","email":"","orcid":"","institution":"Canadian Memorial Chiropractic College","correspondingAuthor":false,"prefix":"","firstName":"Deborah","middleName":"","lastName":"Kopansky-Giles","suffix":""},{"id":345387092,"identity":"f5bf9192-3489-4f8c-955f-1d2d10c8c146","order_by":3,"name":"Patricia Tavares","email":"","orcid":"","institution":"Canadian Memorial Chiropractic College","correspondingAuthor":false,"prefix":"","firstName":"Patricia","middleName":"","lastName":"Tavares","suffix":""},{"id":345387093,"identity":"b9c08aa7-cf1d-40da-ab93-58dadbe963f8","order_by":4,"name":"Jennifer Ward","email":"","orcid":"","institution":"University of Manitoba","correspondingAuthor":false,"prefix":"","firstName":"Jennifer","middleName":"","lastName":"Ward","suffix":""},{"id":345387094,"identity":"44d1b6b7-30ae-4df4-b626-2e85a1ca7b7d","order_by":5,"name":"Jacqueline Ladwig","email":"","orcid":"","institution":"University of Manitoba","correspondingAuthor":false,"prefix":"","firstName":"Jacqueline","middleName":"","lastName":"Ladwig","suffix":""},{"id":345387095,"identity":"14ba3ac6-2b05-443f-9ca7-373f98b3fb19","order_by":6,"name":"Cheryl Glazebrook","email":"","orcid":"","institution":"University of Manitoba","correspondingAuthor":false,"prefix":"","firstName":"Cheryl","middleName":"","lastName":"Glazebrook","suffix":""},{"id":345387096,"identity":"0be770af-d95e-4632-876a-cfbec3536644","order_by":7,"name":"Silvano Mior","email":"","orcid":"","institution":"Canadian Memorial Chiropractic College","correspondingAuthor":false,"prefix":"","firstName":"Silvano","middleName":"","lastName":"Mior","suffix":""},{"id":345387097,"identity":"b80f8ee6-3a4c-445e-81d5-26192130aa35","order_by":8,"name":"Melissa Atkinson-Graham","email":"","orcid":"","institution":"Canadian Memorial Chiropractic College","correspondingAuthor":false,"prefix":"","firstName":"Melissa","middleName":"","lastName":"Atkinson-Graham","suffix":""},{"id":345387098,"identity":"ecfb8b9e-2458-40aa-b36f-da7ba67995a2","order_by":9,"name":"Jean Moss","email":"","orcid":"","institution":"World Spine Care Canada","correspondingAuthor":false,"prefix":"","firstName":"Jean","middleName":"","lastName":"Moss","suffix":""},{"id":345387099,"identity":"d9dbf569-9b13-4704-9409-57421c1198a1","order_by":10,"name":"Nicole Robak","email":"","orcid":"","institution":"University of Manitoba","correspondingAuthor":false,"prefix":"","firstName":"Nicole","middleName":"","lastName":"Robak","suffix":""},{"id":345387100,"identity":"6846f019-7be8-43b8-9ea1-09b74bf6a7bb","order_by":11,"name":"Elena Broeckelmann","email":"","orcid":"","institution":"University of Manitoba","correspondingAuthor":false,"prefix":"","firstName":"Elena","middleName":"","lastName":"Broeckelmann","suffix":""},{"id":345387101,"identity":"a682e1c5-e98a-49a0-99ea-55921bdc0633","order_by":12,"name":"David A Monias","email":"","orcid":"","institution":"Cross Lake Band","correspondingAuthor":false,"prefix":"","firstName":"David","middleName":"A","lastName":"Monias","suffix":""},{"id":345387102,"identity":"205a94a0-0662-43a0-aa58-66cc75d22db2","order_by":13,"name":"Donnie Z Mckay","email":"","orcid":"","institution":"Cross Lake Band","correspondingAuthor":false,"prefix":"","firstName":"Donnie","middleName":"Z","lastName":"Mckay","suffix":""},{"id":345387103,"identity":"44756f71-111a-4041-8331-55431ce5a065","order_by":14,"name":"Helga Hamilton","email":"","orcid":"","institution":"Cross Lake Health Services, Cross Lake","correspondingAuthor":false,"prefix":"","firstName":"Helga","middleName":"","lastName":"Hamilton","suffix":""},{"id":345387104,"identity":"2938e42f-f259-4ba8-921f-eb8c80da8c7e","order_by":15,"name":"Muriel Scott","email":"","orcid":"","institution":"Cross Lake Health Services, Cross Lake","correspondingAuthor":false,"prefix":"","firstName":"Muriel","middleName":"","lastName":"Scott","suffix":""},{"id":345387105,"identity":"ab0f2365-fd71-4dee-ac8c-c93be63a6358","order_by":16,"name":"Randall Smolinski","email":"","orcid":"","institution":"Cross Lake Nursing Station","correspondingAuthor":false,"prefix":"","firstName":"Randall","middleName":"","lastName":"Smolinski","suffix":""},{"id":345387106,"identity":"3cfb3099-e89a-4b5b-92b9-5754a56755be","order_by":17,"name":"Eric L Hurwitz","email":"","orcid":"","institution":"University of Hawai'i","correspondingAuthor":false,"prefix":"","firstName":"Eric","middleName":"L","lastName":"Hurwitz","suffix":""},{"id":345387107,"identity":"e86bd103-d15e-4ec8-9ebf-e05a42d2b01c","order_by":18,"name":"Anthony D Woolf","email":"","orcid":"","institution":"Royal Cornwall Hospital","correspondingAuthor":false,"prefix":"","firstName":"Anthony","middleName":"D","lastName":"Woolf","suffix":""},{"id":345387108,"identity":"1e52a54e-b989-42d8-b0c8-884acd86a857","order_by":19,"name":"Scott Haldeman","email":"","orcid":"","institution":"World Spine Care","correspondingAuthor":false,"prefix":"","firstName":"Scott","middleName":"","lastName":"Haldeman","suffix":""}],"badges":[],"createdAt":"2024-08-22 18:53:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4959958/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4959958/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12998-025-00576-1","type":"published","date":"2025-03-13T15:56:57+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":66837993,"identity":"f1c63628-cd50-4e2a-b027-8aa1038f1eba","added_by":"auto","created_at":"2024-10-17 04:31:21","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":39378,"visible":true,"origin":"","legend":"\u003cp\u003eMixed-method sequential exploratory design flow chart\u003c/p\u003e","description":"","filename":"fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-4959958/v1/c28ce1bd1d4a190edaceadec.png"},{"id":66839019,"identity":"a23430d5-03a8-4bdb-bd21-a045bf3dce21","added_by":"auto","created_at":"2024-10-17 04:39:21","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":668488,"visible":true,"origin":"","legend":"\u003cp\u003eGSCI model of care and Levels of spine care\u003c/p\u003e","description":"","filename":"fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-4959958/v1/5c6ddc629b22afef63b55cec.png"},{"id":66837992,"identity":"4db3189f-5db6-4e45-a5bd-c03960c9bba5","added_by":"auto","created_at":"2024-10-17 04:31:21","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":129210,"visible":true,"origin":"","legend":"\u003cp\u003eLogic framework for Phase 2-3\u003c/p\u003e","description":"","filename":"fig3.png","url":"https://assets-eu.researchsquare.com/files/rs-4959958/v1/a002682489cd09092c5702ab.png"},{"id":66837995,"identity":"ad6271e9-3b4e-47e7-bfa1-596c00bc8718","added_by":"auto","created_at":"2024-10-17 04:31:21","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":63479,"visible":true,"origin":"","legend":"\u003cp\u003eProject timelines\u003c/p\u003e","description":"","filename":"fig4.png","url":"https://assets-eu.researchsquare.com/files/rs-4959958/v1/735f8b0f6d8d8ecb0fde4773.png"},{"id":78688828,"identity":"9e83bfc7-4b71-4153-b59d-1fb766c04006","added_by":"auto","created_at":"2025-03-17 16:02:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2563063,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4959958/v1/f34f6645-48a5-46f7-9aef-e897598e283f.pdf"},{"id":66837996,"identity":"de471f16-7665-4379-ae28-74735395f92b","added_by":"auto","created_at":"2024-10-17 04:31:21","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":1300390,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile1ImplementationToolkitAppendices17.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4959958/v1/897ccfcdd34bf3f144ad07a5.pdf"}],"financialInterests":"Competing interest reported. The authors declare that they have no competing interests. The lead author AB (the manuscript’s guarantor) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; and that no important aspects of the study have been omitted.","formattedTitle":"Assessing the readiness and feasibility to implement a model of care for spine disorders and related disability in Cross Lake, an Indigenous community in northern Manitoba, Canada: A research protocol","fulltext":[{"header":"Background","content":"\u003cp\u003eMusculoskeletal disorders affect over 1.71 billion people worldwide,\u0026nbsp;[1]\u0026nbsp;and are the leading contributor to disability. Disability is amplified in remote communities and low-middle income countries (LMICs) where access to care and health resources are limited.\u0026nbsp;[2, 3]\u0026nbsp;Among musculoskeletal disorders, spine pain remains the leading cause of global disability since 1990,\u0026nbsp;[4-6]\u0026nbsp;and is one of the most common complaints seen by primary care clinicians [7]. Moreover, spine pain accounts for nearly 50% of all opioid prescriptions.\u0026nbsp;[7, 8]\u0026nbsp;Spine disorders disproportionately affect economically marginalized individuals, rural populations, women, and older people.\u0026nbsp;[4, 5]\u0026nbsp;Because of population growth and ageing, the number of people living with spine pain and associated disability is rapidly increasing\u0026nbsp;with projections of 843 million people living with low back pain\u0026nbsp;[4]\u0026nbsp;and 269 million people having neck pain by 2050.\u0026nbsp;[9]\u0026nbsp;Hence, spine pain is expected to place an ever-increasing demand on health systems that are already challenged to support appropriate and timely treatment for spine pain and disability.\u0026nbsp;[2, 10, 11]\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDespite musculoskeletal disorders posing significant burdens to individuals, communities and economies, they have received minimal attention from global and national policy makers.\u0026nbsp;[12, 13]\u0026nbsp; To tackle the world-wide problem of spine disorders, World Spine Care (WSC), a multinational, not-for-profit, charitable organization, has been delivering spine services for the past 15 years in Botswana, the Dominican Republic, India, and Ghana in collaboration with the local community and with governmental support.\u0026nbsp;[14]\u0026nbsp;The WSC program has been recognized by the World Health Organization (WHO) Integrated, People-Centred Health Services (IPCHS) program as a global promising practice.\u0026nbsp;[15]\u003c/p\u003e\n\u003cp\u003eIn 2018, the WSC\u0026rsquo;s Global Spine Care Initiative (GSCI) published a series of papers describing a new model of spine care (MoC) with the flexibility to be implemented in any region of the world.\u0026nbsp;[16-29]\u0026nbsp;The MoC outlines the most up to date evidence-based spine care and services for a person or a population group as they progress through the stages of a condition, injury or event to ensure \u0026ldquo;\u003cem\u003ethat people\u003c/em\u003e\u003cem\u003e\u0026nbsp;get access to care and\u003c/em\u003e\u003cem\u003e\u0026nbsp;get the right care, at the right time\u003c/em\u003e, \u003cem\u003eby the right team, and in the right place\u003c/em\u003e\u0026quot; and helps guide policy makers to transform care in order to address a specific health concern.\u0026nbsp;[29, 30]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe activities and initiatives of WSC and the GSCI are consistent with the United Nations\u0026rsquo; Sustainable Development Goals (SDG) as they help to mitigate the impact of spine conditions on peoples\u0026rsquo; health (SDG Target 3.4), and promote healthy lives and well-being for all (Goal 3)\u0026nbsp;[31]\u0026nbsp; However, the MoC needs to be rigorously tested with a focus on implementation, sustainability, scalability, and impact on individuals, their families, and healthcare systems, particularly in underserved communities. Implementation requires addressing important contextual factors to accessing healthcare interventions, such as clinician and patient attitudes, traditional beliefs, socio-cultural norms and behavior. System level barriers include lack of support or interest from government ministries, human resource shortages, high patient out-of-pocket costs, lack of conveniently located facilities, gender discrimination, or cultural values and preferences of\u0026nbsp;communities.\u0026nbsp;[32-36]\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContext\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBoth in Canada and internationally, colonization has been recognized as a having a fundamental impact on the health of Indigenous peoples.\u0026nbsp;[37, 38]\u0026nbsp;Examples of discrimination in health care against Indigenous peoples in Canada are well documented, and often involve the mismanagement of pain,\u0026nbsp;[39-41]\u0026nbsp;with for instance, opioid-related overdose events more likely to occur among First Nations people in Western Canada than their non\u0026ndash;First Nations counterparts.\u0026nbsp;[42]\u0026nbsp;Comprehensive care for Indigenous peoples includes access to family, community, traditions and ceremonies, all of which are central to healing. Yet many Indigenous persons, especially those who live in rural or remote communities, are often required to travel long distances to receive services, leading to removal from their community and/or family support system, and high costs. These issues may also be compounded by language barriers and difficulty in accessing culturally safe and meaningful health care services.\u0026nbsp;[43]\u0026nbsp;Promising and emerging responses aligning with the Truth and Reconciliation Commission of Canada,\u0026nbsp;[44]\u0026nbsp;include Indigenous directed health and health related services, efforts to increase the number of Indigenous health care providers, cultural safety training and trauma-informed care, and interventions addressing implicit (unconscious, pro-settler) bias of care providers to reduce health inequities and provide the best care.\u0026nbsp;[45]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSetting and site selection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIndigenous populations in Manitoba, especially those in the northern communities, bear an excessive burden of injury, and acute and chronic diseases compared with the Canadian population as a whole. These groups have limited access to health care, and serious illnesses require patients to fly to southern Manitoba for care.\u0026nbsp;[43, 46]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA GSCI team member (JW), an Indigenous chiropractor with over 20 years\u0026rsquo; experience delivering spine care near The Pas on Opaskwayak Cree Nation, in northern Manitoba, was instrumental in engaging community leaders of Cross Lake Band/Pimicikamak Cree Nation (https://crosslakeband.ca/), an Indigenous community committed to increasing healthcare services. Since its first site tream visit in April 2022, and in accordance\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ewith the University of Manitoba Framework for Research Engagement with First Nation, Metis, and Inuit Peoples, members of the GSCI have developed a strong partnership with Cross Lake community where the GSCI MoC will be implemented. Cross Lake is located 786 km north of Winnipeg, the capital of Manitoba. Cross Lake has an on-reserve population of 6,734 and an off-reserve population of 2,715.\u0026nbsp;[47]\u0026nbsp;Inhabitants include First Nations peoples, M\u0026eacute;tis, and people of non-Indigenous origin. The majority of the population maintain treaty status and the Indigenous language most commonly spoken locally is Cree.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGlobal aims\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo mitigate the increasing burden of spine pain in communities that are underserved, WSC developed a four-phase project. In \u003cstrong\u003ePhase 1\u003c/strong\u003e (completed in 2018), the GSCI developed an evidence-based model of spine care (MoC) encompassing a triaging system and care pathways that can be cutumized and implemented in underserved communities. [15-29] This protocol describes a site-specific customization and pre-implementation study (\u003cstrong\u003ePhase 2\u003c/strong\u003e), as well as a feasibility study (\u003cstrong\u003ePhase 3\u003c/strong\u003e) in Cross Lake. Knowledge generated will provide essential guidance for the \u003cstrong\u003ePhase 4\u003c/strong\u003e scaling up, sustainability, and impact study in other underserved communities in northern Canada and around the globe.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSpecific objectives\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePhase 2. Site-specific customization and pre-implementation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1. Confirm the nature of, and extent to which, spinal disorders impact individuals within the underserved community. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2. Measure the perceived value of, and intention to adopt, the MoC triaging system and tailored care approach. Engage with community partners to identify factors that may impact MoC implementation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3. Estimate the extent of: I) community partners support and engagement throughout the pre-implementation phase; II) local clinicians and caregivers adoption and application of the MoC as intended; and III) people with spine symptoms would utilize the MoC.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePhase 3. Feasibility to implement the GSCI MoC\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1. Identify, estimate, and understand the extent to which: i) pain and related disability outcomes are important to people with spine symptoms or concerns; and ii) if and how the MoC can be integrated into new or existing community-based programs.