Collaborative care programs for common mental illnesses in low- and middle-income countries: A multi-methods assessment of implementation context in Guatemala

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However, their routine implementation within primary care and communities is limited. To enhance implementation outcomes, strategies of evidence-informed interventions should be carefully tailored to context. Here, we conducted a contextual assessment to identify key community and health system factors prior to selecting implementation strategies for the first collaborative care program for Maya Indigenous People living with CMIs in Guatemala. Methods : This multi methods study combined systems thinking and implementation science tools. We used routinely collected administrative data to create behavior-over-time (BOT) graphs showcasing the number of primary care visits for CMIs in 10 municipal health districts (2018-2022). We conducted semi-structured interviews at one municipal health district following the ‘Practical, Robust Implementation and Sustainability Model’ (PRISM) framework. Participants (n=20) were Ministry of Health coordinators and providers, community leaders with CMIs, and traditional Maya providers. We conducted rapid matrix-based thematic analysis. Results : BOT graphs showed fluctuations in CMI visits, which participants linked to health system and community factors. For instance, historical advocacy for mental health and the training of primary care workers in mental health had increased the number of CMI visits, while the COVID-19 pandemic suddenly decreased CMI visits in 2020. Overall, less than 1% of primary care visits addressed CMIs, which participants indicated did not meet the large and increasing need for mental health services. Civil war violence, natural disasters and alcohol use have increased the mental health needs of young adults over time. Participants indicated that a collaborative care program could increase CMI visits, if implementation strategies address health system and community factors, such as ensuring access to psychotropic medications, and engaging Maya traditional providers in mental health services. Conclusions: By combining BOT graphs, a systems thinking tool, with PRISM we identified dynamic health system and community factors that may influence the implementation of a collaborative care program for CMIs. This is an example on how to conduct pragmatic contextual assessments with readily accessible administrative data and rapid qualitative methods prior to selecting implementation strategies of evidence-informed interventions. Implementation context systems science global mental health depression anxiety health system collaborative care primary care Indigenous People Guatemala Figures Figure 1 Figure 2 Contributions to the Literature Implementation strategies for primary care interventions in low- and middle-income countries must address dynamic, multi-level contexts. In rural Guatemala, a collaborative care mental health program may be acceptable and effective, if immediate infrastructural (e.g. medication availability) and community needs (e.g. engagement of traditional providers) are addressed. While historical and structural factors (e.g. civil war violence) are beyond the scope of health system interventions, they should be acknowledged when designing implementation strategies. This study demonstrates how behavior-over-time graphs, a systems thinking tool, can be integrated with implementation science to capture the dynamic factors shaping mental health service delivery. 1. Background Common mental illnesses (CMIs), like depression, anxiety and trauma, are major contributors to the global burden of disease and are among the top causes of disability worldwide ( 1 ). In low and middle income countries (LMICs) this burden is particularly high and expected to continue increasing ( 1 , 2 ). A wide mental health treatment gap, higher than 90% in most LMICs, partly drives this burden ( 3 , 4 ). The small proportion of the population with access to mental healthcare in LMICs, may still experience low quality care and stigma in vertical mental healthcare settings that often rely on long-term institutionalization ( 5 , 6 ). The World Health Organization’s (WHO) Mental Health Action Plan 2013–2030 advocates for the integration of mental health services within primary care and community settings ( 7 ). Integrated mental health services have the potential to reach a wide proportion of the population, address physical and mental health needs, and reduce mental health stigma ( 7 , 8 ). Collaborative care programs are multi-component interventions in which stepped-care protocols are delivered by a team of primary care providers supervised by mental health specialists ( 9 ). It is considered the highest and most complete model of integration ( 9 ). A large body of evidence suggests that collaborative care programs are effective at improving outcomes from a wide range of CMIs, including depression, anxiety and trauma ( 10 – 13 ). The collaborative care program, originally developed in the US, has now been implemented in LMICs like Vietnam, Nepal, Colombia and Mexico ( 14 – 18 ). Systematic reviews and meta-analysis focused on LMICs indicate that, when compared to usual care, collaborative care programs may reduce symptoms, improve quality of life, and improve the recovery of people living with mental illnesses ( 9 , 19 ). Despite this body of evidence, collaborative care programs for CMIs are yet to be delivered in routine primary care and community settings in most LMICs ( 20 – 22 ). The barriers to the implementation of primary care services for CMIs in LMICs have been previously described in detail ( 23 ). Results indicate that primary care mental health services have been underprioritized for multiple reasons, including the overreliance on mental health specialists, mental health stigma, and the underestimation of mortality and morbidity associated with mental illnesses ( 24 , 25 ). A qualitative systematic review summarized the discrete barriers and facilitators to the implementation of mental health programs in primary care settings in LMICs following the Consolidated Framework for Implementation Research (CFIR) ( 26 ). This study identified current limitations in the literature and ways to address such gaps: adapting programs to context; conducting implementation studies that use comprehensive frameworks and involve health users; and assessing the dynamic and complex inter-relationships between the multiple elements that make up health systems ( 26 ). Studies have suggested that, given the dynamic and complex nature of contextual factors, systems thinking approaches are needed to identify sustainable opportunities for improving the delivery of mental health services ( 27 , 28 ). A systems thinking systematic review mapped the barriers and facilitators to the sustainability of mental health services in LMICs ( 27 ). This called for conducing systems thinking research involving stakeholders in low-resource settings to validate results and obtain more nuanced information ( 27 ). Altogether, these studies indicate that the implementation of mental health services, such as collaborative care programs, in LMICs warrants a deep and dynamic understanding of the context, composed by unique health systems and communities ( 26 – 28 ). As a way to address the evidence-to-practice gap, implementation researchers have repeatedly called for the tailoring of implementation strategies of evidence-informed interventions to contextual factors ( 29 – 31 ). Implementation strategies are the ‘methods or techniques used to enhance adoption, implementation, and sustainment’ (the ‘how’) of an evidence-informed intervention (the ‘what’), such as the collaborative care program ( 32 ). Tailoring implementation strategies requires a deep understanding of the context where the intervention will be implemented prior to selecting strategies that match such context ( 29 ). While the methods for tailoring implementation strategies have been described, they are still being developed ( 29 ). One of the central challenges concerns the assessment and prioritization of contextual implementation factors, prior to selecting the strategies ( 29 , 30 ). To being to address this gap, implementation researchers have called for using systems thinking methods to improve the assessment of context, a central aspect of the tailoring of implementation strategies and the field of implementation science at large ( 28 , 29 , 33 , 34 ). Systems thinking is a discipline that aims to understand the dynamic behavior of complex adaptative systems ( 35 ). Primary healthcare systems and community settings in LMICs may be understood as complex adaptive systems ( 35 ), made up of heterogeneous elements (e.g. clinics, people, resources, cultures) that are organized hierarchically (e.g. providers, clinic, health system) and interact with each other, producing emergent system behaviors and effects. These behaviors and effects cannot be explained by looking at the individual elements due to their complex nature, persist over time due to their dynamic nature, and can adapt to changing circumstances due to their adaptative nature. For these reasons, systems thinking approaches may help to improve the contextual assessments prior to selecting implementation strategies. Rather than looking at discrete barriers and facilitators, systems thinking tools may help to see the ‘health system-community’ as a whole, the inter-relationships between contextual factors and their dynamic nature. By improving the understanding of interrelationships between contextual factors and points in the system that may be intervened to initiate change, systems thinking approaches may facilitate the selection and prioritization of implementation strategies (the ‘how’) of mental health programs (the ‘what’), such as the collaborative care program. This study aimed to assess the community and health system contextual factors, prior to selecting implementation strategies for a collaborative care program for CMIs within primary care in rural Guatemala, utilizing a systems thinking approach. In doing so, we provide an applied, pragmatic example of how implementation science frameworks may be combined with systems thinking tools to improve the assessment of local context in preparation for mental health implementation efforts in LMICs. 