Primary Health Care Research & Development


Process evaluation of infertility management in primary care: has open access HSG been normalized?

Scott Wilkesa1 c1 and Greg Rubina2

a1 Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK

a2 Durham University School of Medicine and Health, Wolfson Research Institute, Stockton on Tees, UK


Aim To map the results of four empirical quantitative and qualitative studies to the Normalization Process Model (NPM) to explain why open access hysterosalpingography (HSG) for the initial management of infertile couples has or has not normalized in primary care.

Background The NPM is an applied theoretical model to help understand the factors that lead to the routine embedding of a complex intervention in everyday practice. Open access HSG has recently become available for the initial assessment of infertility in primary care.

Methods The results of two qualitative studies (a focus group study and an in-depth interview study with patients and professionals) and two quantitative studies (a pilot survey and a pragmatic cluster-randomized controlled trial) evaluating open access HSG are interpreted by mapping the results to the NPM.

Findings Application of the model shows that open access HSG would confer an advantage to all agencies if they could be sure that the expertise was present and supported within primary care.

Conclusions Open access HSG was adopted but not normalized into everyday practice. Despite demonstration of modest workability, it has been counteracted by limited integration. Further evaluation of integration within contexts is required.

(Received February 13 2009)

(Accepted June 22 2009)

Key words

  • family practice;
  • hysterosalpingography;
  • infertility;
  • normalization;
  • open access investigations;
  • primary care


c1 Correspondence to: Scott Wilkes, Institute of Health and Society, Newcastle University, 21 Claremont Place, Newcastle upon Tyne, NE2 4AA, UK. Email: