“Primary care is primary care”: Use of Normalization Process Theory to explore the implementation of primary care services for transgender individuals in Ontario

Abstract

Background In Ontario, Canada, healthcare for transgender individuals is accessed through primary care; however, there are a limited number of practitioners providing transgender care, and patients are often on waiting lists and/or traveling great distances to receive care. Understanding how primary care is implemented and delivered to transgender individuals is key to improving access and eliminating healthcare barriers. The purpose of this study is to understand how the implementation of primary care services for transgender individuals compares across various models of primary care delivery in Ontario. Methods A qualitative, exploratory, multiple-case study guided by Normalization Process Theory (NPT) was used to compare transgender care delivery and implementation across three primary care models. Three cases known to provide transgender primary care and represent different primary care models in Ontario, Canada (i.e., family health team, community health centre, fee-for service physician) were explored. The NoMAD survey, a tool to measure implementation processes, and qualitative interviews with primary care practitioners and allied healthcare staff were administered. Results Using the NPT framework to guide analysis, key themes emerged about successful implementation of primary care services for transgender individuals. These themes include creating a safe space for patients, identifying gaps in services, understanding practitioners’ roles, and the need for more training and education in transgender care for practitioners. Conclusions Primary care services for transgender individuals can and should be delivered in all models of primary care. Training and awareness for healthcare practitioners are needed to develop capacity in providing primary care to transgender individuals. A greater number of practitioners and organizations are needed to take on this work, embedding and normalizing transgender care into routine practice to address barriers to access and improve quality of care for transgender individuals.

Primary Care for Transgender Individuals: A Review of the Literature Reflecting a Canadian Perspective

“…Canadian-specific primary-care guidelines, from Ontario and British Columbia, are readily available online for practitioners to support the delivery of care to this vulnerable population (Dahl et al, 2015;Rainbow Health Ontario, 2015). In a recent study from Ontario, primary-care providers delivering transgender care identified the Ontario guidelines from Rainbow Health Ontario as their key resources in practice (Ziegler et al, 2019). Another example of online continuing education is the Trans Health Connection, which was funded by the Ontario Ministry of Health and Long-term care.…”

Models of Care and Team Activities in the Delivery of Transgender Primary Care: An Ontario Case Study

“…33 For this study, the delivery of primary care services was explored, while an exploration of influences on implementation are reported elsewhere. 34 Using purposeful sampling, three cases were selected: a solo practice FFS, CHC, and FHT. A key informant from Rainbow Health Ontario (RHO) and the first author, identified eligible organizations known to provide primary care services to transgender individuals.…”

Provider and Manager Perspectives on the Use of an Integrated Clinical Pathway for Community-Dwelling Older Adults: A Qualitative Case Study

“…The Normalization Process Theory (NPT) [ 21 22 ] is a conceptual framework used in implementation science to examine how various complex healthcare interventions support clinical activities in different contexts [ 23 24 25 26 ]. We adopted the NPT in our analysis as it focuses on understanding “the processes through which a practice or practices become, (or do not become) routinely incorporated in everyday work of individuals and groups” ([ 22 ] p.2).…”