2. Methods 2.1. Study Setting We conducted this study in Sololá, a rural department in Guatemala. Sololá’s population primarily identifies as Maya Indigenous People, who have experienced historical discrimination ( 36 ) and were disproportionally targeted by the Civil War ( 37 ). As a result, Maya Indigenous People experience large health and mental health disparities compared to the non-indigenous Guatemalans ( 38 ). As a striking example, studies indicate that the life expectancy of Maya indigenous is 13 years shorter than the non-Indigenous ( 36 ). Moreover, among those exposed to Civil War violence, the odds of depression, anxiety and trauma for Indigenous People were respectively 2.9, 4.5 and 52.00 those of non-indigenous Guatemalans ( 38 ). Western biomedical health systems are often in conflict with explanatory models of disease held by Maya Indigenous People ( 36 , 39 ), which further widens the mental health treatment gap. Recently, the Guatemala’s Ministry of Health and Social Welfare (‘Ministry of Health’) identified Sololá as a department invested in delivering primary care mental health services for their population, a key factor to engaging stakeholders and ensuring the study feasibility. 2.2. Overview of study design This multi methods study used quantitative systems thinking tools and rapid qualitative methods ( 40 ). The quantitative component consisted of creating behavior-over-time (BOT graphs) using secondary, routinely collected data by the Ministry of Health in Sololá. The qualitative component consisted of semi-structured interviews with stakeholders to identify key contextual factors for the implementation of a collaborative care program for CMIs, the first one in the country ( 41 , 42 ). Implementation science framework Our qualitative and quantitative phases were guided by PRISM, an expansion of the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework ( 43 ), which describes the influence of dynamic multi-level contexts on the implementation of complex interventions ( 44 , 45 ). PRISM is considered a determinant and evaluation framework ( 46 ), and utilizes concepts from the diffusion of innovations theory, quality improvement, chronic care models, and implementation research ( 45 ). We used PRISM to elicit multi-level contextual factors key to the implementation of a collaborative care program for CMIs in rural Guatemala from a wide range of stakeholders. We followed its six dimensions: 1) organizational characteristics, 2) implementation and sustainability infrastructure, 3) external environment, 4) community characteristics, 5) organizational perspectives of the intervention and 6) community perspectives of the intervention ( 44 ). We assessed contextual factors at the health area (Sololá department level), health district (municipality) and community levels ( See Table 1 ). Table 1 PRISM dimensions, definitions, selected questions, data collection tools and participants PRISM Dimensions Definition Selected questions from semi-structured interviews Other data collection tools Participants Organizational characteristics Public primary care mental health services: detection, referrals, follow-ups, coordination among HCWs; documentation of common mental illnesses How do providers in this health district / community identify young people with CMI? How do providers register CMI in the health information system? -Health area ¶ -Health district § -Community ¥ Implementation and sustainability Infrastructure What’s currently in place to implement the program; previous efforts to implement primary care mental health services; what’s needed How ready is the health district / your community to implement this program? What’s already available? What is missing? -Health area ¶ -Health district § -Community ¥ Community characteristics Practices for seeking mental health support How do young people CMI problem look for support in your community? What challenges do young people face when seeking support for CMI? -Health area ¶ -Health district § -Community ¥ External environment Institutions, organizations, individuals beyond the health system providing mental health support; community circumstances or events influencing the implementation of mental health services and the prevalence of common mental illnesses Who supports young people with CMI in this community? What are the factors that have influenced the implementation of mental health services in this health district over time? What are the circumstances that have influenced the number of young people with CMIs in your community? Annotations on quantitative BOT graphs (health area, health district participants) Annotations on qualitative BOT graphs (community participants) -Health area ¶ -Health district § -Community ¥ Organizational perspectives of the intervention Health-area and health-district perspectives of the program What is your reaction to this program? To what extent would you support this program? What could facilitate the implementation of this program in this health area / district? Can you think of any implementation challenges [case vignette ] Collaborative care case vignette -Health area ¶ -Health district § Community perspectives of the intervention Community members and community lay providers perspectives of the program What is your reaction to this program? To what extent would you support it / participate? What could motivate young people to participate? Can you think of any challenges to participation? Collaborative care case vignette -Community ¥ BOT graph: Behavior over time graph; CMI: Common mental illnesses ¶ Health area participants included health service coordinators § Health district participants included ¥ Community participants included young leaders with lived experience with common mental illnesses; religious leader who support young people with CMI; and Maya providers (Maya therapists, traditional birth attendants) Ethics Statement This study was approved by Columbia University Irving Medical Campus (CUIMC) Institutional Review Board (IRB) (Protocol No. 10-2022) and the Guatemala’s Ministry of Health and Social Welfare National Health Ethics Committee (IRB-AAAU3592). All participants provided verbal informed consent prior to initiating study procedures. 2.3. Quantitative phase Data sources We used routinely collected administrative data from municipal health centers and community health posts within 10 municipal health districts in Sololá, Guatemala from January 2018 to December 2022.The Ministry of Health’s Administrative Health Information System (SIGSA, in Spanish) runs and maintains the database for surveillance and administrative purposes ( 47 ). However, mental health data is rarely analyzed. Data is collected daily by primary care workers on paper-based standardized forms and it is then entered into an electronic database within the municipal health district on a weekly basis. Finally, data is consolidated monthly and sent to the national-level health information system. The database includes the following information: 1) sociodemographic characteristics (name, age, sex, ethnicity, language, municipality and village), 2) health facility (municipal health district, type of health facility, name of health facility), 3) type of visit (new visit, follow-up), 4) prescribed medication, and 5) diagnosis (name and code) following the International Classification of Disorders version 10 (ICD-10: 2019) ( 48 ). Analysis: Behavior-over-time (BOT) graphs A BOT graph is a systems thinking tool that showcases the behavior of key system-level variables over time. Here, we created BOT graphs showing the number of CMIs by quarter and by year for each municipal health district. Using de-identified SIGSA data, stratified by municipal health district, year and month, we created new diagnosis variables following the ICD-10 classification, grouped as follows: 1) Any health diagnosis, including all primary care visits 2) any neurological mental or substance use illness, including all primary care visits coded for ‘Mental and behavioral disorders’ (F:00-F:99 codes and sub-codes); and 3) any CMI (depression, anxiety and trauma), including all primary care visits coded for ‘Depressive episode’ (F:32 codes and sub-codes), ‘Recurrent depressive disorder’ (F:33 codes and sub-codes), ‘Phobic anxiety disorders’ (F:40 codes and sub-codes), ‘Other anxiety disorders’ (F:41 codes and sub-codes), and ‘Reaction to severe stress, and adjustment disorders’ (F:43 codes and sub-codes). We used R studio and the packages ggplot2, lubridate, and zoo to build the BOT graphs ( 49 ). In the qualitative phase, we used our BOT graphs as reference models to elicit systemic factors underlying fluctuations in CMI visits from key system actors ( 50 , 51 ). 2.4. Qualitative phase Participants Participants included a wide range of stakeholders from Sololá department and Santiago Atitlán, one of the largest rural municipalities with a recognized history of support for public mental health services. Participants included Ministry of Health coordinators in Sololá (department level); coordinators, primary care providers or mental health providers from Santiago Atitlan (municipal health district); young adult leaders with lived CMI experience; and traditional Maya healers ( See Table 2 ) . We used purposive sampling to select potential participants from an a priori mapping of community leaders. We invited participants who were closely involved in the delivery of mental health services and / or had lived CMI experience, and selected leaders who may become future implementation partners. Eligibility criteria included: 1) working in the Ministry of Health within Sololá or living in Santiago Atitlan; and 2) being 18 + years of age. All participants provided verbal informed consent prior to initiating study procedures. Our final sample size was based on qualitative saturation. Table 2 Percentage of visits for common mental illnesses (CMI), depression, anxiety, trauma, and other mental, neurological and substance use illnesses (other MNS) of the total primary care visits by health district in Sololá, Guatemala Health district % CMI visits % Depression visits % Anxiety visits % Trauma visits Other MNS 1 0.04 0.01 0.03 0.01 0.03 2 0.49 0.07 0.05 0.37 0.32 3 0.78 0.18 0.37 0.22 0.76 4 0.44 0.06 0.23 0.15 0.28 5 0.40 0.09 0.19 0.13 0.31 6 0.62 0.15 0.23 0.25 0.34 7 0.07 0.01 0.03 0.03 0.09 8* 0.50 0.11 0.26 0.13 0.21 9 0.21 0.09 0.09 0.03 0.18 10 0.07 0.02 0.03 0.02 0.09 TOTAL 0.30 0.07 0.13 0.10 0.22 *Study health district Collection of semi-structured interviews We conducted semi-structured interviews, following PRISM’s domains ( See Table 1 ). We defined PRISM ‘External Factors’, as the community and health system factors influencing the delivery and need for primary care services for CMIs. To capture external factors, we used BOT graphs as boundary objects to guide our conversation (see quantitative phase; ( See Supplementary Material 1) ( 52 ). For participants with limited reading ability, we asked them to build their own BOT graphs showcasing key external events linked to mental health needs within their communities ( See Supplementary Material 2) ( 53 ). In the last phase of the interview, we captured PRISM ‘Community’ and ‘Organizational perspectives of the intervention’ by presenting participants with a case vignette of a collaborative care program for CMI ( See Supplementary Material 3 ). The other three PRISM domains were explored using open-ended questions. We adapted and pilot-tested interview guides among investigators (DS, APA) prior to initiating data collection. Interviews lasted 45–90 minutes, were audio-recorded and conducted in private spaces, such as public health posts or participants’ houses. Interviews were conducted in Spanish (APA) or Maya Tz’utujil language (DS). Data was collected between March and April 2023 until we reached saturation. Thematic analysis Thematic analysis was conducted by a Guatemalan implementation and mental health researcher (APA), a Maya Indigenous qualitative researcher (DS), and a mental health researcher (JK). We conducted a deductive-inductive rapid matrix-based thematic analysis ( 54 , 55 ). First, we developed verbatim transcripts of interview audio recordings. Then, we extracted data to create interview summaries outlining key results for each PRISM dimension, while allowing for emergent themes and identifying representative quotes (See Supplementary Material 4) . Two independent analysts reviewed the interview summaries. Finally, we consolidated the interview summaries into a matrix displaying PRISM dimensions and emergent themes in the columns and the four participant sub-groups (Sololá department, municipal health district, traditional Maya provider, community leader) in the rows. We then reviewed the matrix, comparing and contrasting results between and within participants. Through this process, we identified key factors for the implementation of a collaborative care program for CMIs in the primary care system. 3. Results 3.1. Quantitative results From January 2018 to December 2022, there were 12,447 primary care visits for CMIs in the 10 health districts of Sololá, which corresponds to 0.30% of all primary care visits (4,215,663) (See Table 2 ). Similarly, the percentage of CMI primary care visits was lower than 1% at each of the 10 health districts. BOT graphs showcasing the number of primary care CMI visits by 3-month period, from January 2018 to December 2022 and for each Sololá health district are shown in Fig. 1. Study health district 8, where we conducted semi structured interviews, is shown in blue and the rest are shown in orange. 3.2. Qualitative results Participants We interviewed 20 stakeholders ( See Table 3 ). Of them, 12 were Ministry of Health workers: four department-level coordinators and eight municipal district-level coordinators and/or providers. Their roles included nurses, physicians, social workers, psychologists and one epidemiologist. The other eight participants were community members: Traditional Maya providers (n = 2), religious leaders (n = 1), and young adults with lived CMI experience and community leadership (n = 5). Traditional Maya providers included a Maya healer ( Ajq’umani’eel in Maya T’zutujil; Terapeuta Maya in Spanish) and a Maya midwife ( Ly’oom in Maya T’zutujil; Comadrona in Spanish). Most participants identified as female (65%) and all, except one, identified as Maya Indigenous of Tz’utujil and Kaqchiquel ethnicities. Table 3 Characteristics and numbers of participants for the qualitative phase Group: N Roles Sex: N (Total %) Ethnicity: N (Total %) Health area: 4 Health service and epidemiology coordinators Female: 3 Male: 1 Kaqchiquel: 3 T’zutujil: 0 Ladino/a: 1 Health district: 8 Health service coordinators; primary healthcare providers; mental healthcare providers Female: 6 Male: 2 Kaqchiquel: 3 T’zutujil: 5 Ladino/a: 0 Community: 8 Terapeutas; comadronas; religious leaders; youth leaders with lived experience Female: 4 Male: 4 Kaqchiquel: 0 T’zutujil: 8 Ladino/a: 0 Total: 20 -- Female: 13 (65%) Male: 7 (35%) Kaqchiquel: 6 (30%) T’zutujil: 13 (65%) Ladino: 1 (5%) PRISM dimensions Below we present qualitative according to each of the six PRISM dimensions. Exemplary quotes for each theme and PRISM dimension, identified through rapid thematic analysis, are provided in Table 4 . Additionally, Fig. 2 , showcases an annotated BOT graph summarizing participants’ contributions and annotations from semi structured interviews. The graph displays overall findings regarding perceived changes in ( 1 ) the number of young adults with CMIs, ( 2 ) the delivery of primary care mental health services, and ( 3 ) related community and health system factors from 1990 to the present and into the future in the Santiago Atitlan health district. Table 4 Exemplary quotes corresponding to PRISM dimensions and emergent themes from semi structured interviews PRISM domain Theme Quotes Organizational characteristics Identification, referrals and treatment --"We identify them sometimes during home visits. People tell you 'my daughter ‘or ‘my son', an adolescent, 'doesn't want to go to school, doesn’t want to go out, they're afraid to go out'. I quickly think they're afraid, they do need a psychologist" ( Female auxiliary nurse, health district) Documentation of CMIs -- "Everyone registers. For example here, the psychologist registers in her SIGSA form them when they visit her. But also physicians, auxiliaries, professional nurses register, but they leave it like ‘stress disorder’ or ‘anxiety crisis’, ‘nerve crises’. There’s like three diagnoses. Everyone registers it, but just like that" (Female professional nurse, health district) Implementation and sustainability Infrastructure Past initiatives to implement mental health services --"We wanted to make something more of mental health, make other rural health districts in Sololá accept it. Even at the national level it was not receiving attention. So, we tried to see how we could support people here in Atitlan, and we achieved it. Then later, the health area hired the other psychologists, 11 more" (Male coordinator, health district) Concerns about weak infrastructure for the program --"The administrative barriers would be that psychologists have a [ clinical ] profile, lack of educational updates, lack of training of providers. There's always a need to train specialists, right. Also, physical space for mental healthcare. There's space in [ health district 9], at least. Also, continuity of human resources. Tools for specialists and medications" (Male epidemiology coordinator, health area) Community characteristics Limited mental healthcare seeking -- ‘Of 10 people 3 seek help, of those 7 that do not look for help 4 only ask for advice from the 3 that sought professional help, the rest do not look for help because they have nowhere to go to and with time it gets worse’ ( Male, youth religious leader) Financial constraints --"These problems can affect anyone, the difference is the family's social class and having financial means, as they can quickly look for support because they have the means and has family support, while a person that doesn’t have means cannot pay for a treatment, they can't even pay 100 quetzales " (Male, leader with CMI experience, community) Stigma and gender roles --"There is taboo related to psychological support. People that don't accept, people that don't recognize that they have a problem. So they prefer to do nothing about it and that is when they fall into alcoholism and drug use" (Female mental HCW, health district) Medical distrust --"But if a doctor or nurse receives me with anger or doesn't treat me well, instead of helping me it makes my situation worse. It is about trying to be kind to people. We as providers need to try to be kind all the time to recover the people's trust" (Female comadrona ) Accompaniment from Maya healers and religious leaders -- “Maya priests, spiritual guides, are dedicated mental health with their own world understanding. Dedicated to overcoming interpersonal and family conflicts, even community problems too. They are like counselors, who are identified as such and are called to intervene. And they are not linked to the healthcare systems and don't have documentation of the cases. Instead, they have their own population, who looks for them due to their recognition and leadership " (Male epidemiology coordinator, health area) Insufficient mental health organizations "Sometimes when I make an appointment the psychologist says, 'I have time in one month'. But if one needs help faster, I communicate with the one nonprofit, and I send them with this nonprofit [...] that has psychologist too, but they charge. But I tell them that they say, 'the auxiliary sent me', sometimes they make a discount and I say, 'thanks God!' " (Female auxiliary nurse, health district) External environment Community factors influencing CMIs and primary care services for CMIs See Fig. 2.2 Organizational perspectives of the intervention Positive to mixed reactions to the program "I truly see it as very good; it would truly see it as a dream if it were to be here. It would really help us a lot with comprehensive care, which is what we want right, it is what we really want" (Mental HCW, health district) Mixed reactions about program’s feasibility " I would be a little bit worried about the system. And having enough time. Because auxiliary nurses have a lot to do and paperwork " (Male social work coordinator, health area) Community perspectives of the intervention Positive reactions to the program "Is there any possibility of having this program here in Guatemala? Because I see that it is very necessary for the mental problems that we have" (Female youth leader) Concerns about participation and health system’s capacity "M aybe the fear [ would hinder participation ]... the fear of sharing their truth " (Female school teacher) PRISM: Organizational Characteristics Identification, referrals and treatment of CMIs Participants indicated that frontline primary care workers are the ones who identify young adults with CMIs during health promotion activities, home visits and primary care visits. Those working at the community level, like rastreadores ( tracers) and auxiliary nurses, are the first ones to detect, followed by those working within primary care facilities, like professional nurses and general physicians. Providers and coordinators highlighted the need for having detection checklists and training in brief counseling skills. Currently, providers detect people based on their appearance (e.g. neglected look), attitude (e.g. sad, angry, desperate, afraid), conversation topics (e.g. family or financial problems), and multiple primary care visits with limited improvement despite medical treatment. When the CMI seems mild to the provider, they aim to provide emotional support through brief conversations. If it seems severe, primary care providers direct the person and their relatives to the one public primary care psychologist, who may provide psychoeducation and psychotherapy. However, there are long waiting times (2–3 months), which providers and community members identified as a significant barrier and source of frustration. Since there are no public psychiatrists in Sololá, most people who need pharmacotherapy have to be referred to the National Psychiatric Hospital in Guatemala City, which is six to eight hours away and significantly reduced outpatient services since the COVID-19 pandemic. Documentation of CMIs in the health information system Health coordinators expressed concerned about the under-registration of CMIs within primary care, mainly due to the limited mental health training of primary care workers. For instance, auxiliary nurses frequently register anxiety disorders as ‘nerve crisis’ ( crisis nerviosa, nervios) in the SIGSA system. While psychologists use more specific terms, such as ‘post-traumatic stress disorder’, their information system is independent and does not feed into SIGSA. Providers and coordinators expressed the need for a unified information system and a set of standardized indicators to monitor mental health diagnosis and services, similar to prioritized programs (e.g. immunization). PRISM: Implementation and sustainability infrastructure Past mental health service initiatives Ministry of Health workers emphasized that Santiago Atitlán was the first municipal health district in Sololá to have a psychologist, due to the leadership of the district director and decades-long mental health advocacy (See Fig. 2 ). While providers indicated that having a psychologist within the health district was very helpful, they also emphasized the need for Tz’utujil-speaking specialists. One provider indicated that the Inclusive Health System model (Modelo Incluyente en Salud, MIS) , was a primary care strengthening program that temporarily improved mental health services by providing training primary care workers in the detection and treatment of mental illnesses (See Fig. 2) . Concerns about weak infrastructure for the collaborative care program Most Ministry of Health workers highlighted infrastructural weaknesses within the health system that would need to be addressed for the collaborative care program to be implemented. Limitations included mental health being a low priority for most Ministry of Health leaders at the national- and department-level; insufficient mental health training and rising burnout among primary care workers (especially post-COVID-19); scarce mental health specialists and psychotropic medications in primary care; and a lack of legal policies to support mental health resources and supplies. PRISM: Community characteristics Limited mental health support seeking Participants reported that most young adults do not seek mental health care when needed, typically only doing so once they face considerable impairment in daily functioning and after experiencing symptoms for two to three years. Early help-seeking is often attributed to encouragement and support from friends and family members, particularly parents. Many young adults prefer to manage CMI symptoms by participating in sports or seeking guidance and assistance from friends or Maya providers. Both community members and healthcare providers expressed ongoing concern regarding problematic coping strategies, such as self-medication or the use of alcohol and drugs, which frequently result in substance use disorders or the escalation of CMIs. Financial constraints limit mental healthcare seeking Young adults with lived CMI experience indicated that financial limitations are a significant barrier to accessing mental health services. This is because most are not aware of the availability and role of the public primary care psychologist. Also, while local private and nonprofit offering psychotherapy have increased, these services remain unaffordable for most people. According to one community participant, financial barriers to mental healthcare have contributed to suicide cases among young adults. Stigma and gender roles limit mental healthcare seeking Most Ministry of Health and community participants noted that widespread attitudes toward mental health play a significant role in limiting healthcare-seeking behaviors within the community. Cultural norms discourage people from sharing their feelings and emotions, and make mental health an ‘unspoken’ or ‘taboo’ topic. Men are particularly affected, as multiple female participants indicated that a strong ‘ machista’ makes them hesitant to share and show their feelings. In addition, there is a widespread perception that those who seek mental healthcare are ‘crazy’ or ‘mad’. Medical distrust and the role of Maya providers and religious leaders Community members and Maya providers noted that negative past experiences with primary care providers limit mental healthcare seeking. Mistreatment and lack of understanding of cultural norms and available resources by primary care providers lead to distrust and make people afraid to seek care. Moreover, a Maya midwife narrated examples of people who experienced worsening CMI symptoms after interacting with an unempathetic and uncaring provider. Accompaniment from Maya providers and religious leaders Many participants indicated that traditional Maya providers, including therapists and midwives, provide culturally appropriate, trusted and continuous support to young adults with CMIs. Their support differs from Western approaches, as it is based on spirituality, energy balance and Maya cosmovision. For instance, a health coordinator described that Maya healers’ perform rituals to find the person’s loss soul in ‘ perdida del alma’ , which translates to ‘soul loss’ and is a culturally grounded illness that resembles what psychiatry may diagnose as post-traumatic stress disorder (PTSD). Several participants used the Spanish term ‘ acompañamiento’ , which translates to accompaniment when referring to Maya traditional support, a process in which the provider ‘walks along’ with the person over time, listening closely to understand their problems, providing advice and natural remedies, encouraging them to ‘go out’ and ‘be active’ and involving family members in their care. Accompaniment lasts until the person is feeling better, usually for 2–3 months. Similarly, religious leaders provide support by listening, encouraging reflection and providing religious advice. Insufficient mental health organizations Most participants indicated that there is a lack of and urgent need for organizations beyond the Ministry of Health to support people living with CMIs who are unable to afford private mental health services. PRISM: External environment Factors influencing the need for and delivery of primary care mental health services Participants referred to external factors that have increased the number of young adults with CMIs, including historical events, such as the civil war during and natural disasters, as well as the recent increase in interpersonal violence and drug use and unemployment within the community (See Fig. 2). Advocacy for mental health and the deployment of the Inclusive Health Model (MIS) increased the delivery of primary care mental health services in the past. However, the COVID-19 pandemic both increased the mental health needs within the community, while leading to a sudden decrease in primary care mental health services (See Fig. 2). PRISM: Organizational perspectives of the intervention (Collaborative care program for CMIs) Positive to mixed reactions to the program Every Ministry of Health worker saw the program as a potentially useful and helpful, and most strongly supported it. Participants indicated that the program would be effective at increasing the number of primary mental health visits in the future. Participants highlighted its stepped-care nature, as it could both facilitate the detection and treatment of people with CMIs, while helping to save limited resources. Its multidisciplinary approach could facilitate the delivery of integrated and comprehensive mental health services by involving multiple types of providers at different community and health system levels. The program could also reduce the work overload of psychologists. Mixed reactions about program’s feasibility Most Ministry of Health workers considered the program to be feasible, except for ensuring the availability of psychotropic medications. Other concerns included the feasibility of training primary care workers in mental health, due to time limitations and high staff turnover, and the feasibility of ensuring health users’ right to privacy, which would need to be addressed through specific training. Coordinators were especially concerned about the feasibility of delivering mental health services on top of other primary care programs, such as maternal and child health. To address this challenge, coordinators and providers recommended integrating the program into existing ones, such as prenatal care and chronic diseases care (e.g. diabetes). PRISM: Community perspectives of the intervention (Collaborative care program for CMIs) Positive reactions to the program Most community participants expressed strong support and enthusiasm for the program, with some expressing strong encouragement for its prompt implementation. Most participants liked the program overall, its multidisciplinary nature, and though it would address a significant treatment gap among the growing population with CMIs. Some participants emphasized that Maya providers and religious leaders would need to be involved in the program, in coordination but not together with primary care providers. Most participants highlighted the need to involve family members to achieve long-lasting recovery from CMIs. Concerns about the health system’s infrastructure and community participation A common concern about the program was the potential barriers to young adult participation in services. Participants noted that gossip ( chismes) and lack of confidentiality from providers could discourage engagement. Others mentioned the fear of sharing personal problems might limit participation. Finally, one community participant expressed skepticism about the public health system’s capacity and the availability of financial resources to successfully implement the program. 4. Discussion This multi-methods study assessed the health system- and community-level factors relevant to the implementation of a collaborative care program for Maya Indigenous young adults living with CMIs in rural Guatemala. We utilized systems thinking tools, BOT graphs and an implementation science framework, PRISM, to explore the dynamic behavior of public primary care mental health services and key factors to implement a collaborative care program for CMIs. Two important findings emerged from this study. First, the current number of primary care visits for CMIs is largely insufficient to address the community needs. To address community needs, the number of mental health visits would need to significantly increase over time. Second, a collaborative care program help to increase the number of common mental illness visits. To ensure the program’s fit, it would need to include strategies designed to address contextual factors, such as addressing the users’ right to privacy and engaging Maya healers. Infrastructural gaps, such as the lack availability of psychotropic medications and limited mental health funding, would need to be address through short- and long-term strategies. Our first finding, the low percentage of primary care CMI visits in Sololá, Guatemala (less than 1% of all primary care visits) is consistent with other studies indicating a large national mental health treatment gap ( 56 , 57 ). The National Mental Health Survey 2009 showed that just over 2% of people with mental illnesses access mental health services of any type ( 58 ). Similarly, a secondary analysis of the National Disability Survey 2016, showed that less than 6% of Guatemalans with anxiety or depression received psychotropic medications in the past 12 months ( 59 ). Our study confirmed that the mental health treatment gap in Guatemala is partially driven by the limited availability of primary care mental health services. As expected, the number of CMI visits evolved over time, being at the lowest during the COVID-19 pandemic. Qualitative data shed light on other factors that may have led to fluctuations in the number of primary care visits for CMIs. External factors, such as a natural disaster in 2005 simultaneously increased the mental health needs among young adults and the mental health awareness, leading to advocacy for additional resources within primary care to provide mental health services. Internal health district factors, such as the overreliance on mental health specialists, may be unintentionally separating the delivery of mental health services from the rest of primary care services. Our qualitative findings also pointed at the need to improve the documentation of CMIs, which is an essential component of collaborative care programs and a gap in other LMICs ( 60 , 61 ). The collaborative care program for CMIs was perceived as a potentially acceptable and effective intervention among young adults. However, most subgroups of participants expressed concerns about the health system’s infrastructural support for the program and the program’s fit within the system ( 42 ). Fit is considered essential to the successful implementation and sustainability of programs. To increase fit, implementation strategies (the ‘how’) and the delivered interventions (the ‘what’) should be tailored to the health system and community contexts. Based on our findings, health system-level implementation strategies should address the need for training primary care providers in the detection, brief counseling, and documentation of CMIs, while training mental health specialists in supervision and ongoing consultations in coordination with primary care workers. Community strategies should involve Maya People’s explanatory models of mental health and engage traditional Maya providers and religious leaders who are trusted by the community and already support those with CMIs. A strategy could, for example, provide Maya healers, midwives and religious leaders with tools to better screen and accompany young adults with CMI in coordination with primary care and mental health providers. Enhancing fit also requires strengthening the health system’s implementation and sustainability infrastructure through longer term strategies. For instance, ensuring administrative support for the program could facilitate the availability of psychotropic medications within primary care facilities. Finally, strategies should address the stigma against people with CMIs and mental health services. External factors, such as high unemployment levels and historical exposure to violence, cannot not be addressed through primary care services only, but need to be acknowledged when designing and implementing the collaborative care program for CMIs. Longer-term and wider multi-sectoral mental health initiatives could address the social determinants of mental health. This study responded to multiple calls for using systems science methods to assess multi-level dynamic context in implementation science ( 28 , 29 , 33 , 34 ). In implementation research, qualitative methods are often utilized to capture the perspectives of stakeholders prior, during and after an implementation effort ( 62 ). Qualitative systems thinking methodologies have been used in systematic reviews to describe the drivers of complex public health problems ( 63 ) and the multi-level factors influencing the sustainability of mental health services in LMICs ( 27 ). In this study, we used BOT graphs as boundary objects to capture the systems perspectives of stakeholders ( 51 , 52 ), including the dynamic health system and community factors that have influenced the implementation of mental health services and the mental health needs among the community. Our study showed that it is feasible to use data collected through Guatemala’s Ministry of Health’s information system to explore the behavior of key indicators of primary care services over time, which is an underutilized but powerful source of information. We completed the first phase of the tailoring of implementation strategies of a collaborative care program for CMIs within the public primary care system in Guatemala. The second phase, the selection of implementation strategies, will be published in a separate manuscript. Results from this study should be interpreted considering three main limitations. First, our purposive sampling of participants took place in one department, Sololá, and one of ten rural health districts, Santiago Atitlan. Stakeholders’ perceptions may be different in other settings and continue to evolve as they experience the program’s implementation ( 64 ). Second, results from this setting may not be generalizable to other departments and health districts in Guatemala. However, given that the public health system structure is similar across the country our study may provide guidance to other settings looking to assess context and initiate implementation initiatives with the primary care system. Importantly, other rapid qualitative analysis should be conducted in a set of health districts across the country to validate and enrich our results. Third, health information systems in Guatemala and other LMICs, particularly the indicators related to mental health services, may have important limitations. Issues include under-reporting by health care providers and lack of information about health service coverage and population sizes. Future studies should focus on assessing and making recommendations related to the documentation and analysis of routinely collected mental health data within Guatemala’s public primary care system. 5. Conclusions Our rapid multi-methods study assessed relevant contextual factors for the implementation of a collaborative care program for CMIs in rural Guatemala. Guided by an systems thinking tools and an implementation science framework, PRISM, we identified key contextual factors that may guide the future selection and development of implementation strategies. For example, a context of medical pluralism, with traditional Maya and Western health practices, calls for strategies that respond to diverse mental health explanatory models and involve traditional Maya providers and religious providers. Through systems thinking tools, we captured the dynamic behavior of primary care mental health visits over time. For example, our BOT graphs showed that the primary care system is still experiencing the aftermath of the COVID-19 pandemic, with decreased delivery of primary care services and trust from community members. Implementation strategies should address key dynamic contextual factors, such as distrust from the community coupled with a heightened awareness of the mental health needs within the community. This study sets the foundation for the future selection of implementation strategies for a collaborative care program for CMIs in rural Guatemala, which will be described in a separate manuscript. Our methodologies may aid other global health implementation researchers preparing for the implementation of primary care interventions in Central America and other LMICs. Abbreviations BOT graphs – Behavior-over-time graphs CMIs – Common mental illnesses ICD - International Classification of Disorders LMICs – Low and middle income countries PRISM - Practical, Robust Implementation and Sustainability Model SIGSA – Spanish translation of ‘Ministry of Health’s Administrative Health Information System’ WHO - World Health Organization Declarations Ethics approval and consent to participate: This study was approved by Columbia University Irving Medical Campus (CUIMC) Institutional Review Board (IRB) (Protocol No. 10-2022) and the Guatemala’s Ministry of Health and Social Welfare National Health Ethics Committee (IRB-AAAU3592). All participants provided verbal informed consent prior to initiating study procedures. Consent for publication : Not applicable Availability of data and materials: Data will be shared upon reasonable request. Competing interests : The authors declare that they have no competing interests Funding: The authors received no financial support for the research, authorship, and/or publication of this article. Authors' contributions: APA – Conceptualization, Formal Analysis, Investigation, Resources, Data curation, Project Administration, Writing – Original Draft, Writing – Review and Editing; CB – Conceptualization, Supervision, Review and Editing; MPF – Conceptualization, Supervision, Review and Editing; EZ – Conceptualization, Supervision, Review and Editing; DS – Methodology, Formal Analysis, Investigation, Resources, Writing – Review and Editing; LT – Conceptualization, Writing - Review and Editing; RS – Conceptualization, Supervision, Writing - Review and Editing; JK - Conceptualization, Supervision, Writing – Original Draft, Writing - Review and Editing Acknowledgements : We would like to acknowledge our partners: the Program for Mental Health at the Ministry of Health and Social Welfare in Guatemala, particularly Dr. Aracely Tellez; and the Inclusive Health Institute in Guatemala, particularly Dr. Juan Carlos Verdugo and Dr. Lidia Morales. 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Supplementary Files COREQchecklistEngpaniaguaavila.xlsx SupplementarymaterialsPaniaguaAvila.pdf Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Major revision 03 Oct, 2025 Reviewers agreed at journal 13 Aug, 2025 Reviewers invited by journal 08 Aug, 2025 Editor assigned by journal 24 Jul, 2025 First submitted to journal 23 Jul, 2025 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-7199908","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":497776814,"identity":"6b5f3d03-2468-4621-a4d5-330d74676aa9","order_by":0,"name":"Alejandra Paniagua-Avila","email":"data:image/png;base64,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","orcid":"https://orcid.org/0000-0002-1152-3785","institution":"Columbia University Medical Center: Columbia University Irving Medical Center","correspondingAuthor":true,"prefix":"","firstName":"Alejandra","middleName":"","lastName":"Paniagua-Avila","suffix":""},{"id":497776815,"identity":"f5b0687d-0683-4648-9010-41727628b4de","order_by":1,"name":"Charles Branas","email":"","orcid":"","institution":"Columbia University Department of Epidemiology","correspondingAuthor":false,"prefix":"","firstName":"Charles","middleName":"","lastName":"Branas","suffix":""},{"id":497776816,"identity":"60ea57dd-e80b-4519-92ca-af69e413227c","order_by":2,"name":"Meredith P Fort","email":"","orcid":"","institution":"Colorado School of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Meredith","middleName":"P","lastName":"Fort","suffix":""},{"id":497776817,"identity":"9ca7d280-7c0a-4731-8da3-6dec59b95452","order_by":3,"name":"Ezra Susser","email":"","orcid":"","institution":"Columbia University Department of Epidemiology","correspondingAuthor":false,"prefix":"","firstName":"Ezra","middleName":"","lastName":"Susser","suffix":""},{"id":497776818,"identity":"213a0873-c6dd-4561-80fe-94c6cd7258d4","order_by":4,"name":"Diego Sapalu","email":"","orcid":"","institution":"Asociacion para la Salud Mental, Guatemala","correspondingAuthor":false,"prefix":"","firstName":"Diego","middleName":"","lastName":"Sapalu","suffix":""},{"id":497776819,"identity":"f3b82833-c447-44f9-9cae-cb6e90f4e350","order_by":5,"name":"Lourdes Trigueros","email":"","orcid":"","institution":"Independent Researcher","correspondingAuthor":false,"prefix":"","firstName":"Lourdes","middleName":"","lastName":"Trigueros","suffix":""},{"id":497776820,"identity":"27c5f563-ff17-4e72-b3a9-a74ecfc19bf9","order_by":6,"name":"Rachel Shelton","email":"","orcid":"","institution":": Columbia University Department of Sociomedical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Rachel","middleName":"","lastName":"Shelton","suffix":""},{"id":497776821,"identity":"a806c9c2-f710-40cf-a156-95228c1b4158","order_by":7,"name":"Jeremy Kane","email":"","orcid":"","institution":"Columbia University Department of Epidemiology","correspondingAuthor":false,"prefix":"","firstName":"Jeremy","middleName":"","lastName":"Kane","suffix":""}],"badges":[],"createdAt":"2025-07-23 22:24:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7199908/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7199908/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89232402,"identity":"0cb3326e-ddcb-4f30-bd79-eb5f113cd545","added_by":"auto","created_at":"2025-08-17 14:24:51","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":93296,"visible":true,"origin":"","legend":"\u003cp\u003eBehavior-over-time (BOT) graphs displaying the number of common mental illness visits by health district in Sololá, Guatemala from January 2018 to December 2022. Study health district 8 is shown in turquoise. Other health districts are shown in orange.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7199908/v1/b1e287df276d21ff12ad0d32.jpg"},{"id":89232401,"identity":"ee219885-75bd-4ff0-bab2-bd75c3b4637f","added_by":"auto","created_at":"2025-08-17 14:24:51","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":157501,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAnnotated qualitative behavior-over-time (BOT) graph.