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2. Estimate key parameters to inform a future \u003cstrong\u003ePhase\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;4\u003c/strong\u003e (upscaling) project.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFollowing established principles to guide ethical research within Canadian Indigenous communities, [48] team members completed recommended training (Tri-Council Policy Statement (TCPS 2), First Nations Principles of OCAP, Personal Health Information Act) prior to obtaining ethics approval from the University of Manitoba\u0026rsquo;s Research Ethics Board for each study component. The 3-year project will be conducted and reported in accordance with the requirements of the Standards for Reporting Implementation Studies (StaRI) Statement. [49] \u0026nbsp; \u0026nbsp;\u003c/p\u003e"},{"header":"Methods/ Design ","content":"\u003cp\u003eUsing participatory, sequential mixed-methods approaches,\u0026nbsp;[50, 51]\u0026nbsp;the research team will actively engage local partners and Knowledge Keepers throughout the study at the meso- (community leaders,\u0026nbsp;health administrators),\u0026nbsp;and the micro-levels (local clinicians, people with spine problems, community residents), and collect quantitative followed by qualitative information\u0026nbsp;(Figure 1).\u0026nbsp;Participatory research involves the co-production of knowledge that is relevant to policy and practice, with an explicit focus on end users\u0026rsquo; concerns, participation, and outcomes to enable practice change by empowering those most likely to use the new knowledge.\u0026nbsp;[52, 53]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFig 1.\u003c/strong\u003e Mixed-method sequential exploratory design flow chart\u003c/p\u003e\n\u003cp\u003eWe acknowledge the inherent differences between Western methods and Indigenous ways of knowing and the risks in trying to integrate these approaches (e.g., generalizing Indigenous traditions by taking them out of context; denying cultural differences in order to find commonality; assimilating Indigenous knowledge in a way that it becomes invisible).\u0026nbsp;[54]\u0026nbsp;To address power imbalances and philosophical differences, the team will seek to understand, with humility and respect, Indigenous knowledges and ways of knowing. Through discussion, we will select Indigenous-Western knowledge linking frameworks (principles and methods),\u0026nbsp;[55]\u0026nbsp;such as \u003cem\u003eEtuaptmumk\u003c/em\u003e (Two-Eyed Seeing),\u0026nbsp;[56]\u0026nbsp;considering specific context (history, place, distinct character, and beliefs of the Indigenous community), and seek to adopt seven principles found in Indigenous and Western science (Relationality, Reciprocity, Reflexivity, Respect, Reverence, Responsivity, and Responsibility), helping political, academic and other actors fulfill their obligations to both truth and reconciliation and gender-based analysis plus policies and practices.\u0026nbsp;[55]\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePhase 2. Site-specific customization and pre-implementation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQuantitative and qualitative methods will be used to gather insights from our partners pertaining to the implementation of the GSCI MoC:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eQuantitative studies (community health survey, chart review) will be conducted to understand our partners\u0026rsquo; needs and priorities, and the perceived impact of spine problems.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eQualitative studies (individual interviews and focus groups) will be conducted to explore partners intentions to adopt and implement MOC, focusing on understanding the local context and potential implementation challenges and facilitators, and the meaning and values of select clinical outcomes (pain level, pain medication used, function, disability, and quality of life).\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003ePhase 3. Feasibility\u003c/strong\u003e \u003cstrong\u003estudy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe will use an observational pre-post design, using mixed-methods research. Mixed-methods research uses quantitative and qualitative research integration to develop contextual understanding of complex multi-level systems.\u0026nbsp;[50]\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eQuantitative studies (adoption survey, chart review, clinical outcomes) will be conducted to assess partners\u0026rsquo; perceived acceptability, appropriateness, and feasibility to implement the MoC and related implementation support strategies, and care delivery process (GSCI triaging, care pathways) for people seeking care for spine symptoms, and its potential clinical impact (pain, medication used, function, disability, quality of life). \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003eQualitative studies will be conducted toward the end of the study to explore our partners\u0026rsquo; experiences with the new services, and intentions to maintain the MoC and related support strategies.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eStudy participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eCommunity health survey, new clinical service and community movement program\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eAll adults 18 years and older with spine symptoms (pain, disability) or concerns (e.g., prior problems with their neck or back) residing in Cross Lake, Manitoba, will be eligible for inclusion. Translation will be used with adults who prefer to communicate in Cree.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eChart reviews\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eClinical records of consenting consecutive adult patients presenting at the Cross Lake Nursing Station run by Health Canada over a 12-month period will be accessed and information will be de-identified.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAdoption questionnaire, qualitative interviews or focus\u0026nbsp;\u003c/u\u003e\u003cu\u003egroups\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003ePartners likely to influence implementation of the MoC including the Chief and community Band council members, community Elders and knowledge keepers, as well as Directors of Cross Lake Health Services, \u0026nbsp;representatives of the local government, and all licensed local care providers (e.g., medical doctors, nurses, allied health care providers) and local community health workers (paid or volunteer CHWs), exercise therapists, massage therapists, and traditional healers will be eligible for inclusion.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecruitment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants recruitment started in March 2023 (chart review) and will end in March 2026 (clinical service)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplementation blueprint\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWith our partners, we will co-create an implementation blueprint to support high value-based spine care (i.e., safe, timely, effective, efficient, equitable, patient-centred).\u0026nbsp;[57]\u0026nbsp;The 8-step process will be underpinned by implementation science frameworks that consider the multilevel and dynamic interactions between the interventions, the perspective and characteristics of diverse recipients (leaders, clinicians, patients, residents), the infrastructure, and the external environment (e.g., clinical guidelines):\u0026nbsp;[12, 58, 59]\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e1. Engaging local partners\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eRelationship-building with the community is essential for sustainable development.\u0026nbsp;[60]\u0026nbsp;Prior to launching the study, a structured site visit of WSC and GSCI members (n=5) took place to engage with the community leadership and an Elder.\u0026nbsp;A research agreement was signed on July 7, 2022 between Cross Lake Band/Pimicikamak Cree Nation, World Spine Care, University of Manitoba, and Universit\u0026eacute; du Qu\u0026eacute;bec \u0026agrave; Trois-Rivi\u0026egrave;res, and a data transfer agreement (GSCI, Health and Welfare Canada Cross Lake Nursing Station in collaboration with the \u0026nbsp;Department of Indigenous Services Canada/Government of Canada) was signed on August 22, 2022 to determine data collection, storage and ownership.\u003c/p\u003e\n\u003cp\u003ePeriodic site visits will be planned during the 3-year study period to i) assess organizational issues (infrastructure requirements, partners and researchers roles and responsibilities, understand intake and flow of patients with spine symptoms, including GSCI MoC fit and acceptability); ii)\u0026nbsp;monitor service implementation and research activities and co-identify viable solutions with community partners; and iii) assess how best to sustain the MoC and related support strategies.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2. Local context and population needs\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn Canada, healthcare for Indigenous persons living on reserve in northern communities is managed federally. Under the universal healthcare plan, coverage for basic hospital and medical care at no charge to patients, but each province creates its own health insurance plan with some degree of variability across provinces.\u0026nbsp;[61]\u0026nbsp;In Manitoba, up to seven visits per year to a chiropractor are partially covered under the provincial health plan, but not under the federal health plan. Outpatient physical therapy is covered through an individual\u0026rsquo;s employment benefits. Both chiropractic care and physical therapy are healthcare services covered by Manitoba Public Insurance (motor vehicle accident injuries), and the Workers Compensation Board of Manitoba (workplace injury).\u003c/p\u003e\n\u003cp\u003eCross Lake Nursing Station is managed by Health Canada, with resident nurses and general practitioner physicians as fly-in\u0026nbsp;staff, providing essential care to community members. It has limited access to allied health care focused on spinal problems. Those in need of spine care must travel to nearby cities. Both The Pas (a 401 km drive) and Thompson (a 255 km drive) have hospitals with access to telehealth for specialized services available in Winnipeg, including orthopedic spine surgeons. More serious illnesses and spine care needs require residents to fly to Winnipeg (520 km).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e3.\u003c/em\u003e \u003cem\u003eSelecting spine care model and interventions to meet needs\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe GSCI MoC is a person- and people-centered, classification system and care pathway which considers the influence of cultural, economic, and healthcare system design elements. It identifies the resources needed to support the model\u0026rsquo;s delivery of care (Figure 2).\u0026nbsp;[16, 29, 62]\u0026nbsp;This MoC provides a triage system and care pathways grouped into four specific categories of spine care aligned with high quality clinical practice guidelines:\u0026nbsp;[63-66]\u0026nbsp;\u003c/p\u003e\n\u003col style=\"list-style-type: lower-roman;\"\u003e\n \u003cli\u003ecommunity-based (e.g., education, reassurance, exercise programs, self-care);\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eprimary care (community-based health care, providing screening for serious conditions, and ongoing accessible, comprehensive, evidence-based coordinated care);\u0026nbsp;\u003c/li\u003e\n \u003cli\u003esecondary care (acute trauma and emergency care, imaging and diagnostic testing, surgical interventions); and\u0026nbsp;\u003c/li\u003e\n \u003cli\u003etertiary care (specialized medical and surgical care for complex spine problems). \u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThese categories of care are to be integrated into the available healthcare system in partnership with local communities, existing healthcare facilities/providers, patients, and health policy makers (Additional file 1, Appendix 1. Implementation toolkit).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFig 2.\u003c/strong\u003e GSCI model of care and levels of spine care\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cem\u003e4. Gathering program materials\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTwo logic models or road maps will be used to plan, execute, report, and synthesize the current implementation project: The administrative logic model provides an overview of the activities, output, and outcomes of the study (Additional file 1, Appendix 2); while the Implementation Research Logic Model (Figure 3) presents the shared relationships among context, implementation strategies and process, service and clinical outcomes, allowing for the comprehensive specification of all introduced and present implementation strategies, as well as their changes (adaptations, additions, discontinuations) during the project.\u0026nbsp;[67]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFig. 3.\u0026nbsp;\u003c/strong\u003eLogic framework (phase 2 and 3 studies)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e5. Identifying implementation support strategies\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMultifaceted strategies implemented in communities that are underserved and LMICs targeting infrastructure, supervision, other management techniques, training combined with group problem-solving can result in moderate to large practice changes.\u0026nbsp;[68]\u0026nbsp;Strategies targeting healthcare providers (e.g., educational training with clinician reminders and group problem-solving, practice facilitation, outreach visits, and input from local opinion leaders) and healthcare recipients (e.g., mass media interventions, self-management support, behavioural interventions and mobile phone text messaging)\u0026nbsp;are generally effective in improving care.\u0026nbsp;[68, 69]\u0026nbsp;Increasing the frequency and the duration of strategies are likely to result in greater success and sustained practice change and better patient low back pain outcomes.\u0026nbsp;[70]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e6. Comparing existing programs and culturally adapt processes\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAdditional file 1, Appendix 3 provides a detailed description of implementation support strategies. Following the Effective Practice for Organizational Change (EPOC) taxonomy of health systems interventions to expand equitable access to spine care,\u0026nbsp;[71]\u0026nbsp;we have provisionally selected eight implementation support strategies, along with 29 sub-strategies, targeting stakeholders across all levels to promote and sustain local interest in implementing the GSCI MoC (Table 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u0026nbsp;\u003c/strong\u003eProvisionally selected implementation support strategies and sub-strategies\u003c/p\u003e\n\u003cp\u003eContext-specific strategies are required for successful evidence implementation, and a number of common barriers can be addressed simultaneously using locally available, low-cost resources.\u0026nbsp;[72]\u0026nbsp;Guided by adaptation frameworks,\u0026nbsp;[73-75]\u0026nbsp;and in accordance with initial study findings and input from our partners,\u0026nbsp;proposed\u0026nbsp;support strategies will be modified, refined and culturally adapt to overcome implementation barriers or abandon.\u0026nbsp;[53, 76]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e7. Adapting material for new context and monitoring\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePrior to study onset, all relevant study documentation (GSCI triage system and care pathways, information, instructions, training materials, and measures) will be translated and culturally adapted following a 4-step process prior to being administered: i) questionnaire adaptation/creation; ii) expert team, partners, and local PIs (AB, SP) review; iii) pre-testing of measures for readability and understandability; and iv) data collection.\u0026nbsp;[77-79]\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e8. \u003cem\u003eCo-refining the GSCI MoC and related support strategies with community partners\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eUsing appreciative inquiry, [80] an affirmative approach to project evaluation shifting away from deficits-oriented evaluation methods towards a strengths-based or \u0026ldquo;desire-based\u0026rdquo; inquiry, [96, 97] we will engage with community partners to discuss pre- and post-implementation study findings and promote self-determining further adaptions of the GSCI MoC and proposed implementation support strategies. We will deliberately choose to initially focus on factors that contribute to positive health care encounters through the discussion of experiences and best practices, and using that positive potential within participants, the community, and the wider system to create positive changes and commit to a way forward. [80] \u0026nbsp;\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProcedures, Data Collection, Evaluation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 3 outlines the project phases,\u0026nbsp;methods for data collection and designated timelines. Study instruments are available upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePhase 2. Customization and pre-implementation\u0026nbsp;\u003c/strong\u003e(Year 1)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuantitative data\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAt the onset of the study, we will conduct a community health survey and a retrospective chart review to confirm the nature of and extent to which spinal disorders impact individuals within selected underserved communities.