Implementation and sustainability of systems change for mental health promotion and substance misuse prevention: A qualitative study

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Additionally, populations that experience stigma and/or discrimination because of race, class, gender, or another identity group experience disproportionately higher rates of mental health disorders than populations that do not experience such marginalization. One way to address upstream social determinants that influence mental health is through systems change initiatives. In 2019, Indiana implemented a statewide Regional Prevention System (RPS) focused on systems change to promote mental health and prevent substance misuse. Methods We developed a semi-structured interview guide to collect insights about the RPS implementation and sustainability. Potential participants were identified based on their role as an active regional coordinator (n = 9). We conducted qualitative interviews with all 9 regional coordinators in Indiana. Interview recordings were transcribed and coded using an a priori coding framework based on constructs from the Theory of Innovation Implementation and the Consolidated Framework for Implementation Research. Results Insights about the RPS implementation process are presented across four domains: innovation, system-level, organization-level, and sustainability. In terms of implementation barriers, coordinators encountered hesitancy and distrust from community members, which they had to overcome to gain buy-in. They also described stigma, including community and individual social norms towards mental health and substance misuse, as barriers that challenged efforts to engage community members in the RPS. Facilitators of implementation included having established community infrastructure and external partnerships. In communities without existing infrastructure to support prevention efforts, particularly rural communities, the implementation process took longer but community members welcomed the additional support and valued the new communication platforms created by the RPS. On sustainability, coordinators provided examples of communities that were able to obtain grant funding in support of prevention initiatives launched through the RPS. Conclusion The process of implementing and sustaining prevention efforts through the RPS varied across communities. Prioritizing the delivery of systems-change efforts in underserved communities that are ready for change, rather than statewide efforts, may offer a better strategy for addressing disparities in the social determinants of health that influence mental health and substance misuse. Mental health substance use prevention implementation science Figures Figure 1 Background More than 1 in 5 adults and 1 in 6 youth in the U.S. are living with a mental health disorder, such as anxiety or depression. 1 In addition, more than 48 million Americans had a substance use disorder in 2022. 2 Notably, the prevalence of mental health and substance use disorders in Indiana exceeds national averages. 3 Social determinants of health (SDOH), the circumstances in which people live and work, are known to influence individual mental health and overall well-being. 4 Differences in SDOH across communities are largely responsible for health inequities. 5 For instance, food insecurity, inadequate housing, low socioeconomic status, limited access to educational opportunities, and exposure to trauma and violence contribute to differences in mental health and substance use disorder prevalence and treatment accessibility. 6 Additionally, populations that experience stigma and/or discrimination because of race, class, gender, or other identity groups experience higher rates of mental health disorders than populations that do not experience such marginalization. 6 One way to address the upstream SDOH that contribute to mental health disparities and substance use behaviors in communities is by implementing health equity initiatives that seek to foster systems change. 7 Programs that address mental health and substance use within communities typically provide services at the individual-level, yet broader policies and practices that create “systems change” are needed to address upstream SDOH. 8 , 9 In this context, the “system” consists of all the individuals, programs, policies, and organizations that influence community health. The “change” includes new policies and practices that modify or mitigate upstream SDOH and offer opportunities to improve mental health outcomes and prevent substance misuse. 6 While prior research has examined the implementation of state initiatives aimed at improving the delivery of mental health treatment and recovery services, 10 , 11 little research has examined statewide mental health and substance misuse prevention initiatives. Even fewer studies have examined the sustainability of such initiatives. In 2019, Indiana’s Division of Mental Health and Addiction (DMHA) created a Regional Prevention System (RPS) to promote mental health and prevent substance misuse. The RPS was designed to accomplish this goal by implementing systems change to address upstream SDOH and reduce health inequities. When the RPS first began, DMHA divided the state into 10 regions and identified a regional coordinator living within each region to facilitate local implementation and engagement of stakeholders. As independent contractors external to other community organizations, regional coordinators acted as change agents tasked with spanning organizational boundaries, building bridges across community members from all sectors, and empowering communities to address barriers to social services and reduce marginalization of populations around the state. 12 To engage stakeholders in conversations around mental health promotion and substance misuse prevention, the coordinators established new “consultation boards” comprised of local community members within every county in the state. These consultation boards were open to all community members and met on a quarterly basis, with some communities choosing to meet more frequently (i.e., bimonthly or monthly). They also facilitated ongoing board meetings to identify priorities for systems change and encourage community members to take action. Community members from each county then chose the top priorities that they wanted to focus on addressing and defined their own action steps. Given that priorities were identified by the community, not by the state or the regional coordinators, the initiatives that community members chose to implement varied across regions and included a range of activities such as developing community resource guides, reducing barriers to social services and mental health treatment, and pursuing funding opportunities to expand prevention programming. In January 2024, Indiana’s DMHA announced that the state would be transitioning away from the RPS and enacted a plan for integrating the newly created community boards with existing mental health infrastructure (e.g., other local coalitions) to carry forward the systems change efforts initiated through the RPS. This created a unique opportunity to study the implementation and sustainability of the initiatives developed through the RPS. Our study examined the implementation and sustainability of the RPS, Indiana’s statewide systems change initiative to prevent and reduce mental health and substance use disorders. In order to understand the implementation process from the perspectives of the individuals leading local efforts, we conducted qualitative interviews with all active regional coordinators across Indiana. Our interview questions and analyses were guided by the Theory of Innovation Implementation and the Consolidated Framework for Implementation Research. Insights from this study may inform future efforts to implement regional approaches that address SDOH, promote mental health, and prevent substance misuse. As such, our findings may be of interest to other states and communities looking to implement systems change initiatives. Conceptual Framework The RPS represents an effort to create community-wide systems change. This research was guided by the Theory of Innovation Implementation as a foundational framework, 13 which helps study the process of implementing and sustaining changes within organizations. Since the RPS was a statewide initiative involving multiple organizations, we also incorporated constructs from the Consolidated Framework for Implementation Research (CFIR), a systematic framework for assessing implementation barriers and facilitators, to define the system-level domain. 14 In doing so, we developed a comprehensive framework that expands upon previous applications of implementation theories and allows us to examine the relationship between contextual factors that influence implementation and sustainability of systems-change initiatives (Fig. 1 ). Innovation Domain The innovation domain comes directly from the CFIR and represents the “thing” being implemented. 14 Thus, the innovation can be defined as details about the “thing” being implemented. The innovation can take a variety of forms such as a clinical treatment, an educational program, or a service. Thematic categories within the innovation construct include those related to characteristics of the innovation itself, such as the source (the group that developed the innovation), relative advantage over existing innovations or practices, complexity, and cost. In this study, the RPS serves as the innovation of interest. System-Level Domain We adapted constructs from the "outer setting domain” (i.e., system-level factors) of the CFIR to define the system-level domain in our framework, which can include multiple levels. 14 In this study, we define levels of interest as the county, region, and state. The system-level constructs we examined include system readiness, system policies and laws, and sociocultural norms. System readiness is defined as the extent to which the system is prepared for change. This includes existing conditions of the community (e.g., economic, environmental, or technological capabilities) and previously existing infrastructure (e.g., partnerships/connections) that may expedite or impede implementation. System policies and laws are defined as legislation, regulations, guidelines, and recommendations from professional organizations or accrediting bodies. 14 Finally, sociocultural norms are defined as broadly held social norms/attitudes, values, and beliefs that may influence implementation. This construct also includes external societal pressures that may drive implementation. Organization-Level Domain The organization-level domain in our framework is comprised of constructs adapted from the theory of innovation implementation. 13 These include organizational climate, organizational readiness, and organizational policies and procedures. Organizational climate refers to the extent to which an innovation is perceived to be rewarded, supported, and expected. 13 In 2009, Weiner et al. built upon Klein & Sorra’s work and proposed that implementation is also influenced by organizational readiness and policies and procedures put in place. 15 Organizational readiness is the extent to which employees are prepared to make necessary changes to support implementation of the innovation. Organizational policies and practices include plans, activities, structures, and strategies within an organization that shape the implementation climate. 15 Sustainability Domain The sustainability domain includes constructs from both the theory of innovation implementation and CFIR. These include implementation effectiveness, innovation efficacy, innovation effectiveness, and sustainability. Implementation effectiveness refers to the consistency, quality, and appropriateness of innovation use. Innovation efficacy is the shared belief of individuals who are implementing the innovation in their own capabilities. Innovation effectiveness is the innovation itself (i.e., changes in outcomes or perceived impacts). Finally, sustainability refers to the extent to which system-level changes are maintained or persist beyond the implementation period. Despite the importance of sustainability, in prior studies that utilize that theory of innovation implementation, 16 sustainability is often discussed tangentially related to implementation but is not defined as a stand-alone construct. 17 By incorporating the sustainability construct from the CFIR in our framework, we expand the use of theory to more explicitly examine how implementation processes influence sustainability. Methods Setting, Study Participants and Recruitment When the RPS was first established, Indiana’s DMHA identified 10 regions across the state, each containing 1 to12 counties, and contracted with a coordinator to serve each region. Each regional coordinator (n = 9) was contacted as a potential interviewee and their contact information was obtained from Indiana’s DMHA. Recruitment messages were sent by email in January 2024. All participants were offered a $ 50 gift card as an incentive to participate in the study. At the time of recruitment and data collection, one region (Region 7- Marion County) was vacant, so there were 9 active regional coordinators serving the state. All 9 coordinators responded to our request and completed an interview, representing 91 out of 92 counties in Indiana. As a matter of procedural ethics, 18 we chose not to collect or report on individual demographic information about the regional coordinators to avoid deductive disclosure of any participants which might allow persons who know certain facts about participants due to their involvement in the RPS to link by any quotations or other information presented back to the study participants. This study was approved by the Institutional Review Board (IRB) at Indiana University. Interview Guide Development We developed a semi-structured interview guide to collect insights about the RPS implementation process and sustainability efforts (see supplementary files). This semi-structured interview guide was created by members of the research team to learn more about experiences implementing the RPS across regions, system- and organization-level factors influencing implementation. Participants were also asked about the sustainability of RPS efforts, as the coordinators were preparing for the integration of the RPS into existing community infrastructure at the time of our interviews. Questions were informed by and corresponded to the domains of interest presented in our conceptual framework. Interviews were conducted by one team member and lasted approximately 45–60 minutes. All interviews were conducted, recorded, and transcribed via Microsoft Teams. After completion of the interviews, one member of the research team reviewed all transcripts to ensure accuracy. Codebook Development and Analysis After transcription, interviews were qualitatively coded in accordance with criteria for high-quality qualitative research and established thematic analysis methodology. 