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePanel A shows the perceived number of young people with CMI (Red line) and the perceived implementation of primary care services for young people with CMI over time (Blue line) in the study health district 9. Panel B summarizes how external factors have influenced the behavior of CMIs and services in the study health district 9 from the participants perspectives\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7199908/v1/b881281c0066780133e941cd.jpg"},{"id":89233855,"identity":"35d01145-d6dd-4ba1-ba40-fd908b602fc6","added_by":"auto","created_at":"2025-08-17 14:40:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1898977,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7199908/v1/6001b40b-f00d-4089-8514-96dde800923d.pdf"},{"id":89231036,"identity":"3769b51e-0f08-418b-8215-67cdcc2737d5","added_by":"auto","created_at":"2025-08-17 14:16:51","extension":"xlsx","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":13133,"visible":true,"origin":"","legend":"","description":"","filename":"COREQchecklistEngpaniaguaavila.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-7199908/v1/32613a305e0ef7137816fecb.xlsx"},{"id":89233292,"identity":"c6af210b-75f9-4127-ac60-1534500e4451","added_by":"auto","created_at":"2025-08-17 14:32:51","extension":"pdf","order_by":7,"title":"","display":"","copyAsset":false,"role":"supplement","size":268971,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementarymaterialsPaniaguaAvila.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7199908/v1/55c2fa29dac7b283f2a0ed43.pdf"}],"financialInterests":"","formattedTitle":"Collaborative care programs for common mental illnesses in low- and middle-income countries: A multi-methods assessment of implementation context in Guatemala","fulltext":[{"header":"Contributions to the Literature ","content":"\u003cul\u003e\n \u003cli\u003eImplementation strategies for primary care interventions in low- and middle-income countries must address dynamic, multi-level contexts.\u003c/li\u003e\n \u003cli\u003eIn rural Guatemala, a collaborative care mental health program may be acceptable and effective, if immediate infrastructural (e.g. medication availability) and community needs (e.g. engagement of traditional providers) are addressed. \u0026nbsp;\u003c/li\u003e\n \u003cli\u003eWhile historical and structural factors (e.g. civil war violence) are beyond the scope of health system interventions, they should be acknowledged when designing implementation strategies.\u003c/li\u003e\n \u003cli\u003eThis study demonstrates how behavior-over-time graphs, a systems thinking tool, can be integrated with implementation science to capture the dynamic factors shaping mental health service delivery.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"1. Background","content":"\u003cp\u003eCommon mental illnesses (CMIs), like depression, anxiety and trauma, are major contributors to the global burden of disease and are among the top causes of disability worldwide (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). In low and middle income countries (LMICs) this burden is particularly high and expected to continue increasing (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). A wide mental health treatment gap, higher than 90% in most LMICs, partly drives this burden (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). The small proportion of the population with access to mental healthcare in LMICs, may still experience low quality care and stigma in vertical mental healthcare settings that often rely on long-term institutionalization (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe World Health Organization\u0026rsquo;s (WHO) Mental Health Action Plan 2013\u0026ndash;2030 advocates for the integration of mental health services within primary care and community settings (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Integrated mental health services have the potential to reach a wide proportion of the population, address physical and mental health needs, and reduce mental health stigma (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Collaborative care programs are multi-component interventions in which stepped-care protocols are delivered by a team of primary care providers supervised by mental health specialists (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). It is considered the highest and most complete model of integration (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). A large body of evidence suggests that collaborative care programs are effective at improving outcomes from a wide range of CMIs, including depression, anxiety and trauma (\u003cspan additionalcitationids=\"CR11 CR12\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The collaborative care program, originally developed in the US, has now been implemented in LMICs like Vietnam, Nepal, Colombia and Mexico (\u003cspan additionalcitationids=\"CR15 CR16 CR17\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Systematic reviews and meta-analysis focused on LMICs indicate that, when compared to usual care, collaborative care programs may reduce symptoms, improve quality of life, and improve the recovery of people living with mental illnesses (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Despite this body of evidence, collaborative care programs for CMIs are yet to be delivered in routine primary care and community settings in most LMICs (\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe barriers to the implementation of primary care services for CMIs in LMICs have been previously described in detail (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Results indicate that primary care mental health services have been underprioritized for multiple reasons, including the overreliance on mental health specialists, mental health stigma, and the underestimation of mortality and morbidity associated with mental illnesses (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). A qualitative systematic review summarized the discrete barriers and facilitators to the implementation of mental health programs in primary care settings in LMICs following the Consolidated Framework for Implementation Research (CFIR) (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). This study identified current limitations in the literature and ways to address such gaps: adapting programs to context; conducting implementation studies that use comprehensive frameworks and involve health users; and assessing the dynamic and complex inter-relationships between the multiple elements that make up health systems (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Studies have suggested that, given the dynamic and complex nature of contextual factors, systems thinking approaches are needed to identify sustainable opportunities for improving the delivery of mental health services (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). A systems thinking systematic review mapped the barriers and facilitators to the sustainability of mental health services in LMICs (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). This called for conducing systems thinking research involving stakeholders in low-resource settings to validate results and obtain more nuanced information (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Altogether, these studies indicate that the implementation of mental health services, such as collaborative care programs, in LMICs warrants a deep and dynamic understanding of the context, composed by unique health systems and communities (\u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAs a way to address the evidence-to-practice gap, implementation researchers have repeatedly called for the tailoring of implementation strategies of evidence-informed interventions to contextual factors (\u003cspan additionalcitationids=\"CR30\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Implementation strategies are the \u0026lsquo;methods or techniques used to enhance adoption, implementation, and sustainment\u0026rsquo; (the \u0026lsquo;how\u0026rsquo;) of an evidence-informed intervention (the \u0026lsquo;what\u0026rsquo;), such as the collaborative care program (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Tailoring implementation strategies requires a deep understanding of the context where the intervention will be implemented prior to selecting strategies that match such context (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). While the methods for tailoring implementation strategies have been described, they are still being developed (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). One of the central challenges concerns the assessment and prioritization of contextual implementation factors, prior to selecting the strategies (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). To being to address this gap, implementation researchers have called for using systems thinking methods to improve the assessment of context, a central aspect of the tailoring of implementation strategies and the field of implementation science at large (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSystems thinking is a discipline that aims to understand the dynamic behavior of complex adaptative systems (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Primary healthcare systems and community settings in LMICs may be understood as complex adaptive systems (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e), made up of heterogeneous elements (e.g. clinics, people, resources, cultures) that are organized hierarchically (e.g. providers, clinic, health system) and interact with each other, producing emergent system behaviors and effects. These behaviors and effects cannot be explained by looking at the individual elements due to their complex nature, persist over time due to their dynamic nature, and can adapt to changing circumstances due to their adaptative nature. For these reasons, systems thinking approaches may help to improve the contextual assessments prior to selecting implementation strategies. Rather than looking at discrete barriers and facilitators, systems thinking tools may help to see the \u0026lsquo;health system-community\u0026rsquo; as a whole, the inter-relationships between contextual factors and their dynamic nature. By improving the understanding of interrelationships between contextual factors and points in the system that may be intervened to initiate change, systems thinking approaches may facilitate the selection and prioritization of implementation strategies (the \u0026lsquo;how\u0026rsquo;) of mental health programs (the \u0026lsquo;what\u0026rsquo;), such as the collaborative care program.