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCommunity health survey\u003c/em\u003e\u003cem\u003e:\u003c/em\u003e Through in-person interviews, team members will administer the health survey in either in English or Cree language based on participant preference, in randomly selected households. The survey questionnaire contains 154 questions derived from the 2020 Canadian Community Health Survey\u0026nbsp;[81]\u0026nbsp;and the Global Burden of Disease\u0026nbsp;[82],\u0026nbsp;covering socio-demographics, general health, spine pain and related disability, chronic comorbid conditions, self-care, spine care received, and satisfaction with care.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eChart review:\u003c/em\u003e De-identified data on consecutive charts from adult community members seeking musculoskeletal care within the preceding year at Cross Lake Nursing Station will be reviewed to access spine-related health care utilization.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQualitative data\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQualitative methodology will be used to explore and understand partner\u0026rsquo;s perspectives and experiences about the GSCI MoC and related implementation strategies.\u0026nbsp;[83]\u0026nbsp;Using in-person\u0026nbsp;\u003cem\u003esemi-structured interviews\u003c/em\u003e, we will identify perceived individual, organizational, and contextual factors shaping the uptake of MoC within the community, and better understand perceptions about spine care needs, what is culturally safe and acceptable spine care, as well as meaningful clinical outcomes to use in patients with spine symptoms.\u0026nbsp;\u003cem\u003eFocus groups or individual in-person or online interviews\u003c/em\u003e of local clinicians and CHWs will serve to better understand the intention and readiness to adopt the MoC and explore implementation barriers.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe interview guides will be informed by the Theoretical Domain Framework\u0026nbsp;(TDF)\u0026nbsp;[84], offering an ecological lens in which to consider multi-level influences on behavior change.\u0026nbsp;[85]\u0026nbsp;The TDF has been widely used across health disciplines, health conditions and settings. The framework will guide the data collection, coding, analysis, and reporting of findings to gain a comprehensive understanding of relevant modifiable determinants, to facilitate the design of implementation strategies that will address them.\u0026nbsp;[86]\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u0026nbsp;\u003c/strong\u003eDescription of project phases, Timing, Data Collection\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePhase 3. Feasibility study\u0026nbsp;\u003c/strong\u003e(Year 2-3)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1) Implementation\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e(Year 2)\u003c/p\u003e\n\u003cp\u003ePhase 3 will begin after baseline data collection, the MoC and related implementation strategies have been refined, culturally adapted, and prepared for initiating the implementation. Local clinicians will have been trained to apply the GSCI triage and care pathways on patients with spine symptoms or concerns (Additional file 1, Appendix 4, Tables 1-3). In parallel, we will prepare and launch the new spine care service and community movement program (Additional file 1, Appendix 5).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2) Post-implementation\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e(Year 3)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuantitative data\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe will administer\u0026nbsp;\u003cem\u003eadoption survey questionnaires\u003c/em\u003e to meso- and micro-level partners 6 months after initiating implementation of the MoC, inquiring about the perceived acceptability, appropriateness, and feasibility to implement the MoC and related implementation support strategies. These three brief measures will be collected after implementation of the new clinical service and community movement program as users need to first experience the MoC (triage and care pathways) and implementation strategies (e.g., educational training modules, self-care tools) and have initiated the use of the MoC prior to completing these questionnaires. The same measures will be administered\u0026nbsp;again 2-3 months before the study ends.\u003c/p\u003e\n\u003cp\u003eA second \u003cem\u003echart review\u003c/em\u003e will be conducted 9-12 months post-implementation to estimate and understand the extent to which: i) local clinicians and caregivers accepted, adopted, and applied the \u0026nbsp;GSCI MoC as intended; and ii) people with spine symptoms have accepted recommended care.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eService and clinical\u003c/em\u003e\u003cem\u003e\u0026nbsp;outcomes\u003c/em\u003e\u003cem\u003e:\u003c/em\u003e Consecutive, consenting adult patients who agreed to participate in the project and meet inclusion criteria will be inducted into the study. At the end of each patient care episode for a complaint of spine symptoms, patient charts will be reviewed to determine the care delivered (i.e., process through which patients with spine condition are diagnosed, treated, referred or managed over time) along with the patient\u0026rsquo;s self-reported outcome measures. Validated patient reported health outcome questionnaires (pain, function, disability, quality of life) will be administered before and after care over a 2-month period.\u0026nbsp;The results from the patient health outcome measures will be used to estimate key parameters such as effect sizes to inform the selection of a primary outcome and to calculate the sample size for a future study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQualitative data\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe will conduct a second series of in-person TDF-guided interviews and focus groups\u0026nbsp;[83]\u0026nbsp;among the same partners 9-12 months after initiating implementation, to understand if and how the MoC was implemented, gather information on\u0026nbsp;local clinicians\u0026rsquo; and CHWs\u0026rsquo; intentions to continue use of the MoC, community leaders\u0026rsquo; willingness to maintain the new clinical service and community movement program, and community leaders\u0026rsquo; priority toward helping scale up this project in other communities.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Sources\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe aforementioned objectives\u0026nbsp;will be addressed using the following data sources (Table 4) as described in the project timelines (Figure 4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4\u003c/strong\u003e Summary of data collection\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFig 4.\u003c/strong\u003e Project timelines\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplementation, Service and Clinical outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study outcomes were selected to reflect the hypothesized mechanism of effect of the proposed implementation support strategies of the MoC, while considering the need to minimize respondent burden and maintain participant confidentiality. The measures have established psychometric properties, and can be compared when the MoC is implemented in other settings.\u0026nbsp;[87-92]\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDrawing on the RE-AIM evaluation framework, study outcomes will focus on\u0026nbsp;reach, adoption, implementation, and maintenance.\u0026nbsp;[93-95]\u0026nbsp;The Proctor et al.\u0026nbsp;[96]\u0026nbsp;and\u0026nbsp;Lewis et al.\u0026nbsp;[97]\u0026nbsp;taxonomies will serve to further characterize selected primary process outcomes, downstream service, and clinical outcomes measures. Further, we will use appreciative inquiry\u0026nbsp;[80]\u0026nbsp;involving a four phase cycle (i.e., Discovery \u0026nbsp;\u0026lsquo;\u003cem\u003evaluing the best of what is\u0026rsquo;\u003c/em\u003e, Dream \u003cem\u003e\u0026lsquo;envisioning what might be\u0026rsquo;\u003c/em\u003e, Design \u003cem\u003e\u0026lsquo;dialoguing what should be\u0026rsquo;\u003c/em\u003e, and Delivery/Destiny \u003cem\u003e\u0026lsquo;innovating what will be\u0026rsquo;\u003c/em\u003e)\u0026nbsp;[98, 99]\u0026nbsp;to reflect on the extent to which the proposed GSCI MoC and services align with key concepts of the Indigenous Healthcare Quality Framework.\u0026nbsp;[99]\u0026nbsp;This framework represents the person-centered perspectives and the requirements of healthcare systems and provider factors that are required for the achievement and sustainability of health care for Indigenous people that is high quality, culturally safe and free of racism. It also considers the continuous cycles experienced throughout the lives of Indigenous people, and the vital connection to the land held by First Nations, Inuit, and Metis peoples.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1. Primary implementation outcomes\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eReach\u0026nbsp;\u003c/em\u003e\u003c/strong\u003ecan be defined as \u0026ldquo;\u0026hellip;the integration of a practice within a service setting and its subsystems\u0026rdquo;.\u0026nbsp;[96]\u0026nbsp;We will adapt the THET-Partnership-Health-Check-Tool to evaluate stakeholders engagement\u0026nbsp;[100]\u0026nbsp;using quantitative methods (e.g. administrative data such as support letters, formal memoranda of understanding, meeting attendance, and partners adoption survey).\u0026nbsp;[101]\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAdoption\u003c/em\u003e\u003c/strong\u003e relating to the readiness for implementation\u0026nbsp;[102]\u0026nbsp;will be gathered using validated 4-item measures of acceptability of intervention measure (AIM), intervention appropriateness measure (IAM), and feasibility of intervention measure (FIM).\u0026nbsp;[103, 104]\u0026nbsp;\u003cem\u003eAcceptability\u003c/em\u003e is the perception among stakeholders that the intervention is agreeable, palatable, and satisfactory. \u003cem\u003eAppropriateness\u0026nbsp;\u003c/em\u003eis the perceived fit, relevance, or compatibility of the innovation for a given setting, provider, or consumer. \u003cem\u003eFeasibility\u003c/em\u003e is the extent to which the intervention can be successfully carried out within the given setting.\u0026nbsp;[105]\u0026nbsp;The implementation measures are scored with a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree), with higher average scores indicating greater readiness for implementation. These measures have demonstrated strong psychometric properties, and readability is at the 5th grade level.\u0026nbsp;[103]\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eImplementation (\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eadaptability\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e, fidelity)\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eis the consistency at which the different parts of the GSCI triage and care pathways are implemented across settings, clinicians, and patients, and at what cost, and how was the program adapted.\u0026nbsp;[95]\u0026nbsp; \u003cem\u003eAdaptability\u003c/em\u003e can be defined as \u0026ldquo;the degree to which an intervention can be adapted, tailored, refined, or reinvented to meet local needs\u0026rdquo;, while \u003cem\u003eFidelity\u003c/em\u003e \u0026ldquo;the degree to which an intervention was implemented as intended\u0026rdquo;.\u0026nbsp;[96]\u0026nbsp;An Adaptation framework will capture adaptations made during the study. An Implementation Status Report will collect clinical and implementation activities.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eMaintenance\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eis the extent to which the MoC triaging and care pathways become part of routine practice. Constructs explored with stakeholders will pertain to leadership engagement, intention to continue to use MoC and the community program, environmental context, planning, relative advantage and available resources.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCost\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eare the resources (personnel, material) utilized by the strategies and their costs,\u0026nbsp;[106]\u0026nbsp;including the delivery of the new services, staff/clinician training, patients\u0026rsquo; external referrals for advanced imaging and medical specialist consultation, and travels.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2. Secondary outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eService outcomes\u003c/em\u003e\u003c/strong\u003e refers to local clinicians delivering care during clinical encounters, people with spine symptoms applying advice on self-care (e.g., home exercise), and community members attending activities (e.g., community movement program). Service outcomes may be determined by an observer with some professional training or self-reported using the MoC fidelity checklist.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eClinical outcomes\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eare considered secondary outcomes as the aim is to determine whether questionnaires can be routinely collected as planned. When a patient attends for consultation, socio-demographic, baseline and follow-up measures will be obtained using validated questionnaires: a) Numeric rating scale (NRS) to assess pain; b) WHODAS 2.0 (WHO Disability Assessment Schedule 2.0) to measure ability; c) Patient Specific Functional Scale for function; and d)\u0026nbsp;EuroQol (EQ-5D 3L) for health-related quality of life. We recognize however the need to discuss with our partners the selection of culturally adapted outcome measures.\u0026nbsp;[107]\u0026nbsp;For instance. Indigenous perspectives of pain are often more holistic, encompassing mental, spiritual, emotional, and physical hurt.\u0026nbsp;[108]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eS\u003c/strong\u003e\u003cstrong\u003etudy sample\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eCommunity Health Survey (CHS):\u003c/u\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e50 homes in the community will be randomly selected using a household list available from the community\u0026rsquo;s urban planning. A trained local RA (MS) will orally administer the CHS at the study onset to up to three adults living in these households (total of 150 surveys). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eChart reviews:\u003c/u\u003e Chart reviews will be conducted pre- and post-implementation on 50 consecutive charts (or until data saturation) by team members (JW, PT). They will extract data from charts in the local clinic in the community or in households visited in the case where it is customary for the patient to keep their chart at home. A total of 100 charts will be extracted during the study period.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eSemi-structured interviews and focus groups:\u003c/u\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eAll interviews will be conducted pre- and post-implementation by the co-authors (AB, JL) in English or a local RA (MS) with patients in the local language at the study onset and again at the end of the study:\u003c/p\u003e\n\u003cp\u003ei) \u0026nbsp;Semi-structured interviews: Using maximum variability principles, a purposive sample of 10-13 individuals will be drawn among community leaders (n=10), respondents of the chart review (n=2-3) and community health survey (n=4-5) to seek respondents across a spectrum (spread of age, gender, occupation, pain duration, disability level) to ensure that all viewpoints would be adequately represented;\u003c/p\u003e\n\u003cp\u003eii) \u0026nbsp;A focus group or semi-structured interviews will be conducted with 6-8 local clinicians and 1-2 CHWs representing a wide range in years in practice and health disciplines.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAdoption surveys\u003c/u\u003e: Between 4 to 8 participants per partner group (decision-makers/local leaders; local clinicians/CHWs, people with spine symptoms, community residents) will complete 3 short implementation surveys pre- and post-implementation, either paper-based or orally administered by RAs.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eMoC Fidelity checklists:\u003c/u\u003e GSCI primary spine care clinicians will complete the fidelity checklists while observing 4-6-consecutive clinical encounters between the local clinicians and CHWs (n=6-8 per setting) and people seeking spine care 3 and 6 months after online and in-person training.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eClinical outcomes:\u003c/u\u003e Clinical outcomes will be collected on consecutive patients before and after care at two time points.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnalysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUsing appreciative inquiry,\u0026nbsp;[80]\u0026nbsp;we will seek input from our partners in the interpretation of the findings and dissemination and implementation of the research results. Where available, analyses will consider sex, gender and age-related differences and patterns in the data. We will complete yearly implementation status reports, including a model of care matrix, partner\u0026rsquo;s analysis table, and implementation strategy plan.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eQuantitative Data Analysis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStatistical analyses will be conducted using SAS Analytics Software (SAS Institute). Data from the Community health survey (CHS), chart reviews (CR), and implementation measures will be analyzed descriptively. Frequency distributions and proportions will be generated for categorical variables, and means, standard deviations, and medians with interquartile ranges will be computed for continuous variables.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor the CHS, we will analyze three self-reported measures of in-community spine symptoms in the 12 months prior to the survey:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ei) \u0026nbsp;whether the respondent reduced their participation or level of activity as a result of spine symptoms and related co-morbidities,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eii) \u0026nbsp;whether the respondent consulted someone for their spine problem, and if so, the type of care received, satisfaction with community-based care, and self-management strategies used, and\u003c/p\u003e\n\u003cp\u003eiii) \u0026nbsp;reported general health status, and community activities and gatherings.\u003c/p\u003e\n\u003cp\u003eThe CR will provide an understanding of the type of spine care received (pharmaceutical and non-pharmaceutical care, referrals for imaging or treatment) in the 12 months prior to data collection. Pre- and post-implementation results will be contrasted to highlight any trends observed in spine care\u0026nbsp;delivery.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eImplementation outcomes:\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eReach\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003ewill be reported descriptively as the proportion of partners (community leaders, residents) that engage with each of the implementation support sub-strategies, and local clinicians completing training and adopting the MoC and care pathway.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAdoption\u003c/em\u003e\u003c/strong\u003e:\u0026nbsp;Descriptive statistics will be used to summarize data related to demographics, and AIM, IAM and FIM total scores. Associations of AIM, IAM, and FIM with other measures, such as characteristics, will be assessed via Spearman rank correlations for continuous measures and Wilcoxon rank sum tests or Kruskal-Wallis tests for categorical measures.\u0026nbsp;[105]\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAdaptations\u003c/em\u003e\u003c/strong\u003e to the implementation support strategies will be reported descriptively, with adaptations summarized using a modified version of a consistent coding framework of adaptations (FRAME)\u0026nbsp;[109].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFidelity\u003c/em\u003e\u003c/strong\u003e will be reported as the number of people seeking spine care, provided each of the steps involved in triaging and/or using the spine care pathway were administered. The overall fidelity score will be calculated based on the number of people with spine symptoms seeking care across communities appropriately triaged based on the GSCI MoC.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCosting\u003c/em\u003e\u003c/strong\u003e will be reported descriptively as costs of providing the new clinical service and community movement program, training material, MRI and CT scan costs, visits to medical specialists, and related travelling expenses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eQualitative Data Analysis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll interviews and focus groups will be audio recorded and transcribed verbatim. Coding and analysis will be managed using NVivo (QSR International, Version 12). Qualitative data analysis will be conducted through an interpretivist lens,\u0026nbsp;[110]\u0026nbsp; exploring participants\u0026rsquo; experiences and thoughts. Two PhD students (NR, EB) will independently code each transcript\u0026nbsp;guided by a mutual understanding of the TDF domain definitions and constructs within a domain,\u0026nbsp;[84]\u0026nbsp;and\u0026nbsp;will meet weekly to review coding and achieve consensus. Two senior authors (AB, SM) familiar with the TDF will review the coded transcripts to solve any disagreements from the original coders to increase the reliability of coding (crystallization). Data will be analyzed using a combination of deductive and inductive coding. Deductive codes will be derived from the TDF domains, following a coding guideline to ensure consistency between coders.\u0026nbsp;Data analysis will be carried out by pairs of trained RAs and two senior authors who will independently code the same subset of transcripts.\u0026nbsp;[111]\u0026nbsp;Coders will then meet after every 3-4 transcripts to discuss and reach consensus on code allocation, and the coding schemes will be refined and amended via an iterative process.\u0026nbsp;The emergent coding tree will reflect both deductive and inductive codes.\u0026nbsp;[84, 111]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eKey modifiable barriers identified will be mapped onto behavior change intervention techniques to inform the development and refinement of culturally acceptable implementation support strategies designed to support or change the health system to increase adoption of the evidence-based practice of the GSCI MoC into usual care.\u0026nbsp;[111, 112]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eStudy risk and risk mitigation strategies, and knowledge management and dissemination plans are presented in Additional files 1, Appendices 6 and 7 respectively.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eSpine pain is a highly prevalent and disabling, yet invisible condition. Major international clinical guidelines recognize that the vast majority of people with spine pain can be effectively managed with physical and psychosocial interventions, and discourage use of pain medication, steroid injections and spinal surgery. [\u003cspan additionalcitationids=\"CR64 CR65\" citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e] However, the undertreatment of pain is systematically reported in the literature, particularly in marginalized populations. [\u003cspan additionalcitationids=\"CR40\" citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan additionalcitationids=\"CR114\" citationid=\"CR113\" class=\"CitationRef\"\u003e113\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR115\" class=\"CitationRef\"\u003e115\u003c/span\u003e] In addition, many health systems globally are not designed to support non-phamacological spine care approaches, with inadequate payment systems favouring medical care over patients\u0026rsquo; self-management and rehabilitation, deep-rooted medical traditions and beliefs about care for spine pain, [\u003cspan citationid=\"CR116\" class=\"CitationRef\"\u003e116\u003c/span\u003e] and difficulty in accessing culturally safe and meaningful health care services for Indigenous peoples. [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]\u003c/p\u003e \u003cp\u003ePromising solutions, practices and policies include providing accessible and culturally acceptable high-value spine care services, cultural safety training and trauma-informed care, addressing care providers\u0026rsquo; biaises, and incentives to increase the number of Indigenous health care providers [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR116\" class=\"CitationRef\"\u003e116\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eResults from this project are expected to further advance our understanding on the experiences and challenges of accessing spine care in a remote northern Indigenous community, and inform planning of a study aiming to determine the most effective means of sustaining and scaling the GSCI MoC to larger communities and to determine its personal, social and economic impact on underserved communities. To maximize the fit between the proposed spine care services, practice settings, and the broader ecological system, we will regularly engage with key partners and work toward reaching a mutual understanding throughout the project, seek to continually learn and problem solve, co-adapt implementation strategies with a primary focus on ongoing improvement considering multi-level contexts (e.g., culture, support, time, resources, funding). [\u003cspan additionalcitationids=\"CR118\" citationid=\"CR117\" class=\"CitationRef\"\u003e117\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR119\" class=\"CitationRef\"\u003e119\u003c/span\u003e]\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eImplementing the GSCI Model of Care in Cross Lake is expected to help reduce the burden of spine problems and related healthcare costs for the local community and serve as a scalable model for programs in other northern Canada regions and sites around the globe.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8761%;\"\u003e\n \u003cp\u003eCHS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83.1239%;\"\u003e\n \u003cp\u003eCommunity Health Survey\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8761%;\"\u003e\n \u003cp\u003eCHW\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83.1239%;\"\u003e\n \u003cp\u003eCommunity Health Worker\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8761%;\"\u003e\n \u003cp\u003eCR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83.1239%;\"\u003e\n \u003cp\u003eChart Review\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8761%;\"\u003e\n \u003cp\u003eEPOC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83.1239%;\"\u003e\n \u003cp\u003eEffective Practice for Organizational Change\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8761%;\"\u003e\n \u003cp\u003eGSCI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83.1239%;\"\u003e\n \u003cp\u003eGlobal Spine Care Initiative: https://www.globalspinecareinitiative.org/\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8761%;\"\u003e\n \u003cp\u003eIPCHS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83.1239%;\"\u003e\n \u003cp\u003eIntegrated, People-Centred Health Services\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8761%;\"\u003e\n \u003cp\u003eLMICs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83.1239%;\"\u003e\n \u003cp\u003eLow- and Middle-Income Countries\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8761%;\"\u003e\n \u003cp\u003eMoC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83.1239%;\"\u003e\n \u003cp\u003eModel of Care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8761%;\"\u003e\n \u003cp\u003eMRC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83.1239%;\"\u003e\n \u003cp\u003eMedical Research Council\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8761%;\"\u003e\n \u003cp\u003eMSK\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83.1239%;\"\u003e\n \u003cp\u003eMusculoskeletal\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8761%;\"\u003e\n \u003cp\u003eRA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83.1239%;\"\u003e\n \u003cp\u003eResearch Assistant\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8761%;\"\u003e\n \u003cp\u003eREB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83.1239%;\"\u003e\n \u003cp\u003eResearch Ethics Board\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8761%;\"\u003e\n \u003cp\u003eSDG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83.1239%;\"\u003e\n \u003cp\u003eSustainable Development Goals\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8761%;\"\u003e\n \u003cp\u003eTDF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83.1239%;\"\u003e\n \u003cp\u003eTheoretical Domain Framework\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8761%;\"\u003e\n \u003cp\u003eUK\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83.1239%;\"\u003e\n \u003cp\u003eUnited Kingdom\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8761%;\"\u003e\n \u003cp\u003eWHO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83.1239%;\"\u003e\n \u003cp\u003eWorld Health Organization\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8761%;\"\u003e\n \u003cp\u003eWSC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83.1239%;\"\u003e\n \u003cp\u003eWorld Spine Care:\u003ca href=\"https://www.worldspinecare.org/\"\u003e\u0026nbsp;\u003c/a\u003ehttps://www.worldspinecare.org/\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8761%;\"\u003e\n \u003cp\u003eWSCC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83.1239%;\"\u003e\n \u003cp\u003eWorld Spine Care Canada:\u003ca href=\"https://www.worldspinecare.org/\"\u003e\u0026nbsp;\u003c/a\u003e https://www.worldspinecare.org/canada\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFollowing established principles to guide ethical research within Canadian Indigenous communities, [49] team members completed recommended training (Tri-Council Policy Statement (TCPS 2), First Nations Principles of OCAP, Personal Health Information Act) prior to obtaining ethics approval from the University of Manitoba\u0026rsquo;s Research Ethics Board for each study component: Qualitative (#HE2022-0248); Chart review: (HE2022-0249), Community health survey (HE2022-0250), Adoption survey (HE2022-0394), Community movement program (HE2023-0017), and Care pathway (HE2023-0144).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests. The lead author AB (the manuscript\u0026rsquo;s guarantor) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; and that no important aspects of the study have been omitted.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis project received financial support from Health Canada Substance Use and Addictions Program (agreement # 2223 HQ 000126), The Canadian Chiropractic Research Foundation (CCRF), The Canadian Chiropractic Association (CCA), and The Skoll Foundation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors\u0026apos; contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA.B., S.P., D.K.G., P.T., E.L.H., A. D.W., J.W., M.A.G., S.M., and S.H. developed the concept and design with input from all authors.\u003c/p\u003e\n\u003cp\u003eD.A.M., D.Z.M., H.H., M.S., R.S., M.J., and M.F.W. provided needed guidance and context.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA.B., wrote the main manuscript text and prepared figures 1, 3, and 4 with input from all authors. D.K.G., P.T., E.L.H., A. D.W., M.N., and S.H. prepared figure 2. All authors critically revised the manuscript for important intellectual content. A.B., S.P., and J.M. provided administrative, technical, or material support. A.B. and S.H. supervised the team.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank Cross Lake Band Council members for their guidance and ongoing support, Dr. Simon K Sarpong, and the entire staff at the Health Canada Cross Lake Nursing Station for their assistance with the clinical program, and Dr. Margareta Nordin for her strong leadership, and tireless work ethic and determination to help reduce the global burden of musculoskeletal conditions.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCieza A, Causey K, Kamenov K, Hanson SW, Chatterji S, Vos T. Global estimates of the need for rehabilitation based on the Global Burden of Disease study 2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2021;396(10267):2006-17. https://doi.org/.10.1016/s0140-6736(20)32340-0.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHoy D, Geere JA, Davatchi F, Meggitt B, Barrero LH. A time for action: Opportunities for preventing the growing burden and disability from musculoskeletal conditions in low- and middle-income countries. Best Pract Res Clin Rheumatol. 2014;28(3):377\u0026thinsp;\u0026ndash;\u0026thinsp;93. https://doi.org/.10.1016/j.berh.2014.07.006.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBriggs AM, Jordan JE, Sharma S, Young JJ, Chua J, Foster HE et al. Context and priorities for health systems strengthening for pain and disability in low- and middle-income countries: a secondary qualitative study and content analysis of health policies. Health Policy Plan. 2022;38(2):129\u0026thinsp;\u0026ndash;\u0026thinsp;49. https://doi.org/.10.1093/heapol/czac061.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFerreira ML, de Luca K, Haile LM, Steinmetz JD, Culbreth GT, Cross M et al. Global, regional, and national burden of low back pain, 1990\u0026ndash;2020, its attributable risk factors, and projections to 2050: a systematic analysis of the Global Burden of Disease Study 2021. Lancet Rheumatol. 2023;5(6):e316-e29. https://doi.org/.10.1016/S2665-9913(23)00098-X.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSafiri S, Kolahi A-A, Hoy D, Buchbinder R, Mansournia MA, Bettampadi D et al. Global, regional, and national burden of neck pain in the general population, 1990\u0026ndash;2017: systematic analysis of the Global Burden of Disease Study 2017. BMJ. 2020;368:m791. https://doi.org/.10.1136/bmj.m791.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVos Tea. Global burden of 369 diseases and injuries in 204 countries and territories, 1990\u0026ndash;2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020;396(10258):1204-22. https://doi.org/.10.1016/s0140-6736(20)30925-9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFinley CR, Chan DS, Garrison S, Korownyk C, Kolber MR, Campbell S, et al. What are the most common conditions in primary care? Systematic review. Can Fam Physician. 