18 , 19 Given the complexity of the RPS as an innovation and the nuances of implementing the RPS across diverse community settings, we combined theoretical constructs from the CFIR and the Theory of Innovation Implementation to create a comprehensive framework allowing us to capture rich insights about the RPS implementation process. 18 , 20 To develop our codebook, we first defined the four overarching domains in our framework. Next, we defined the 11 main constructs representing these domains, drawing on established constructs from the CFIR and the Theory of Innovation Implementation. 13 , 14 We further defined a priori themes within each construct based on the updated list of CFIR constructs. 14 We then conducted thematic analysis in which we applied a priori themes to quotations capturing the essence of a particular construct. To ensure interrater reliability, two coders independently reviewed the same transcript and then compared codes. In instances where coders disagreed, we discussed the code application until 100% agreement and consensus was reached. The remaining interviews were divided between the researchers for individual coding. After coding was completed, the two coders met to review the application of codes by exporting all coded excerpts from the transcripts, reviewing quotations within each theme, and discussing any concerns about accuracy of coding applications. As an added check to ensure rigor of our findings and trustworthiness of our interpretation of the data, 20 all members of the research team reviewed the final results of the analysis and accuracy of themes applied to illustrative quotes presented in this manuscript. Results Key Qualitative Insights Key insights about implementing the RPS as a health equity initiative focused on systems change to promote mental health and prevent substance misuse are presented across constructs within the following four domains: innovation, system-level, organization-level, and sustainability. Innovation Domain Themes that were identified within the innovation domain and illustrative quotes from the interviews are presented in Table 1 . Participants described experiences related to the innovation source, evidence base, adaptability, relative advantage, trialability, and complexity of the RPS. More specifically, participants identified DMHA, many times referred to as “the state,” as the organization seeking to implement the RPS (i.e., the innovation source). In communities where DMHA was viewed as credible and trustworthy, this helped facilitate engagement in the RPS. Participants, however, also encountered distrust of the state in many communities, and had to overcome this hesitancy to gain buy-in from many individuals. For example, one coordinator described their experience at one of the first consultation board meetings they led, “ I almost felt like I was in a war at one of the first meetings...there were a lot of people on the call and they did not want me there.” _____________________ Table 1 about here _____________________ While several participants described the feeling of not being wanted or needed when first implementing the RPS, in some cases, they were able to find common goals with community members. Establishing a common goal allowed them to overcome some of the hesitancy and distrust initially encountered. One participant described how they were able to overcome the community’s sense of distrust by consistently showing up to community meetings and displaying a sense of support. Participants also described perceived duplication between the RPS and other community coalitions focused on substance misuse prevention, including Drug Free Communities and Local Coordinating Councils. In other words, in communities where individuals did not perceive any relative advantage of the RPS compared to existing initiatives or coalitions, they were less willing to engage in the RPS. As one coordinator said, “ We were always being compared to other systems in place across communities, systems of care, drug free communities, local coordinating councils, like why are you here doing this work when there’s other agencies doing similar work.” System-Level Domain Themes that were identified within the system-level domain are presented in Table 2 . Most themes that emerged from participant descriptions of the implementation experience related to system readiness and sociocultural norms, whereas system policies and laws were rarely mentioned. In terms of system readiness, participants described existing infrastructure and established partnerships in the community as facilitators of implementation. For example, one participant shared that one of their counties experienced a public health epidemic in previous years. Through the aid of state and federal stakeholders, the county established a robust infrastructure, which remained in place and helped support implementation of future initiatives. As the coordinator said, “Some counties do it very well, and [omitted county] does an excellent job of sustaining and handling all the things that they do… They have a lot of infrastructure, they have people with experience doing these things that has been passed down to other people in those organizations and they do a fantastic job of handling issues and knowing about sustainability and applying for funding that hasn't happened in all these other counties.” _____________________ Table 2 about here _____________________ Sociocultural norms that reflected stigma embedded in the community, were frequently described as barriers to implementation of the RPS. Coordinators, however, also described positive changes in stigma and attitudes over time, indicating that this was a barrier during the initial implementation phase that coordinators were able to overcome. As one participant described, “And then there is stigma. My gosh, four years ago you bring up [substance misuse] and it's like, oh I don't want to talk about that. And you're like, why not? But I don't get that anymore. I don't get that anymore from anybody. It's just a matter of fact we have these issues. We want to make folks better and open and know there's resources and share them.” While system policies and laws were rarely mentioned, one policy that was noted as a facilitator of implementation was the use of a regional dashboard tool to identify community priorities for systems change. Several participants stated that the development of a regional dashboard defining action steps towards a shared goal was a significant catalyst to driving change in the community. As one participant described, “Over the past year we started actually working on the dashboard goals and trying to work to get some tangible things. Once we started doing that, we started getting more people around the table, really gaining a lot more diversity of thought, gaining a lot of momentum.” Organization-Level Domain Themes that were identified within the organization-level domain are presented in Table 3 . Despite the challenges between the coordinators and counties, nearly all participants described adverse community conditions that drove their organizations to work together for the betterment of their community. Other public health challenges increased the urgency for organizations to respond and served as a catalyst to generate partnerships. For example, coordinators indicated that homelessness was a rampant issue in their communities, “So that's how I knew that [mental health] was getting to be a big issue for the state to get involved, but it's been brought up in all of my 9 regions about homelessness, including youth homelessness.” _____________________ Table 3 about here _____________________ Other adverse community conditions identified were increased use of electronic cigarettes, increased rates of death by suicide in the youth population, and increased resource needs for maternal mental health. As one coordinator described, “So over one of our big areas with building capacity in our local communities and [county], small, roughly 10,000 people, no conversations were happening in their community at all. And there was a big vaping epidemic at the school.” While coordinators agreed that the counties identified prominent issues that needed to be addressed, the climate and attitudes of the community, at times, prevented implementation. Specifically, stigma was a major contributor to whether community organizations partook in events. The coordinator stated, “Those are big issues and we've at least overcome one big thing in four years that I've noticed and it's still there, but not like it was. And that's stigma.” Sustainability Domain Themes that were identified within the sustainability domain are presented in Table 4 . Numerous positive outcomes were described which encouraged the sustainability of efforts initiated through the RPS. Building partnerships with community organizations was consistently mentioned by participants as being an outcome of the RPS, and many coordinators said that their communities were trying to find ways to sustain their new relationships and communication channels beyond the RPS. For example, one participant described the benefit of knowing what neighboring counties were doing and therefore encouraged them to implement something similar, “Like then gaining knowledge of what other counties are doing, especially my smaller communities, they kind of get, I don't want say stuck, but sometimes it's hard to keep thinking of new things to do when you're small and when you have very little manpower.” _____________________ Table 4 about here _____________________ Additional positive outcomes resulting from implementation of the RPS included improved skills and community initiative to seek out additional grant funding to continue expanding programs. Moreover, several participants described the perspective that the RPS took regarding stigma of mental health and substance use, “In some of the small rural communities, conversations were not happening around prevention at all and just me coming in this position, coming into the communities allowing that conversation to happen has allowed…some conversation happened. Destigmatize mental health substance use and make small changes in the communities.” Comments about sustaining efforts after the RPS implementation ends were not always positive. Specifically, many participants described disappointment, sadness, and at times, anger, expressed by their communities upon learning about the transition away from the RPS. Rural communities were particularly concerned about their ability to sustain communication platforms without the RPS. As one participant described their community members’ response, “There are people who are angry that this [transition from RPS] happened and there are people who are like, just sad that they were, you know, there are people who are disappointed. They were just getting going.” Discussion Addressing upstream SDOH that influence mental health and substance misuse outcomes requires a shift from implementing programs that address individual-level social factors to policies and practices that create systems-level change within and across communities. 9 , 21 Indiana’s RPS provides one example of a statewide initiative that focused on promoting mental health and preventing substance misuse through systems-change. We conducted qualitative interviews with all 9 regional coordinators in Indiana to learn more about the process of implementing the RPS and perceptions around sustainability of efforts initiated through the RPS. Our assessment of the RPS implementation process demonstrates barriers and facilitators of implementing systems-change initiatives for promoting mental health and preventing substance misuse. Moreover, these barriers and facilitators differed across communities, with some factors being unique to rural communities. Several communities expressed a desire to sustain systems-change beyond the RPS transition and identified concerns about the sustainability of newly-built relationships and communication channels, which were most prominent in rural communities. Given the unique challenges faced by rural communities and the documented disparities in mental health and substance use treatment services in such communities, 22 , 23 rural communities may benefit from additional, directed support in the absence of statewide efforts. During the initial implementation of the RPS, many coordinators were met with hesitancy from community members. This type of hesitancy and resistance to change is common when implementing new initiatives. 13 – 17 It took time and efforts for community members to understand how the RPS differed from existing community initiatives for mental health promotion and substance misuse prevention. Coordinators shared strategies that they used to overcome these initial challenges and gain stakeholder buy-in, such as continuously showing up to meetings and educating community members about the purpose of the RPS. As coordinators described, stigma was also a major barrier during the initial RPS implementation. Stigma is a well-documented barrier to initiatives for mental health and substance use. 24 – 28 Increasing health literacy has been shown to decrease mental health stigma, and in turn increase willingness to seek help and interact with individuals with mental health conditions. 29 As coordinators persisted in raising awareness about mental health and substance use and demonstrating that it is ok to have conversations about these topics, they perceived an increase in mental health literacy and a decrease in stigma encountered over time. Finding a common mission or goal to align community members with also helped garner buy-in and facilitate implementation of the RPS. For example, several coordinators described issues related to SDOH in their communities, such as homelessness, as factors that motivated organizations to come together and collaborate towards creating systems change. Coordinators also found the use of a dashboard tool to organize these efforts and explicitly document action steps helpful. One of the primary outcomes of the RPS was the new relationships and communication platforms established. In line with findings from implementation research literature, 30 we identified the importance of having a motivated implementation lead, or champion, to facilitate the development of such relationships among external stakeholders and to share information about community needs back to DMHA. Rural communities especially appeared to benefit from having a lead that represented their community because they frequently felt as if they lacked communication and resources, making it difficult to compete against their urban/suburban counterparts for funding opportunities. Notably, some communities were able to obtain grant funding for the first time with the support of the RPS, demonstrating the benefit such efforts may have on communities that do not have previous experience pursuing grants. Not surprisingly, the RPS transition was met with feelings of disbelief, sadness, disappointment, and frustration. These feelings are not uncommon when initiatives are discontinued. 31 , 32 However, they are detrimental to sustainability efforts. 33 Additionally, ongoing cycles of efforts to start new initiatives and then ending them a few years later has the potential to erode trust among communities, making it more challenging to implement future initiatives. In communities with existing infrastructure, such as other coalitions focused on promoting mental health and preventing substance misuse, efforts initiated through the RPS may be more likely to be carried forward throughout the transition and sustained. However, in communities with more limited resources, it remains unclear whether efforts initiated through the RPS will continue when there is no longer a coordinator dedicated to facilitating communication between organizations. This further underscores the need to provide additional support to rural communities in the absence of statewide efforts to avoid exacerbating existing disparities in these communities. To circumvent such challenges, future efforts should consider sustainability early on, even during the pre-implementation phase, to ensure a plan is in place. Future research should examine the sustainability of other regional- and state-level initiatives to enhance our understanding of effective ways to implement and sustain systems change. Our study has strengths and limitations. We used purposive sampling and conducted interviews with all regional coordinators involved in a statewide initiative. While we were able to capture perspectives from individuals embedded in 9 different regions of the state, given that the RPS was unique to Indiana, our study findings may not be generalizable to similar initiatives in other states. When implementing similar initiatives, it is important to consider the unique sociodemographic makeup of counties or regions involved, as this may impact the implementation process. As a limitation, our study did not include Marion County, which is the most populated county in Indiana and, as an urban county, is very different from the 91 counties served by the coordinators represented in our study. Thus, the perspectives and experiences of the regional coordinators in this study should be interpreted with this in mind. Our study employed a novel theoretical framework developed based on constructs of the Theory of Innovation Implementation and the CFIR. By applying implementation science methods to examine the implementation and sustainability of a system-level innovation, we expand the application of theory and generate insights that enhance our understanding of implementation processes for systems-focused innovations. Finally, given that our study was conducted during the transition period away from the RPS, we were able to generate insights into potential sustainability of systems-changes initiated through the RPS from the perspective of the regional coordinators. However, we were not able to assess actual sustainability of these efforts beyond the transition period at this time. We also were not able to capture the perspectives of representatives from other community organizations who were involved in the RPS. Future research should examine longer-term sustainability from the perspectives of these representatives. Conclusion The process of implementing and sustaining prevention efforts through the RPS was different in every community. All coordinators believed that they helped facilitate the establishment of new relationships among community organizations and enhanced communication channels. The benefits of these new relationships were particularly prominent in rural communities, some of whom were able to obtain state funding for the first time and implemented new initiatives to promote mental health and prevent substance misuse. However, since the process of integrating the RPS into existing community infrastructure is still underway, it remains unclear whether the new relationships and communication channels established by the coordinators will be sustained over time. Given concerns expressed by coordinators about how this transition may disproportionately affect rural communities, policymakers should consider alternative strategies for providing ongoing support to rural communities. Declarations Ethics approval and consent to participate: This study was approved by the Institutional Review Board at Indiana University. Consent for publication: Not applicable. Availability of data and materials: The dataset generated during the current study is not publicly available due to potentially identifiable information contained in interview transcripts. De-identified excerpts may be shared upon reasonable request. Competing interests: Dr. Burns has previously served as a regional coordinator and received compensation from the Indiana Division of Mental Health and Addiction (DMHA) for work performed in Marion County, IN (excluded from this study). At the time of this study, Dr. Burns was no longer in this role and no longer receiving any personal compensation from DMHA. Funding: This study was funded by WISE Indiana (Wellbeing Informed by Science and Evidence in Indiana), a partnership between the Indiana Clinical and Translational Sciences Institute’s Monon Collaborative (CTSI) and the Indiana Family and Social Services Administration (FSSA). WISE Indiana and Indiana FSSA reviewed and approved this manuscript. Authors’ contributions: AB, LM, and BP developed the interview guide. AB conducted all interviews with key informants. AB and HK analyzed and interpreted the qualitative data. AB led the writing of the manuscript; HK and LM also made major contributions. BP, JB, and MA provided critical review and feedback throughout manuscript development. All authors read and approved the final manuscript. Acknowledgements: The authors thank the following individuals for their support and contributions to this work: Makayla Pearson and Aaron Zych (WISE Indiana); Alejandra Capshew (Irsay Institute); Emily Meanwell (Indiana University); LeeAnn Sell and Mary Ellen Van Booven (Center for Survey Research). All were compensated for their work related to this project. References National Institute of Mental Health (NIMH). Mental Illness. Accessed September 11, 2024. https://www.nimh.nih.gov/health/statistics/mental-illness Lipari RN, Park-Lee E. Key Substance Use and Mental Health Indicators in the United States: Results from the 2019 National Survey on Drug Use and Health . 2020. Deferio JJ, Breitinger S, Khullar D, Sheth A, Pathak J. Social determinants of health in mental health care and research: a case for greater inclusion. J Am Med Inform Assoc . 2019;26(8-9):895-899. doi:10.1093/JAMIA/OCZ049 World Health Organization. Social determinants of health. 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A theory of organizational readiness for change. Implement Sci . 2009;4(1). doi:10.1186/1748-5908-4-67 Dimartino LD, Birken SA, Hanson LC, et al. The influence of formal and informal policies and practices on health care innovation implementation: A mixed-methods analysis. Health Care Manage Rev . 2018;43(3):249-260. doi:10.1097/HMR.0000000000000193 Burns A, Gutta J, Kooreman H, Spitznagle M, Yeager VA. Strategic use of tobacco treatment specialists as an innovation for tobacco cessation health systems change within health care organizations. Health Care Manage Rev . 2023;48(4). doi:10.1097/HMR.0000000000000380 Alegría M, Nemoyer A, Falgas I, Wang Y, Alvarez K. Social Determinants of Mental Health: Where We Are and Where We Need to Go. doi:10.1007/s11920-018-0969-9 Burns A, Menachemi N, Mazurenko O, Salyers MP, Yeager VA. State Policies Associated with Availability of Mobile Crisis Teams. Adm Policy Ment Health . Published online March 18, 2024. doi:10.1007/s10488-024-01368-0 Burns A, Vest JR, Menachemi N, Mazurenko O, Salyers MP, Yeager VA. Market Factors Associated with Comprehensive Behavioral Health Crisis Care Availability: A Resource Dependence Theory Study. Inquiry . 2024;61. doi:10.1177/00469580241256822 Urquhart R, Kendell C, Cornelissen E, et al. Identifying factors influencing sustainability of innovations in cancer survivorship care: a qualitative study. BMJ Open . 2021;11:42503. doi:10.1136/bmjopen-2020-042503 McKay VR, Morshed AB, Brownson RC, Proctor EK, Prusaczyk B. Letting Go: Conceptualizing Intervention De-implementation in Public Health and Social Service Settings. Am J Community Psychol . 2018;62(1-2):189-202. doi:10.1002/AJCP.12258 Tables Table 1: Illustrative quotes within the Innovation Domain Construct Illustrative Quote ( Subtheme ) Innovation “What we’re trying to change is something that's been deeply ingrained, and that's a distrust.” ( Source ) “And I almost felt like I was in a war at one of the first meetings...there were a lot of people on the call and they did not want me there .” ( Source ) “A lot of people in my region were already involved with DMHA when I took this job… this is a fairly fluent region and they were receptive for the most part.” ( Source ) “We knew what we were hoping to create and that was healthier Hoosiers. We were looking at the five pillars of health and we were looking at how to impact community systems change, but we weren't sure exactly what role to take to get there. And so, we were constantly learning through research, through data, through partnerships with community members.” ( Evidence-base ) “We were always being compared to other systems in place across communities, systems of care, drug free communities, local coordinating councils, like why are you here doing this work when there’s other agencies doing similar work.” ( Relative advantage ) “I’m always being adaptable because things change at any moment. So, always being on your toes and being able to adapt to what the conversations go like. You might have one way thought out, but they can go completely differently.” ( Adaptability ) “I was the guinea pig for lack of a better term in rolling out the regional prevention system. So for me it didn't look like anything… we knew we were hoping to create opportunities for everyone in Indiana, whether you live there, work there in the region or in the state to have opportunities to be healthier… one of the things our community did is we really tried to bounce around and not just stay centralized in one city within each of our counties because that's what's already happening. I was able to make connections with the schools in one county and help them get some prevention programming in their schools because they had nothing at all in their county happening. So, we started small and I made those connections for them.” ( Trialability ) “Of course, there's a lot of different things happening, and so adding another meeting was obviously a little bit challenging, especially in the bigger communities.” ( Complexity ) Table 2: Illustrative quotes within the System-Level Domain Construct Illustrative Quote ( Subtheme ) System Readiness “Some counties do it very well, and [omitted county] does an excellent job of sustaining and handling all the things that they do... They have a lot of infrastructure. They have people with experience doing these things that has been passed down to other people in those organizations and they do a fantastic job of handling issues and knowing about sustainability and applying for funding. That hasn't happened in all these other counties.” ( Physical/Work Infrastructure ) “A lot of them told me that one of the best things that came out of this was that we thought we knew each other in our county because we sometimes are on the same meetings, but we didn't know each other as well as we do now. So that's another sign I think that proves that communication has improved during this regional system and that's what it was supposed to be about.” ( Partnerships & Connections ) Sociocultural Norms “And then there is stigma. My gosh, four years ago you bring up [substance misuse] and it's like, oh I don't want to talk about that. And you're like, why not? But I don't get that anymore. I don't get that anymore from anybody. It's just a matter of fact we have these issues. We want to make folks better and open and know there's resources and share them.” ( Local Attitudes/Conditions ) “There is a community down in [omitted region] that I feel like there's just a lot of political turmoil around prevention in and I feel like some success for some of the people in that county was being able to join together outside of that political turmoil and say we feel that what's going on over there isn't right.” ( Local Attitudes/Conditions ) “They met two or three extra times a year just for special work projects, so they had been meeting and they had projects on their agenda that they were driving forward.” ( External Market/Performance Measurement Pressure ) “That's how I knew that it was getting to be a big issue for the state to get involved, but it's been brought up in all of my 9 regions about homelessness, including youth homelessness.” ( External Market/Performance Measurement Pressure ) “Then, just like awareness issues like bringing awareness to prevention and substance misuse, and mental health issues and we've done a couple listening sessions across the communities with youth and having action focused after those listings, sessions like [county] had multiple youth death by suicides in six month period.” ( External Market/Performance Measurement Pressure ) “They're one of the biggest areas in maternal mental health needs, [county]. So, addressing that like Family Services as well has been a big area and just providing linkages to those resources in the community.” ( External Market/Performance Measurement Pressure ) System Policies and Laws “Over the past year we started actually working on the dashboard goals and trying to work to get some tangible things. Once we started doing that, we started getting more people around the table, really gaining a lot more diversity of thought, gaining a lot of momentum.” ( System policies ) Table 3: Illustrative quotes identified within the Organization-Level Domain Construct Illustrative Quote ( Subtheme ) Organizational Readiness “It was a challenge getting people to switch from program-focused thinking to system changes.” ( Organizational readiness ) “I have a lot of people that have attended the Congress or other things that DMHA has put on, like the prevention convention and different things of that nature. They got pretty hooked on that and made friends there too.” ( Organizational readiness ) “You know, not everyone who probably should have been at that table, chose to be at that table.” ( Organizational readiness ) Organizational Climate “So over one of our big areas with building capacity in our local communities and [county], small, roughly 10,000 people, no conversations were happening in their community at all. And there was a big vaping epidemic at the school.” ( Tension for change ) “And because of that, you know you tend to not speak out, you tend to not say, you know, why is our LCC continuing to fund the same programs for the 10th year in a row while our overdose rates are progressively getting worse and more and more people who are going through this program are still are actually using drugs at higher rate.” ( Tension for change ) Organizational Policies and Practices Not Applicable Table 4: Illustrative quotes identified within the Sustainability Domain Construct Illustrative Quote (Subtheme) Implementation Effectiveness “There were a lot of new initiatives, new organizations. Maybe not new to the Community, but they were new to the partnership with DMHA.” ( Communications/partnerships) “A lot of my counties have been kind of discussing just that connecting piece has been super beneficial for them.” ( Communications/partnerships) “Gaining knowledge of what other counties are doing, especially my smaller communities, they kind of get, I don't want to say stuck, but sometimes it's hard to keep thinking of new things to do when you're small and when you have very little manpower.” ( Communications/partnerships) Innovation Efficacy “I've been doing this almost four years and the amount of people that asked me to take their name off of a list or not contact them again, I could do on less than one hand. And most of it was because they just didn't think they had time or they didn't see how they could contribute anything.” ( Efficacy ) Innovation Effectiveness “You know, we've had a lot of funded entities in this region and I think to me some of the greatest successes in that were little tiny counties who never applied for anything before who were finally like we were finally at the point with us last prevention request for funding, that they collaborated together and got other organizations and they applied.” ( Actual Outcomes) “In some of the small rural communities, conversations were not happening around prevention at all and just me coming in this position, coming into the communities allowing that conversation to happen has allowed…some conversation happened. Destigmatize mental health substance use and make small changes in the communities.” ( Actual Outcomes ) “So, I think that was the main impact that the Community members and partnerships and organizations felt heard.” ( Actual Outcomes) Sustainability “There are people who are angry that this happened and there are people who are like, just sad that they were, you know, there are people who are disappointed. They were just getting going…But I mean it, it was like not surprising to me that there were people who said, yeah, here you come with another state initiative.” ( Actual Outcomes) “I've been told that the community, it seems, from kind of some of the perspectives of the influencers in the room there. It's just people are mean to each other. They're very high school-y. Cliquish, they're very just like if you don't fit in here, you don't fit in there and or if you don't fit in here, you know you're not included in in our conversations, you're not included in the meeting invites. You're not included in those things and we don't do that in the regional prevention system.” ( Actual Outcomes) Additional Declarations Competing interest reported. Dr. Burns has previously served as a regional coordinator and received compensation from the Indiana Division of Mental Health and Addiction (DMHA) for work performed in Marion County, IN (excluded from this study). At the time of this study, Dr. Burns was no longer in this role and no longer receiving any personal compensation from DMHA. Cite Share Download PDF Status: Published Journal Publication published 27 Nov, 2024 Read the published version in BMC Health Services Research → Version 1 posted Editorial decision: Revision requested 17 Sep, 2024 Editor assigned by journal 17 Sep, 2024 Submission checks completed at journal 17 Sep, 2024 First submitted to journal 12 Sep, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5079647","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":355130059,"identity":"fe057af9-37f1-4d1e-876e-5e553a121b9c","order_by":0,"name":"Ashlyn Burns","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAq0lEQVRIiWNgGAWjYFACHjZmEMUPJtlI0SLZTLIWgwPEauHvP3vscWHbvTzj4zwGDB/KDhPWInEjL914ZltxsdlhHgPGGeeI0MJwg8dMmrctIXEbUAszbxsRWuTPn4Fo2dwM1PKXGC0GB3IgWjYwA7UwEqPF8EaOufGMcwmJMw6zFRzsOZdOWIsc0GGPC8oSEvv7D2988KPMmrAWFHCARPWjYBSMglEwCnABAHhoNp2rKRR0AAAAAElFTkSuQmCC","orcid":"","institution":"Indiana University School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Ashlyn","middleName":"","lastName":"Burns","suffix":""},{"id":355130060,"identity":"4b609fda-85a5-4f1f-a684-43c8e8334612","order_by":1,"name":"Haleigh Kampman","email":"","orcid":"","institution":"Indiana University Fairbanks School of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Haleigh","middleName":"","lastName":"Kampman","suffix":""},{"id":355130061,"identity":"16919caf-9d2a-4659-89b3-ef78c9f568ab","order_by":2,"name":"Lauren Magee","email":"","orcid":"","institution":"Indiana University Paul H. O’Neill School of Public and Environmental Affairs","correspondingAuthor":false,"prefix":"","firstName":"Lauren","middleName":"","lastName":"Magee","suffix":""},{"id":355130062,"identity":"384edbb4-dfcb-43b6-93ea-7d08b188ab19","order_by":3,"name":"Justin Blackburn","email":"","orcid":"","institution":"Indiana University Fairbanks School of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Justin","middleName":"","lastName":"Blackburn","suffix":""},{"id":355130065,"identity":"1736f74d-e875-450f-ae8c-7439fc253a84","order_by":4,"name":"Madison Alton","email":"","orcid":"","institution":"Family and Social Services Administration","correspondingAuthor":false,"prefix":"","firstName":"Madison","middleName":"","lastName":"Alton","suffix":""},{"id":355130066,"identity":"7584675f-c9bf-4ac5-bd25-037f9ab31401","order_by":5,"name":"Bernice Pescosolido","email":"","orcid":"","institution":"Indiana University College of Arts \u0026 Sciences","correspondingAuthor":false,"prefix":"","firstName":"Bernice","middleName":"","lastName":"Pescosolido","suffix":""}],"badges":[],"createdAt":"2024-09-12 19:23:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5079647/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5079647/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12913-024-11962-5","type":"published","date":"2024-11-27T15:58:23+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":68877895,"identity":"f8f244f4-e142-4d99-96eb-7266f19d0a3c","added_by":"auto","created_at":"2024-11-13 05:08:09","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":163172,"visible":true,"origin":"","legend":"\u003cp\u003eFramework for studying the implementation of sustainable systems-change, adapted from the Theory of Innovation Implementation and the Consolidated Framework for Implementation Research\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5079647/v1/625821cf00cbd99b5c78c343.png"},{"id":70390971,"identity":"8ad97898-98b5-4169-9c30-58d4fe260881","added_by":"auto","created_at":"2024-12-02 17:30:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":715295,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5079647/v1/13f47fa4-dac3-4e1c-b832-f0aa7a2adb4e.pdf"}],"financialInterests":"Competing interest reported. Dr. Burns has previously served as a regional coordinator and received compensation from the Indiana Division of Mental Health and Addiction (DMHA) for work performed in Marion County, IN (excluded from this study). At the time of this study, Dr. Burns was no longer in this role and no longer receiving any personal compensation from DMHA.","formattedTitle":"Implementation and sustainability of systems change for mental health promotion and substance misuse prevention: A qualitative study","fulltext":[{"header":"Background","content":"\u003cp\u003eMore than 1 in 5 adults and 1 in 6 youth in the U.S. are living with a mental health disorder, such as anxiety or depression.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e In addition, more than 48\u0026nbsp;million Americans had a substance use disorder in 2022.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Notably, the prevalence of mental health and substance use disorders in Indiana exceeds national averages.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Social determinants of health (SDOH), the circumstances in which people live and work, are known to influence individual mental health and overall well-being.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Differences in SDOH across communities are largely responsible for health inequities.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e For instance, food insecurity, inadequate housing, low socioeconomic status, limited access to educational opportunities, and exposure to trauma and violence contribute to differences in mental health and substance use disorder prevalence and treatment accessibility.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Additionally, populations that experience stigma and/or discrimination because of race, class, gender, or other identity groups experience higher rates of mental health disorders than populations that do not experience such marginalization.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eOne way to address the upstream SDOH that contribute to mental health disparities and substance use behaviors in communities is by implementing health equity initiatives that seek to foster systems change.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Programs that address mental health and substance use within communities typically provide services at the individual-level, yet broader policies and practices that create \u0026ldquo;systems change\u0026rdquo; are needed to address upstream SDOH.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e In this context, the \u0026ldquo;system\u0026rdquo; consists of all the individuals, programs, policies, and organizations that influence community health. The \u0026ldquo;change\u0026rdquo; includes new policies and practices that modify or mitigate upstream SDOH and offer opportunities to improve mental health outcomes and prevent substance misuse.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e While prior research has examined the implementation of state initiatives aimed at improving the delivery of mental health treatment and recovery services,\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e little research has examined statewide mental health and substance misuse prevention initiatives. Even fewer studies have examined the sustainability of such initiatives.\u003c/p\u003e \u003cp\u003e In 2019, Indiana\u0026rsquo;s Division of Mental Health and Addiction (DMHA) created a Regional Prevention System (RPS) to promote mental health and prevent substance misuse. The RPS was designed to accomplish this goal by implementing systems change to address upstream SDOH and reduce health inequities. When the RPS first began, DMHA divided the state into 10 regions and identified a regional coordinator living within each region to facilitate local implementation and engagement of stakeholders. As independent contractors external to other community organizations, regional coordinators acted as change agents tasked with spanning organizational boundaries, building bridges across community members from all sectors, and empowering communities to address barriers to social services and reduce marginalization of populations around the state.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e To engage stakeholders in conversations around mental health promotion and substance misuse prevention, the coordinators established new \u0026ldquo;consultation boards\u0026rdquo; comprised of local community members within every county in the state. These consultation boards were open to all community members and met on a quarterly basis, with some communities choosing to meet more frequently (i.e., bimonthly or monthly). They also facilitated ongoing board meetings to identify priorities for systems change and encourage community members to take action. Community members from each county then chose the top priorities that they wanted to focus on addressing and defined their own action steps. Given that priorities were identified by the community, not by the state or the regional coordinators, the initiatives that community members chose to implement varied across regions and included a range of activities such as developing community resource guides, reducing barriers to social services and mental health treatment, and pursuing funding opportunities to expand prevention programming. In January 2024, Indiana\u0026rsquo;s DMHA announced that the state would be transitioning away from the RPS and enacted a plan for integrating the newly created community boards with existing mental health infrastructure (e.g., other local coalitions) to carry forward the systems change efforts initiated through the RPS. This created a unique opportunity to study the implementation and sustainability of the initiatives developed through the RPS.\u003c/p\u003e \u003cp\u003eOur study examined the implementation and sustainability of the RPS, Indiana\u0026rsquo;s statewide systems change initiative to prevent and reduce mental health and substance use disorders. In order to understand the implementation process from the perspectives of the individuals leading local efforts, we conducted qualitative interviews with all active regional coordinators across Indiana. Our interview questions and analyses were guided by the Theory of Innovation Implementation and the Consolidated Framework for Implementation Research. Insights from this study may inform future efforts to implement regional approaches that address SDOH, promote mental health, and prevent substance misuse. As such, our findings may be of interest to other states and communities looking to implement systems change initiatives.