Implementing LGBTQ+ inclusive mental healthcare into practice — A rapid mixed-methods implementation context assessment of an Australian local health network

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With only a small number of LGBTQ + Australians accessing specialist LGBTQ + mental health services, addressing these barriers in mainstream services is crucial to health equity. Method : We used the Mi-PARIHS facilitation planning tool and rapid ethnography to conduct a convergent parallel mixed-methods context assessment of fourteen sites within an Australian Local Health Network’s mental health services, identifying barriers and facilitators to implementing a holistic LGBTQ + model of care. We present a novel analysis using techniques from complexity science exploring correlative interrelationships between barriers and facilitators across domains in the Mi-PARIHS data; subjecting these interrelationships to network-analytic techniques. Results : The small difference in mean Mi-PARIHS domain scores at different sites of the local health network ( H = 17.596, p = 0.0015, η 2 = 0.04), and the network analysis affirmed that implementing an LGBTQ + model of care requires a holistic approach. We developed an explanatory causal model (presented as a causal loop diagram) disentangling what is meant by “holistic”, explicitly proposing how these barriers and facilitators work to maintain the status quo both between and within i-PARIHS domains. Discussion : Our findings recommend: 1) Healthcare leaders need clearly articulate support of LGBTQ + people and their care , as this is crucial for health care workers understanding how LGBTQ + care aligns with their organisation’s values and priorities and — therefore — feeling confident enacting this care; 2) The importance of time , for implementing change and for fostering LGBTQ + clinical champions; and 3) The importance of clearly articulated evidence for, trustworthiness of, and advantages appropriate LGBTQ + care presents for health services in implementation facilitation. We discuss how the novel, complexity science-derived analysis presented in this paper allowed us to operationalise our conception of “holistic” to specific, actionable targets for facilitation. We strongly encourage the use of complexity science techniques in i-PARIHS-driven implementation research as a means of decomposing notional “context-driven” or “holistic” approaches into concrete, operationalised targets for facilitation. Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Contributions to the Literature Improving LGBTQ+ care is something that requires leaders at all levels of health systems to be on-board. Our research identifies the ways that some of the barriers commonly identified in the LGBTQ+ mental health literature not only present problems on their own, but help to uphold each-other . We demonstrate this through the application of a novel methodology looking at interrelationships between barriers. This methodology allowed us to breakdown our concept of needing to intervene “holistically” into clear areas for our facilitators to focus on, and provided insights into ways we (and others) can more rigorously measure success. Introduction Lesbian, gay, bisexual, trans, and queer (LGBTQ+) people experience significant mental health disparities compared to heterosexual and cisgender populations [1–3]. These disparities are understood as stemming from two proximal causes; first, through exposure to the cumulative, traumatic experience of living within a heteronormative, cisgenderist social environment [4–6]; second, through decreased access to healthcare that can delay or prevent treatment entirely [5]. Indeed, the Australian Bureau of Statistics [1] report that a large proportion of LGBTQ + people with a mental illness lasting longer than one year did not access any mental health service. The literature identifies a lack of empathy and affirmation and a lack of provider knowledge as major barriers to access for LGBTQ + people [2,3,7,8]. The Australian Government Department of Health’s National Action Plan for the Health and Wellbeing of LGBTIQA + Australians (hereafter The National Action Plan) identifies a number of key areas of systemic change required to address these health inequalities [7]. Mainstream health services play a vital role in addressing these inequalities; however, evidence suggests they are not meeting their responsibilities to LGBTQ + patients. LGBTQ + people in Australia’s healthcare experiences are often marked by discrimination, exclusion, and lack of clinical knowledge of how to best work with their presenting concerns [3,5,9]. These experiences are not created solely through individual homophobic and transphobic healthcare workers (HCWs), but through the systemic exclusion of LGBTQ + people at multiple levels. Epistemological cisgenderism and heteronormativity permeate how HCWs are trained, the policy environments within which healthcare is delivered, and the data systems used in practice and education; consequently, diminishing the quality of care delivered to LGBTQ + patients [3,5,9–13]. The interactions between- and within- these distinct components that make up the health system as a whole form a complex system ; that is , a system with a large number of components with a large number of causal interrelationships [14,15]. One interventional approach in this context is what the i-PARIHS framework refers to as facilitation ; operationalised through a network of facilitators who apply system-sensitive, problem-focussed, and feedback-driven skills and improvement strategies across a network of key actors within the system in which change is being implemented [16]. Directing this energy appropriately and iteratively to discrete, testable changes is key to successful facilitation [16–18]. The Mobilising Implementation of i-PARIHS facilitation planning tool (Mi-PARIHS) is one such method of enabling this, operationalising the i-PARIHS in the form of a survey in which HCWs rate discrete sub-constructs related to the innovation (the implementation project), recipients (themselves, their colleagues and patients), and their context (their local site, their organisation, the health sector, and broader context) [18]. Methodologies from the complex systems literature may help to interrogate interrelationships between these sub-constructs; establishing how barriers maintain each other through exposing their underlying relational structure [15,19]. The Current Study Plainly, interventions seeking to improve quality of care for LGBTQ + Australians within mainstream services must be holistic; engaging with varied perspectives to identify, critically engage with, and remove barriers to care. However, given the complex interrelationships of barriers to LGBTQ + health equity, knowing where to devote attention can be difficult. Conducting a preliminary assessment to rapidly, prospectively establish the most pressing barriers and facilitators to such an implementation can prove invaluable; enabling targeted enquiry in the more resource-intensive and rich data collection methods utilised in later phases of the implementation planning process [18]. This paper reports on such a rapid assessment of the implementation context for such an intervention within an Australian state-government funded Local Health Network’s (LHN) Division of Mental Health Services (MHS). Study Aims Identify key barriers and facilitators to implementing a holistic LGBTQ + model of care within the LHN MHS. Perform an exploratory decomposition of the interrelationships between Mi-PARIHS items to identify smaller, functional “subsystems” of barriers and facilitators between-domains. Developed an explanatory causal model (presented as a causal loop diagram) disentangling what is meant by “holistic”; moving from a general conceptual acknowledgement to an explicit proposal of how these barriers and facilitators work to maintain the status quo within the LHN both between- and within- i-PARIHS domains. Method Ethics, Funding, Standards & Conformance This research project was funded by the Commonwealth of Australia Medical Research Futures Fund (MRFF, Project: APP2028317) and approved by the Southern Adelaide Clinical Human Research Ethics Committee (Reference: 21.25). This paper conforms to Standards for Reporting Qualitative Research (SRQR) [20]; reported at Appendix B. Participants Study setting The LHN’s MHS consists of a total of 14 distinct service-delivery teams across multiple locations, supported by a local and centralised administrative and support staff, and governed by the state’s Department of Health and Wellbeing (DHW). These 14 services include primary mental health services embedded in GP clinics, secondary mental health services, and tertiary, inpatient services. Recruitment We utilised networks internal to the LHN — specifically, the LGBTQ + inclusion subcommittee — to identify and invite key knowledge-holders within both the individual MHS and the central administrative core to participate.Participants also organically identified people as important for us to speak with, whom we also followed-up with invitations to participate. This leveraging of insider-knowledge about the internal politics, structure, and role-variety within the LHN ensured our ethnography was maximally positioned to interpret the LHN MHS’ culture [21]. Ethics approval did not require individual consent; staff within the Network were informed of the data collection, and were invited to engage (or not) with the research team. In total, two participants asked us to not keep a record of our conversation or include their comments for analysis, which we honoured. We endeavoured to retain participant confidentiality, however the nature of the study and recruitment methodology means some participants would be known to each other. Participant characteristics In total, our notes include contributions from 25 participants. Most participants were women; the remainder non-binary and men. A small handful of participants proactively disclosed that they were transgender or cisgender; most did not. Most participants held clinical roles, and within that subgroup most were in clinical leadership roles. We have elected not to include a precise count or further breakdown of participants by ethnicity, gender, age, or place of work to maintain deidentification and participant confidentiality. Researcher characteristics We report a brief summary of researcher characteristics in Table 1 using the dead reckoning framework [22], and a summary of author contributions using the CReDIT in Table 2 [23]. Table 1 Researcher positionality statement, using the dead reckoning framework [22]. Theme Category Statement Form of positionality Organisation SR, DT, SS, and DR are affiliated with Flinders University. SN is affiliated with the LHN. SD is affiliated with both Flinders and the LHN. Voice We have chosen to use the plural “we” throughout to indicate our positionality within the ethnography; we have also included researchers’ voices explicitly in the results [22]. Sociocultural identities Professional identities All but SR have worked in mental health service delivery; DT and SS have worked predominantly in support work/peer support work roles, DR and SN are psychologists, SD is an occupational therapist. SS and DR have connections to queer and trans community and advocacy groups. DT has past, and SR has current connections in mental health advocacy groups. Personal identities Most of the project team are members of LGBTQ + communities. Relationship to research participants Emic/etic positioning A combination of both. Either SD or SN accompanied SR, DT, and SS in the walkthroughs, and are insiders within the LHN. While SR, DT, and SS are outsiders to work-cultures at the LHN, their lived experience of being LGBTQ + people who access mental health systems also positions them as insiders to accessing such services. This tension between insider-outsider status, in the context of research on LGBTQ + people, is value producing ; ensuring the research is impactful, the research process is constructive, and that the outcomes reflect community reality [24]. Familiarity & rapport SD and SN were familiar with most, but not all, participants; otherwise familiarity with any participant was minimal or non-existent for any other researchers. Power dynamics No author was a supervisor for, or otherwise “outranked”, any participant in the study. In our observation, participants were broadly very open and relaxed when speaking with the researchers. Most participants expressed appreciation that conversations were informal, anonymised, and not audio recorded, which may have contributed to this. Implications of positionality Implications for access SD and SNs positionality within the LHN eased initial access to participants for the research team. However, DT notes that people he contacted by himself during the follow-up recruitment phase — in most cases without SD and SN — were also very open to participating and contributing, making themselves available for the research. Implications for data collection Technical terms used by some participants were, on occasion, difficult for the non-clinically trained (SR, DT) researchers to understand. For example, participants spoke about “Bed flipping” (that is, rearranging inpatient rooms to accommodate different numbers of patients) when describing accommodating transgender patients, an unfamiliar term to SR and DT. However, in all of these cases, participants or clinical members of the research team (DR, SN, SD) were forthcoming with clarifications. Table 2 Author contributions, using the CReDIT attribution taxonomy [23]. Author Contribution Dan Thorpe (DT) Conceptualisation, methodology, investigation, formal analysis, writing – original draft, visualisation, software, project administration. Stefanija Rozitis (SR) Conceptualisation, investigation, validation, writing – review & editing. Damien Wayne Riggs (DR) Conceptualisation, methodology, validation, supervision, writing – review & editing, funding acquisition. Susan Num (SN) Supervision, investigation, writing – review & editing, funding acquisition. Salem Skelton (SS) Validation, investigation, writing – review & editing, funding acquisition. Suzanne Dawson (SD) Supervision, investigation, writing – review & editing, funding acquisition. Sarah Hunter (SH) Conceptualisation, methodology, writing – review & editing, funding acquisition. Anthony K. J. Smith (AS) Writing – review & editing, funding acquisition. Shoshana Rosenberg (SKR) Supervision, funding acquisition, conceptualisation. Materials Ethnographic Materials The researchers kept ethnographic field notes describing their observations during and experiences of the research process. This included: 1) Notes detailing observations made or questions asked by participants while completing the Mi-PARIHS or an informal interview; 2) Notes detailing their experiences and observations of the built environment (including photographs); and 3) Reflexive accounts of their experiences while conducting the research, including resonances with their own lived experiences, the literature, and broader conceptual reflections. The Mi-PARIHS facilitation planning tool The Mi-PARIHS Facilitation Planning Tool [18] consists of 34-items within the (non-facilitation) domains of the i-PARIHS framework; that is, items related to: 1) The innovation itself; 2) Recipients of the innovation; 3) The local context in which the innovation is being implemented; 4) The organisational context in which the innovation is being implemented; and 5) The outer con text (health-systemic, inter-organisational networks, political, etc.). Participants are asked to rate each item on a scale from − 2 (ie., a barrier) to + 2 (ie., a facilitator). While the Mi-PARIHS provides domain total and overall total scores, it is not intended to provide a precise measurement of an underlying construct; as such, Hunter and colleagues (2023) do not report psychometrics. The data are intended, instead, to help with collective sensemaking of the context; identifying priority areas — clear barriers and facilitators, defined as items rated “-2” or “+2” by participants, respectively — for facilitation during implementation. Procedure Walkthroughs In-person walkthroughs of each service delivery site were conducted by SR, accompanied by HCWs from the site and by a clinical member of the research team (SN or SD) and, where available, by DT or SS. After this “walk-through”, SR sat somewhere private with the HCW(s) that had walked them through the service, and completed the Mi-PARIHS facilitation planning tool. In parallel to completing this tool, SR noted any comments next to these questions that the HCW(s) made; these were included for analysis with the ethnographic field notes. In parallel to these walk-throughs, DT invited with named knowledge-holders in roles outside of individual sites to participate. If they agreed to an informal conversation, or to DT observing their work, DT and the participants met online or in-person. These meetings lasted between 10 minutes and 3 hours depending on the participant’s availability. The field notes taken by DT were included for coding to the Mi-PARIHS domains and treated as applying across all sites, unless a participant specifically disclaimed they were speaking to a specific site’s context. Neither the walkthroughs or informal conversations/observations were audio or video recorded, but SR and DT kept field notes. In total, 26,468 words of field notes were captured across 14 sites and six follow-up, informal meetings with administrative stakeholders. The average length of these field notes was 1471 words (sd = 888 words). Notes were handwritten, and then transcribed into NVIVO 14 [25]. Analysis Plan Framework code DT systematically read through the ethnographic field notes four times, coding semantic units of the text to each of the Mi-PARIHS items to saturation [26]. These codes were reviewed by authors DR, SR, and SS, with any disagreements resolved through consensus. Counts of codes to items are reported below. Mi-PARIHS Facilitation Planning Tool Data Identification, classification, and aggregation of site barriers and facilitators. We first used the Mi-PARIHS data to identify and classify barriers and facilitators across sites. Where an item was exclusively identified as either a barrier or facilitator across sites, we labelled these items as “significant” barriers or facilitators. Items that were both barriers and facilitators at different sites were labelled “context-dependent” barriers or facilitators. We provided ridgeline plots (Fig. 1 –Figure 6) of response distributions, generated using the R statistical programming language and associated libraries [27–30], to help the reader make sense of the distribution and directionality of participant responses to each item. Between-domains analysis. Second, we explored the relationships between Mi-PARIHS domains across the whole sample. We conducted a Kruskal-Wallis H Test to establish whether there were significant differences in mean ratings between-domains, with Bonferroni-adjusted Wilcoxon signed-rank tests to establish between which domains these effects were significant; graphically represented with ridgeline plots [27–31]. Between-items analysis. We utilised network analysis approaches to explore relationships between items across the whole sample [15]. The use of network methods to establish how constructs measured by rating scales reinforce or inhibit one another has shown promising results in the psychology literature [15,19]. Mi-PARIHS items are understood to uniquely play-out within the context of the implementation site [18], and therefore require methods of analysis designed to exploratorily tease their interrelationships out within the study data [15,18]. To achieve this in the context of the Mi-PARIHS results, we first generated a spearman correlation matrix of Mi-PARIHS items (reported, alongside assumptions testing, in Appendix A) [29–34], and then — using a cutoff of r s = ± 0.6 — generated a network graph of item relationships, ordered with Hu’s proportional algorithm [15,35,36]. We provide an exploratory analysis of the generated graph in the results [15], and — from this exploratory analysis — generated a Causal Loop Diagram (CLD); articulating testable, hypothetical causal relationships that may enable or inhibit the implementation [37]. Data Mixing Finally, we utilised the framework coded ethnographic field notes throughout to provide readers with examples from this corpus that illuminated the range of responses given by participants within each item. Results Our framework coding resulted in 649 attributions of text to Mi-PARIHS items (Table 3 ). The Mi-PARIHS identified fifteen contextual barriers, nineteen significant facilitators, and no significant barriers (Table 4 ). Table 3 Mi-PARIHS codebook for framework code of ethnographic field notes, including counts of coded segments (references) and number of files in which Mi-PARIHS construct was coded. Mi-PARIHS Question & Domain References (N.) Files (N) Innovation 56 16 1 The LGBTQ + Model of Care is informed by strong evidence 11 8 2 The LGBTQ + Model of Care is accessible and useable 6 6 3 The LGBTQ + Model of Care requires adaptation or tailoring to implement 15 10 4 The LGBTQ + Model of Care has clear outcome measures 7 7 5 The LGBTQ + Model of Care will be trusted 8 6 6 The LGBTQ + Model of Care offers an advantage over current practice 9 9 Recipients 151 29 7 There is local data that supports the need to introduce the LGBTQ + Model of Care 15 8 8 Individuals/team want to implement the LGBTQ + Model of Care in practice 6 6 9 There is a shared view on LGBTQ + Models of Care 70 25 10 Key individuals/stakeholders are supportive of implementing the LGBTQ + Model of Care 26 12 11 There are clinical champions supportive of implementing the LGBTQ + Model of Care 7 5 12 Individuals/team have the knowledge/skills to implement the LGBTQ + Model of Care 17 10 13 Barriers have been identified in discussion with individuals/team 10 9 Local context 271 26 14 There is sufficient time to implement the LGBTQ + Model of Care 13 7 15 There is commitment to provide appropriate resources to implement the LGBTQ + Model of Care 21 12 16 The local infrastructure can support the implementation of the LGBTQ + Model of Care 74 12 17 Individuals feel actively involved in decisions that affect them 11 8 18 There is clarity around individual’s roles and responsibilities 14 7 19 The culture supports innovation and change 12 7 20 The formal and informal leaders create a vision, motivation and reinforcement for the implementation of the LGBTQ + Model of Care 26 13 21 There is good multi-disciplinary collaboration and teamwork 3 3 22 There are mechanisms for staff to receive feedback on their work 11 9 23 There is past experience of implementing change 60 18 24 There is a learning and innovation culture 26 11 Organisational context 125 21 25 The LGBTQ + Model of Care aligns with the strategic priorities of the organisation 37 6 26 The organisation has systems and processes in place that will support the implementation of the LGBTQ + Model of Care 52 13 27 The organisational culture supports innovation and change 4 3 28 There is a history of successful and sustained change across the organisation 2 1 29 The organisational values are clear 4 2 30 Organisational and/or senior leaders support opportunities for engagement and consultation from consumers, public and staff 13 10 31 Organisational and/or senior leaders actively engage with local staff 13 6 Outer context 46 17 32 The LGBTQ + Model of Care aligns with the strategic priorities of the wider health system 19 6 33 There are incentives or disincentives that reinforce the implementation of the LGBTQ + Model of Care 9 6 34 There are inter-organisational networks that would be helpful 18 13 Total 649 32 Table 4 Descriptive statistics & barrier/facilitator classifications — Mi-PARIHS data. Mi-PARIHS Question & Domain Max Mean SD SE Min Classification Innovation 1 The LGBTQ + Model of Care is informed by strong evidence. 2 0.64 1.5 0.45 -2 Contextual 2 The LGBTQ + Model of Care is accessible and useable. 2 1.27 1.42 0.43 -2 Contextual 3 The LGBTQ + Model of Care requires adaptation or tailoring to implement. 2 1.64 0.81 0.24 0 Facilitator 4 The LGBTQ + Model of Care has clear outcome measures. 2 0.27 1.56 0.47 -2 Contextual 5 The LGBTQ + Model of Care will be trusted. 2 1.64 0.67 0.20 0 Facilitator 6 The LGBTQ + Model of Care offers an advantage over current practice. 2 1.64 0.81 0.24 0 Facilitator Recipients 7 There is local data that supports the need to introduce the LGBTQ + Model of Care . 2 0.18 1.78 0.54 -2 Contextual 8 Individuals/team want to implement the LGBTQ + Model of Care in practice. 2 1.45 0.69 0.21 0 Facilitator 9 There is a shared view on LGBTQ + Models of Care. 2 1.73 0.65 0.20 0 Facilitator 10 Key individuals/stakeholders are supportive of implementing the LGBTQ + Model of Care. 2 1.82 0.6 0.18 0 Facilitator 11 There are clinical champions supportive of implementing the LGBTQ + Model of Care. 2 1.18 1.33 0.40 -2 Contextual 12 Individuals/team have the knowledge/skills to implement the LGBTQ + Model of Care. 2 1.09 0.83 0.25 0 Facilitator 13 Barriers have been identified in discussion with individuals/team. 2 0.82 0.87 0.26 0 Facilitator Local context 14 There is sufficient time to implement the LGBTQ + Model of Care. 2 0 1.9 0.57 -2 Contextual 15 There is commitment to provide appropriate resources to implement the LGBTQ + Model of Care. 2 0.64 1.57 0.47 -2 Contextual 16 The local infrastructure can support the implementation of the LGBTQ + Model of Care. 2 0.73 1.85 0.56 -2 Contextual 17 Individuals feel actively involved in decisions that affect them. 2 1.27 1.27 0.38 -2 Contextual 18 There is clarity around individual’s roles and responsibilities. 2 1.82 0.6 0.18 0 Facilitator 19 The culture supports innovation and change. 2 1.73 0.65 0.20 0 Facilitator 20 The formal and informal leaders create a vision, motivation and reinforcement for the implementation of the LGBTQ + Model of Care. 2 2 0 0 2 Facilitator 21 There is good multi-disciplinary collaboration and teamwork. 2 2 0 0 2 Facilitator 22 There are mechanisms for staff to receive feedback on their work. 2 1.91 0.3 0.09 1 Facilitator 23 There is past experience of implementing change. 2 1.73 0.65 0.20 0 Facilitator 24 There is a learning and innovation culture. 2 1.25 0.71 0.21 0 Facilitator Organisational context 25 The LGBTQ + Model of Care aligns with the strategic priorities of the organisation 2 1.55 1.21 0.36 -2 Contextual 26 The organisation has systems and processes in place that will support the implementation of the LGBTQ + Model of Care 2 1.91 0.3 0.09 1 Facilitator 27 The organisational culture supports innovation and change. 2 1.91 0.3 0.09 1 Facilitator 28 There is a history of successful and sustained change across the organisation. 2 1.82 0.4 0.12 1 Facilitator 29 The organisational values are clear. 2 1.55 1.04 0.31 -1 Contextual 30 Organisational and/or senior leaders support opportunities for engagement and consultation from consumers, public and staff. 2 1.73 0.9 0.27 -1 Contextual Outer context 31 Organisational and/or senior leaders actively engage with local staff 2 1.55 1.21 0.36 -2 Contextual 32 The LGBTQ + Model of Care aligns with the strategic priorities of the wider health system. 2 1.64 1.21 0.36 -2 Contextual 33 There are incentives or disincentives that reinforce the implementation of the LGBTQ + Model of Care. 2 1.36 1.03 0.31 -1 Facilitator 34 There are inter-organisational networks that would be helpful 2 1 1.41 0.43 -2 Contextual Within-domain findings Innovation HCWs identified trustworthiness as the most significant facilitator in this domain. HCWs attributed this to being informed by strong evidence . One participant gave a lower score “ with a comment that ‘more learning would be good for sure’ ”, indicating that their rating was a reflection of their own lack of awareness of the evidence base. The advantage over current practice such a change would represent was clear to most; “ [the LHN] does need to do better and to fund more work for LGBTQ + care ”. However, this was less clear to some HCWs — “’There are no complaints about it’ (lack of LGBTQ + friendliness; lack of LGBTQ + inclusion)” — indicating that there is work to be done in articulating the benefits of the change over current practice. HCWs agreed that the model would require adaptation or tailoring . We were cautioned by participants not to be too directive; " ’I think if you're talking about how you communicate with [patients] that's trickier... People resist this, ‘I can talk to people how I want’. You have to give a strong reasoning .” HCWs were broadly positive about the accessibility and usability of an LGBTQ + model of care in their context. Indeed — as one participant put it — “ Many service users are in fact LGBTQ+ ”, and as a result — as another participant put it — “ Staff take up opportunities for training, look for resources and LGBTQ + practice is discussed at meetings ”; there is already awareness, investment, and engagement with these issues. HCWs were less confident about how clear the outcome measures for change are. While the “ YES survey can be used ” — the Australian national standard measure for mental health consumer experiences [38]— with some modifications, some HCWs were less sure. As one participant put it, “ it will be clear… when we know what we are doing and start to track it.” Recipients In this domain, HCWs most highly rated key individuals/stakeholders are supportive of implementation . HCWs identified local LGBTQ + champions, managers, and frontline staff as key — in the words of one participant, “ honestly it is everyone ” — to the success of the implementation. It follows that HCWs broadly positively rated that, within their teams, there was a shared view on LGBTQ + Models of Care and that individuals and teams want to implement . Participants indicated that “ The majority is in favour ”, despite it being “ hard to get 100% on anything ”. Most sites had clinical champions supportive of implementation. These team members were highly valued and broadly effective, hence high scores on this item. The site that rated this item as a significant barrier “claimed no staff there are LGBTQIA+… [within] a team of 300 ”. Population estimates lead us to expect that between 10–12 staff at this site would likely identify as LGBTQIA+ [39]. Where HCWs identified, at their site, that individuals and teams have the knowledge and skills to implement , this was “ because they are proactive about training ”. Most participants, on the balance, acknowledged their teams had the “ skills but not the knowledge… They have the insight to know they could do better … but they need guidance ”. Some participants’ teams anticipated our visit, and as such barriers had been identified. For example, large, changing teams — especially within 24/7 services, like hospitals — which can “ make it hard to get everyone onboard” and team “ indifference ” — “ some staff (especially older staff) are forgetful of the correct pronouns of a service user. This seems not… malicious but is unhelpful. ” The item in this domain in which HCWs were most divided was whether there are local data that support the need to introduce the LGBTQ + model of care . Where this was scored low, it was generally in acknowledgment of Electronic Medical Record (EMR) limitations (discussed in the Local Context results). However , where this was rated more highly, this was reflective of the ways in which informal, anecdotal, and data from other sources For example, “ the youth clinic [at site] are aware that 30–40% of their clients are LGBTQ+”. Local Context Participants were unanimous in agreeing that the LHN’s MHS have good multi-disciplinary collaboration , and robust mechanisms for staff to receive feedback on their work . Within this item, and within the individuals feel actively involved in decisions that affect them item, consumer feedback was named as what “guides practice” at a number of sites. However, some participants noted the current form of the Your Experience of Service (YES) survey [38] should be replaced by a shorter-form, and include demographic markers for gender, sexuality, and cultural identification. Two sites rated the individuals feel actively involved in decisions item as 0 and − 2. The former, interestingly, was the only site in which administrative staff were involved in filling out the Mi-PARIHS tool; a cohort that “ feel overworked and that they are already being asked to do things that clinical staff should do for themselves. ” The latter pushed-back on what they perceived the model of care might be, “ There is anecdotal feedback from service users that they would like to have LGBTIQA + sensitive practice… [but] sometimes attempts to improve things backfire or are not suitable for everyone.” Participants were also highly positive about formal and informal leaders creating a vision, motivation and reinforcement for the implementation . This highly positive result reflects the value of and respect for the work of LGBTQ + champions. Participants broadly felt there is clarity around individual’s roles and responsibilities . However, they observed this was not universal for all HCWs; some staff had an “ attitude [of] ‘Why do I have to?’, ‘Why can’t I just treat everyone the same’” . Finally, in terms of LGBTQ + staff, it was identified that more clarity was needed in both the LHN’s HR systems and in the policy space. Participant responses for past experiences of implementing change , culture supporting innovation and change , and learning and innovation culture broadly clustered around efforts their sites had already made towards LGBTQ + inclusion. For example, “ The practice is trans-affirming in terms of use of names”. Barriers named by participants within these items were broadly encapsulated in infrastructure, resourcing, and time items. There was disagreement amongst participants whether the local infrastructure can support the implementation . Where this was scored low, it was generally in acknowledgment that the primary EMR is unable to capture gender and sexuality data. Even where ratings were higher, participants acknowledged these limitations: “ [while] It’s possible to free text and add notes about a patient’s gender or sexual orientation… there is only one section to do this so busy doctors who have very urgent notes to write will just delete whatever is there and write their notes. ” Participants were also unsure if there was commitment to provide appropriate resources to implement . We note that existing attempts by HCWs to make their spaces more inclusive are often “ paid for by staff themselves. On the one hand it shows that staff really are committed, on the other hand it’s not sustainable for staff to carry responsibility for this or other ways of making the space welcoming. ” Finally, participants broadly felt there was not sufficient time to implement an LGBTQ + model of care . As one participant begrudgingly put it, “ if we have to we will make time ”. However, as one participant explained, “ we are busy… so [that means] it needs to be embedded like good First Nations practice, become routine” ; the role of the researchers — and, particularly, the facilitators and implementation specialists in later phases of the project — is, in this framing, to ensure our model can become embedded in this manner. Organisational Context Participants broadly agreed that the LHN’s organisational culture supports innovation and change – having a strong focus on “ continuous improvement… compared to other LHNs” . This was also reflected in how organisation and senior leaders support opportunities for engagement — “ patient voice and decision-making is centred ” — but one participant did note that, in their experience, “ formal channels are very tied to organisational prerogative which… [can be] disconnected from the material reality of patients and staff.” One participant described the organisation’s systems and processes that will support the implementation as “ a work in progress ”. While most participants were able to identify positive steps in the right direction that had already been made by the LHN, there was a sense in the responses that this was in early stages and that our implementation could build on this momentum. Participants identified that there is a history of successful and sustained change across the organisation . A senior worker in the administrative core described the success of changes within the LHN and within LHNs more broadly as coming from “ having respect from the broader group that you know the subject matter… [and if you do not, then] ‘bring along’ [senior clinicians] and develop them as clinical champions ”. The organisational values were clear to most participants, however a few did clarify that — “ [they’re clear] for the general public but not for LGBTQ + people. Not for Indigenous health.” While we note that the LHN’s core priorities, as published, include delivering equitable services to diverse populations, we acknowledge that these participants were most likely referring to whether or not they perceived this priority as clear, well articulated, or as having materially changed care on the ground for these populations. This reasoning was echoed by the same group of participants in their ratings of the alignment of the implementation with the strategic priorities of the organisation . Participants reported that organisational leaders actively engage with local staff . Indeed, one site noted that they were “ very proud to say that the idea of having LGBTIQA + champions [was] their own initiative ”, and that the spread of this to other sites was something they were honoured to have had taken up by senior leaders. Where this was rated lower participants did not provide specific feedback, however we note that their sites were further geographically removed than others. Outer Context The LGBTQ + model of care aligns with the strategic priorities of the wider health system in the view of participants in this study; “I think that moving from a biomedical model of care to a psychosocial determinants perspective is where health is slowly headed .” One participant felt LGBTQ + people in general were made a low priority by health systems. In short, there is still work to be done to shift these priorities across health more broadly, although they are shifting. This was echoed by participants’ descriptions of incentives or disincentives that reinforce the implementation. Participants made it clear that there were health-systemic incentives to implementing the model of care from a health prevention perspective — “ patients would feel valued [and therefore] would be willing to present…” — however, participants also expressed concerns about the lack of a clear leader within the DHW for inclusion; “ … it’s difficult not having someone who can be that central person [to work towards change]”. Finally, participants identified inter-organisational networks that would be helpful in most cases, and “ even though [participant] couldn’t name SHINE, Minus 18, Thorne Harbor, once I did he said “oh yeah that’s all the stuff I found online when I needed resources for a trans patient”... there is an ability to find them .” These networks were also important for providing training and information, with participants repeatedly naming silver rainbow training (facilitated by Thorne Harbour Health) and SHINE’s online LGBTQ + training. Between-domains findings Mean response distributions across domains A Kruskal-Wallis H-Test showed there was a significant, but small difference in distribution of ratings across domains (Fig. 6; H = 17.596, p = 0.0015, η 2 = 0.04). While pairwise, Bonferroni-adjusted Wilcoxon signed-rank tests found significant differences between the Organisational Context domain and the Innovation (Bonferroni adjusted p = 0.017) and Recipients (Bonferroni adjusted p = 0.0007) domains, the small effect sizes ( r = 0.26 and r = 0.32, respectively) indicate caution in over-interpreting these domains as the primary target for facilitator intervention within the implementation of the LGBTQ + model of care. Figure 6 Ridgeline plot showing the distribution of mean item ratings within Mi-PARIHS domains Correlative relationships between items The items with no moderate or greater correlations with other items were Individuals/teams have the knowledge and skills (recipients), commitment to provide appropriate resources to implemen t (local context), formal and informal leaders create a vision (local context), good multi-disciplinary collaborati on (local context ), past experience of implementing change (local context), and incentives or disincentives that reinforce (outer context). As such, these items are excluded from this graph. 28/34 items in the Mi-PARIHS had a moderate (> r s ≥ + 0.60 | ≤-0.60) or greater correlation with another item within the scale. There are two highly connected sub-graphs within Fig. 7 , connected (therefore, mediated) by a string of components conceptualisable as “ roles, values, engagement, and consultation ”. We refined these two sub-graphs, and presented them as a CLD (Fig. 8 ). Exploratory causal model of local and organisational leadership factors supporting implementation The central column of mediating roles, values, and engagement & consultation factors is represented in a reduced form here by the green, dashed-outline circle. Dashed lines are used in the CLD to indicate correlative relationships that were below our cutoff-point for generating the correlation network diagram, but that were nonetheless theoretically sound relationships and therefore worthwhile including in the CLD. The relationship between Organisational cultural supports innovation and change & sufficient time was r s = + 0.54. The relationship between Clinical champions supportive of implementation & barriers identified in discussions was r s = + 0.49. The relationship between Local Infrastructure cannot support and clear outcomes was r s = -4.2, Local Infrastructure cannot support and trustworthy was r s = -4.5. The top loop of the CLD represents factors that are broadly the domain of or strongly influenced by organisational leaders’ decisions. Health systemic priorities shape organisational innovation and change cultures both directly, and through the ways in which these priorities shape systems and processes within health services and, in turn, how senior leaders engage with local staff . A healthy innovation and change culture is one that allots sufficient time to implement change. This time, in turn, enables a learning and innovation culture within sites; a culture which, when healthy and where there is sufficient time, produces clinical champions for change within sites. These champions, mediated by the chain of local and organisational factors connecting these two loops and the local factors supporting implementation, build towards a history of sustained change ; with these sustained changes in turn informing wider health systemic priorities . The bottom loop within the CLD represents factors that are broadly within the immediate locus of local sites and facilitators. Beginning at the top of the loop, the strategic priorities of the organisation are key to producing the circumstances where individuals can feel involved in decisions affecting them . This enables individuals to speak-up in discussions of barriers to changes , which — as they are engaged in evaluating the change through speaking up — enables them to clearly see outcomes of the change and — if positive — trust the change. We also note the weak, but present, mediation of clinical champions to identifying barriers. The only negative feedback loop within this CLD also mediates this sub-loop; with local infrastructure’s inability to provide insights into LGBTQ + patient outcomes eroding trustworthiness and, in turn, clear outcomes and the identification of barriers . While complex, this series of relationships are crucial as, where this trust exists, it enables engagement with the possibility that the change might be advantageous over current practice . However, this sense of advantage over current practice is also shaped by inter-organisational networks ; particularly, in our sample, through the trainings offered by LGBTQ + organisations which also enforce the advantages LGBTQ + models of care have over business-as-usual. This ability to engage with the potential advantageousness of the change encourages HCWs to collect their own data (ideally reinforced through empirical data collection) about the effectiveness of the change which, as these data enable comparison , in turn supports the growth of the site’s own culture of innovation and change . As values shift, so do people’s desire to engage in implementing changes, which in turn feeds back through the levels of the organisation to shift the strategic priorities of the organisation . Discussion This rapid context assessment provides illuminating initial insights for further investigation. The novel, complexity science-informed approach to analysis presented within this paper allowed us to operationalise our conception of “holistic” to specific, actionable targets for facilitation. This would not have been possible to the same extent from traditional quantitative or qualitative inquiries into these data alone. First, the Kruskal-Wallis analysis of the i-PARIHS results showed no one domain substantively presented more barriers than another; untangling and making sense of this result was only made possible through the network analytic results. Second, this approach also has positive implications for the continuous evaluation of the implementation while in motion, an important component of the i-PARIHS framework (and use-case for the Mi-PARIHS) [16–18]. While measuring the impact of our intended implementation’s impact on removing some of the barriers is simple — for example, the proposed changes to the LHN’s EMR being completed (or not) by the LHN and DHW is binary — others are more fraught — such as trying to unpack whether HCWs have enough time [40]. CLDs imply causal dependence, and as such also imply distal measures for establishing convergent validity of measurements of constructs in the Mi-PARIHS; sufficient time , for example, can be distally convergently validated through attendance at training sessions offered as part of the implementation (ie., learning and innovation culture ) and through the number of clinical champions at sites. Given their importance to our outcomes, we strongly recommend the integration of approaches from complexity science — including those demonstrated in this study — into implementation science methodologies more broadly. Recommendations The results demonstrate that we must fully consider the interplay between different levels of the Health Network in the design of our LGBTQ + model of care, and that we need to consider proximal and distal means of measuring the implementation in motion to ensure the success of the implementation. These considerations encourage key actions from senior leaders, the implementation team, and staff within the MHS. These recommendations broadly align with those in The National Action Plan [7]; with overlaps addressed in Fig. 9 below. Senior leaders Senior leaders first need to act through their engagement with local staff about LGBTQ + issues. While so-called “performative corporate activism” — social media posts, attendance at events, or more general participation in social justice causes by a corporate entity — is sometimes received negatively, it is nonetheless an important and effective means of publicly establishing an organisation’s position on a social cause [41]. We encourage leaders within the LHN and the DHW to make their position clear to staff and to the general public through such actions. Second, we encourage leadership of the LHN and the DHW to buy-into this implementation process. This buy-in, in our study context, means leadership both on the ground with local staff on LGBTQ + issues, and through the allocation of adequate resourcing; both of which were identified in our data, and in similar implementation projects in the literature, as crucial [42]. The latter is first present in our model in terms of time ; for learning, for the implementation to take place successfully and without impacting business as usual, and — more broadly — because additional time enables potential clinical champions for LGBTQ + patients to commit to such roles without fear for their workload management. We also encourage leadership to directly financially resource LGBTQ + care through the allocation of technical budget for changes to the LHN’s Electronic Medical Record (EMR) software. This infrastructure is an easy to miss barrier that substantively impedes a number of facilitators in our model; resolving this is crucial to implementation success. Finally, we encourage leadership within the LHN and the DHW to engage with the broader sector — both in advocating for explicit consideration of LGBTQ + perspectives in national standards, and strengthening partnerships with LGBTQ + specialist organisations that can deliver training, offer consultation — on policies, procedures, and patient data systems like the LHN’s EMR, and offer referral pathways for LGBTQ + consumers requiring more specialised care. Implementation facilitators Our results also present clear actions for the implementation facilitators. First, facilitators must clearly articulate the outcomes, trustworthiness, and advantages over current practice — in terms of the evidence base, the accessibility of the model of care, and the utility to everyone’s practice — that the LGBTQ + model of care represents, both in terms of shifting the strategic priorities of the organisation, and in terms of individual HCW’s practices. Second, facilitators need to enable discussions of barriers to implementation, make individuals feel involved in decisions about how to tailor the model to their service site, and — in turn — support managers to build a culture of innovation and change within their sites. This will be achieved through the application of co-design methods throughout the design of, and implementation of the LGBTQ + model of care; leveraging and building upon the repeatedly identified, valued work being done by LGBTQ + champions already at work within the LHN. Finally, facilitators need to involve the LGBTQ + specialist service delivery sector in our implementation plan, drawing on their existing authority in this space and in their expertise in training HCWs to deliver this care. Limitations We acknowledge that — while the Mi-PARIHS is designed for such usage [18] — our sample size remains small, and potentially biased as a result. While our work contains valuable insights for researchers conducting similar implementations, we caution readers from generalising our findings wholesale. Our rapid assessment methods and the scope of this paper are firmly aligned to our implementation context. We additionally note that the responses to the Mi-PARIHS were broadly positive, something that was surprising to the research team and may indicate a research bias; those who care about this cause may be more biased to view the situation more positively. However, we note that our aggregation methodology and specifically the inclusion of and consideration afforded to contextual barriers and facilitators in our analysis may help to provide some balance to the more positively-skewed responses. Conclusion This rapid context assessment ahead of implementing an LGBTQ + model of care within an LHN’s MHS makes clear that improving LGBTQ + mental health service delivery and outcomes requires a holistic approach. Utilising the novel, complexity science-derived analytic approach allowed us to explicitly operationalise what it means to be holistic in the context of our implementation project. Being able to name causal antecedents to barriers and facilitators in a way that is drawn from primary data, reinforcing rather than relying solely upon theory or from population surveys exploring health inequalities, is invaluable for both building trust in an implementation’s program of change, and for ensuring this program of change is adequately targeted. We strongly encourage the application of these techniques to other implementation projects. Declarations Ethics approval and consent to participate Ethics approval did not require individual consent; staff within the Network were informed of the data collection, and were invited to engage (or not) with the research team. In total, two participants asked us to not keep a record of our conversation or include their comments for analysis, which we honoured. Consent for publication Consent for publication has been sought from all named authors. No individual consent for publication from participants was required due to the nature of the study. Availability of data Due to the sensitivity of these data, and the potential for reidentification of participants, we have chosen to not make these data available for further analyses. Competing interests The authors declare they have no competing interests. Funding This project is funded by the Commonwealth of Australia Medical Research Futures Fund (MRFF; Project ID: APP2028317), as part of their Sexuality and Gender Diverse and Innate Variations of Sex Characteristics (Streams 1-2) Funding Program. The funder had no role in the conceptualisation, design, data collection, analysis, decision to publish, or preparation of this manuscript. Please see the MRFF funding agreement guidelines for further information. Authors’ contributions Please see Table 2 for author contributions, using the CReDIT attribution taxonomy. 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domains\u003c/em\u003e\u003c/p\u003e","description":"","filename":"image6.png","url":"https://assets-eu.researchsquare.com/files/rs-8072582/v1/35b55636c473fa6b77e82d84.png"},{"id":97668825,"identity":"7b61cf07-444a-4a8a-b8f5-4c1fc3760490","added_by":"auto","created_at":"2025-12-08 09:26:20","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":485727,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eCorrelation network diagram of relationships between-Mi-PARIHS items, where node size is proportional to node-degree, and edge weight is proportional to r\u003c/em\u003e\u003csub\u003e\u003cem\u003es\u003c/em\u003e\u003c/sub\u003e\u003c/p\u003e\n\u003cp\u003eThe items with no moderate or greater correlations with other items were \u003cem\u003eIndividuals/teams have the knowledge and skills\u003c/em\u003e (recipients), \u003cem\u003ecommitment to provide appropriate resources to implemen\u003c/em\u003et (local context), \u003cem\u003eformal and informal leaders create a vision\u003c/em\u003e(local context), \u003cem\u003egood multi-disciplinary collaborati\u003c/em\u003eon (local context\u003cem\u003e), past experience of implementing change\u003c/em\u003e (local context), and \u003cem\u003eincentives or disincentives that reinforce\u003c/em\u003e (outer context). As such, these items are excluded from this graph.\u003c/p\u003e","description":"","filename":"image7.png","url":"https://assets-eu.researchsquare.com/files/rs-8072582/v1/836424250485ceab8a1067fe.png"},{"id":97461717,"identity":"43f4dd6b-390e-4fa3-abe7-27f1d52dc988","added_by":"auto","created_at":"2025-12-04 15:30:52","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":371644,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eCausal Loop Diagram proposing relationships between Mi-PARIHS items and implementation success.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe central column of mediating roles, values, and engagement \u0026amp; consultation factors is represented in a reduced form here by the green, dashed-outline circle.\u003c/p\u003e\n\u003cp\u003eDashed lines are used in the CLD to indicate correlative relationships that were below our cutoff-point for generating the correlation network diagram, but that were nonetheless theoretically sound relationships and therefore worthwhile including in the CLD. The relationship between \u003cem\u003eOrganisational cultural supports innovation and change \u003c/em\u003e\u0026amp; \u003cem\u003esufficient time\u003c/em\u003e was r\u003csub\u003es \u003c/sub\u003e= +0.54.\u003csub\u003e \u003c/sub\u003eThe relationship between \u003cem\u003eClinical champions supportive of implementation \u003c/em\u003e\u0026amp; \u003cem\u003ebarriers identified in discussions\u003c/em\u003e was r\u003csub\u003es \u003c/sub\u003e= +0.49. The relationship between \u003cem\u003eLocal Infrastructure cannot support\u003c/em\u003e and \u003cem\u003eclear outcomes\u003c/em\u003e was r\u003csub\u003es \u003c/sub\u003e= -4.2, \u003cem\u003eLocal Infrastructure cannot support\u003c/em\u003e and \u003cem\u003etrustworthy \u003c/em\u003ewas r\u003csub\u003es \u003c/sub\u003e= -4.5.\u003c/p\u003e","description":"","filename":"image8.png","url":"https://assets-eu.researchsquare.com/files/rs-8072582/v1/92ead279b38d4ec6552fc908.png"},{"id":97461714,"identity":"4f73d23e-2991-40a5-ad26-620d9759cfea","added_by":"auto","created_at":"2025-12-04 15:30:52","extension":"png","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":164803,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eSankey diagram showing alignment between our recommendations and the National Action Plan focus areas.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"image9.png","url":"https://assets-eu.researchsquare.com/files/rs-8072582/v1/a80e658ba2ec74b9f580bf29.png"},{"id":97892828,"identity":"e4149a50-2fee-445b-8214-bfc6e90fdf85","added_by":"auto","created_at":"2025-12-10 15:22:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3411632,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8072582/v1/5bc45010-3d83-43b7-8190-7a609d48ea14.pdf"},{"id":97461712,"identity":"c7a7ac2c-a8c9-4a4e-9e19-172912d67fb7","added_by":"auto","created_at":"2025-12-04 15:30:52","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":44105,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixA.docx","url":"https://assets-eu.researchsquare.com/files/rs-8072582/v1/9a8cf1f1e3495f9618b1d1cb.docx"},{"id":97669735,"identity":"8fcf7a7e-a97b-400f-a0fe-326256eaffca","added_by":"auto","created_at":"2025-12-08 09:28:48","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":25196,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixB.docx","url":"https://assets-eu.researchsquare.com/files/rs-8072582/v1/73bae022e7b4d01c4ab93241.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Implementing LGBTQ+ inclusive mental healthcare into practice — A rapid mixed-methods implementation context assessment of an Australian local health network","fulltext":[{"header":"Contributions to the Literature","content":"\u003cul\u003e\n \u003cli\u003eImproving LGBTQ+ care is something that requires leaders at all levels of health systems to be on-board.\u003c/li\u003e\n \u003cli\u003eOur research identifies the ways that some of the barriers commonly identified in the LGBTQ+ mental health literature not only present problems on their own, but help to uphold \u003cem\u003eeach-other\u003c/em\u003e. We demonstrate this through the application of a novel methodology looking at interrelationships between barriers.\u003c/li\u003e\n \u003cli\u003eThis methodology allowed us to breakdown our concept of needing to intervene \u0026ldquo;holistically\u0026rdquo; into clear areas for our facilitators to focus on, and provided insights into ways we (and others) can more rigorously measure success.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Introduction","content":"\u003cp\u003eLesbian, gay, bisexual, trans, and queer (LGBTQ+) people experience significant mental health disparities compared to heterosexual and cisgender populations [1\u0026ndash;3]. These disparities are understood as stemming from two proximal causes; first, through exposure to the cumulative, traumatic experience of living within a heteronormative, cisgenderist social environment [4\u0026ndash;6]; second, through decreased access to healthcare that can delay or prevent treatment entirely [5]. Indeed, the Australian Bureau of Statistics [1] report that a large proportion of LGBTQ\u0026thinsp;+\u0026thinsp;people with a mental illness lasting longer than one year did not access any mental health service. The literature identifies a lack of empathy and affirmation and a lack of provider knowledge as major barriers to access for LGBTQ\u0026thinsp;+\u0026thinsp;people [2,3,7,8]. The Australian Government Department of Health\u0026rsquo;s \u003cem\u003eNational Action Plan for the Health and Wellbeing of LGBTIQA\u0026thinsp;+\u0026thinsp;Australians\u003c/em\u003e (hereafter \u003cem\u003eThe National Action Plan)\u003c/em\u003e identifies a number of key areas of systemic change required to address these health inequalities [7].\u003c/p\u003e\u003cp\u003eMainstream health services play a vital role in addressing these inequalities; however, evidence suggests they are not meeting their responsibilities to LGBTQ\u0026thinsp;+\u0026thinsp;patients. LGBTQ\u0026thinsp;+\u0026thinsp;people in Australia\u0026rsquo;s healthcare experiences are often marked by discrimination, exclusion, and lack of clinical knowledge of how to best work with their presenting concerns [3,5,9]. These experiences are not created solely through individual homophobic and transphobic healthcare workers (HCWs), but through the systemic exclusion of LGBTQ\u0026thinsp;+\u0026thinsp;people at multiple levels. Epistemological cisgenderism and heteronormativity permeate how HCWs are trained, the policy environments within which healthcare is delivered, and the data systems used in practice and education; consequently, diminishing the quality of care delivered to LGBTQ\u0026thinsp;+\u0026thinsp;patients [3,5,9\u0026ndash;13].\u003c/p\u003e\u003cp\u003eThe interactions between- and within- these distinct components that make up the health system as a whole form a \u003cem\u003ecomplex system\u003c/em\u003e; \u003cem\u003ethat is\u003c/em\u003e, a system with a large number of components with a large number of causal interrelationships [14,15]. One interventional approach in this context is what the i-PARIHS framework refers to as \u003cem\u003efacilitation\u003c/em\u003e; operationalised through a network of facilitators who apply system-sensitive, problem-focussed, and feedback-driven skills and improvement strategies across a network of key actors within the system in which change is being implemented [16]. Directing this energy appropriately and iteratively to \u003cem\u003ediscrete, testable\u003c/em\u003e changes is key to successful facilitation [16\u0026ndash;18]. The Mobilising Implementation of i-PARIHS facilitation planning tool (Mi-PARIHS) is one such method of enabling this, operationalising the i-PARIHS in the form of a survey in which HCWs rate discrete sub-constructs related to the \u003cem\u003einnovation\u003c/em\u003e (the implementation project), \u003cem\u003erecipients\u003c/em\u003e (themselves, their colleagues and patients), and their \u003cem\u003econtext\u003c/em\u003e (their local site, their organisation, the health sector, and broader context) [18]. Methodologies from the complex systems literature may help to interrogate interrelationships \u003cem\u003ebetween\u003c/em\u003e these sub-constructs; establishing how barriers maintain \u003cem\u003eeach other\u003c/em\u003e through exposing their underlying relational structure [15,19].\u003c/p\u003e\u003cp\u003eThe Current Study\u003c/p\u003e\u003cp\u003ePlainly, interventions seeking to improve quality of care for LGBTQ\u0026thinsp;+\u0026thinsp;Australians within mainstream services must be \u003cem\u003eholistic;\u003c/em\u003e engaging with varied perspectives to identify, critically engage with, and remove barriers to care. However, given the complex interrelationships of barriers to LGBTQ\u0026thinsp;+\u0026thinsp;health equity, knowing \u003cem\u003ewhere\u003c/em\u003e to devote attention can be difficult. Conducting a preliminary assessment to rapidly, prospectively establish the most pressing barriers and facilitators to such an implementation can prove invaluable; enabling targeted enquiry in the more resource-intensive and rich data collection methods utilised in later phases of the implementation planning process [18].\u003c/p\u003e\u003cp\u003eThis paper reports on such a rapid assessment of the implementation context for such an intervention within an Australian state-government funded Local Health Network\u0026rsquo;s (LHN) Division of Mental Health Services (MHS).\u003c/p\u003e\u003cp\u003e\u003cem\u003eStudy Aims\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eIdentify key barriers and facilitators to implementing a holistic LGBTQ\u0026thinsp;+\u0026thinsp;model of care within the LHN MHS.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003ePerform an exploratory decomposition of the interrelationships between Mi-PARIHS items to identify smaller, functional \u0026ldquo;subsystems\u0026rdquo; of barriers and facilitators between-domains.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eDeveloped an explanatory causal model (presented as a causal loop diagram) disentangling what is meant by \u0026ldquo;holistic\u0026rdquo;; moving from a general conceptual acknowledgement to an explicit proposal of how these barriers and facilitators work to maintain the \u003cem\u003estatus quo\u003c/em\u003e within the LHN both \u003cem\u003ebetween-\u003c/em\u003e and \u003cem\u003ewithin-\u003c/em\u003e i-PARIHS domains.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003eEthics, Funding, Standards \u0026amp; Conformance\u003c/p\u003e\u003cp\u003e This research project was funded by the Commonwealth of Australia Medical Research Futures Fund (MRFF, Project: APP2028317) and approved by the Southern Adelaide Clinical Human Research Ethics Committee (Reference: 21.25). This paper conforms to Standards for Reporting Qualitative Research (SRQR) [20]; reported at Appendix B.\u003c/p\u003e\u003cp\u003eParticipants\u003c/p\u003e\n\u003ch3\u003eStudy setting\u003c/h3\u003e\n\u003cp\u003e The LHN\u0026rsquo;s MHS consists of a total of 14 distinct service-delivery teams across multiple locations, supported by a local and centralised administrative and support staff, and governed by the state\u0026rsquo;s Department of Health and Wellbeing (DHW). These 14 services include primary mental health services embedded in GP clinics, secondary mental health services, and tertiary, inpatient services.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eRecruitment\u003c/h2\u003e\u003cp\u003e We utilised networks internal to the LHN \u0026mdash; specifically, the LGBTQ\u0026thinsp;+\u0026thinsp;inclusion subcommittee \u0026mdash; to identify and invite key knowledge-holders within both the individual MHS and the central administrative core to participate.Participants also organically identified people as important for us to speak with, whom we also followed-up with invitations to participate. This leveraging of insider-knowledge about the internal politics, structure, and role-variety within the LHN ensured our ethnography was maximally positioned to interpret the LHN MHS\u0026rsquo; culture [21].\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003cp\u003edid not require individual consent; staff within the Network were informed of the data collection, and were invited to engage (or not) with the research team. In total, two participants asked us to not keep a record of our conversation or include their comments for analysis, which we honoured.\u003c/p\u003e\u003c/p\u003e\u003cp\u003eWe endeavoured to retain participant confidentiality, however the nature of the study and recruitment methodology means some participants would be known to each other.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eParticipant characteristics\u003c/h3\u003e\n\u003cp\u003e In total, our notes include contributions from 25 participants. Most participants were women; the remainder non-binary and men. A small handful of participants proactively disclosed that they were transgender or cisgender; most did not. Most participants held clinical roles, and within that subgroup most were in clinical leadership roles. We have elected not to include a precise count \u003cem\u003eor\u003c/em\u003e further breakdown of participants by ethnicity, gender, age, or place of work to maintain deidentification and participant confidentiality.\u003c/p\u003e\n\u003ch3\u003eResearcher characteristics\u003c/h3\u003e\n\u003cp\u003eWe report a brief summary of researcher characteristics in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e using the dead reckoning framework [22], and a summary of author contributions using the CReDIT in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e [23].\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cem\u003eResearcher positionality statement, using the dead reckoning framework\u003c/em\u003e [22].\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTheme\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eStatement\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eForm of positionality\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOrganisation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSR, DT, SS, and DR are affiliated with Flinders University. SN is affiliated with the LHN. SD is affiliated with both Flinders and the LHN.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVoice\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eWe have chosen to use the plural \u0026ldquo;we\u0026rdquo; throughout to indicate our positionality within the ethnography; we have also included researchers\u0026rsquo; voices explicitly in the results [22].\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSociocultural identities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eProfessional identities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAll but SR have worked in mental health service delivery; DT and SS have worked predominantly in support work/peer support work roles, DR and SN are psychologists, SD is an occupational therapist. SS and DR have connections to queer and trans community and advocacy groups. DT has past, and SR has current connections in mental health advocacy groups.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePersonal identities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMost of the project team are members of LGBTQ\u0026thinsp;+\u0026thinsp;communities.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRelationship to research participants\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEmic/etic positioning\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eA combination of both. Either SD or SN accompanied SR, DT, and SS in the walkthroughs, and are insiders within the LHN. While SR, DT, and SS are outsiders to work-cultures at the LHN, their lived experience of being LGBTQ\u0026thinsp;+\u0026thinsp;people who access mental health systems also positions them as \u003cem\u003einsiders\u003c/em\u003e to accessing such services. This tension between insider-outsider status, in the context of research on LGBTQ\u0026thinsp;+\u0026thinsp;people, is \u003cem\u003evalue producing\u003c/em\u003e; ensuring the research is impactful, the research process is constructive, and that the outcomes reflect community reality [24].\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFamiliarity \u0026amp; rapport\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSD and SN were familiar with most, but not all, participants; otherwise familiarity with any participant was minimal or non-existent for any other researchers.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePower dynamics\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo author was a supervisor for, or otherwise \u0026ldquo;outranked\u0026rdquo;, any participant in the study. In our observation, participants were broadly very open and relaxed when speaking with the researchers. Most participants expressed appreciation that conversations were informal, anonymised, and not audio recorded, which may have contributed to this.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eImplications of positionality\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eImplications for access\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSD and SNs positionality within the LHN eased initial access to participants for the research team. However, DT notes that people he contacted by himself during the follow-up recruitment phase \u0026mdash; in most cases without SD and SN \u0026mdash; were also very open to participating and contributing, making themselves available for the research.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eImplications for data collection\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTechnical terms used by some participants were, on occasion, difficult for the non-clinically trained (SR, DT) researchers to understand. For example, participants spoke about \u0026ldquo;Bed flipping\u0026rdquo; (that is, rearranging inpatient rooms to accommodate different numbers of patients) when describing accommodating transgender patients, an unfamiliar term to SR and DT. However, in all of these cases, participants or clinical members of the research team (DR, SN, SD) were forthcoming with clarifications.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cem\u003eAuthor contributions, using the CReDIT attribution taxonomy\u003c/em\u003e [23].\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAuthor\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eContribution\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDan Thorpe (DT)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eConceptualisation, methodology, investigation, formal analysis, writing \u0026ndash; original draft, visualisation, software, project administration.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStefanija Rozitis (SR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eConceptualisation, investigation, validation, writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDamien Wayne Riggs (DR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eConceptualisation, methodology, validation, supervision, writing \u0026ndash; review \u0026amp; editing, funding acquisition.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSusan Num (SN)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSupervision, investigation, writing \u0026ndash; review \u0026amp; editing, funding acquisition.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSalem Skelton (SS)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eValidation, investigation, writing \u0026ndash; review \u0026amp; editing, funding acquisition.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSuzanne Dawson (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSupervision, investigation, writing \u0026ndash; review \u0026amp; editing, funding acquisition.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSarah Hunter (SH)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eConceptualisation, methodology, writing \u0026ndash; review \u0026amp; editing, funding acquisition.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnthony K. J. Smith (AS)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWriting \u0026ndash; review \u0026amp; editing, funding acquisition.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eShoshana Rosenberg (SKR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSupervision, funding acquisition, conceptualisation.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eMaterials\u003c/p\u003e\n\u003ch3\u003eEthnographic Materials\u003c/h3\u003e\n\u003cp\u003eThe researchers kept ethnographic field notes describing their observations during and experiences of the research process. This included: 1) Notes detailing observations made or questions asked by participants while completing the Mi-PARIHS or an informal interview; 2) Notes detailing their experiences and observations of the built environment (including photographs); and 3) Reflexive accounts of their experiences while conducting the research, including resonances with their own lived experiences, the literature, and broader conceptual reflections.\u003c/p\u003e\n\u003ch3\u003eThe Mi-PARIHS facilitation planning tool\u003c/h3\u003e\n\u003cp\u003eThe Mi-PARIHS Facilitation Planning Tool [18] consists of 34-items within the (non-facilitation) domains of the i-PARIHS framework; that is, items related to: 1) The \u003cem\u003einnovation\u003c/em\u003e itself; 2) \u003cem\u003eRecipients\u003c/em\u003e of the innovation; 3) The \u003cem\u003elocal context\u003c/em\u003e in which the innovation is being implemented; 4) The \u003cem\u003eorganisational context\u003c/em\u003e in which the innovation is being implemented; and 5) The \u003cem\u003eouter con\u003c/em\u003etext (health-systemic, inter-organisational networks, political, etc.). Participants are asked to rate each item on a scale from \u0026minus;\u0026thinsp;2 (ie., a barrier) to +\u0026thinsp;2 (ie., a facilitator). While the Mi-PARIHS provides domain total and overall total scores, it is not intended to provide a precise measurement of an underlying construct; as such, Hunter and colleagues (2023) do not report psychometrics. The data are intended, instead, to help with collective sensemaking of the context; identifying priority areas \u0026mdash; \u003cem\u003eclear\u003c/em\u003e barriers and facilitators, defined as items rated \u0026ldquo;-2\u0026rdquo; or \u0026ldquo;+2\u0026rdquo; by participants, respectively \u0026mdash; for facilitation during implementation.\u003c/p\u003e\u003cp\u003eProcedure\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eWalkthroughs\u003c/h2\u003e\u003cp\u003eIn-person walkthroughs of each service delivery site were conducted by SR, accompanied by HCWs from the site and by a clinical member of the research team (SN or SD) and, where available, by DT or SS. After this \u0026ldquo;walk-through\u0026rdquo;, SR sat somewhere private with the HCW(s) that had walked them through the service, and completed the Mi-PARIHS facilitation planning tool. In parallel to completing this tool, SR noted any comments next to these questions that the HCW(s) made; these were included for analysis with the ethnographic field notes.\u003c/p\u003e\u003cp\u003eIn parallel to these walk-throughs, DT invited with named knowledge-holders in roles outside of individual sites to participate. If they agreed to an informal conversation, or to DT observing their work, DT and the participants met online or in-person. These meetings lasted between 10 minutes and 3 hours depending on the participant\u0026rsquo;s availability. The field notes taken by DT were included for coding to the Mi-PARIHS domains and treated as applying across all sites, unless a participant specifically disclaimed they were speaking to a specific site\u0026rsquo;s context.\u003c/p\u003e\u003cp\u003eNeither the walkthroughs or informal conversations/observations were audio or video recorded, but SR and DT kept field notes. In total, 26,468 words of field notes were captured across 14 sites and six follow-up, informal meetings with administrative stakeholders. The average length of these field notes was 1471 words (sd\u0026thinsp;=\u0026thinsp;888 words). Notes were handwritten, and then transcribed into NVIVO 14 [25].\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eAnalysis Plan\u003c/h3\u003e\n\u003cp\u003eFramework code\u003c/p\u003e\u003cp\u003eDT systematically read through the ethnographic field notes four times, coding semantic units of the text to each of the Mi-PARIHS items to saturation [26]. These codes were reviewed by authors DR, SR, and SS, with any disagreements resolved through consensus. Counts of codes to items are reported below.\u003c/p\u003e\u003cp\u003eMi-PARIHS Facilitation Planning Tool Data\u003c/p\u003e\u003cp\u003eIdentification, classification, and aggregation of site barriers and facilitators. We first used the Mi-PARIHS data to identify and classify barriers and facilitators across sites. Where an item was exclusively identified as either a barrier or facilitator across sites, we labelled these items as \u0026ldquo;significant\u0026rdquo; barriers or facilitators. Items that were both barriers and facilitators at different sites were labelled \u0026ldquo;context-dependent\u0026rdquo; barriers or facilitators. We provided ridgeline plots (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u0026ndash;Figure 6) of response distributions, generated using the R statistical programming language and associated libraries [27\u0026ndash;30], to help the reader make sense of the distribution and directionality of participant responses to each item.\u003c/p\u003e\u003cp\u003eBetween-domains analysis. Second, we explored the relationships \u003cem\u003ebetween\u003c/em\u003e Mi-PARIHS domains across the whole sample. We conducted a Kruskal-Wallis H Test to establish whether there were significant differences in mean ratings between-domains, with Bonferroni-adjusted Wilcoxon signed-rank tests to establish between which domains these effects were significant; graphically represented with ridgeline plots [27\u0026ndash;31].\u003c/p\u003e\u003cp\u003eBetween-items analysis. We utilised network analysis approaches to explore relationships between items across the whole sample [15]. The use of network methods to establish how constructs measured by rating scales reinforce or inhibit one another has shown promising results in the psychology literature [15,19]. Mi-PARIHS items are understood to uniquely play-out within the context of the implementation site [18], and therefore require methods of analysis designed to exploratorily tease their interrelationships out \u003cem\u003ewithin\u003c/em\u003e the study data [15,18]. To achieve this in the context of the Mi-PARIHS results, we first generated a spearman correlation matrix of Mi-PARIHS items (reported, alongside assumptions testing, in Appendix A) [29\u0026ndash;34], and then \u0026mdash; using a cutoff of r\u003csub\u003es\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6 \u0026mdash; generated a network graph of item relationships, ordered with Hu\u0026rsquo;s proportional algorithm [15,35,36]. We provide an exploratory analysis of the generated graph in the results [15], and \u0026mdash; from this exploratory analysis \u0026mdash; generated a Causal Loop Diagram (CLD); articulating testable, hypothetical causal relationships that may enable or inhibit the implementation [37].\u003c/p\u003e\u003cp\u003eData Mixing\u003c/p\u003e\u003cp\u003eFinally, we utilised the framework coded ethnographic field notes throughout to provide readers with examples from this corpus that illuminated the range of responses given by participants within each item.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOur framework coding resulted in 649 attributions of text to Mi-PARIHS items (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The Mi-PARIHS identified fifteen contextual barriers, nineteen significant facilitators, and no significant barriers (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cem\u003eMi-PARIHS codebook for framework code of ethnographic field notes, including counts of coded segments (references) and number of files in which Mi-PARIHS construct was coded.\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eMi-PARIHS Question \u0026amp; Domain\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eReferences (N.)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eFiles (N)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cem\u003eInnovation\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e56\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003e16\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe LGBTQ\u0026thinsp;+\u0026thinsp;Model of Care is informed by strong evidence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe LGBTQ\u0026thinsp;+\u0026thinsp;Model of Care is accessible and useable\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe LGBTQ\u0026thinsp;+\u0026thinsp;Model of Care requires adaptation or tailoring to implement\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe LGBTQ\u0026thinsp;+\u0026thinsp;Model of Care has clear outcome measures\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe LGBTQ\u0026thinsp;+\u0026thinsp;Model of Care will be trusted\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe LGBTQ\u0026thinsp;+\u0026thinsp;Model of Care offers an advantage over current practice\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cem\u003eRecipients\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e151\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003e29\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThere is local data that supports the need to introduce the LGBTQ\u0026thinsp;+\u0026thinsp;Model of Care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIndividuals/team want to implement the LGBTQ\u0026thinsp;+\u0026thinsp;Model of Care in practice\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThere is a shared view on LGBTQ\u0026thinsp;+\u0026thinsp;Models of Care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eKey individuals/stakeholders are supportive of implementing the LGBTQ\u0026thinsp;+\u0026thinsp;Model of Care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThere are clinical champions supportive of implementing the LGBTQ\u0026thinsp;+\u0026thinsp;Model of Care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIndividuals/team have the knowledge/skills to implement the LGBTQ\u0026thinsp;+\u0026thinsp;Model of Care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBarriers have been identified in discussion with individuals/team\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cem\u003eLocal context\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e271\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThere is sufficient time to implement the LGBTQ\u0026thinsp;+\u0026thinsp;Model of Care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThere is commitment to provide appropriate resources to implement the LGBTQ\u0026thinsp;+\u0026thinsp;Model of Care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe local infrastructure can support the implementation of the LGBTQ\u0026thinsp;+\u0026thinsp;Model of Care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIndividuals feel actively involved in decisions that affect them\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThere is clarity around individual\u0026rsquo;s roles and responsibilities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe culture supports innovation and change\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe formal and informal leaders create a vision, motivation and reinforcement for the implementation of the LGBTQ\u0026thinsp;+\u0026thinsp;Model of Care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThere is good multi-disciplinary collaboration and teamwork\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThere are mechanisms for staff to receive feedback on their work\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThere is past experience of implementing change\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThere is a learning and innovation culture\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cem\u003eOrganisational context\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e125\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe LGBTQ\u0026thinsp;+\u0026thinsp;Model of Care aligns with the strategic priorities of the organisation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe organisation has systems and processes in place that will support the implementation of the LGBTQ\u0026thinsp;+\u0026thinsp;Model of Care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe organisational culture supports innovation and change\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThere is a history of successful and sustained change across the organisation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe organisational values are clear\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOrganisational and/or senior leaders support opportunities for engagement and consultation from consumers, public and staff\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOrganisational and/or senior leaders actively engage with local staff\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cem\u003eOuter context\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe LGBTQ\u0026thinsp;+\u0026thinsp;Model of Care aligns with the strategic priorities of the wider health system\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThere are incentives or disincentives that reinforce the implementation of the LGBTQ\u0026thinsp;+\u0026thinsp;Model of Care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThere are inter-organisational networks that would be helpful\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e649\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e32\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cem\u003eDescriptive statistics \u0026amp; barrier/facilitator classifications \u0026mdash; Mi-PARIHS data.\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eMi-PARIHS Question \u0026amp; Domain\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMax\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eSE\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eMin\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eClassification\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cem\u003eInnovation\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe LGBTQ\u0026thinsp;+\u0026thinsp;Model of Care is informed by strong evidence.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eContextual\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe LGBTQ\u0026thinsp;+\u0026thinsp;Model of Care is accessible and useable.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eContextual\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe LGBTQ\u0026thinsp;+\u0026thinsp;Model of Care requires adaptation or tailoring to implement.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eFacilitator\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe LGBTQ\u0026thinsp;+\u0026thinsp;Model of Care has clear outcome measures.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eContextual\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe LGBTQ\u0026thinsp;+\u0026thinsp;Model of Care will be trusted.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eFacilitator\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe LGBTQ\u0026thinsp;+\u0026thinsp;Model of Care offers an advantage over current practice.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eFacilitator\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cem\u003eRecipients\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThere is local data that supports the need to introduce the LGBTQ\u0026thinsp;+\u0026thinsp;Model of Care .\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eContextual\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIndividuals/team want to implement the LGBTQ\u0026thinsp;+\u0026thinsp;Model of Care in practice.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eFacilitator\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThere is a shared view on LGBTQ\u0026thinsp;+\u0026thinsp;Models of Care.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eFacilitator\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eKey individuals/stakeholders are supportive of implementing the LGBTQ\u0026thinsp;+\u0026thinsp;Model of Care.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eFacilitator\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThere are clinical champions supportive of implementing the LGBTQ\u0026thinsp;+\u0026thinsp;Model of Care.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eContextual\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIndividuals/team have the knowledge/skills to implement the LGBTQ\u0026thinsp;+\u0026thinsp;Model of Care.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eFacilitator\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBarriers have been identified in discussion with individuals/team.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eFacilitator\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cem\u003eLocal context\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThere is sufficient time to implement the LGBTQ\u0026thinsp;+\u0026thinsp;Model of Care.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eContextual\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThere is commitment to provide appropriate resources to implement the LGBTQ\u0026thinsp;+\u0026thinsp;Model of Care.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eContextual\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe local infrastructure can support the implementation of the LGBTQ\u0026thinsp;+\u0026thinsp;Model of Care.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eContextual\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIndividuals feel actively involved in decisions that affect them.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eContextual\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThere is clarity around individual\u0026rsquo;s roles and responsibilities.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eFacilitator\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe culture supports innovation and change.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eFacilitator\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe formal and informal leaders create a vision, motivation and reinforcement for the implementation of the LGBTQ\u0026thinsp;+\u0026thinsp;Model of Care.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eFacilitator\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThere is good multi-disciplinary collaboration and teamwork.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eFacilitator\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThere are mechanisms for staff to receive feedback on their work.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eFacilitator\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThere is past experience of implementing change.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eFacilitator\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThere is a learning and innovation culture.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eFacilitator\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cem\u003eOrganisational context\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe LGBTQ\u0026thinsp;+\u0026thinsp;Model of Care aligns with the strategic priorities of the organisation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eContextual\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe organisation has systems and processes in place that will support the implementation of the LGBTQ\u0026thinsp;+\u0026thinsp;Model of Care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eFacilitator\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe organisational culture supports innovation and change.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eFacilitator\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThere is a history of successful and sustained change across the organisation.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eFacilitator\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe organisational values are clear.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eContextual\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOrganisational and/or senior leaders support opportunities for engagement and consultation from consumers, public and staff.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eContextual\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cem\u003eOuter context\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOrganisational and/or senior leaders actively engage with local staff\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eContextual\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe LGBTQ\u0026thinsp;+\u0026thinsp;Model of Care aligns with the strategic priorities of the wider health system.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eContextual\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThere are incentives or disincentives that reinforce the implementation of the LGBTQ\u0026thinsp;+\u0026thinsp;Model of Care.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eFacilitator\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThere are inter-organisational networks that would be helpful\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eContextual\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eWithin-domain findings\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eInnovation\u003c/h2\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eHCWs identified \u003cem\u003etrustworthiness\u003c/em\u003e as the most significant facilitator in this domain. HCWs attributed this to being \u003cem\u003einformed by strong evidence\u003c/em\u003e. One participant gave a lower score \u0026ldquo;\u003cem\u003ewith a comment that \u0026lsquo;more learning would be good for sure\u0026rsquo;\u003c/em\u003e\u0026rdquo;, indicating that their rating was a reflection of their own lack of awareness of the evidence base.\u003c/p\u003e\u003cp\u003eThe \u003cem\u003eadvantage over current practice\u003c/em\u003e such a change would represent was clear to most; \u0026ldquo;\u003cem\u003e[the LHN] does need to do better and to fund more work for LGBTQ\u0026thinsp;+\u0026thinsp;care\u003c/em\u003e\u0026rdquo;. However, this was less clear to some HCWs \u0026mdash; \u003cem\u003e\u0026ldquo;\u0026rsquo;There are no complaints about it\u0026rsquo; (lack of LGBTQ\u0026thinsp;+\u0026thinsp;friendliness; lack of LGBTQ\u0026thinsp;+\u0026thinsp;inclusion)\u0026rdquo; \u0026mdash;\u003c/em\u003e indicating that there is work to be done in articulating the benefits of the change over current practice.\u003c/p\u003e\u003cp\u003eHCWs agreed that the model would require \u003cem\u003eadaptation or tailoring\u003c/em\u003e. We were cautioned by participants not to be too directive; \"\u003cem\u003e\u0026rsquo;I think if you're talking about how you communicate with [patients] that's trickier... People resist this, \u0026lsquo;I can talk to people how I want\u0026rsquo;. You have to give a strong reasoning\u003c/em\u003e.\u0026rdquo;\u003c/p\u003e\u003cp\u003eHCWs were broadly positive about \u003cem\u003ethe accessibility and usability of an LGBTQ\u0026thinsp;+\u0026thinsp;model of care\u003c/em\u003e in their context. Indeed \u0026mdash; as one participant put it \u0026mdash; \u0026ldquo;\u003cem\u003eMany service users are in fact LGBTQ+\u003c/em\u003e\u0026rdquo;, and as a result \u0026mdash; as another participant put it \u0026mdash; \u0026ldquo;\u003cem\u003eStaff take up opportunities for training, look for resources and LGBTQ\u0026thinsp;+\u0026thinsp;practice is discussed at meetings\u003c/em\u003e\u0026rdquo;; there is already awareness, investment, and engagement with these issues.\u003c/p\u003e\u003cp\u003eHCWs were less confident about how \u003cem\u003eclear the outcome measures\u003c/em\u003e for change are. While the \u0026ldquo;\u003cem\u003eYES survey can be used\u003c/em\u003e\u0026rdquo; \u0026mdash; the Australian national standard measure for mental health consumer experiences [38]\u0026mdash; with some modifications, some HCWs were less sure. As one participant put it, \u0026ldquo;\u003cem\u003eit will be clear\u0026hellip; when we know what we are doing and start to track it.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eRecipients\u003c/h2\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eIn this domain, HCWs most highly rated \u003cem\u003ekey individuals/stakeholders are supportive of implementation\u003c/em\u003e. HCWs identified local LGBTQ\u0026thinsp;+\u0026thinsp;champions, managers, and frontline staff as key \u0026mdash; in the words of one participant, \u0026ldquo;\u003cem\u003ehonestly it is everyone\u003c/em\u003e\u0026rdquo; \u0026mdash; to the success of the implementation.\u003c/p\u003e\u003cp\u003eIt follows that HCWs broadly positively rated that, within their teams, there was \u003cem\u003ea shared view on LGBTQ\u0026thinsp;+\u0026thinsp;Models of Care\u003c/em\u003e and that \u003cem\u003eindividuals and teams want to implement\u003c/em\u003e. Participants indicated that \u0026ldquo;\u003cem\u003eThe majority is in favour\u003c/em\u003e\u0026rdquo;, despite it being \u0026ldquo;\u003cem\u003ehard to get 100% on anything\u003c/em\u003e\u0026rdquo;.\u003c/p\u003e\u003cp\u003eMost sites had \u003cem\u003eclinical champions supportive of implementation.\u003c/em\u003e These team members were highly valued and broadly effective, hence high scores on this item. The site that rated this item as a significant barrier \u003cem\u003e\u0026ldquo;claimed no staff there are LGBTQIA+\u0026hellip; [within] a team of 300\u003c/em\u003e\u0026rdquo;. Population estimates lead us to expect that between 10\u0026ndash;12 staff at this site would likely identify as LGBTQIA+ [39].\u003c/p\u003e\u003cp\u003eWhere HCWs identified, at their site, that \u003cem\u003eindividuals and teams have the knowledge and skills to implement\u003c/em\u003e, this was \u0026ldquo;\u003cem\u003ebecause they are proactive about training\u003c/em\u003e\u0026rdquo;. Most participants, on the balance, acknowledged their teams had the \u0026ldquo;\u003cem\u003eskills but not the knowledge\u0026hellip; They have the insight to know they could do better \u0026hellip; but they need guidance\u003c/em\u003e\u0026rdquo;.\u003c/p\u003e\u003cp\u003eSome participants\u0026rsquo; teams anticipated our visit, and as such \u003cem\u003ebarriers had been identified.\u003c/em\u003e For example, large, changing teams \u0026mdash; especially within 24/7 services, like hospitals \u0026mdash; which can \u0026ldquo;\u003cem\u003emake it hard to get everyone onboard\u0026rdquo;\u003c/em\u003e and team \u0026ldquo;\u003cem\u003eindifference\u003c/em\u003e\u0026rdquo; \u0026mdash; \u0026ldquo;\u003cem\u003esome staff (especially older staff) are forgetful of the correct pronouns of a service user. This seems not\u0026hellip; malicious but is unhelpful.\u003c/em\u003e\u0026rdquo;\u003c/p\u003e\u003cp\u003eThe item in this domain in which HCWs were most divided was whether \u003cem\u003ethere are local data that support the need to introduce the LGBTQ\u0026thinsp;+\u0026thinsp;model of care\u003c/em\u003e. Where this was scored low, it was generally in acknowledgment of Electronic Medical Record (EMR) limitations (discussed in the \u003cem\u003eLocal Context\u003c/em\u003e results). \u003cem\u003eHowever\u003c/em\u003e, where this was rated more highly, this was reflective of the ways in which informal, anecdotal, and data from other sources For example, \u0026ldquo;\u003cem\u003ethe youth clinic [at site] are aware that 30\u0026ndash;40% of their clients are LGBTQ+\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eLocal Context\u003c/h2\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eParticipants were unanimous in agreeing that the LHN\u0026rsquo;s MHS have \u003cem\u003egood multi-disciplinary collaboration\u003c/em\u003e, and robust \u003cem\u003emechanisms for staff to receive feedback on their work\u003c/em\u003e. Within this item, and within the \u003cem\u003eindividuals feel actively involved in decisions that affect them\u003c/em\u003e item, consumer feedback was named as what \u003cem\u003e\u0026ldquo;guides practice\u0026rdquo;\u003c/em\u003e at a number of sites. However, some participants noted the current form of the Your Experience of Service (YES) survey [38] should be replaced by a shorter-form, and include demographic markers for gender, sexuality, and cultural identification.\u003c/p\u003e\u003cp\u003eTwo sites rated the \u003cem\u003eindividuals feel actively involved in decisions\u003c/em\u003e item as 0 and \u0026minus;\u0026thinsp;2. The former, interestingly, was the only site in which administrative staff were involved in filling out the Mi-PARIHS tool; a cohort that \u0026ldquo;\u003cem\u003efeel overworked and that they are already being asked to do things that clinical staff should do for themselves.\u003c/em\u003e\u0026rdquo; The latter pushed-back on what they perceived the model of care might be, \u0026ldquo;\u003cem\u003eThere is anecdotal feedback from service users that they would like to have LGBTIQA\u0026thinsp;+\u0026thinsp;sensitive practice\u0026hellip; [but] sometimes attempts to improve things backfire or are not suitable for everyone.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eParticipants were also highly positive about \u003cem\u003eformal and informal leaders creating a vision, motivation and reinforcement for the implementation\u003c/em\u003e. This highly positive result reflects the value of and respect for the work of LGBTQ\u0026thinsp;+\u0026thinsp;champions.\u003c/p\u003e\u003cp\u003eParticipants broadly felt \u003cem\u003ethere is clarity around individual\u0026rsquo;s roles and responsibilities\u003c/em\u003e. However, they observed this was not universal for all HCWs; some staff had an \u0026ldquo;\u003cem\u003eattitude [of] \u0026lsquo;Why do I have to?\u0026rsquo;, \u0026lsquo;Why can\u0026rsquo;t I just treat everyone the same\u0026rsquo;\u0026rdquo;\u003c/em\u003e. Finally, in terms of LGBTQ\u0026thinsp;+\u0026thinsp;staff, it was identified that more clarity was needed in both the LHN\u0026rsquo;s HR systems and in the policy space.\u003c/p\u003e\u003cp\u003eParticipant responses for \u003cem\u003epast experiences of implementing change\u003c/em\u003e, \u003cem\u003eculture supporting innovation and change\u003c/em\u003e, and \u003cem\u003elearning and innovation culture\u003c/em\u003e broadly clustered around efforts their sites had already made towards LGBTQ\u0026thinsp;+\u0026thinsp;inclusion. For example, \u0026ldquo;\u003cem\u003eThe practice is trans-affirming in terms of use of names\u0026rdquo;.\u003c/em\u003e Barriers named by participants within these items were broadly encapsulated in infrastructure, resourcing, and time items.\u003c/p\u003e\u003cp\u003eThere was disagreement amongst participants \u003cem\u003ewhether the local infrastructure can support the implementation\u003c/em\u003e. Where this was scored low, it was generally in acknowledgment that the primary EMR is unable to capture gender and sexuality data. Even where ratings were higher, participants acknowledged these limitations: \u0026ldquo;\u003cem\u003e[while] It\u0026rsquo;s possible to free text and add notes about a patient\u0026rsquo;s gender or sexual orientation\u0026hellip; there is only one section to do this so busy doctors who have very urgent notes to write will just delete whatever is there and write their notes.\u003c/em\u003e\u0026rdquo;\u003c/p\u003e\u003cp\u003eParticipants were also unsure if there was \u003cem\u003ecommitment to provide appropriate resources to implement\u003c/em\u003e. We note that existing attempts by HCWs to make their spaces more inclusive are often \u0026ldquo;\u003cem\u003epaid for by staff themselves. On the one hand it shows that staff really are committed, on the other hand it\u0026rsquo;s not sustainable for staff to carry responsibility for this or other ways of making the space welcoming.\u003c/em\u003e\u0026rdquo;\u003c/p\u003e\u003cp\u003eFinally, participants broadly felt there was not \u003cem\u003esufficient time to implement an LGBTQ\u0026thinsp;+\u0026thinsp;model of care\u003c/em\u003e. As one participant begrudgingly put it, \u0026ldquo;\u003cem\u003eif we have to we will make time\u003c/em\u003e\u0026rdquo;. However, as one participant explained, \u0026ldquo;\u003cem\u003ewe are busy\u0026hellip; so [that means] it needs to be embedded like good First Nations practice, become routine\u0026rdquo;\u003c/em\u003e; the role of the researchers \u0026mdash; and, particularly, the facilitators and implementation specialists in later phases of the project \u0026mdash; is, in this framing, to ensure our model \u003cem\u003ecan\u003c/em\u003e become embedded in this manner.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eOrganisational Context\u003c/h2\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eParticipants broadly agreed that the LHN\u0026rsquo;s \u003cem\u003eorganisational culture supports innovation and change\u003c/em\u003e \u0026ndash; having a strong focus on \u0026ldquo;\u003cem\u003econtinuous improvement\u0026hellip; compared to other LHNs\u0026rdquo;\u003c/em\u003e. This was also reflected in how \u003cem\u003eorganisation and senior leaders support opportunities for engagement\u003c/em\u003e \u0026mdash; \u0026ldquo;\u003cem\u003epatient voice and decision-making is centred\u003c/em\u003e\u0026rdquo; \u0026mdash; but one participant did note that, in their experience, \u0026ldquo;\u003cem\u003eformal channels are very tied to organisational prerogative which\u0026hellip; [can be] disconnected from the material reality of patients and staff.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eOne participant \u003cem\u003edescribed the organisation\u0026rsquo;s systems and processes that will support the implementation\u003c/em\u003e as \u0026ldquo;\u003cem\u003ea work in progress\u003c/em\u003e\u0026rdquo;. While most participants were able to identify positive steps in the right direction that had already been made by the LHN, there was a sense in the responses that this was in early stages and that our implementation could build on this momentum.\u003c/p\u003e\u003cp\u003eParticipants identified that \u003cem\u003ethere is a history of successful and sustained change across the organisation\u003c/em\u003e. A senior worker in the administrative core described the success of changes within the LHN and within LHNs more broadly as coming from \u0026ldquo;\u003cem\u003ehaving respect from the broader group that you know the subject matter\u0026hellip; [and if you do not, then] \u0026lsquo;bring along\u0026rsquo; [senior clinicians] and develop them as clinical champions\u003c/em\u003e\u0026rdquo;.\u003c/p\u003e\u003cp\u003e\u003cem\u003eThe organisational values were clear\u003c/em\u003e to most participants, however a few did clarify that \u0026mdash; \u0026ldquo;\u003cem\u003e[they\u0026rsquo;re clear] for the general public but not for LGBTQ\u0026thinsp;+\u0026thinsp;people. Not for Indigenous health.\u0026rdquo;\u003c/em\u003e While we note that the LHN\u0026rsquo;s core priorities, as published, include delivering equitable services to diverse populations, we acknowledge that these participants were most likely referring to whether or not they perceived this priority as clear, well articulated, or as having materially changed care on the ground for these populations. This reasoning was echoed by the same group of participants in their ratings of \u003cem\u003ethe alignment of the implementation with the strategic priorities of the organisation\u003c/em\u003e.\u003c/p\u003e\u003cp\u003eParticipants reported that \u003cem\u003eorganisational leaders actively engage with local staff\u003c/em\u003e. Indeed, one site noted that they were \u0026ldquo;\u003cem\u003every proud to say that the idea of having LGBTIQA\u0026thinsp;+\u0026thinsp;champions [was] their own initiative\u003c/em\u003e\u0026rdquo;, and that the spread of this to other sites was something they were honoured to have had taken up by senior leaders. Where this was rated lower participants did not provide specific feedback, however we note that their sites were further geographically removed than others.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eOuter Context\u003c/h2\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eThe LGBTQ\u0026thinsp;+\u0026thinsp;model of care aligns with the strategic priorities of the wider health system\u003c/em\u003e in the view of participants in this study; \u003cem\u003e\u0026ldquo;I think that moving from a biomedical model of care to a psychosocial determinants perspective is where health is slowly headed\u003c/em\u003e.\u0026rdquo; One participant felt LGBTQ\u0026thinsp;+\u0026thinsp;people in general were \u003cem\u003emade\u003c/em\u003e a low priority by health systems. In short, there is still work to be done to shift these priorities across health more broadly, although they \u003cem\u003eare\u003c/em\u003e shifting.\u003c/p\u003e\u003cp\u003eThis was echoed by participants\u0026rsquo; descriptions of \u003cem\u003eincentives or disincentives that reinforce the implementation.\u003c/em\u003e Participants made it clear that there were health-systemic incentives to implementing the model of care from a health prevention perspective \u0026mdash; \u0026ldquo;\u003cem\u003epatients would feel valued [and therefore] would be willing to present\u0026hellip;\u0026rdquo;\u003c/em\u003e \u0026mdash; however, participants also expressed concerns about the lack of a clear leader within the DHW for inclusion; \u0026ldquo;\u003cem\u003e\u0026hellip; it\u0026rsquo;s difficult not having someone who can be that central person [to work towards change]\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eFinally, participants identified \u003cem\u003einter-organisational networks that would be helpful\u003c/em\u003e in most cases, and \u0026ldquo;\u003cem\u003eeven though [participant] couldn\u0026rsquo;t name SHINE, Minus 18, Thorne Harbor, once I did he said \u0026ldquo;oh yeah that\u0026rsquo;s all the stuff I found online when I needed resources for a trans patient\u0026rdquo;... there is an ability to find them\u003c/em\u003e.\u0026rdquo; These networks were also important for providing training and information, with participants repeatedly naming silver rainbow training (facilitated by Thorne Harbour Health) and SHINE\u0026rsquo;s online LGBTQ\u0026thinsp;+\u0026thinsp;training.\u003c/p\u003e\u003cp\u003eBetween-domains findings\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eMean response distributions across domains\u003c/h2\u003e\u003cp\u003eA Kruskal-Wallis H-Test showed there was a significant, but small difference in distribution of ratings across domains (Fig.\u0026nbsp;6; \u003cem\u003eH\u003c/em\u003e\u0026thinsp;=\u0026thinsp;17.596, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0015, \u003cem\u003eη\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u0026thinsp;\u003cem\u003e=\u003c/em\u003e\u0026thinsp;0.04). While pairwise, Bonferroni-adjusted Wilcoxon signed-rank tests found significant differences between the \u003cem\u003eOrganisational Context\u003c/em\u003e domain and the \u003cem\u003eInnovation\u003c/em\u003e (Bonferroni adjusted \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.017) and \u003cem\u003eRecipients\u003c/em\u003e (Bonferroni adjusted \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0007) domains, the small effect sizes (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.26 and \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.32, respectively) indicate caution in over-interpreting these domains as the primary target for facilitator intervention within the implementation of the LGBTQ\u0026thinsp;+\u0026thinsp;model of care.\u003c/p\u003e\u003cp\u003eFigure 6\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eRidgeline plot showing the distribution of mean item ratings within Mi-PARIHS domains\u003c/h2\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eCorrelative relationships between items\u003c/h2\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe items with no moderate or greater correlations with other items were \u003cem\u003eIndividuals/teams have the knowledge and skills\u003c/em\u003e (recipients), \u003cem\u003ecommitment to provide appropriate resources to implemen\u003c/em\u003et (local context), \u003cem\u003eformal and informal leaders create a vision\u003c/em\u003e (local context), \u003cem\u003egood multi-disciplinary collaborati\u003c/em\u003eon (local context\u003cem\u003e), past experience of implementing change\u003c/em\u003e (local context), and \u003cem\u003eincentives or disincentives that reinforce\u003c/em\u003e (outer context). As such, these items are excluded from this graph.\u003c/p\u003e\u003cp\u003e28/34 items in the Mi-PARIHS had a moderate (\u0026gt;\u0026thinsp;r\u003csub\u003es\u003c/sub\u003e\u0026thinsp;\u0026ge;\u0026thinsp;+\u0026thinsp;0.60 | \u0026le;-0.60) or greater correlation with another item within the scale. There are two highly connected sub-graphs within Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e7\u003c/span\u003e, connected (therefore, mediated) by a string of components conceptualisable as \u0026ldquo;\u003cem\u003eroles, values, engagement, and consultation\u003c/em\u003e\u0026rdquo;. We refined these two sub-graphs, and presented them as a CLD (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eExploratory causal model of local and organisational leadership factors supporting implementation\u003c/h2\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe central column of mediating roles, values, and engagement \u0026amp; consultation factors is represented in a reduced form here by the green, dashed-outline circle.\u003c/p\u003e\u003cp\u003eDashed lines are used in the CLD to indicate correlative relationships that were below our cutoff-point for generating the correlation network diagram, but that were nonetheless theoretically sound relationships and therefore worthwhile including in the CLD. The relationship between \u003cem\u003eOrganisational cultural supports innovation and change\u003c/em\u003e \u0026amp; \u003cem\u003esufficient time\u003c/em\u003e was r\u003csub\u003es\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;+\u0026thinsp;0.54. The relationship between \u003cem\u003eClinical champions supportive of implementation\u003c/em\u003e \u0026amp; \u003cem\u003ebarriers identified in discussions\u003c/em\u003e was r\u003csub\u003es\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;+\u0026thinsp;0.49. The relationship between \u003cem\u003eLocal Infrastructure cannot support\u003c/em\u003e and \u003cem\u003eclear outcomes\u003c/em\u003e was r\u003csub\u003es\u003c/sub\u003e = -4.2, \u003cem\u003eLocal Infrastructure cannot support\u003c/em\u003e and \u003cem\u003etrustworthy\u003c/em\u003e was r\u003csub\u003es\u003c/sub\u003e = -4.5.\u003c/p\u003e\u003cp\u003eThe top loop of the CLD represents factors that are broadly the domain of \u003cem\u003eor\u003c/em\u003e strongly influenced by organisational leaders\u0026rsquo; decisions. \u003cem\u003eHealth systemic priorities\u003c/em\u003e shape \u003cem\u003eorganisational innovation and change cultures\u003c/em\u003e both directly, and through the ways in which these priorities shape \u003cem\u003esystems and processes within health services\u003c/em\u003e and, in turn, how \u003cem\u003esenior leaders engage with local staff\u003c/em\u003e. A healthy \u003cem\u003einnovation and change culture\u003c/em\u003e is one that allots \u003cem\u003esufficient time\u003c/em\u003e to implement change. This time, in turn, enables a \u003cem\u003elearning and innovation culture\u003c/em\u003e within sites; a culture which, when healthy and where there is sufficient time, produces \u003cem\u003eclinical champions for change\u003c/em\u003e within sites. These champions, mediated by the chain of local and organisational factors connecting these two loops \u003cem\u003eand\u003c/em\u003e the local factors supporting implementation, build towards a \u003cem\u003ehistory of sustained change\u003c/em\u003e; with these \u003cem\u003esustained changes\u003c/em\u003e in turn \u003cem\u003einforming wider health systemic priorities\u003c/em\u003e.\u003c/p\u003e\u003cp\u003eThe bottom loop within the CLD represents factors that are broadly within the immediate locus of local sites and facilitators. Beginning at the top of the loop, the \u003cem\u003estrategic priorities of the organisation\u003c/em\u003e are key to producing the circumstances where \u003cem\u003eindividuals can feel involved in decisions affecting them\u003c/em\u003e. This enables individuals to speak-up in \u003cem\u003ediscussions of barriers to changes\u003c/em\u003e, which \u0026mdash; as they are engaged in evaluating the change through speaking up \u0026mdash; enables them to clearly see outcomes of the change and \u0026mdash; if positive \u0026mdash; \u003cem\u003etrust\u003c/em\u003e the change. We also note the weak, but present, mediation of \u003cem\u003eclinical champions\u003c/em\u003e to identifying barriers. The only negative feedback loop within this CLD \u003cem\u003ealso\u003c/em\u003e mediates this sub-loop; with \u003cem\u003elocal infrastructure\u0026rsquo;s\u003c/em\u003e inability to provide insights into LGBTQ\u0026thinsp;+\u0026thinsp;patient outcomes eroding \u003cem\u003etrustworthiness\u003c/em\u003e and, in turn, \u003cem\u003eclear outcomes\u003c/em\u003e and the \u003cem\u003eidentification of barriers\u003c/em\u003e. While complex, this series of relationships are crucial as, where this trust exists, it enables engagement with the possibility that the change might be \u003cem\u003eadvantageous over current practice\u003c/em\u003e. However, this sense of \u003cem\u003eadvantage over current practice\u003c/em\u003e is \u003cem\u003ealso\u003c/em\u003e shaped by \u003cem\u003einter-organisational networks\u003c/em\u003e; particularly, in our sample, through the trainings offered by LGBTQ\u0026thinsp;+\u0026thinsp;organisations which \u003cem\u003ealso\u003c/em\u003e enforce the advantages LGBTQ\u0026thinsp;+\u0026thinsp;models of care have over business-as-usual. This ability to engage with the potential advantageousness of the change encourages HCWs to collect their own data (ideally reinforced through empirical data collection) about the effectiveness of the change which, as these data enable \u003cem\u003ecomparison\u003c/em\u003e, in turn supports the growth of the site\u0026rsquo;s own \u003cem\u003eculture of innovation and change\u003c/em\u003e. As values shift, so do people\u0026rsquo;s \u003cem\u003edesire to engage\u003c/em\u003e in implementing changes, which in turn feeds back through the levels of the organisation to shift the \u003cem\u003estrategic priorities of the organisation\u003c/em\u003e.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis rapid context assessment provides illuminating initial insights for further investigation. The novel, complexity science-informed approach to analysis presented within this paper allowed us to operationalise our conception of \u0026ldquo;holistic\u0026rdquo; to specific, actionable targets for facilitation. This would not have been possible to the same extent from traditional quantitative or qualitative inquiries into these data alone. First, the Kruskal-Wallis analysis of the i-PARIHS results showed no one domain substantively presented more barriers than another; \u003cem\u003euntangling\u003c/em\u003e and \u003cem\u003emaking sense of\u003c/em\u003e this result was only made possible through the network analytic results. Second, this approach also has positive implications for the continuous evaluation of the implementation while in motion, an important component of the i-PARIHS framework (and use-case for the Mi-PARIHS) [16\u0026ndash;18]. While measuring the impact of our intended implementation\u0026rsquo;s impact on removing some of the barriers is simple \u0026mdash; for example, the proposed changes to the LHN\u0026rsquo;s EMR being completed (or not) by the LHN and DHW is binary \u0026mdash; others are more fraught \u0026mdash; such as trying to unpack whether HCWs have enough time [40]. CLDs imply causal dependence, and as such also imply distal measures for establishing convergent validity of measurements of constructs in the Mi-PARIHS; \u003cem\u003esufficient time\u003c/em\u003e, for example, can be distally convergently validated through attendance at training sessions offered as part of the implementation (ie., \u003cem\u003elearning and innovation culture\u003c/em\u003e) and through the number of clinical champions at sites. Given their importance to our outcomes, we strongly recommend the integration of approaches from complexity science \u0026mdash; including those demonstrated in this study \u0026mdash; into implementation science methodologies more broadly.\u003c/p\u003e\u003cp\u003eRecommendations\u003c/p\u003e\u003cp\u003eThe results demonstrate that we must fully consider the interplay between different levels of the Health Network in the design of our LGBTQ\u0026thinsp;+\u0026thinsp;model of care, and that we need to consider proximal and distal means of measuring the implementation in motion to ensure the success of the implementation. These considerations encourage key actions from senior leaders, the implementation team, and staff within the MHS. These recommendations broadly align with those in \u003cem\u003eThe National Action Plan\u003c/em\u003e [7]; with overlaps addressed in Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e9\u003c/span\u003e below.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eSenior leaders\u003c/h2\u003e\u003cp\u003eSenior leaders first need to act through their engagement with local staff about LGBTQ\u0026thinsp;+\u0026thinsp;issues. While so-called \u0026ldquo;performative corporate activism\u0026rdquo; \u0026mdash; social media posts, attendance at events, or more general participation in social justice causes by a corporate entity \u0026mdash; is sometimes received negatively, it is nonetheless an important and effective means of publicly establishing an organisation\u0026rsquo;s position on a social cause [41]. We encourage leaders within the LHN and the DHW to make their position clear to staff and to the general public through such actions.\u003c/p\u003e\u003cp\u003eSecond, we encourage leadership of the LHN and the DHW to \u003cem\u003ebuy-into\u003c/em\u003e this implementation process. This buy-in, in our study context, means leadership both \u003cem\u003eon the ground\u003c/em\u003e with local staff on LGBTQ\u0026thinsp;+\u0026thinsp;issues, and through the allocation of adequate resourcing; both of which were identified in our data, and in similar implementation projects in the literature, as crucial [42]. The latter is first present in our model in terms of \u003cem\u003etime\u003c/em\u003e; for learning, for the implementation to take place successfully and without impacting business as usual, and \u0026mdash; more broadly \u0026mdash; because additional time enables potential clinical champions for LGBTQ\u0026thinsp;+\u0026thinsp;patients to commit to such roles without fear for their workload management. We also encourage leadership to directly financially resource LGBTQ\u0026thinsp;+\u0026thinsp;care through the allocation of technical budget for changes to the LHN\u0026rsquo;s Electronic Medical Record (EMR) software. This infrastructure is an easy to miss barrier that substantively impedes a number of facilitators in our model; resolving this is crucial to implementation success.\u003c/p\u003e\u003cp\u003eFinally, we encourage leadership within the LHN and the DHW to engage with the broader sector \u0026mdash; both in advocating for explicit consideration of LGBTQ\u0026thinsp;+\u0026thinsp;perspectives in national standards, and strengthening partnerships with LGBTQ\u0026thinsp;+\u0026thinsp;specialist organisations that can deliver training, offer consultation \u0026mdash; on policies, procedures, and patient data systems like the LHN\u0026rsquo;s EMR, and offer referral pathways for LGBTQ\u0026thinsp;+\u0026thinsp;consumers requiring more specialised care.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003eImplementation facilitators\u003c/h2\u003e\u003cp\u003eOur results also present clear actions for the implementation facilitators. First, facilitators must clearly articulate the outcomes, trustworthiness, and advantages over current practice \u0026mdash; in terms of the evidence base, the accessibility of the model of care, and the utility to \u003cem\u003eeveryone\u0026rsquo;s\u003c/em\u003e practice \u0026mdash; that the LGBTQ\u0026thinsp;+\u0026thinsp;model of care represents, both in terms of shifting the \u003cem\u003estrategic priorities\u003c/em\u003e of the organisation, and in terms of individual HCW\u0026rsquo;s practices.\u003c/p\u003e\u003cp\u003eSecond, facilitators need to enable discussions of barriers to implementation, make individuals feel involved in decisions about how to tailor the model to their service site, and \u0026mdash; in turn \u0026mdash; support managers to build a culture of innovation and change within their sites. This will be achieved through the application of co-design methods throughout the design of, and implementation of the LGBTQ\u0026thinsp;+\u0026thinsp;model of care; leveraging and building upon the repeatedly identified, valued work being done by LGBTQ\u0026thinsp;+\u0026thinsp;champions already at work within the LHN.\u003c/p\u003e\u003cp\u003eFinally, facilitators need to involve the LGBTQ\u0026thinsp;+\u0026thinsp;specialist service delivery sector in our implementation plan, drawing on their existing authority in this space and in their expertise in training HCWs to deliver this care.\u003c/p\u003e\u003cp\u003eLimitations\u003c/p\u003e\u003cp\u003eWe acknowledge that \u0026mdash; while the Mi-PARIHS is designed for such usage [18] \u0026mdash; our sample size remains small, and potentially biased as a result. While our work contains valuable insights for researchers conducting similar implementations, we caution readers from generalising our findings wholesale. Our rapid assessment methods and the scope of this paper are firmly aligned to our implementation context. We additionally note that the responses to the Mi-PARIHS were broadly positive, something that was surprising to the research team and may indicate a research bias; those who care about this cause may be more biased to view the situation more positively. However, we note that our aggregation methodology and specifically the inclusion of and consideration afforded to \u003cem\u003econtextual\u003c/em\u003e barriers and facilitators in our analysis may help to provide some balance to the more positively-skewed responses.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis rapid context assessment ahead of implementing an LGBTQ\u0026thinsp;+\u0026thinsp;model of care within an LHN\u0026rsquo;s MHS makes clear that improving LGBTQ\u0026thinsp;+\u0026thinsp;mental health service delivery and outcomes requires a holistic approach. Utilising the novel, complexity science-derived analytic approach allowed us to explicitly operationalise what it \u003cem\u003emeans\u003c/em\u003e to be holistic in the context of our implementation project. Being able to name \u003cem\u003ecausal antecedents\u003c/em\u003e to barriers and facilitators in a way that is drawn from primary data, reinforcing rather than relying solely upon theory or from population surveys exploring health inequalities, is invaluable for both building trust in an implementation\u0026rsquo;s program of change, and for ensuring this program of change is adequately targeted. We strongly encourage the application of these techniques to other implementation projects.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eEthics approval did not require individual consent; staff within the Network were informed of the data collection, and were invited to engage (or not) with the research team. In total, two participants asked us to not keep a record of our conversation or include their comments for analysis, which we honoured.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eConsent for publication has been sought from all named authors. No individual consent for publication from participants was required due to the nature of the study.\u003c/p\u003e\n\u003cp\u003eAvailability of data\u003c/p\u003e\n\u003cp\u003eDue to the sensitivity of these data, and the potential for reidentification of participants, we have chosen to not make these data available for further analyses.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis project is funded by the Commonwealth of Australia Medical Research Futures Fund (MRFF; Project ID: APP2028317), as part of their Sexuality and Gender Diverse and Innate Variations of Sex Characteristics (Streams 1-2) Funding Program. The funder had no role in the conceptualisation, design, data collection, analysis, decision to publish, or preparation of this manuscript. Please see the MRFF funding agreement guidelines for further information.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026rsquo; contributions\u003c/p\u003e\n\u003cp\u003ePlease see Table 2 for author contributions, using the CReDIT attribution taxonomy.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eOur sincere thanks to the Southern Adelaide Local Health Network\u0026rsquo;s LGBTQI+ inclusion subcommittee for their invaluable assistance in this project.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAustralian Bureau of Statistics. Mental health findings for LGBTQ+ Australians [Internet]. ABS Website. 2024 [cited 2025 Aug 19]. https://www.abs.gov.au/articles/mental-health-findings-lgbtq-australians. Accessed 19 Aug 2025 \u003c/li\u003e\n\u003cli\u003eLampe NM, Barbee H, Tran NM, Bastow S, McKay T. Health Disparities Among Lesbian, Gay, Bisexual, Transgender, and Queer Older Adults: A Structural Competency Approach. 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Report No.: 122. https://www.latrobe.edu.au/__data/assets/pdf_file/0009/1185885/Private-Lives-3.pdf \u003c/li\u003e\n\u003cli\u003eMeyer IH. Prejudice, Social Stress, and Mental Health in Lesbian, Gay, and Bisexual Populations: Conceptual Issues and Research Evidence. Psychol Bull. 2003;129:674\u0026ndash;97. https://doi.org/10.1037/0033-2909.129.5.674 \u003c/li\u003e\n\u003cli\u003eAustralian Government Department of Health and Aged Care. National Action Plan for the Health and Wellbeing of LGBTIQA+ People 2025-2035 [Internet]. Canberra, Ngunnawal Country, ACT: Australian Government Department of Health and Aged Care; 2024 Dec. https://www.health.gov.au/sites/default/files/2024-12/national-action-plan-for-the-health-and-wellbeing-of-lgbtiqa-people-2025-2035.pdf. 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Stanford, Calif: Stanford Business Books; 2011. \u003c/li\u003e\n\u003cli\u003eAustralian Government Department of Health and Aged Care. Your Experience of Service: Australia\u0026rsquo;s National Mental Health Consumer Experience of Care Survey [Internet]. 2015 [cited 2025 Sept 10]. https://www.amhocn.org/training-and-service-development/experience-measures/application-for-use. Accessed 10 Sept 2025 \u003c/li\u003e\n\u003cli\u003eAustralian Bureau of Statistics. Estimates and characteristics of LGBTI+ populations in Australia [Internet]. Aust. Bur. Stat. Website. 2022 [cited 2025 Sept 10]. https://www.abs.gov.au/statistics/people/people-and-communities/estimates-and-characteristics-lgbti-populations-australia/latest-release. Accessed 10 Sept 2025 \u003c/li\u003e\n\u003cli\u003eGovasli L, Solvoll B-A. Nurses\u0026rsquo; experiences of busyness in their daily work. Nurs Inq. 2020;27:e12350. https://doi.org/10.1111/nin.12350 \u003c/li\u003e\n\u003cli\u003eBraga L, Grinstein A, Tardin M, Perin M. Understanding reaction to corporate activism: The moderating role of polarization. PNAS Nexus. 2024;3:313. https://doi.org/10.1093/pnasnexus/pgae313 \u003c/li\u003e\n\u003cli\u003eBeverage HN, Herschell AD. Organizational Change Strategies to Support High-Quality Behavioral Health Care for LGBTQ Individuals. Community Ment Health J. 2023;1\u0026ndash;8. https://doi.org/10.1007/s10597-023-01135-9\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"implementation-science-communications","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"iscm","sideBox":"Learn more about [Implementation Science Communications](https://implementationsciencecomms.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ISCM/default.aspx","title":"Implementation Science Communications","twitterHandle":"@ImplementSci","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8072582/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8072582/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e: A complex system of interrelated barriers across different levels of the mental health sector contribute to lesbian, gay, bisexual, trans, and queer (LGBTQ+) people experiencing significant mental health disparities compared to heterosexual and cisgender populations in Australia. With only a small number of LGBTQ + Australians accessing specialist LGBTQ + mental health services, addressing these barriers in mainstream services is crucial to health equity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod\u003c/strong\u003e: We used the Mi-PARIHS facilitation planning tool and rapid ethnography to conduct a convergent parallel mixed-methods context assessment of fourteen sites within an Australian Local Health Network’s mental health services, identifying barriers and facilitators to implementing a holistic LGBTQ + model of care. We present a novel analysis using techniques from complexity science exploring correlative interrelationships between barriers and facilitators across domains in the Mi-PARIHS data; subjecting these interrelationships to network-analytic techniques.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: The small difference in mean Mi-PARIHS domain scores at different sites of the local health network (\u003cem\u003eH\u003c/em\u003e = 17.596, \u003cem\u003ep\u003c/em\u003e = 0.0015, \u003cem\u003eη\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e \u003cem\u003e=\u003c/em\u003e 0.04), and the network analysis affirmed that implementing an LGBTQ + model of care requires a \u003cem\u003eholistic\u003c/em\u003e approach. We developed an explanatory causal model (presented as a causal loop diagram) disentangling what is meant by “holistic”, explicitly proposing how these barriers and facilitators work to maintain the status quo both between and within i-PARIHS domains.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion\u003c/strong\u003e: Our findings recommend: 1) \u003cem\u003eHealthcare leaders need clearly articulate support of LGBTQ + people and their care\u003c/em\u003e, as this is crucial for health care workers understanding how LGBTQ + care aligns with their organisation’s values and priorities and — therefore — feeling confident enacting this care; 2) \u003cem\u003eThe importance of time\u003c/em\u003e, for implementing change and for fostering LGBTQ + clinical champions; and 3) \u003cem\u003eThe importance of clearly articulated evidence for, trustworthiness of, and advantages appropriate LGBTQ + care presents for health services\u003c/em\u003e in implementation facilitation. We discuss how the novel, complexity science-derived analysis presented in this paper allowed us to operationalise our conception of “holistic” to specific, actionable targets for facilitation. We strongly encourage the use of complexity science techniques in i-PARIHS-driven implementation research as a means of decomposing notional “context-driven” or “holistic” approaches into concrete, operationalised targets for facilitation.\u003c/p\u003e","manuscriptTitle":"Implementing LGBTQ+ inclusive mental healthcare into practice — A rapid mixed-methods implementation context assessment of an Australian local health network","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-04 15:30:47","doi":"10.21203/rs.3.rs-8072582/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-24T14:36:41+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-27T14:17:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"219094257768398454452657653720542044371","date":"2026-02-25T11:52:19+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-17T20:10:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"24901080363723080771095668790640529458","date":"2025-12-02T16:14:54+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-02T16:11:34+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-28T05:34:17+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-12T23:56:50+00:00","index":"","fulltext":""},{"type":"submitted","content":"Implementation Science Communications","date":"2025-11-10T04:09:14+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"implementation-science-communications","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"iscm","sideBox":"Learn more about [Implementation Science Communications](https://implementationsciencecomms.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ISCM/default.aspx","title":"Implementation Science Communications","twitterHandle":"@ImplementSci","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"915cbb53-aab0-47d5-887c-ceef32bf2ea5","owner":[],"postedDate":"December 4th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-08T08:08:35+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-04 15:30:47","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8072582","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8072582","identity":"rs-8072582","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}