2018;64(11):832\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC clinical practice guideline for prescribing opioids for pain \u0026mdash; United States, 2022. MMWR Recomm Rep. 2022;71(No. RR-3):1\u0026ndash;95. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/.http://dx.doi.org/10.15585/mmwr.rr7103a1\u003c/span\u003e\u003cspan address=\".10.15585/mmwr.rr7103a1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWu AM, Cross M, Elliott J, Culbreth G, Haile L, Steinmetz J et al. Global, Regional, and National Burden of Neck Pain, 1990 to 2020 and Projections to 2050: A Systematic Analysis of the Global Burden of Disease Study 2021. Lancet. 2024;6(3):E142-E55. https://doi.org/.10.2139/ssrn.4427441.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBriggs A, Woolf A, Dreinh\u0026ouml;fer K, Homb N, Hoy D, Kopansky-Giles D, et al. Reducing the global burden of musculoskeletal conditions. Bull World Health Organ. 2018;96:366\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/.http://dx.doi.org/10.2471/BLT.17.204891\u003c/span\u003e\u003cspan address=\".10.2471/BLT.17.204891\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health O. Low back pain - Fact sheets 2023 [ \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/news-room/fact-sheets/detail/low-back-pain\u003c/span\u003e\u003cspan address=\"https://www.who.int/news-room/fact-sheets/detail/low-back-pain\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBriggs AM, Shiffman J, Shawar YR, \u0026Aring;kesson K, Ali N, Woolf AD. Global health policy in the 21st century: Challenges and opportunities to arrest the global disability burden from musculoskeletal health conditions. Best Pract Res Clin Rheumatol. 2020;34(5):101549. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/.https://doi.org/10.1016/j.berh.2020.101549\u003c/span\u003e\u003cspan address=\".10.1016/j.berh.2020.101549\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChhabra HS, Tamai K, Alsebayel H, AlEissa S, Alqahtani Y, Arand M et al. SPINE20 recommendations 2023: One Earth, one family, one future WITHOUT spine DISABILITY. Brain Spine. 2023;3:102688. https://doi.org/.10.1016/j.bas.2023.102688.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaldeman S, Outerbridge G, Eberspaecher S, Brady O, Kopansky-Giles D, Nordin M et al. World Spine Care: A Charity Providing Spine Care in Botswana, Dominican Republic, India and Ghana. ISSLS Book: Lumbar Spine Online Textbook. Section 6, Chap. 1. August, 2018. 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOrganization WH. Framework for Integrated, People-Centred Health Services. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/health-topics/integrated-people-centered-care#tab=tab_1\u003c/span\u003e\u003cspan address=\"https://www.who.int/health-topics/integrated-people-centered-care#tab=tab_1\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e Accessed March 26, 2024. 2016.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaldeman S, Nordin M, Chou R, C\u0026ocirc;t\u0026eacute; P, Hurwitz EL, Johnson CD et al. The Global Spine Care Initiative: World Spine Care executive summary on reducing spine-related disability in low- and middle-income communities. Eur Spine J. 2018;27(6):776\u0026thinsp;\u0026ndash;\u0026thinsp;85. https://doi.org/.10.1007/s00586-018-5722-x.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohnson CD, Haldeman S, Nordin M, Chou R, C\u0026ocirc;t\u0026eacute; P, Hurwitz EL et al. The Global Spine Care Initiative: methodology, contributors, and disclosures. European Spine Journal. 2018;27(6):786\u0026thinsp;\u0026ndash;\u0026thinsp;95. https://doi.org/.10.1007/s00586-018-5723-9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHurwitz EL, Randhawa K, Yu H, C\u0026ocirc;t\u0026eacute; P, Haldeman S. The Global Spine Care Initiative: a summary of the global burden of low back and neck pain studies. Eur Spine J. 2018;10.1007/s00586-017-5432-9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/.10.1007/s00586-017-5432-9\u003c/span\u003e\u003cspan address=\".10.1007/s00586-017-5432-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHurwitz EL, Randhawa K, Torres P, Yu H, Verville L, Hartvigsen J et al. The Global Spine Care Initiative: a systematic review of individual and community-based burden of spinal disorders in rural populations in low- and middle-income communities. Eur Spine J. 2018;27(Suppl 6):802\u0026thinsp;\u0026ndash;\u0026thinsp;15. https://doi.org/.10.1007/s00586-017-5393-z.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGreen BN, Johnson CD, Haldeman S, Kane EJ, Clay MB, Griffith EA et al. The Global Spine Care Initiative: public health and prevention interventions for common spine disorders in low- and middle-income communities. Eur Spine J. 2018;27(Suppl 6):838\u0026thinsp;\u0026ndash;\u0026thinsp;50. https://doi.org/.10.1007/s00586-018-5635-8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNordin M, Randhawa K, Torres P, Yu H, Haldeman S, Brady O et al. The Global Spine Care Initiative: a systematic review for the assessment of spine-related complaints in populations with limited resources and in low- and middle-income communities. Eur Spine J. 2018;27(Suppl 6):816\u0026thinsp;\u0026ndash;\u0026thinsp;27. https://doi.org/.10.1007/s00586-017-5446-3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAcaroğlu E, Nordin M, Randhawa K, Chou R, C\u0026ocirc;t\u0026eacute; P, Mmopelwa T et al. The Global Spine Care Initiative: a summary of guidelines on invasive interventions for the management of persistent and disabling spinal pain in low- and middle-income communities. Eur Spine J. 2018;27(Suppl 6):870-8. https://doi.org/.10.1007/s00586-017-5392-0.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCedraschi C, Nordin M, Haldeman S, Randhawa K, Kopansky-Giles D, Johnson CD et al. The Global Spine Care Initiative: a narrative review of psychological and social issues in back pain in low- and middle-income communities. Eur Spine J. 2018;27(Suppl 6):828\u0026thinsp;\u0026ndash;\u0026thinsp;37. https://doi.org/.10.1007/s00586-017-5434-7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAcaroğlu E, Mmopelwa T, Y\u0026uuml;ksel S, Ayhan S, Nordin M, Randhawa K et al. The Global Spine Care Initiative: a consensus process to develop and validate a stratification scheme for surgical care of spinal disorders as a guide for improved resource utilization in low- and middle-income communities. Eur Spine J. 2018;27(Suppl 6):879\u0026thinsp;\u0026ndash;\u0026thinsp;88. https://doi.org/.10.1007/s00586-017-5332-z.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmeis A, Randhawa K, Yu H, C\u0026ocirc;t\u0026eacute; P, Haldeman S, Chou R et al. The Global Spine Care Initiative: a review of reviews and recommendations for the non-invasive management of acute osteoporotic vertebral compression fracture pain in low- and middle-income communities. Eur Spine J. 2018;27(Suppl 6):861-9. https://doi.org/.10.1007/s00586-017-5273-6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaldeman S, Johnson CD, Chou R, Nordin M, C\u0026ocirc;t\u0026eacute; P, Hurwitz EL et al. The Global Spine Care Initiative: classification system for spine-related concerns. Eur Spine J. 2018;27(6):889\u0026ndash;900. https://doi.org/.10.1007/s00586-018-5724-8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaldeman S, Johnson CD, Chou R, Nordin M, C\u0026ocirc;t\u0026eacute; P, Hurwitz EL et al. The Global Spine Care Initiative: care pathway for people with spine-related concerns. Eur Spine J. 2018;27(Suppl 6):901\u0026thinsp;\u0026ndash;\u0026thinsp;14. https://doi.org/.10.1007/s00586-018-5721-y.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKopansky-Giles D, Johnson CD, Haldeman S, Chou R, C\u0026ocirc;t\u0026eacute; P, Green BN et al. The Global Spine Care Initiative: resources to implement a spine care program. Eur Spine J. 2018;27(6):915\u0026thinsp;\u0026ndash;\u0026thinsp;24. https://doi.org/.10.1007/s00586-018-5725-7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohnson CD, Haldeman S, Chou R, Nordin M, Green BN, C\u0026ocirc;t\u0026eacute; P et al. The Global Spine Care Initiative: model of care and implementation. Eur Spine J. 2018;27(Suppl 6):925\u0026thinsp;\u0026ndash;\u0026thinsp;45. https://doi.org/.10.1007/s00586-018-5720-z.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSpeerin R, Slater H, Li L, Moore K, Chan M, Dreinh\u0026ouml;fer K et al. Moving from evidence to practice: Models of care for the prevention and management of musculoskeletal conditions. Best Pract Res Clin Rheumatol. 2014;28(3):479\u0026ndash;515. https://doi.org/.10.1016/j.berh.2014.07.001.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUnited Nations. Sustainable Development Goals (DSDG), Department of Economic and Social Affairs, Sustainable Development. 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDawkins B, Renwick C, Ensor T, Shinkins B, Jayne D, Meads D. What factors affect patients\u0026rsquo; ability to access healthcare? An overview of systematic reviews. Trop Med Int Health. 2021;26(10):1177\u0026ndash;88. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/.https://doi.org/10.1111/tmi.13651\u003c/span\u003e\u003cspan address=\".10.1111/tmi.13651\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeters DH, Tran NT, Adam T. Implementation research in health: a practical guide. Alliance for Health Policy and Systems Research, World Health Organization; 2013.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePati MK, Swaroop N, Kar A, Aggarwal P, Jayanna K, Van Damme W. A narrative review of gaps in the provision of integrated care for noncommunicable diseases in India. Public Health Rev. 2020;41:8. https://doi.org/.10.1186/s40985-020-00128-3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOosterveer TM, Young TK. Primary health care accessibility challenges in remote indigenous communities in Canada's north. Int J Circumpolar Health. 2015;74:29576. https://doi.org/.10.3402/ijch.v74.29576.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWinn CS, Chisholm BA, Hummelbrunner JA. Factors affecting recruitment and retention of rehabilitation professionals in Northern Ontario, Canada: a cross-sectional study. Rural Remote Health. 2014;14:2619.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCunningham M, Chapter V. Health. United Nations, Permanent Forum on Indigenous Issues, State of the world\u0026rsquo;s Indigenous peoples. New York: United Nations; 2009. pp. 156\u0026ndash;87.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMowbray M. Social determinants and Indigenous health: The International experience and its policy implications. Geneva, Switzerland: World Health Organization Commission on Social Determinants of Health; 2007.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWylie L, McConkey S. Insiders\u0026rsquo; Insight: Discrimination against Indigenous Peoples through the Eyes of Health Care Professionals. J Racial Ethn Health Disparities. 2019;6(1):37\u0026ndash;45. https://doi.org/.10.1007/s40615-018-0495-9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoyer Y. Healing racism in Canadian health care. CAMJ. 2017;189(46):E1408-E9. https://doi.org/.10.1503/cmaj.171234.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTang SY, Browne AJ. 'Race' matters: racialization and egalitarian discourses involving Aboriginal people in the Canadian health care context. Ethn Health. 2008;13(2):109\u0026thinsp;\u0026ndash;\u0026thinsp;27. https://doi.org/.10.1080/13557850701830307.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBelzak L, Halverson J. The opioid crisis in Canada: a national perspective. Health Promot Chronic Dis Prev Can. 2018;38(6):224\u0026thinsp;\u0026ndash;\u0026thinsp;33. https://doi.org/.10.24095/hpcdp.38.6.02.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCanadian Pain Task Force. Working together to better understand, prevent, and manage chronic pain: What we heard. Oct 2020. Health Canada, Ottawa, ON, Canada (Accessed December 26 2023). 2020. Report No.: ISBN: 978-0-660-36395-0.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTRC. Truth and Reconciliation Commission of Canada: Calls for Action. Manitoba: Winnipeg; 2015.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAllan B, Smylie J. First Peoples, second class treatment: The role of racism in the health and well-being of Indigenous Peoples in Canada. Toronto: Wellesley Institute; 2015.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHudson I, Cohen B. Manitoba inequality update: Low income families left behind. 2018. Report 978-1-77125-394-9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCanada PMoCJT. Supporting and improving Indigenous-led health care for First Nations in British Columbia 2023 [ \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.pm.gc.ca/en/news/news-releases/2023/04/14/supporting-and-improving-indigenous-led-health-care-first-nations\u003c/span\u003e\u003cspan address=\"https://www.pm.gc.ca/en/news/news-releases/2023/04/14/supporting-and-improving-indigenous-led-health-care-first-nations\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHayward A, Sjoblom E, Sinclair S, Cidro J. A New Era of Indigenous Research: Community-based Indigenous Research Ethics Protocols in Canada. J Empir Res Hum Res Ethics. 2021;16(4):403\u0026thinsp;\u0026ndash;\u0026thinsp;17. https://doi.org/.10.1177/15562646211023705.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePinnock H, Barwick M, Carpenter CR, Eldridge S, Grandes G, Griffiths CJ et al. Standards for Reporting Implementation Studies (StaRI): explanation and elaboration document. BMJ Open. 2017;7(4):e013318. https://doi.org/.10.1136/bmjopen-2016-013318.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGreen CA, Duan N, Gibbons RD, Hoagwood KE, Palinkas LA, Wisdom JP. Approaches to mixed methods dissemination and implementation research: Methods, strengths, caveats, and opportunities. Adm Policy Ment Health. 2015;42(5):508\u0026thinsp;\u0026ndash;\u0026thinsp;23. https://doi.org/.10.1007/s10488-014-0552-6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNelson G, Ochocka J, Griffin K, Lord J. Nothing about me, without me: participatory action research with self-help/mutual aid organizations for psychiatric consumer/survivors. Am J Community Psychol. 1998;26(6):881\u0026ndash;912. https://doi.org/.10.1023/a:1022298129812.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNguyen T, Graham ID, Mrklas KJ, Bowen S, Cargo M, Estabrooks CA et al. How does integrated knowledge translation (IKT) compare to other collaborative research approaches to generating and translating knowledge? Learning from experts in the field. Health Res Policy Syst. 2020;18(1):35. https://doi.org/.10.1186/s12961-020-0539-6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbayneh S, Lempp H, Hanlon C. Participatory action research to pilot a model of mental health service user involvement in an Ethiopian rural primary healthcare setting: study protocol. Res Involv Engagem. 2020;6(1):2. https://doi.org/.10.1186/s40900-019-0175-x.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStinson J, Lusis E, Murphy T, Ryan B et al. What are Indigenous and Western ways of knowing? drawn from Levac L, McMurtry L, Stienstra D, Learning across Indigenous and Western Knowledge Systems and Intersectionality: Reconciling Social Science Research Approaches. In: Guelph Uo, editor. 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLevac L, McMurtry L, Stienstra D, Baikie G, Hanson C, Mucina D. Learning across Indigenous and Western Knowledge Systems and Intersectionality. Reconciling Social Science Research Approaches. University of Guelph; 2018. p. 40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoher SIG, Yu Z, Martin DH, Benoit AC. How is Etuaptmumk/Two-Eyed Seeing characterized in Indigenous health research? A scoping review. PLoS One. 2021;16(7):e0254612. https://doi.org/.10.1371/journal.pone.0254612.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmith T. What is value-based care? These are the key elements: JAMA Network, AMA; 2020 [ \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ama-assn.org/\u003c/span\u003e\u003cspan address=\"https://www.ama-assn.org/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLewis CC, Scott K, Marriott BR. A methodology for generating a tailored implementation blueprint: an exemplar from a youth residential setting. Implementation Sci. 2018;13(1):68. https://doi.org/.10.1186/s13012-018-0761-6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSkivington K, Matthews L, Simpson SA, Craig P, Baird J, Blazeby JM et al. A new framework for developing and evaluating complex interventions: update of Medical Research Council guidance. BMJ. 2021;374:n2061. https://doi.org/.10.1136/bmj.n2061.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMbah MF, Bailey M, Shingruf A. Considerations for relational research methods for use in Indigenous contexts: implications for sustainable development. Int J Soc Res Methodol. 2023;10.1080/13645579.2023.2185345:1\u0026ndash;16. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/.10.1080/13645579.2023.2185345\u003c/span\u003e\u003cspan address=\".10.1080/13645579.2023.2185345\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCanada Go. Understand how health care works in Canada. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.canada.ca/en/immigration-refugees-citizenship/services/new-immigrants/new-life-canada/health-care-card.html\u003c/span\u003e\u003cspan address=\"https://www.canada.ca/en/immigration-refugees-citizenship/services/new-immigrants/new-life-canada/health-care-card.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (Accessed July 26 2021). 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrady O, Haldeman S, Nordin M, Outerbridge G, Hondras M, Kopansky-Giles D, et al. Global Forum: Spine research in underserved, low income and culturally unique communities. The WSC Charity Research Program \u0026ndash; Challenges and Facilitators. J Bone Joint Surg Am. 2016;98:e110.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParikh P, Santaguida P, Macdermid J, Gross A, Eshtiaghi A. Comparison of CPG\u0026rsquo;s for the diagnosis, prognosis and management of non-specific neck pain: a systematic review. BMC Musculoskelt Disord. 2019;20(1):81. https://doi.org/.10.1186/s12891-019-2441-3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCorp N, Mansell G, Stynes S, Wynne-Jones G, Mors\u0026oslash; L, Hill JC et al. Evidence-based treatment recommendations for neck and low back pain across Europe: A systematic review of guidelines. Eur J Pain. 2021;25(2):275\u0026thinsp;\u0026ndash;\u0026thinsp;95. https://doi.org/.10.1002/ejp.1679.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLin I, Wiles L, Waller R, Goucke R, Nagree Y, Gibberd M et al. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med [Internet]. 2019;10.1136/bjsports-2018-099878.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health O. WHO guideline for non-surgical management of chronic primary low back pain in adults in primary and community care settings. Geneva: World Health Organization 2023 [ \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003efile:///C:/Users/bussiera/Downloads/9789240081789-eng%20(1).pdf\u003c/span\u003e\u003cspan address=\"http://file:///C:/Users/bussiera/Downloads/9789240081789-eng%20(1).pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmith JD, Li DH, Rafferty MR. The implementation research logic model: a method for planning, executing, reporting, and synthesizing implementation projects. Implementation Sci. 2020;15(1):84. https://doi.org/.10.1186/s13012-020-01041-8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRowe AK, Rowe SY, Peters DH, Holloway KA, Ross-Degnan D. The effectiveness of training strategies to improve healthcare provider practices in low-income and middle-income countries. BMJ Glob Health. 2021;6(1). https://doi.org/.10.1136/bmjgh-2020-003229.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePantoja T, Opiyo N, Lewin S, Paulsen E, Ciapponi A, Wiysonge CS et al. Implementation strategies for health systems in low-income countries: an overview of systematic reviews. Cochrane Database Syst Rev. 2017;9(9):CD011086-CD. https://doi.org/.10.1002/14651858.CD011086.pub2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMesner SA, Foster NE, French SD. Implementation interventions to improve the management of non-specific low back pain: a systematic review. BMC Musculoskelet Disord. 2016;17:258. https://doi.org/.10.1186/s12891-016-1110-z.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEPOC. Cochrane-Effective Practice and Organisation of Care (EPOC) taxonomy of health systems interventions. EPOC Resources for review authors. Oslo: Norwegian Knowledge Centre for the Health Services; 2016. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://zenodo.org/records/5105851\u003c/span\u003e\u003cspan address=\"https://zenodo.org/records/5105851\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWhitehorn A, Fu L, Porritt K, Lizarondo L, Stephenson M, Marin T et al. Mapping clinical barriers and evidence-based implementation strategies in low-to-middle income countries (LMICs). Worldviews Evid Based Nurs. 2021;18(3):190\u0026ndash;200. https://doi.org/.10.1111/wvn.12503.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShayo MJ, Shayo P, Haukila KF, Norman K, Burke C, Ngowi K et al. Expanding access to rehabilitation using mobile health to address musculoskeletal pain and disability. Front Rehabil Sci. 2022;3:982175. https://doi.org/.10.3389/fresc.2022.982175.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilliams AB, Wang H, Burgess J, Li X, Danvers K. Cultural adaptation of an evidence-based nursing intervention to improve medication adherence among people living with HIV/AIDS (PLWHA) in China. Int J Nurs Stud. 2013;50(4):487\u0026thinsp;\u0026ndash;\u0026thinsp;94. https://doi.org/.10.1016/j.ijnurstu.2012.08.018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCard JJ, Solomon J, Cunningham SD. How to adapt effective programs for use in new contexts. Health Promot Pract. 2011;12(1):25\u0026ndash;35. https://doi.org/.10.1177/1524839909348592.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChevalier JM, Buckles DJ. Participatory action research: Theory and methods for engaged inquiry (2nd ed.). Routledge. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4324/9781351033268\u003c/span\u003e\u003cspan address=\"10.4324/9781351033268\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoateng GO, Neilands TB, Frongillo EA, Melgar-Qui\u0026ntilde;onez HR, Young SL. Best Practices for Developing and Validating Scales for Health, Social, and Behavioral Research: A Primer. Front Public Health. 2018;6(149). https://doi.org/.10.3389/fpubh.2018.00149.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTsang S, Royse CF, Terkawi AS. Guidelines for developing, translating, and validating a questionnaire in perioperative and pain medicine. Saudi J Anaesth. 2017;11(Suppl 1):S80-S9. https://doi.org/.10.4103/sja.SJA_203_17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeaton D, Bombardier C, Guillemin F, Ferraz M. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine (Phila Pa 1976). 2000;25:3186\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMurphy L, Kordyl P, Thorne M. Appreciative inquiry: a method for measuring the impact of a project on the well-being of an Indigenous community. Health Promot J Austr. 2004;15(3):211\u0026ndash;4. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/.https://doi.org/10.1071/HE04211\u003c/span\u003e\u003cspan address=\".10.1071/HE04211\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStatistic Canada. Canadian Community Health Survey (CCHS). Annual Component \u0026ndash; 2020 Questionnaires. Statistic Canada. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www23.statcan.gc.ca/imdb/p3Instr.pl?Function=assembleInstr\u0026amp;a=1\u0026amp;⟨=en\u0026amp;Item_Id=1262397#qb1262741\u003c/span\u003e\u003cspan address=\"https://www23.statcan.gc.ca/imdb/p3Instr.pl?Function=assembleInstr\u0026amp;a=1\u0026amp;⟨=en\u0026amp;Item_Id=1262397#qb1262741\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (Accessed July 05 2024). 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInstitute for Health Metrics and Evaluation (IME). Global Burden of Disease (GBD) [Internet]. Seattle, Washington. 2021 May. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.healthdata.org/research-analysis/gbd\u003c/span\u003e\u003cspan address=\"https://www.healthdata.org/research-analysis/gbd\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e 2021 [.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBradshaw C, Atkinson S, Doody O. Employing a qualitative description approach in health care research. Glob Qual Nurs Res. 2017;4:2333393617742282. https://doi.org/.10.1177/2333393617742282.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCane J, O'Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci. 2012;7(1):37. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.implementationscience.com/content/7/1/37\u003c/span\u003e\u003cspan address=\"http://www.implementationscience.com/content/7/1/37\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNorton TC, Rodriguez DC, Willems S. Applying the Theoretical Domains Framework to understand knowledge broker decisions in selecting evidence for knowledge translation in low- and middle-income countries. Health Res Policy Syst. 2019;17(1):60. https://doi.org/.10.1186/s12961-019-0463-9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMichie S, Johnston M, Francis J, Hardeman W, Eccles M. From theory to intervention: mapping theoretically derived behavioural determinants to behaviour change techniques. Appl Psychol. 2008;57. https://doi.org/.10.1111/j.1464-0597.2008.00341.x.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchoenwald SK, Garland AF, Chapman JE, Frazier SL, Sheidow AJ, Southam-Gerow MA. Toward the Effective and Efficient Measurement of Implementation Fidelity. Adm Policy Ment Health and Ment Health Serv Res. 2011;38(1):32\u0026ndash;43. https://doi.org/.10.1007/s10488-010-0321-0.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVelentgas P, Dreyer N, Nourjah P, Smith S, Torchia M. Developing a Protocol for Observational Comparative Effectiveness Research: A User's Guide. Rockville (MD): Agency for Healthcare Research and Quality (US); 2013 Jan. Publication No.: 12(13)-EHC099. 2013.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWillmeroth T, Wesselborg B, Kuske S. Implementation Outcomes and Indicators as a New Challenge in Health Services Research: A Systematic Scoping Review. Inquiry. 2019;56:46958019861257. https://doi.org/.10.1177/0046958019861257.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhadjesari Z, Boufkhed S, Vitoratou S, Schatte L, Ziemann A, Daskalopoulou C et al. Implementation outcome instruments for use in physical healthcare settings: a systematic review. Implement Sci. 2020;15(1):66. https://doi.org/.10.1186/s13012-020-01027-6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eClinton-McHarg T, Yoong SL, Tzelepis F, Regan T, Fielding A, Skelton E et al. Psychometric properties of implementation measures for public health and community settings and mapping of constructs against the Consolidated Framework for Implementation Research: a systematic review. Implementation Sci. 2016;11(1):148. https://doi.org/.10.1186/s13012-016-0512-5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLewis CC, Fischer S, Weiner BJ, Stanick C, Kim M, Martinez RG. Outcomes for implementation science: an enhanced systematic review of instruments using evidence-based rating criteria. Implementation Sci. 2015;10(1):155. https://doi.org/.10.1186/s13012-015-0342-x.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGlasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion interventions: the RE-AIM framework. Am J Public Health. 1999;89.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGlasgow RE, Harden SM, Gaglio B, Rabin B, Smith ML, Porter GC et al. RE-AIM Planning and Evaluation Framework: Adapting to New Science and Practice With a 20-Year Review. Front Public Health. 2019;7(64). https://doi.org/.10.3389/fpubh.2019.00064.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKwan BM, McGinnes HL, Ory MG, Estabrooks PA, Waxmonsky JA, Glasgow RE. RE-AIM in the Real World: Use of the RE-AIM Framework for Program Planning and Evaluation in Clinical and Community Settings. Front Public Health. 2019;7(345). https://doi.org/.10.3389/fpubh.2019.00345.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eProctor E, Silmere H, Raghavan R, Hovmand P, Aarons G, Bunger A et al. Outcomes for implementation research: Conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health and Ment Health Serv Res. 2011;38(2):65\u0026ndash;76. https://doi.org/.10.1007/s10488-010-0319-7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLewis C, Proctor E, Brownson R. Measurement Issues in Dissemination and Implementation Research. In: Ross C. Brownson GAC, and Enola K. Proctor, editor. Dissemination and Implementation Research in Health: Translating Science to Practice. Oxford Scholarship Online. 2017;10.1093/oso/9780190683214.001.0001. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/.10.1093/oso/9780190683214.001.0001\u003c/span\u003e\u003cspan address=\".10.1093/oso/9780190683214.001.0001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCooperrider D. What is Appreciative Inquiry? 2019 [ \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.davidcooperrider.com/ai-process/\u003c/span\u003e\u003cspan address=\"https://www.davidcooperrider.com/ai-process/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIndigenous Healthcare Quality Partnership. Indigenous healthcare quality framework. 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGedde M, de Vries E. Accessed July 26, al. TCHe. The International Health Links Manual A guide to starting up and maintaining long term international health partnerships. Tropical Health and Education Trust (THET). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.thet.org/wp-content/uploads/2017/08/Links-Manual-In-Full-Low-Res-72dpi.pdf\u003c/span\u003e\u003cspan address=\"https://www.thet.org/wp-content/uploads/2017/08/Links-Manual-In-Full-Low-Res-72dpi.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2021). 2009.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGedde M. Accessed February 14, THET. Partnership for Global Health. The Tropical Health and Education Trust (THET): \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.thet.org/principles-of-partnership/\u003c/span\u003e\u003cspan address=\"https://www.thet.org/principles-of-partnership/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2024). 2009.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGlasgow R, Mckay H, Piette J, Reynolds K. The RE-AIM framework for evaluating interventions: what can it tell us about approaches to chronic illness management? Patient Educ Couns. 2001;44:119\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeiner BJ, Lewis CC, Stanick C, Powell BJ, Dorsey CN, Clary AS et al. Psychometric assessment of three newly developed implementation outcome measures. Implementation Sci. 2017;12(1):108. https://doi.org/.10.1186/s13012-017-0635-3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcLaughlin M, Duff J, Sutherland R, Campbell E, Wolfenden L, Wiggers J. Protocol for a mixed methods process evaluation of a hybrid implementation-effectiveness trial of a scaled-up whole-school physical activity program for adolescents: Physical Activity 4 Everyone (PA4E1). Trials. 2020;21(1):268. https://doi.org/.10.1186/s13063-020-4187-5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTarfa A, Sayles H, Bares SH, Havens JP, Fadul N. Acceptability, Feasibility, and Appropriateness of Implementation of Long-acting Injectable Antiretrovirals: A National Survey of Ryan White Clinics in the United States. Open Forum Infect Dis. 2023;10(7):ofad341. https://doi.org/.10.1093/ofid/ofad341.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCidav Z, Mandell D, Pyne J, Beidas R, Curran G, Marcus S. A pragmatic method for costing implementation strategies using time-driven activity-based costing. Implementation Sci. 2020;15(1):28. https://doi.org/.10.1186/s13012-020-00993-1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJulien N, Lacasse A, Labra O, Asselin H. Review of chronic non-cancer pain research among Aboriginal people in Canada. Int J Qual Health Care. 2018;30(3):178\u0026thinsp;\u0026ndash;\u0026thinsp;85. https://doi.org/.10.1093/intqhc/mzx195.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBailey NGN, Knott R, Grenier G, Craig KD, Kramer JLK. Physical pain among Indigenous Peoples in Canada: a scoping review. Can J Anaesth. 2023;70(6):1047-63. https://doi.org/.10.1007/s12630-023-02461-y.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWiltsey Stirman S, Baumann AA, Miller CJ. The FRAME: an expanded framework for reporting adaptations and modifications to evidence-based interventions. Implementation Sci. 2019;14(1):58. https://doi.org/.10.1186/s13012-019-0898-y.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVerhoef M, Mulkins A, Boon H. Integrative health care: How can we determine whether patients benefit? J Altern Comp Med. 2005;11(Suppl 1):57\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAtkins L, Francis J, Islam R, O\u0026rsquo;Connor D, Patey A, Ivers N et al. A guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems. Implementation Sci. 2017;12(1):77. https://doi.org/.10.1186/s13012-017-0605-9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBussi\u0026egrave;res A, Al Zoubi F, Quon J, Ahmed S, Thomas A, Stuber K, et al. Fast tracking the design of theory-based KT interventions through a consensus process. Implement Sci. 2015;10(1):18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEmerson AJ, Hegedus T, Mani R, Baxter GD. Chronic musculoskeletal pain experiences in marginalized populations: a mixed methods study protocol to understand the influence of geopolitical, historical, and societal factors. Phys Ther Rev. 2020;25(4):292\u0026ndash;301. https://doi.org/.10.1080/10833196.2020.1807803.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePag\u0026eacute; G, Mittinty MM, Gyakye deGraft-Johnson K. Disparities in back pain 2021 [updated July 2021; cited 2024 February 15]. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.iasp-pain.org/resources/fact-sheets/disparities-in-back-pain/\u003c/span\u003e\u003cspan address=\"https://www.iasp-pain.org/resources/fact-sheets/disparities-in-back-pain/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReyes SG, Bajaj PM, Alvandi BA, Kurapaty SS, Patel AA, Divi SN. Impact of Social Determinants of Health in Spine Surgery. Curr Rev Musculoskelet Med. 2023;16(1):24\u0026ndash;32. https://doi.org/.10.1007/s12178-022-09811-1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTraeger AC, Buchbinder R, Elshaug AG, Croft PR, Maher CG. Care for low back pain: can health systems deliver? Bull World Health Organ. 2019;97(6):423\u0026thinsp;\u0026ndash;\u0026thinsp;33. https://doi.org/.10.2471/blt.18.226050.