\u003c/p\u003e\n\u003ch3\u003eConceptual Framework\u003c/h3\u003e\n\u003cp\u003eThe RPS represents an effort to create community-wide systems change. This research was guided by the Theory of Innovation Implementation as a foundational framework,\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e which helps study the process of implementing and sustaining changes within organizations. Since the RPS was a statewide initiative involving multiple organizations, we also incorporated constructs from the Consolidated Framework for Implementation Research (CFIR), a systematic framework for assessing implementation barriers and facilitators, to define the system-level domain.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e In doing so, we developed a comprehensive framework that expands upon previous applications of implementation theories and allows us to examine the relationship between contextual factors that influence implementation and sustainability of systems-change initiatives (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eInnovation Domain\u003c/h2\u003e \u003cp\u003eThe innovation domain comes directly from the CFIR and represents the \u0026ldquo;thing\u0026rdquo; being implemented.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e Thus, the \u003cem\u003einnovation\u003c/em\u003e can be defined as details about the \u0026ldquo;thing\u0026rdquo; being implemented. The innovation can take a variety of forms such as a clinical treatment, an educational program, or a service. Thematic categories within the innovation construct include those related to characteristics of the innovation itself, such as the source (the group that developed the innovation), relative advantage over existing innovations or practices, complexity, and cost. In this study, the RPS serves as the innovation of interest.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSystem-Level Domain\u003c/h3\u003e\n\u003cp\u003eWe adapted constructs from the \"outer setting domain\u0026rdquo; (i.e., system-level factors) of the CFIR to define the system-level domain in our framework, which can include multiple levels.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e In this study, we define levels of interest as the county, region, and state. The system-level constructs we examined include system readiness, system policies and laws, and sociocultural norms. \u003cem\u003eSystem readiness\u003c/em\u003e is defined as the extent to which the system is prepared for change. This includes existing conditions of the community (e.g., economic, environmental, or technological capabilities) and previously existing infrastructure (e.g., partnerships/connections) that may expedite or impede implementation. \u003cem\u003eSystem policies and laws\u003c/em\u003e are defined as legislation, regulations, guidelines, and recommendations from professional organizations or accrediting bodies.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e Finally, \u003cem\u003esociocultural norms\u003c/em\u003e are defined as broadly held social norms/attitudes, values, and beliefs that may influence implementation. This construct also includes external societal pressures that may drive implementation.\u003c/p\u003e\n\u003ch3\u003eOrganization-Level Domain\u003c/h3\u003e\n\u003cp\u003eThe organization-level domain in our framework is comprised of constructs adapted from the theory of innovation implementation.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e These include organizational climate, organizational readiness, and organizational policies and procedures. \u003cem\u003eOrganizational climate\u003c/em\u003e refers to the extent to which an innovation is perceived to be rewarded, supported, and expected.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e In 2009, Weiner et al. built upon Klein \u0026amp; Sorra\u0026rsquo;s work and proposed that implementation is also influenced by organizational readiness and policies and procedures put in place.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e \u003cem\u003eOrganizational readiness\u003c/em\u003e is the extent to which employees are prepared to make necessary changes to support implementation of the innovation. \u003cem\u003eOrganizational policies and practices\u003c/em\u003e include plans, activities, structures, and strategies within an organization that shape the implementation climate.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003ch3\u003eSustainability Domain\u003c/h3\u003e\n\u003cp\u003eThe sustainability domain includes constructs from both the theory of innovation implementation and CFIR. These include implementation effectiveness, innovation efficacy, innovation effectiveness, and sustainability. \u003cem\u003eImplementation effectiveness\u003c/em\u003e refers to the consistency, quality, and appropriateness of innovation use. \u003cem\u003eInnovation efficacy\u003c/em\u003e is the shared belief of individuals who are implementing the innovation in their own capabilities. \u003cem\u003eInnovation effectiveness\u003c/em\u003e is the innovation itself (i.e., changes in outcomes or perceived impacts). Finally, \u003cem\u003esustainability\u003c/em\u003e refers to the extent to which system-level changes are maintained or persist beyond the implementation period. Despite the importance of sustainability, in prior studies that utilize that theory of innovation implementation,\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e sustainability is often discussed tangentially related to implementation but is not defined as a stand-alone construct.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e By incorporating the sustainability construct from the CFIR in our framework, we expand the use of theory to more explicitly examine how implementation processes influence sustainability.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eSetting, Study Participants and Recruitment\u003c/h2\u003e \u003cp\u003eWhen the RPS was first established, Indiana\u0026rsquo;s DMHA identified 10 regions across the state, each containing 1 to12 counties, and contracted with a coordinator to serve each region. Each regional coordinator (n\u0026thinsp;=\u0026thinsp;9) was contacted as a potential interviewee and their contact information was obtained from Indiana\u0026rsquo;s DMHA. Recruitment messages were sent by email in January 2024. All participants were offered a \u003cspan\u003e$\u003c/span\u003e50 gift card as an incentive to participate in the study. At the time of recruitment and data collection, one region (Region 7- Marion County) was vacant, so there were 9 active regional coordinators serving the state. All 9 coordinators responded to our request and completed an interview, representing 91 out of 92 counties in Indiana. As a matter of procedural ethics,\u003csup\u003e \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e \u003c/sup\u003e we chose not to collect or report on individual demographic information about the regional coordinators to avoid deductive disclosure of any participants which might allow persons who know certain facts about participants due to their involvement in the RPS to link by any quotations or other information presented back to the study participants. This study was approved by the Institutional Review Board (IRB) at Indiana University.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eInterview Guide Development\u003c/h3\u003e\n\u003cp\u003eWe developed a semi-structured interview guide to collect insights about the RPS implementation process and sustainability efforts (see supplementary files). This semi-structured interview guide was created by members of the research team to learn more about experiences implementing the RPS across regions, system- and organization-level factors influencing implementation. Participants were also asked about the sustainability of RPS efforts, as the coordinators were preparing for the integration of the RPS into existing community infrastructure at the time of our interviews. Questions were informed by and corresponded to the domains of interest presented in our conceptual framework. Interviews were conducted by one team member and lasted approximately 45\u0026ndash;60 minutes. All interviews were conducted, recorded, and transcribed via Microsoft Teams. After completion of the interviews, one member of the research team reviewed all transcripts to ensure accuracy.\u003c/p\u003e\n\u003ch3\u003eCodebook Development and Analysis\u003c/h3\u003e\n\u003cp\u003eAfter transcription, interviews were qualitatively coded in accordance with criteria for high-quality qualitative research and established thematic analysis methodology.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e Given the complexity of the RPS as an innovation and the nuances of implementing the RPS across diverse community settings, we combined theoretical constructs from the CFIR and the Theory of Innovation Implementation to create a comprehensive framework allowing us to capture rich insights about the RPS implementation process.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e To develop our codebook, we first defined the four overarching domains in our framework. Next, we defined the 11 main constructs representing these domains, drawing on established constructs from the CFIR and the Theory of Innovation Implementation.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e We further defined \u003cem\u003ea priori\u003c/em\u003e themes within each construct based on the updated list of CFIR constructs.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e We then conducted thematic analysis in which we applied \u003cem\u003ea priori\u003c/em\u003e themes to quotations capturing the essence of a particular construct. To ensure interrater reliability, two coders independently reviewed the same transcript and then compared codes. In instances where coders disagreed, we discussed the code application until 100% agreement and consensus was reached. The remaining interviews were divided between the researchers for individual coding. After coding was completed, the two coders met to review the application of codes by exporting all coded excerpts from the transcripts, reviewing quotations within each theme, and discussing any concerns about accuracy of coding applications. As an added check to ensure rigor of our findings and trustworthiness of our interpretation of the data,\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e all members of the research team reviewed the final results of the analysis and accuracy of themes applied to illustrative quotes presented in this manuscript.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003eKey Qualitative Insights\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eKey insights about implementing the RPS as a health equity initiative focused on systems change to promote mental health and prevent substance misuse are presented across constructs within the following four domains: innovation, system-level, organization-level, and sustainability.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eInnovation Domain\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThemes that were identified within the innovation domain and illustrative quotes from the interviews are presented in \u003cstrong\u003eTable 1\u003c/strong\u003e. Participants described experiences related to the innovation source, evidence base, adaptability, relative advantage, trialability, and complexity of the RPS. More specifically, participants identified DMHA, many times referred to as “the state,” as the organization seeking to implement the RPS (i.e., the innovation source). In communities where DMHA was viewed as credible and trustworthy, this helped facilitate engagement in the RPS. Participants, however, also encountered distrust of the state in many communities, and had to overcome this hesitancy to gain buy-in from many individuals. For example, one coordinator described their experience at one of the first consultation board meetings they led, \u003c/p\u003e\n\u003cp\u003e“\u003cem\u003eI almost felt like I was in a war at one of the first meetings...there were a lot of people on the call and they did not want me there.”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e_____________________\u003c/p\u003e\n\u003cp\u003eTable 1 about here\u003c/p\u003e\n\u003cp\u003e_____________________\u003c/p\u003e\n\u003cp\u003eWhile several participants described the feeling of not being wanted or needed when first implementing the RPS, in some cases, they were able to find common goals with community members. Establishing a common goal allowed them to overcome some of the hesitancy and distrust initially encountered. One participant described how they were able to overcome the community’s sense of distrust by consistently showing up to community meetings and displaying a sense of support. Participants also described perceived duplication between the RPS and other community coalitions focused on substance misuse prevention, including Drug Free Communities and Local Coordinating Councils. In other words, in communities where individuals did not perceive any relative advantage of the RPS compared to existing initiatives or coalitions, they were less willing to engage in the RPS. As one coordinator said,\u003c/p\u003e\n\u003cp\u003e“\u003cem\u003eWe were always being compared to other systems in place across communities, systems of care, drug free communities, local coordinating councils, like why are you here doing this work when there’s other agencies doing similar work.”\u003c/em\u003e \u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSystem-Level Domain\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThemes that were identified within the system-level domain are presented in \u003cstrong\u003eTable 2\u003c/strong\u003e. Most themes that emerged from participant descriptions of the implementation experience related to system readiness and sociocultural norms, whereas system policies and laws were rarely mentioned. In terms of system readiness, participants described existing infrastructure and established partnerships in the community as facilitators of implementation. For example, one participant shared that one of their counties experienced a public health epidemic in previous years. Through the aid of state and federal stakeholders, the county established a robust infrastructure, which remained in place and helped support implementation of future initiatives. As the coordinator said, \u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Some counties do it very well, and [omitted county] does an excellent job of sustaining and handling all the things that they do… They have a lot of infrastructure, they have people with experience doing these things that has been passed down to other people in those organizations and they do a fantastic job of handling issues and knowing about sustainability and applying for funding that hasn't happened in all these other counties.”