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTricco AC, Ashoor HM, Cardoso R, MacDonald H, Cogo E, Kastner M et al. Sustainability of knowledge translation interventions in healthcare decision-making: a scoping review. Implementation Sci. 2016;11(1):55. https://doi.org/.10.1186/s13012-016-0421-7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChambers DA, Glasgow RE, Stange KC. The dynamic sustainability framework: addressing the paradox of sustainment amid ongoing change. Implementation Sci. 2013;8(1):117. https://doi.org/.10.1186/1748-5908-8-117.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLaur C, Corrado AM, Grimshaw JM, Ivers N. Trialists perspectives on sustaining, spreading, and scaling-up of quality improvement interventions. Implement Sci Commun. 2021;2(1):35. https://doi.org/.10.1186/s43058-021-00137-6.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1\u0026nbsp;\u003c/strong\u003eGlossary of Terms\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"576\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18.3709%;\"\u003e\n \u003cp\u003eAcupuncture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81.6291%;\"\u003e\n \u003cp\u003eProvider delivered acupuncture, dry needling, or electro-acupuncture/needling.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18.3709%;\"\u003e\n \u003cp\u003eBracing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81.6291%;\"\u003e\n \u003cp\u003eProvider directed bracing for treatment of acute, stable vertebral fractures (post-trauma and osteoporotic)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18.3709%;\"\u003e\n \u003cp\u003eDiffusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81.6291%;\"\u003e\n \u003cp\u003eA passive process by which new evidence is communicated to researchers, educators and educational policy makers using traditional vehicles\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18.3709%;\"\u003e\n \u003cp\u003eDissemination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81.6291%;\"\u003e\n \u003cp\u003eProcess by which targeted and tailored information (main messages or key implications) is transmitted to specific relevant audiences to increase the application and uptake of evidence as well as to bridge research-to-practice gaps.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18.3709%;\"\u003e\n \u003cp\u003eEducation about spine conditions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81.6291%;\"\u003e\n \u003cp\u003eHealth care provider shares information in a report of findings regarding the spine-related concern or condition, including diagnosis, prognosis, therapies, alternatives, and consent. Depending upon the presentation, the provider may reassure individual about the benign and self-limiting nature of the typical course of spinal pain that has no serious pathology, advise patients to remain active and provide information about effective self-care options that address the spinal condition or concern.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18.3709%;\"\u003e\n \u003cp\u003eEpisode of Care (EOC)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81.6291%;\"\u003e\n \u003cp\u003eProcess through which patients with a particular condition are diagnosed, treated, followed, and managed over time. EOC includes any and all interventions used by the primary, secondary and tertiary practitioners to achieve maximum therapeutic recovery of the spinal disorder that brought the patient to the primary spine clinic or the prevention of a given disorder. EOC may involve multiple care providers for those presenting with multiple conditions or comorbidities. \u0026nbsp;The end goal of care is prevention or resolution of the condition based on outcome measure assessments or the achievement of a \u0026ldquo;steady state\u0026rdquo; for chronic conditions which are likely to recur.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18.3709%;\"\u003e\n \u003cp\u003eHeat/cold therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81.6291%;\"\u003e\n \u003cp\u003eRecommendation of home use of physical agents. For example, heating pads, heat wraps, hot baths, warm gel packs, ice packs.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18.3709%;\"\u003e\n \u003cp\u003eImplementation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81.6291%;\"\u003e\n \u003cp\u003eUses robust scientific methods underpinned by theories, models and frameworks to identify research-practice gaps, identify supports and barriers to the uptake of evidence-based innovations, design implementation support strategies to reduce research-practice gaps, evaluate the impact of these strategies on patient care and health outcomes as well as strategies to sustain implementation.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18.3709%;\"\u003e\n \u003cp\u003eKnowledge Translation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81.6291%;\"\u003e\n \u003cp\u003ePlanned activities aims at promoting the uptake and application of research evidence to improve patient care and health outcomes.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18.3709%;\"\u003e\n \u003cp\u003eManual therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81.6291%;\"\u003e\n \u003cp\u003eProvider delivered manipulation, mobilization, massage, and/or soft-tissue therapies.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18.3709%;\"\u003e\n \u003cp\u003eMacro\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81.6291%;\"\u003e\n \u003cp\u003eIndividuals setting policies and priorities at the regional / national level who will enable those resources to be available\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18.3709%;\"\u003e\n \u003cp\u003eMeso\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81.6291%;\"\u003e\n \u003cp\u003eIndividuals involved in organizing service delivery, running clinics, community leaders and Band counselors\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18.3709%;\"\u003e\n \u003cp\u003eMicro\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81.6291%;\"\u003e\n \u003cp\u003eIndividuals delivering the model of care when implemented and those with spinal problems receiving the model of care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18.3709%;\"\u003e\n \u003cp\u003eMind-body therapies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81.6291%;\"\u003e\n \u003cp\u003eRecommendation for self-directed use of one or more of the following: meditation, yoga, biofeedback, tai chi,qigong, relaxation techniques, hypnosis, guided imagery, stress management, or breathing techniques.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18.3709%;\"\u003e\n \u003cp\u003eSelf-care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81.6291%;\"\u003e\n \u003cp\u003eInformation about how one can take care of spinal conditions or concerns. Information distributed from published material, the internet, public health sources, or other communications\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18.3709%;\"\u003e\n \u003cp\u003eSpine symptoms or concerns\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81.6291%;\"\u003e\n \u003cp\u003eIncludes back and/or neck pain; spine-related deformity, injury, neurological conditions, pathology and diseases.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;Episode of Care: The Episode of Care (EOC) according to Hussey et al. (2017) is the process through which patients with a particular condition are diagnosed, treated, followed, and managed over time for each patient. \u0026nbsp;The episode frameworks Hussey et al. have constructed also include the precursor to the episode: the population at risk for developing a given condition or needing a given surgical procedure. \u0026nbsp;The GSCI model includes preventative care of spinal disorders.\u003c/p\u003e\n \u003cp\u003eHere we will define an episode of care to include any and all interventions used by the primary, secondary and tertiary practitioners to achieve maximum therapeutic recovery of the spinal disorder that brought the patient to the primary spine clinic or the prevention of a given disorder. \u0026nbsp;The EOC may involve multiple care providers for those presenting with multiple conditions or comorbidities. \u0026nbsp;The end goal of care is prevention or resolution of the condition based on OM assessments or the achievement of a \u0026ldquo;steady state\u0026rdquo; for chronic conditions which are likely to recur.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18.3709%;\"\u003e\n \u003cp\u003eSustainability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81.6291%;\"\u003e\n \u003cp\u003eTo what extent an evidence-based intervention can deliver its intended benefits over an extended period of time after external support from the donor agency is terminated\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18.3709%;\"\u003e\n \u003cp\u003eTherapeutic exercise\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81.6291%;\"\u003e\n \u003cp\u003eSupervised or prescribed and self-directed exercise regimens aimed at spinal pain or a spinal condition.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u0026nbsp;\u003c/strong\u003eProvisionally selected implementation support strategies and sub-strategies\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eImplementation support strategies (n=8) and sub-strategies (n=29)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1. Health partnerships (year 1-3)\u0026nbsp;\u003c/strong\u003e[121]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.1:\u003c/strong\u003e Partnership agreement signed by health districts or local government executive and local community leader.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.2:\u003c/strong\u003e New or existing Local Implementation Team oversees program.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.3:\u003c/strong\u003e The local Implementation Team is inclusive of a local clinician champion and community leaders to oversee the program and uses a self-assessment and action plan tool.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.4:\u003c/strong\u003e Local implementation team meets weekly; macro level committees meet twice per year.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2. Health workforce capacity development: Local clinicians (year 2)\u0026nbsp;\u003c/strong\u003e[53, 70, 71, 74, 122-125]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2.1:\u003c/strong\u003e Group problem solving (with or without formal teams) or collaborative improvement every 2-3 months.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e2.2:\u0026nbsp;\u003c/strong\u003ePre-service educational training:\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eLocal clinicians register and complete the 2 online educational training sessions at the beginning of year 2.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e2.3:\u003c/strong\u003e On the job training: interactive workshop to ease knowledge integration, practice facilitation and educational outreach visits by a trained GSCI clinician overseeing patient encounters over 2-3 weeks using the Implementation Toolkit (Appendix 3, Table 1 and 3).\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e2.4:\u003c/strong\u003e Local clinician Champion training \u0026ndash;1-day of face-to-face training session by trained a GSCI clinician, hosted by Local Implementation Team.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e2.5:\u003c/strong\u003e Peer coaching (improving routine supervision, benchmarking, or audit with feedback) by local champion for 12 months.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e2.6:\u003c/strong\u003e Weekly contact made with GSCI trained clinician via email and/or Zoom.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3. Health workforce capacity development: Community health workers (CHW) (year 2) \u0026ndash; \u003cem\u003eConcurrent with item 2\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.1:\u003c/strong\u003e CHWs\u0026rsquo; training \u0026ndash;1-day of face-to-face training session hosted by trained GSCI clinician, hosted by Local Implementation Team, and facilitated by the local clinician Champions. Accommodation, meals and transport costs covered by the grant.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e3.2:\u003c/strong\u003e CHWs are trained to 1) recognize serious causes of spine problems via online or paper-based tools; and 2) deliver educational messages (reassurance, advice on self-care such as staying active, and basic exercise) for people with non-complicated spine symptoms/concerns (MoC class classes 1 through 3a, c and 4a) or to refer people with spine problems for further evaluation and treatments to local clinicians (MoC classes 3b, 4b and 5a, b and c). (Appendix 3, Table 2).\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e3.3:\u003c/strong\u003e Equipping and motivating CHWs to conduct outreach and referrals process from community to health centers.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e3.4:\u003c/strong\u003e Weekly contact made with in-community local clinician Champion via phone, email and/or face-to-face site visits for 12 months.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4. Educational tools to promote self-management (year 2-3)\u0026nbsp;\u003c/strong\u003e[124, 126-132]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4.1:\u003c/strong\u003e Self-administered online and paper format patient screening questionnaire to help make informed decision regarding the need to consult a licensed healthcare provider or to self-manage their spine pain (Appendix 3, Table 2).\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e4.2:\u003c/strong\u003e Online and paper format educational and exercise booklet; develop/adapt 1-page information resources (https://www.ccgi-research.com/patient-resources)\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e4.3:\u0026nbsp;\u003c/strong\u003eFollow-up contact made by with in-Community Champion via phone, email and/or face-to-face site visits for 12 months.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e5. Community Movement Program (year 1-3)\u0026nbsp;\u003c/strong\u003e[71, 133, 134]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e5.1:\u003c/strong\u003e In-Community Champion training \u0026ndash;1-day of face-to-face training session hosted by Local Implementation Team in Term 1: train the trainer on adult yoga-like mind-body classes, whereby Yoga instructors are trained on spine health, who, in turn, will deliver consistent messaging on spine health issues. Accommodation, meals and transport costs covered by the grant.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e5.2:\u003c/strong\u003e Community support (community health education or social marketing of health services):\u0026nbsp;spine health educational messages delivered monthly by CHWs through partnership with local community leaders at social gatherings (e.g., the village market or the church), clinic\u0026rsquo;s/healthcare centers, on social media platforms (Facebook via cell phones), using the local radio, and/or targeted at schoolchildren via their teachers.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e5.3:\u003c/strong\u003e Co-design and animate locally accepted community activity/exercise program.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e5.4:\u003c/strong\u003e Follow-up contact made by local clinician Champion with in-community Champion via phone, email and/or face-to-face site visits for 12 months.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e6. Resources (year 1-3)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e6.1:\u003c/strong\u003e Printed posters outlining MoC Principles, triage system and care pathway to be displayed in the Nursing Station (Implementation Toolkit: Appendix 3, Table 1-2).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e6.2:\u003c/strong\u003e Equipment provided to support the delivery of MoC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e6.3:\u003c/strong\u003e Electronic resources housed on the program website (online) included:\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eoverview of program presentation (Microsoft PowerPoint presentation)\u003c/li\u003e\n \u003cli\u003eproject milestones to be achieved each term (over 3 years)\u003c/li\u003e\n \u003cli\u003eonline quality training (GSCI videos), worksheet, peer observation materials\u003c/li\u003e\n \u003cli\u003epatient personal self-care plan templates\u003c/li\u003e\n \u003cli\u003erecess and lunch resources\u003c/li\u003e\n \u003cli\u003epolicy templates\u003c/li\u003e\n \u003cli\u003eexamples of community physical activity\u003c/li\u003e\n \u003cli\u003etips and frequently asked questions\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e7. Provision of prompts and reminders (year 2-3)\u0026nbsp;\u003c/strong\u003e[125]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e7.1:\u003c/strong\u003e Weekly emails or phone calls made by the Local Implementation Team to local clinician and in-Community Champions to encourage implementation.\u003c/p\u003e\n \u003cp\u003e7\u003cstrong\u003e.2:\u003c/strong\u003e Automated or paper-based messages sent each term via the program website or hand delivered to Champions, local clinicians and CHWs to prompt completion of educational training modules/videos/booklet chapters and online (or paper-based) termly performance monitoring and feedback surveys.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e8. Implementation performance monitoring and feedback (year 2-3)\u003c/strong\u003e [135]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e8.1\u003c/strong\u003e: Champions, local clinicians and CHWs complete all surveys via the program website or paper-based.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e8.2:\u003c/strong\u003e Feedback report sent to Champions, local clinicians and CHWs via email or hand-delivered.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eAbbreviations: CHW = Community Health Worker; GSCI = Global Spine Care Initiative; MoC = Model of Car\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u0026nbsp;\u003c/strong\u003eDescription of project phases, Timing, Data Collection\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eStepwise approach to 1) prepare implementation, assessing the current status of spine care in Cross Lake; identifying potential barriers and facilitators to the uptake of the MoC, and co-designing implementable solutions, and 2) evaluate the feasibility to implement a new spine care clinical service and community movement program supported by tailored strategies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 28.5256%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eProject phases\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.4231%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57.0513%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eActivities\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 28.5256%;\"\u003e\n \u003cp\u003eCustomization and pre-implementation (Phase 2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.4231%;\"\u003e\n \u003cp\u003e12 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57.0513%;\"\u003e\n \u003cp\u003eBuild local implementation team\u003c/p\u003e\n \u003cp\u003ePeriodic community engagement site visits \u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSecure REB approvals, Memorandum of Understanding, and data sharing agreement\u003c/p\u003e\n \u003cp\u003eCo-create, refine, culturally adapt, and prepare all study material, select patient health outcome measures\u003c/p\u003e\n \u003cp\u003eDesign database linkages\u003c/p\u003e\n \u003cp\u003eTrain research assistants\u003c/p\u003e\n \u003cp\u003eRecruit study participants for the chart review, Community Health Survey, and qualitative interviews; analyze \u0026amp; interpret data\u003c/p\u003e\n \u003cp\u003ePrepare community movement program; select primary spine care clinicians\u003c/p\u003e\n \u003cp\u003eOnline and in-person educational training of local clinicians and community health workers on GSCI triaging and spine care pathways\u003c/p\u003e\n \u003cp\u003eFidelity \u0026amp; monitoring log (FRAME adaptation framework)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 28.5256%;\"\u003e\n \u003cp\u003eFeasibility (Phase 3)\u003c/p\u003e\n \u003cp\u003e- Implementation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.4231%;\"\u003e\n \u003cp\u003e10 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57.0513%;\"\u003e\n \u003cp\u003eFurther customize MoC tools and implementation support strategies Implement protocols\u003c/p\u003e\n \u003cp\u003eLaunch community education and movement program\u003c/p\u003e\n \u003cp\u003eLaunch new clinical service for people with spine symptoms or concerns\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eCollect implementation, service and patient outcomes\u003c/p\u003e\n \u003cp\u003eImplementation adoption survey (AAF tool)\u003c/p\u003e\n \u003cp\u003eMoC Fidelity checklist, feedback, local team meetings\u003c/p\u003e\n \u003cp\u003eFidelity \u0026amp; monitoring log (FRAME adaptation framework)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 28.5256%;\"\u003e\n \u003cp\u003e- Post-implementation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.4231%;\"\u003e\n \u003cp\u003e12 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57.0513%;\"\u003e\n \u003cp\u003ePost-implementation visit\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSecond chart review and qualitative interviews\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFidelity \u0026amp; monitoring log (FRAME adaptation framework)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 28.5256%;\"\u003e\n \u003cp\u003eData analysis and interpretation (pre- and post-implementation)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.4231%;\"\u003e\n \u003cp\u003e6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57.0513%;\"\u003e\n \u003cp\u003eConduct quantitative and qualitative analyses (pre- and post-implementation)\u003c/p\u003e\n \u003cp\u003eMeet with key stakeholders to help with data interpretation (both pre- and post-implementation data)\u003c/p\u003e\n \u003cp\u003eFidelity \u0026amp; monitoring log (FRAME adaptation framework)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 28.5256%;\"\u003e\n \u003cp\u003eDissemination plan\u003c/p\u003e\n \u003cp\u003eProspect for sustainability and GSCI Initiative \u003cstrong\u003ePhase 4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.4231%;\"\u003e\n \u003cp\u003e2 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57.0513%;\"\u003e\n \u003cp\u003eMeet with health authorities (district, provincial, Federal level) to discuss sustainability of services within the community, and scaling up in other communities.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAAF=Acceptability, Appropriateness, Feasibility; REB-Research Review Board\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4\u003c/strong\u003e Summary of data collection\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"664\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 26.7669%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy Aim\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.5338%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLevel\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.9323%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of data collected\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7895%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTools\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.2932%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcome\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6842%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHow it is done\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 26.7669%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAim A.\u0026nbsp;\u003c/strong\u003eConfirm the nature of and extent to which spinal disorders impact individuals within Cross Lake, northern Manitoba, Canada\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.5338%;\"\u003e\n \u003cp\u003eMicro level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.9323%;\"\u003e\n \u003cp\u003eQuantitative\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eQuantitative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7895%;\"\u003e\n \u003cp\u003eCommunity health survey\u003c/p\u003e\n \u003cp\u003eRetrospective chart review\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.2932%;\"\u003e\n \u003cp\u003ePerceived impact\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6842%;\"\u003e\n \u003cp\u003eTrained research assistants\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 26.7669%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAim B.\u0026nbsp;\u003c/strong\u003eMeasure the value of, and intention of stakeholders to adopt the GSCI MoC, and identify barriers and facilitators impacting the implementation of this model among stakeholders\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.5338%;\"\u003e\n \u003cp\u003eMeso- and micro level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.9323%;\"\u003e\n \u003cp\u003eQualitative\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7895%;\"\u003e\n \u003cp\u003eSemi-structured interviews or\u003c/p\u003e\n \u003cp\u003eFocus groups\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.2932%;\"\u003e\n \u003cp\u003ePerceived TDF barriers and enablers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6842%;\"\u003e\n \u003cp\u003eProject PI, trained research assistants\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 26.7669%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAim C.\u0026nbsp;\u003c/strong\u003eEstimate and understand the extent to which (1) stakeholders support and engage throughout the study, and are empowered to drive the identification and refinement of implementation strategies for their own barriers, (2) local clinicians and caregivers accept, adopt, and apply the GSCI MoC as intended, and (3) people with spine symptoms accept recommended care.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.5338%;\"\u003e\n \u003cp\u003e(1) Meso- and (2, 3) micro level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.9323%;\"\u003e\n \u003cp\u003eQuantitative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7895%;\"\u003e\n \u003cp\u003eAdministrative data (support letters, MUC, meeting attendance, THET-Partnership-Health-Check-Tool)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eEducation training attendance\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eStakeholder adoption\u003c/p\u003e\n \u003cp\u003esurveys\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.2932%;\"\u003e\n \u003cp\u003eReach\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAdherence/Fidelity\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAdoption (Acceptability, Appropriateness, Feasibility (AAF) measures)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6842%;\"\u003e\n \u003cp\u003eLocal implementation team\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eOnline / in-person educational modules\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eResearch assistant\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 26.7669%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAims C and D.\u0026nbsp;\u003c/strong\u003eEstimate/understand the extent to which (1) what health outcomes are important to people with spine symptoms or concerns, 2) the MoC can potentially be integrated into community-based programs, and (3) the implementation efforts are perceived to have a higher burden leading to added cost)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.5338%;\"\u003e\n \u003cp\u003e(1, 3) Micro-level\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(2) Meso- and micro level\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.9323%;\"\u003e\n \u003cp\u003eQualitative\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eQuantitative\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7895%;\"\u003e\n \u003cp\u003eSemi-structured interviews\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAdoption\u003c/p\u003e\n \u003cp\u003esurveys\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.2932%;\"\u003e\n \u003cp\u003ePerceived TDF barriers and enablers\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAdoption (Acceptability, Appropriateness, Feasibility (AAF) measures)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eImplementation (Fidelity, Perceived cost)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6842%;\"\u003e\n \u003cp\u003eTrained research assistants\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eOnline, paper-based, and orally administered\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 26.7669%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAim E.\u0026nbsp;\u003c/strong\u003eEstimate key parameters such as effect sizes to inform the selection of a primary outcome and to calculate the sample size for a future \u003cstrong\u003ePhase 4\u003c/strong\u003e implementation study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.5338%;\"\u003e\n \u003cp\u003eAll levels\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.9323%;\"\u003e\n \u003cp\u003eQuantitative\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7895%;\"\u003e\n \u003cp\u003eSurveys\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eClinical outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.2932%;\"\u003e\n \u003cp\u003eFidelity and context monitoring log and a fidelity checklist.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePain, function, disability, quality of life\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6842%;\"\u003e\n \u003cp\u003eCo-PIs, statistician\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAAF=Acceptability, Appropriateness, Feasibility; TDF=Theoretical Domain Framework\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"chiropractic-and-manual-therapies","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"chmt","sideBox":"Learn more about [Chiropractic \u0026 Manual Therapies](http://chiromt.biomedcentral.com/)","snPcode":"12998","submissionUrl":"https://submission.springernature.com/new-submission/12998/3","title":"Chiropractic \u0026 Manual Therapies","twitterHandle":"@ChiroManTher","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Participatory mixed-methods, Spine care, Value-based healthcare, Implementation science, Medically underserved area, Vulnerable population, Protocol, Chiropractic, Indigenous","lastPublishedDoi":"10.21203/rs.3.rs-4959958/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4959958/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSince the 1990s, spine disorders have remained the leading cause of global disability, disproportionately affecting economically marginalized individuals, rural populations, women, and older people. Back pain related disability is projected to increase the most in remote regions where lifestyle and work are increasingly sedentary, yet resources and access to comprehensive healthcare is generally limited. To help tackle this worldwide health problem, World Spine Care Canada, and the Global Spine Care Initiative (GSCI) launched a four-phase project aiming to address the profound gap between evidence-based spine care and routine care delivered to people with spine symptoms or concerns in communities that are medically underserved. Phase 1 conclusions and recommendations led to the development of a model of care that included a triaging system and spine care pathways that could be implemented and scaled in underserved communities around the world.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe current research protocol describes a site-specific customization and pre-implementation study (Phase 2), as well as a feasibility study (Phase 3) to be conducted in Cross Lake, an Indigenous community in northern Manitoba, Canada. \u003cem\u003eDesign\u003c/em\u003e: Observational pre-post design using a participatory mixed-methods approach. Relationship building with the community established through regular site visits will enable pre- and post-implementation data collection about the model of spine care and provisionally selected implementation strategies using a community health survey, chart reviews, qualitative interviews, and adoption surveys with key partners at the meso (community leaders) and micro (clinicians, patients, community residents) levels. Recruitment started in March 2023 and will end in March 2026. Surveys will be analyzed descriptively and interviews thematically. Findings will inform co-tailoring of implementation support strategies with project partners prior to evaluating the feasibility of the new spine care program.\u003c/p\u003e\u003ch2\u003eDiscussion\u003c/h2\u003e \u003cp\u003eKnowledge generated from this study will provide essential guidance for scaling up, sustainability and impact (Phase 4) in other northern Canada regions and sites around the globe. It is hoped that implementing the GSCI model of care in Cross Lake will help to reduce the burden of spine problems and related healthcare costs for the local community, and serve as a scalable model for programs in other settings.\u003c/p\u003e","manuscriptTitle":"Assessing the readiness and feasibility to implement a model of care for spine disorders and related disability in Cross Lake, an Indigenous community in northern Manitoba, Canada: A research protocol","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-17 04:31:16","doi":"10.21203/rs.3.rs-4959958/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-08-26T19:47:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-26T06:33:27+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-26T06:29:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"Chiropractic \u0026 Manual Therapies","date":"2024-08-22T18:51:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"chiropractic-and-manual-therapies","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"chmt","sideBox":"Learn more about [Chiropractic \u0026 Manual Therapies](http://chiromt.biomedcentral.com/)","snPcode":"12998","submissionUrl":"https://submission.springernature.com/new-submission/12998/3","title":"Chiropractic \u0026 Manual Therapies","twitterHandle":"@ChiroManTher","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"67918599-4b37-4e74-af19-fa7077e4ad41","owner":[],"postedDate":"October 17th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-03-17T15:59:17+00:00","versionOfRecord":{"articleIdentity":"rs-4959958","link":"https://doi.org/10.1186/s12998-025-00576-1","journal":{"identity":"chiropractic-and-manual-therapies","isVorOnly":false,"title":"Chiropractic \u0026 Manual Therapies"},"publishedOn":"2025-03-13 15:56:57","publishedOnDateReadable":"March 13th, 2025"},"versionCreatedAt":"2024-10-17 04:31:16","video":"","vorDoi":"10.1186/s12998-025-00576-1","vorDoiUrl":"https://doi.org/10.1186/s12998-025-00576-1","workflowStages":[]},"version":"v1","identity":"rs-4959958","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4959958","identity":"rs-4959958","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}