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e_____________________\u003c/p\u003e\n\u003cp\u003eTable 2 about here\u003c/p\u003e\n\u003cp\u003e_____________________\u003c/p\u003e\n\u003cp\u003eSociocultural norms that reflected stigma embedded in the community, were frequently described as barriers to implementation of the RPS. Coordinators, however, also described positive changes in stigma and attitudes over time, indicating that this was a barrier during the initial implementation phase that coordinators were able to overcome. As one participant described, \u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“And then there is stigma. My gosh, four years ago you bring up [substance misuse] and it's like, oh I don't want to talk about that. And you're like, why not? But I don't get that anymore. I don't get that anymore from anybody. It's just a matter of fact we have these issues. We want to make folks better and open and know there's resources and share them.”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWhile system policies and laws were rarely mentioned, one policy that was noted as a facilitator of implementation was the use of a regional dashboard tool to identify community priorities for systems change. Several participants stated that the development of a regional dashboard defining action steps towards a shared goal was a significant catalyst to driving change in the community. As one participant described, \u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Over the past year we started actually working on the dashboard goals and trying to work to get some tangible things. Once we started doing that, we started getting more people around the table, really gaining a lot more diversity of thought, gaining a lot of momentum.” \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eOrganization-Level Domain\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThemes that were identified within the organization-level domain are presented in \u003cstrong\u003eTable 3\u003c/strong\u003e. Despite the challenges between the coordinators and counties, nearly all participants described adverse community conditions that drove their organizations to work together for the betterment of their community. Other public health challenges increased the urgency for organizations to respond and served as a catalyst to generate partnerships. For example, coordinators indicated that homelessness was a rampant issue in their communities, \u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“So that's how I knew that [mental health] was getting to be a big issue for the state to get involved, but it's been brought up in all of my 9 regions about homelessness, including youth homelessness.”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e_____________________\u003c/p\u003e\n\u003cp\u003eTable 3 about here\u003c/p\u003e\n\u003cp\u003e_____________________\u003c/p\u003e\n\u003cp\u003eOther adverse community conditions identified were increased use of electronic cigarettes, increased rates of death by suicide in the youth population, and increased resource needs for maternal mental health. As one coordinator described,\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“So over one of our big areas with building capacity in our local communities and [county], small, roughly 10,000 people, no conversations were happening in their community at all. And there was a big vaping epidemic at the school.”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWhile coordinators agreed that the counties identified prominent issues that needed to be addressed, the climate and attitudes of the community, at times, prevented implementation. Specifically, stigma was a major contributor to whether community organizations partook in events. The coordinator stated, \u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Those are big issues and we've at least overcome one big thing in four years that I've noticed and it's still there, but not like it was. And that's stigma.”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSustainability Domain\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThemes that were identified within the sustainability domain are presented in \u003cstrong\u003eTable 4\u003c/strong\u003e. Numerous positive outcomes were described which encouraged the sustainability of efforts initiated through the RPS. Building partnerships with community organizations was consistently mentioned by participants as being an outcome of the RPS, and many coordinators said that their communities were trying to find ways to sustain their new relationships and communication channels beyond the RPS. For example, one participant described the benefit of knowing what neighboring counties were doing and therefore encouraged them to implement something similar, \u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Like then gaining knowledge of what other counties are doing, especially my smaller communities, they kind of get, I don't want say stuck, but sometimes it's hard to keep thinking of new things to do when you're small and when you have very little manpower.”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e_____________________\u003c/p\u003e\n\u003cp\u003eTable 4 about here\u003c/p\u003e\n\u003cp\u003e_____________________\u003c/p\u003e\n\u003cp\u003eAdditional positive outcomes resulting from implementation of the RPS included improved skills and community initiative to seek out additional grant funding to continue expanding programs. Moreover, several participants described the perspective that the RPS took regarding stigma of mental health and substance use,\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“In some of the small rural communities, conversations were not happening around prevention at all and just me coming in this position, coming into the communities allowing that conversation to happen has allowed…some conversation happened. Destigmatize mental health substance use and make small changes in the communities.”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eComments about sustaining efforts after the RPS implementation ends were not always positive. Specifically, many participants described disappointment, sadness, and at times, anger, expressed by their communities upon learning about the transition away from the RPS. Rural communities were particularly concerned about their ability to sustain communication platforms without the RPS. As one participant described their community members’ response, \u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“There are people who are angry that this [transition from RPS] happened and there are people who are like, just sad that they were, you know, there are people who are disappointed. They were just getting going.”\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAddressing upstream SDOH that influence mental health and substance misuse outcomes requires a shift from implementing programs that address individual-level social factors to policies and practices that create systems-level change within and across communities.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e Indiana\u0026rsquo;s RPS provides one example of a statewide initiative that focused on promoting mental health and preventing substance misuse through systems-change. We conducted qualitative interviews with all 9 regional coordinators in Indiana to learn more about the process of implementing the RPS and perceptions around sustainability of efforts initiated through the RPS. Our assessment of the RPS implementation process demonstrates barriers and facilitators of implementing systems-change initiatives for promoting mental health and preventing substance misuse. Moreover, these barriers and facilitators differed across communities, with some factors being unique to rural communities. Several communities expressed a desire to sustain systems-change beyond the RPS transition and identified concerns about the sustainability of newly-built relationships and communication channels, which were most prominent in rural communities. Given the unique challenges faced by rural communities and the documented disparities in mental health and substance use treatment services in such communities,\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e rural communities may benefit from additional, directed support in the absence of statewide efforts.\u003c/p\u003e \u003cp\u003eDuring the initial implementation of the RPS, many coordinators were met with hesitancy from community members. This type of hesitancy and resistance to change is common when implementing new initiatives.\u003csup\u003e\u003cspan additionalcitationids=\"CR14 CR15 CR16\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e It took time and efforts for community members to understand how the RPS differed from existing community initiatives for mental health promotion and substance misuse prevention. Coordinators shared strategies that they used to overcome these initial challenges and gain stakeholder buy-in, such as continuously showing up to meetings and educating community members about the purpose of the RPS. As coordinators described, stigma was also a major barrier during the initial RPS implementation. Stigma is a well-documented barrier to initiatives for mental health and substance use.\u003csup\u003e\u003cspan additionalcitationids=\"CR25 CR26 CR27\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e Increasing health literacy has been shown to decrease mental health stigma, and in turn increase willingness to seek help and interact with individuals with mental health conditions.\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e As coordinators persisted in raising awareness about mental health and substance use and demonstrating that it is ok to have conversations about these topics, they perceived an increase in mental health literacy and a decrease in stigma encountered over time. Finding a common mission or goal to align community members with also helped garner buy-in and facilitate implementation of the RPS. For example, several coordinators described issues related to SDOH in their communities, such as homelessness, as factors that motivated organizations to come together and collaborate towards creating systems change. Coordinators also found the use of a dashboard tool to organize these efforts and explicitly document action steps helpful.\u003c/p\u003e \u003cp\u003eOne of the primary outcomes of the RPS was the new relationships and communication platforms established. In line with findings from implementation research literature,\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e we identified the importance of having a motivated implementation lead, or champion, to facilitate the development of such relationships among external stakeholders and to share information about community needs back to DMHA. Rural communities especially appeared to benefit from having a lead that represented their community because they frequently felt as if they lacked communication and resources, making it difficult to compete against their urban/suburban counterparts for funding opportunities. Notably, some communities were able to obtain grant funding for the first time with the support of the RPS, demonstrating the benefit such efforts may have on communities that do not have previous experience pursuing grants.\u003c/p\u003e \u003cp\u003eNot surprisingly, the RPS transition was met with feelings of disbelief, sadness, disappointment, and frustration. These feelings are not uncommon when initiatives are discontinued.\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e,\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e However, they are detrimental to sustainability efforts.\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e Additionally, ongoing cycles of efforts to start new initiatives and then ending them a few years later has the potential to erode trust among communities, making it more challenging to implement future initiatives. In communities with existing infrastructure, such as other coalitions focused on promoting mental health and preventing substance misuse, efforts initiated through the RPS may be more likely to be carried forward throughout the transition and sustained. However, in communities with more limited resources, it remains unclear whether efforts initiated through the RPS will continue when there is no longer a coordinator dedicated to facilitating communication between organizations. This further underscores the need to provide additional support to rural communities in the absence of statewide efforts to avoid exacerbating existing disparities in these communities. To circumvent such challenges, future efforts should consider sustainability early on, even during the pre-implementation phase, to ensure a plan is in place. Future research should examine the sustainability of other regional- and state-level initiatives to enhance our understanding of effective ways to implement and sustain systems change.\u003c/p\u003e \u003cp\u003eOur study has strengths and limitations. We used purposive sampling and conducted interviews with all regional coordinators involved in a statewide initiative. While we were able to capture perspectives from individuals embedded in 9 different regions of the state, given that the RPS was unique to Indiana, our study findings may not be generalizable to similar initiatives in other states. When implementing similar initiatives, it is important to consider the unique sociodemographic makeup of counties or regions involved, as this may impact the implementation process. As a limitation, our study did not include Marion County, which is the most populated county in Indiana and, as an urban county, is very different from the 91 counties served by the coordinators represented in our study. Thus, the perspectives and experiences of the regional coordinators in this study should be interpreted with this in mind. Our study employed a novel theoretical framework developed based on constructs of the Theory of Innovation Implementation and the CFIR. By applying implementation science methods to examine the implementation and sustainability of a system-level innovation, we expand the application of theory and generate insights that enhance our understanding of implementation processes for systems-focused innovations. Finally, given that our study was conducted during the transition period away from the RPS, we were able to generate insights into potential sustainability of systems-changes initiated through the RPS from the perspective of the regional coordinators. However, we were not able to assess actual sustainability of these efforts beyond the transition period at this time. We also were not able to capture the perspectives of representatives from other community organizations who were involved in the RPS. Future research should examine longer-term sustainability from the perspectives of these representatives.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe process of implementing and sustaining prevention efforts through the RPS was different in every community. All coordinators believed that they helped facilitate the establishment of new relationships among community organizations and enhanced communication channels. The benefits of these new relationships were particularly prominent in rural communities, some of whom were able to obtain state funding for the first time and implemented new initiatives to promote mental health and prevent substance misuse. However, since the process of integrating the RPS into existing community infrastructure is still underway, it remains unclear whether the new relationships and communication channels established by the coordinators will be sustained over time. Given concerns expressed by coordinators about how this transition may disproportionately affect rural communities, policymakers should consider alternative strategies for providing ongoing support to rural communities.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e This study was approved by the Institutional Review Board at Indiana University.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e The dataset generated during the current study is not publicly available due to potentially identifiable information contained in interview transcripts. De-identified excerpts may be shared upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e Dr. Burns has previously served as a regional coordinator and received compensation from the Indiana Division of Mental Health and Addiction (DMHA) for work performed in Marion County, IN (excluded from this study). At the time of this study, Dr. Burns was no longer in this role and no longer receiving any personal compensation from DMHA.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This study was funded by WISE Indiana (Wellbeing Informed by Science and Evidence in Indiana), a partnership between the Indiana Clinical and Translational Sciences Institute’s Monon Collaborative (CTSI) and the Indiana Family and Social Services Administration (FSSA). WISE Indiana and Indiana FSSA reviewed and approved this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions:\u003c/strong\u003e AB, LM, and BP developed the interview guide. AB conducted all interviews with key informants. AB and HK analyzed and interpreted the qualitative data. AB led the writing of the manuscript; HK and LM also made major contributions. BP, JB, and MA provided critical review and feedback throughout manuscript development. All authors read and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e The authors thank the following individuals for their support and contributions to this work: Makayla Pearson and Aaron Zych (WISE Indiana); Alejandra Capshew (Irsay Institute); Emily Meanwell (Indiana University); LeeAnn Sell and Mary Ellen Van Booven (Center for Survey Research). All were compensated for their work related to this project.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eNational Institute of Mental Health (NIMH). Mental Illness. Accessed September 11, 2024. https://www.nimh.nih.gov/health/statistics/mental-illness\u003c/li\u003e\n\u003cli\u003eLipari RN, Park-Lee E. \u003cem\u003eKey Substance Use and Mental Health Indicators in the United States: Results from the 2019 National Survey on Drug Use and Health\u003c/em\u003e. 2020.\u003c/li\u003e\n\u003cli\u003eDeferio JJ, Breitinger S, Khullar D, Sheth A, Pathak J. Social determinants of health in mental health care and research: a case for greater inclusion. \u003cem\u003eJ Am Med Inform Assoc\u003c/em\u003e. 2019;26(8-9):895-899. doi:10.1093/JAMIA/OCZ049\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Social determinants of health. Accessed September 11, 2024. https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1\u003c/li\u003e\n\u003cli\u003ePinals DA, Fuller DA, Pinals MJ. Social Determinants of Health and Mental Health. Accessed September 11, 2024. https://www.ncsc.org/__data/assets/pdf_file/0025/70864/Social-Determinants-of-Health.pdf\u003c/li\u003e\n\u003cli\u003eAlegr\u0026iacute;a M, NeMoyer A, Falg\u0026agrave;s Bagu\u0026eacute; I, Wang Y, Alvarez K. Social Determinants of Mental Health: Where We Are and Where We Need to Go. \u003cem\u003eCurr Psychiatry Rep\u003c/em\u003e. 2018;20(11):95. doi:10.1007/S11920-018-0969-9\u003c/li\u003e\n\u003cli\u003eFranz B, Burns A, Kueffner K, et al. A national overview of nonprofit hospital community benefit programs to address the social determinants of health. \u003cem\u003eHealth Affairs Scholar\u003c/em\u003e. 2023;1(6). doi:10.1093/HASCHL/QXAD078\u003c/li\u003e\n\u003cli\u003eCarey G, Crammond B. Systems change for the social determinants of health Health policies, systems and management in high-income countries. \u003cem\u003eBMC Public Health\u003c/em\u003e. 2015;15(1):1-10. doi:10.1186/S12889-015-1979-8/FIGURES/2\u003c/li\u003e\n\u003cli\u003eFamily and Social Services Administration. DMHA: Prevention partners. Accessed September 11, 2024. https://www.in.gov/fssa/dmha/substance-misuse-prevention-and-mental-health-promotion/prevention-partners/\u003c/li\u003e\n\u003cli\u003eMcCance-Katz EF. SAMHSA: Creating a System of Care That Meets the Needs of People With Mental and Substance Use Disorders. \u003cem\u003ePsychiatr Serv\u003c/em\u003e. 2020;71(5):416-418. doi:10.1176/APPI.PS.202000075\u003c/li\u003e\n\u003cli\u003eScharf DM, Breslau J, Hackbarth NS, Kusuke D, Staplefoote BL, Pincus HA. An Examination of New York State\u0026rsquo;s Integrated Primary and Mental Health Care Services for Adults with Serious Mental Illness. \u003cem\u003eRand Health Q\u003c/em\u003e. 2014;4(3):13. Accessed September 11, 2024. /pmc/articles/PMC5396210/\u003c/li\u003e\n\u003cli\u003eKlein KJ, Sorra JS. The Challenge of Innovation Implementation. \u003cem\u003eThe Academy of Management Review\u003c/em\u003e. 1996;21(4):1055. doi:10.2307/259164\u003c/li\u003e\n\u003cli\u003eDamschroder LJ, Reardon CM, Widerquist MAO, Lowery J. The updated Consolidated Framework for Implementation Research based on user feedback. \u003cem\u003eImplementation Science\u003c/em\u003e. 2022;17(1). doi:10.1186/S13012-022-01245-0\u003c/li\u003e\n\u003cli\u003eWeiner BJ. A theory of organizational readiness for change. \u003cem\u003eImplement Sci\u003c/em\u003e. 2009;4(1). doi:10.1186/1748-5908-4-67\u003c/li\u003e\n\u003cli\u003eDimartino LD, Birken SA, Hanson LC, et al. The influence of formal and informal policies and practices on health care innovation implementation: A mixed-methods analysis. \u003cem\u003eHealth Care Manage Rev\u003c/em\u003e. 2018;43(3):249-260. doi:10.1097/HMR.0000000000000193\u003c/li\u003e\n\u003cli\u003eBurns A, Gutta J, Kooreman H, Spitznagle M, Yeager VA. Strategic use of tobacco treatment specialists as an innovation for tobacco cessation health systems change within health care organizations. \u003cem\u003eHealth Care Manage Rev\u003c/em\u003e. 2023;48(4). doi:10.1097/HMR.0000000000000380\u003c/li\u003e\n\u003cli\u003eAlegr\u0026iacute;a M, Nemoyer A, Falgas I, Wang Y, Alvarez K. Social Determinants of Mental Health: Where We Are and Where We Need to Go. doi:10.1007/s11920-018-0969-9\u003c/li\u003e\n\u003cli\u003eBurns A, Menachemi N, Mazurenko O, Salyers MP, Yeager VA. State Policies Associated with Availability of Mobile Crisis Teams. \u003cem\u003eAdm Policy Ment Health\u003c/em\u003e. Published online March 18, 2024. doi:10.1007/s10488-024-01368-0\u003c/li\u003e\n\u003cli\u003eBurns A, Vest JR, Menachemi N, Mazurenko O, Salyers MP, Yeager VA. Market Factors Associated with Comprehensive Behavioral Health Crisis Care Availability: A Resource Dependence Theory Study. \u003cem\u003eInquiry\u003c/em\u003e. 2024;61. doi:10.1177/00469580241256822\u003c/li\u003e\n\u003cli\u003eUrquhart R, Kendell C, Cornelissen E, et al. Identifying factors influencing sustainability of innovations in cancer survivorship care: a qualitative study. \u003cem\u003eBMJ Open\u003c/em\u003e. 2021;11:42503. doi:10.1136/bmjopen-2020-042503\u003c/li\u003e\n\u003cli\u003eMcKay VR, Morshed AB, Brownson RC, Proctor EK, Prusaczyk B. Letting Go: Conceptualizing Intervention De-implementation in Public Health and Social Service Settings. \u003cem\u003eAm J Community Psychol\u003c/em\u003e. 2018;62(1-2):189-202. doi:10.1002/AJCP.12258\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1:\u003c/strong\u003e Illustrative quotes within the Innovation Domain\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"840\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7143%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eConstruct\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89.2857%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIllustrative Quote (\u003cem\u003eSubtheme\u003c/em\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7143%;\"\u003e\n \u003cp\u003eInnovation\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89.2857%;\"\u003e\n \u003cp\u003e\u0026ldquo;What we\u0026rsquo;re trying to change is something that\u0026apos;s been deeply ingrained, and that\u0026apos;s a distrust.\u0026rdquo; (\u003cem\u003eSource\u003c/em\u003e)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;And I almost felt like I was in a war at one of the first meetings...there were a lot of people on the call and they did not want me there\u003cem\u003e.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(\u003cem\u003eSource\u003c/em\u003e)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;A lot of people in my region were already involved with DMHA when I took this job\u0026hellip; this is a fairly fluent region and they were receptive for the most part.\u0026rdquo; (\u003cem\u003eSource\u003c/em\u003e)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;We knew what we were hoping to create and that was healthier Hoosiers. We were looking at the five pillars of health and we were looking at how to impact community systems change, but we weren\u0026apos;t sure exactly what role to take to get there. And so, we were constantly learning through research, through data, through partnerships with community members.\u0026rdquo; (\u003cem\u003eEvidence-base\u003c/em\u003e)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;We were always being compared to other systems in place across communities, systems of care, drug free communities, local coordinating councils, like why are you here doing this work when there\u0026rsquo;s other agencies doing similar work.\u0026rdquo; (\u003cem\u003eRelative advantage\u003c/em\u003e)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;I\u0026rsquo;m always being adaptable because things change at any moment. So, always being on your toes and being able to adapt to what the conversations go like. You might have one way thought out, but they can go completely differently.\u0026rdquo; (\u003cem\u003eAdaptability\u003c/em\u003e)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;I was the guinea pig for lack of a better term in rolling out the regional prevention system. So for me it didn\u0026apos;t look like anything\u0026hellip; we knew we were hoping to create opportunities for everyone in Indiana, whether you live there, work there in the region or in the state to have opportunities to be healthier\u0026hellip; one of the things our community did is we really tried to bounce around and not just stay centralized in one city within each of our counties because that\u0026apos;s what\u0026apos;s already happening. I was able to make connections with the schools in one county and help them get some prevention programming in their schools because they had nothing at all in their county happening. So, we started small and I made those connections for them.\u0026rdquo; (\u003cem\u003eTrialability\u003c/em\u003e)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;Of course, there\u0026apos;s a lot of different things happening, and so adding another meeting was obviously a little bit challenging, especially in the bigger communities.\u0026rdquo; (\u003cem\u003eComplexity\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2:\u003c/strong\u003e Illustrative quotes within the System-Level Domain\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"834\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.2302%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eConstruct\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87.7698%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIllustrative Quote (\u003cem\u003eSubtheme\u003c/em\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.2302%;\"\u003e\n \u003cp\u003eSystem Readiness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87.7698%;\"\u003e\n \u003cp\u003e\u0026ldquo;Some counties do it very well, and [omitted county] does an excellent job of sustaining and handling all the things that they do... They have a lot of infrastructure. They have people with experience doing these things that has been passed down to other people in those organizations and they do a fantastic job of handling issues and knowing about sustainability and applying for funding. That hasn\u0026apos;t happened in all these other counties.\u0026rdquo; (\u003cem\u003ePhysical/Work Infrastructure\u003c/em\u003e)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;A lot of them told me that one of the best things that came out of this was that we thought we knew each other in our county because we sometimes are on the same meetings, but we didn\u0026apos;t know each other as well as we do now. So that\u0026apos;s another sign I think that proves that communication has improved during this regional system and that\u0026apos;s what it was supposed to be about.\u0026rdquo; (\u003cem\u003ePartnerships \u0026amp; Connections\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.2302%;\"\u003e\n \u003cp\u003eSociocultural Norms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87.7698%;\"\u003e\n \u003cp\u003e\u0026ldquo;And then there is stigma. My gosh, four years ago you bring up [substance misuse] and it\u0026apos;s like, oh I don\u0026apos;t want to talk about that. And you\u0026apos;re like, why not? But I don\u0026apos;t get that anymore. I don\u0026apos;t get that anymore from anybody. It\u0026apos;s just a matter of fact we have these issues. We want to make folks better and open and know there\u0026apos;s resources and share them.\u0026rdquo; (\u003cem\u003eLocal Attitudes/Conditions\u003c/em\u003e)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;There is a community down in [omitted region] that I feel like there\u0026apos;s just a lot of political turmoil around prevention in and I feel like some success for some of the people in that county was being able to join together outside of that political turmoil and say we feel that what\u0026apos;s going on over there isn\u0026apos;t right.\u0026rdquo; (\u003cem\u003eLocal Attitudes/Conditions\u003c/em\u003e)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;They met two or three extra times a year just for special work projects, so they had been meeting and they had projects on their agenda that they were driving forward.\u0026rdquo; (\u003cem\u003eExternal Market/Performance Measurement Pressure\u003c/em\u003e)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;That\u0026apos;s how I knew that it was getting to be a big issue for the state to get involved, but it\u0026apos;s been brought up in all of my 9 regions about homelessness, including youth homelessness.\u0026rdquo; (\u003cem\u003eExternal Market/Performance Measurement Pressure\u003c/em\u003e)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;Then, just like awareness issues like bringing awareness to prevention and substance misuse, and mental health issues and we\u0026apos;ve done a couple listening sessions across the communities with youth and having action focused after those listings, sessions like [county] had multiple youth death by suicides in six month period.\u0026rdquo; (\u003cem\u003eExternal Market/Performance Measurement Pressure\u003c/em\u003e)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;They\u0026apos;re one of the biggest areas in maternal mental health needs, [county]. So, addressing that like Family Services as well has been a big area and just providing linkages to those resources in the community.\u0026rdquo; (\u003cem\u003eExternal Market/Performance Measurement Pressure\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.2302%;\"\u003e\n \u003cp\u003eSystem Policies and Laws\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87.7698%;\"\u003e\n \u003cp\u003e\u0026ldquo;Over the past year we started actually working on the dashboard goals and trying to work to get some tangible things. Once we started doing that, we started getting more people around the table, really gaining a lot more diversity of thought, gaining a lot of momentum.\u0026rdquo; (\u003cem\u003eSystem policies\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3:\u003c/strong\u003e Illustrative quotes identified within the Organization-Level Domain\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"834\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6691%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eConstruct\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86.3309%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIllustrative Quote (\u003cem\u003eSubtheme\u003c/em\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6691%;\"\u003e\n \u003cp\u003eOrganizational Readiness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86.3309%;\"\u003e\n \u003cp\u003e\u0026ldquo;It was a challenge getting people to switch from program-focused thinking to system changes.\u0026rdquo; (\u003cem\u003eOrganizational readiness\u003c/em\u003e)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;I have a lot of people that have attended the Congress or other things that DMHA has put on, like the prevention convention and different things of that nature. They got pretty hooked on that and made friends there too.\u0026rdquo; (\u003cem\u003eOrganizational readiness\u003c/em\u003e)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;You know, not everyone who probably should have been at that table, chose to be at that table.\u0026rdquo; (\u003cem\u003eOrganizational readiness\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6691%;\"\u003e\n \u003cp\u003eOrganizational Climate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86.3309%;\"\u003e\n \u003cp\u003e\u0026ldquo;So over one of our big areas with building capacity in our local communities and [county], small, roughly 10,000 people, no conversations were happening in their community at all. And there was a big vaping epidemic at the school.\u0026rdquo; (\u003cem\u003eTension for change\u003c/em\u003e)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;And because of that, you know you tend to not speak out, you tend to not say, you know, why is our LCC continuing to fund the same programs for the 10th year in a row while our overdose rates are progressively getting worse and more and more people who are going through this program are still are actually using drugs at higher rate.\u0026rdquo; (\u003cem\u003eTension for change\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6691%;\"\u003e\n \u003cp\u003eOrganizational Policies and Practices\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86.3309%;\"\u003e\n \u003cp\u003eNot Applicable\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4:\u003c/strong\u003e Illustrative quotes identified within the Sustainability Domain\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"834\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.1079%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eConstruct\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84.8921%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIllustrative Quote (Subtheme)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.1079%;\"\u003e\n \u003cp\u003eImplementation Effectiveness\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84.8921%;\"\u003e\n \u003cp\u003e\u0026ldquo;There were a lot of new initiatives, new organizations. Maybe not new to the Community, but they were new to the partnership with DMHA.\u0026rdquo; (\u003cem\u003eCommunications/partnerships)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;A lot of my counties have been kind of discussing just that connecting piece has been super beneficial for them.\u0026rdquo; (\u003cem\u003eCommunications/partnerships)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;Gaining knowledge of what other counties are doing, especially my smaller communities, they kind of get, I don\u0026apos;t want to say stuck, but sometimes it\u0026apos;s hard to keep thinking of new things to do when you\u0026apos;re small and when you have very little manpower.\u0026rdquo; (\u003cem\u003eCommunications/partnerships)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.1079%;\"\u003e\n \u003cp\u003eInnovation Efficacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84.8921%;\"\u003e\n \u003cp\u003e\u0026ldquo;I\u0026apos;ve been doing this almost four years and the amount of people that asked me to take their name off of a list or not contact them again, I could do on less than one hand. And most of it was because they just didn\u0026apos;t think they had time or they didn\u0026apos;t see how they could contribute anything.\u0026rdquo; (\u003cem\u003eEfficacy\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.1079%;\"\u003e\n \u003cp\u003eInnovation Effectiveness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84.8921%;\"\u003e\n \u003cp\u003e\u0026ldquo;You know, we\u0026apos;ve had a lot of funded entities in this region and I think to me some of the greatest successes in that were little tiny counties who never applied for anything before who were finally like we were finally at the point with us last prevention request for funding, that they collaborated together and got other organizations and they applied.\u0026rdquo; (\u003cem\u003eActual Outcomes)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;In some of the small rural communities, conversations were not happening around prevention at all and just me coming in this position, coming into the communities allowing that conversation to happen has allowed\u0026hellip;some conversation happened. Destigmatize mental health substance use and make small changes in the communities.\u0026rdquo; (\u003cem\u003eActual Outcomes\u003c/em\u003e)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;So, I think that was the main impact that the Community members and partnerships and organizations felt heard.\u0026rdquo; (\u003cem\u003eActual Outcomes)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.1079%;\"\u003e\n \u003cp\u003eSustainability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84.8921%;\"\u003e\n \u003cp\u003e\u0026ldquo;There are people who are angry that this happened and there are people who are like, just sad that they were, you know, there are people who are disappointed. They were just getting going\u0026hellip;But I mean it, it was like not surprising to me that there were people who said, yeah, here you come with another state initiative.\u0026rdquo; (\u003cem\u003eActual Outcomes)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;I\u0026apos;ve been told that the community, it seems, from kind of some of the perspectives of the influencers in the room there. It\u0026apos;s just people are mean to each other. They\u0026apos;re very high school-y. Cliquish, they\u0026apos;re very just like if you don\u0026apos;t fit in here, you don\u0026apos;t fit in there and or if you don\u0026apos;t fit in here, you know you\u0026apos;re not included in in our conversations, you\u0026apos;re not included in the meeting invites. You\u0026apos;re not included in those things and we don\u0026apos;t do that in the regional prevention system.\u0026rdquo; (\u003cem\u003eActual Outcomes)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Mental health, substance use, prevention, implementation science","lastPublishedDoi":"10.21203/rs.3.rs-5079647/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5079647/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSocial determinants of health have been shown to influence individual mental health and overall well-being. Additionally, populations that experience stigma and/or discrimination because of race, class, gender, or another identity group experience disproportionately higher rates of mental health disorders than populations that do not experience such marginalization. One way to address upstream social determinants that influence mental health is through systems change initiatives. In 2019, Indiana implemented a statewide Regional Prevention System (RPS) focused on systems change to promote mental health and prevent substance misuse.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe developed a semi-structured interview guide to collect insights about the RPS implementation and sustainability. Potential participants were identified based on their role as an active regional coordinator (n\u0026thinsp;=\u0026thinsp;9). We conducted qualitative interviews with all 9 regional coordinators in Indiana. Interview recordings were transcribed and coded using an \u003cem\u003ea priori\u003c/em\u003e coding framework based on constructs from the Theory of Innovation Implementation and the Consolidated Framework for Implementation Research.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eInsights about the RPS implementation process are presented across four domains: innovation, system-level, organization-level, and sustainability. In terms of implementation barriers, coordinators encountered hesitancy and distrust from community members, which they had to overcome to gain buy-in. They also described stigma, including community and individual social norms towards mental health and substance misuse, as barriers that challenged efforts to engage community members in the RPS. Facilitators of implementation included having established community infrastructure and external partnerships. In communities without existing infrastructure to support prevention efforts, particularly rural communities, the implementation process took longer but community members welcomed the additional support and valued the new communication platforms created by the RPS. On sustainability, coordinators provided examples of communities that were able to obtain grant funding in support of prevention initiatives launched through the RPS.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe process of implementing and sustaining prevention efforts through the RPS varied across communities. Prioritizing the delivery of systems-change efforts in underserved communities that are ready for change, rather than statewide efforts, may offer a better strategy for addressing disparities in the social determinants of health that influence mental health and substance misuse.\u003c/p\u003e","manuscriptTitle":"Implementation and sustainability of systems change for mental health promotion and substance misuse prevention: A qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-13 05:08:04","doi":"10.21203/rs.3.rs-5079647/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-09-17T09:43:52+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-09-17T06:29:47+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-09-17T06:24:52+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2024-09-12T19:20:59+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"84dd44fd-4bfb-4abb-94e4-5b2774bf0303","owner":[],"postedDate":"November 13th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-12-02T17:26:22+00:00","versionOfRecord":{"articleIdentity":"rs-5079647","link":"https://doi.org/10.1186/s12913-024-11962-5","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2024-11-27 15:58:23","publishedOnDateReadable":"November 27th, 2024"},"versionCreatedAt":"2024-11-13 05:08:04","video":"","vorDoi":"10.1186/s12913-024-11962-5","vorDoiUrl":"https://doi.org/10.1186/s12913-024-11962-5","workflowStages":[]},"version":"v1","identity":"rs-5079647","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5079647","identity":"rs-5079647","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}