\u003c/p\u003e\u003cp\u003eThis study aimed to assess the community and health system contextual factors, prior to selecting implementation strategies for a collaborative care program for CMIs within primary care in rural Guatemala, utilizing a systems thinking approach. In doing so, we provide an applied, pragmatic example of how implementation science frameworks may be combined with systems thinking tools to improve the assessment of local context in preparation for mental health implementation efforts in LMICs.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1. Study Setting\u003c/h2\u003e\u003cp\u003eWe conducted this study in Solol\u0026aacute;, a rural department in Guatemala. Solol\u0026aacute;\u0026rsquo;s population primarily identifies as Maya Indigenous People, who have experienced historical discrimination (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e) and were disproportionally targeted by the Civil War (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). As a result, Maya Indigenous People experience large health and mental health disparities compared to the non-indigenous Guatemalans (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). As a striking example, studies indicate that the life expectancy of Maya indigenous is 13 years shorter than the non-Indigenous (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Moreover, among those exposed to Civil War violence, the odds of depression, anxiety and trauma for Indigenous People were respectively 2.9, 4.5 and 52.00 those of non-indigenous Guatemalans (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Western biomedical health systems are often in conflict with explanatory models of disease held by Maya Indigenous People (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e), which further widens the mental health treatment gap. Recently, the Guatemala\u0026rsquo;s Ministry of Health and Social Welfare (\u0026lsquo;Ministry of Health\u0026rsquo;) identified Solol\u0026aacute; as a department invested in delivering primary care mental health services for their population, a key factor to engaging stakeholders and ensuring the study feasibility.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2. Overview of study design\u003c/h2\u003e\u003cp\u003eThis multi methods study used quantitative systems thinking tools and rapid qualitative methods (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). The quantitative component consisted of creating behavior-over-time (BOT graphs) using secondary, routinely collected data by the Ministry of Health in Solol\u0026aacute;. The qualitative component consisted of semi-structured interviews with stakeholders to identify key contextual factors for the implementation of a collaborative care program for CMIs, the first one in the country (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003eImplementation science framework\u003c/b\u003e\u003c/p\u003e\u003cp\u003eOur qualitative and quantitative phases were guided by PRISM, an expansion of the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e), which describes the influence of dynamic multi-level contexts on the implementation of complex interventions (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). PRISM is considered a determinant and evaluation framework (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e), and utilizes concepts from the diffusion of innovations theory, quality improvement, chronic care models, and implementation research (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). We used PRISM to elicit multi-level contextual factors key to the implementation of a collaborative care program for CMIs in rural Guatemala from a wide range of stakeholders. We followed its six dimensions: 1) organizational characteristics, 2) implementation and sustainability infrastructure, 3) external environment, 4) community characteristics, 5) organizational perspectives of the intervention and 6) community perspectives of the intervention (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). We assessed contextual factors at the health area (Solol\u0026aacute; department level), health district (municipality) and community levels (\u003cb\u003eSee\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePRISM dimensions, definitions, selected questions, data collection tools and participants\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePRISM Dimensions\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDefinition\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSelected questions from semi-structured interviews\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eOther data collection tools\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eParticipants\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOrganizational characteristics\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePublic primary care mental health services: detection, referrals, follow-ups, coordination among HCWs; documentation of common mental illnesses\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHow do providers in this health district / community identify young people with CMI?\u003c/p\u003e\u003cp\u003eHow do providers register CMI in the health information system?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-Health area\u003csup\u003e\u0026para;\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e-Health district \u003csup\u003e\u0026sect;\u003c/sup\u003e\u003c/p\u003e\u003cp\u003e-Community\u003csup\u003e\u0026yen;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eImplementation and sustainability Infrastructure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWhat\u0026rsquo;s currently in place to implement the program; previous efforts to implement primary care mental health services; what\u0026rsquo;s needed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHow ready is the health district / your community to implement this program?\u003c/p\u003e\u003cp\u003eWhat\u0026rsquo;s already available?\u003c/p\u003e\u003cp\u003eWhat is missing?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-Health area\u003csup\u003e\u0026para;\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e-Health district \u003csup\u003e\u0026sect;\u003c/sup\u003e\u003c/p\u003e\u003cp\u003e-Community\u003csup\u003e\u0026yen;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCommunity characteristics\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePractices for seeking mental health support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHow do young people CMI problem look for support in your community?\u003c/p\u003e\u003cp\u003eWhat challenges do young people face when seeking support for CMI?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-Health area\u003csup\u003e\u0026para;\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e-Health district \u003csup\u003e\u0026sect;\u003c/sup\u003e\u003c/p\u003e\u003cp\u003e-Community\u003csup\u003e\u0026yen;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExternal environment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInstitutions, organizations, individuals beyond the health system providing mental health support; community circumstances or events influencing the implementation of mental health services and the prevalence of common mental illnesses\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eWho supports young people with CMI in this community?\u003c/p\u003e\u003cp\u003eWhat are the factors that have influenced the implementation of mental health services in this health district over time?\u003c/p\u003e\u003cp\u003eWhat are the circumstances that have influenced the number of young people with CMIs in your community?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAnnotations on quantitative BOT graphs (health area, health district participants)\u003c/p\u003e\u003cp\u003eAnnotations on qualitative BOT graphs (community participants)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-Health area\u003csup\u003e\u0026para;\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e-Health district \u003csup\u003e\u0026sect;\u003c/sup\u003e\u003c/p\u003e\u003cp\u003e-Community\u003csup\u003e\u0026yen;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOrganizational perspectives of the intervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHealth-area and health-district perspectives of the program\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eWhat is your reaction to this program?\u003c/p\u003e\u003cp\u003eTo what extent would you support this program?\u003c/p\u003e\u003cp\u003eWhat could facilitate the implementation of this program in this health area / district?\u003c/p\u003e\u003cp\u003eCan you think of any implementation challenges\u003c/p\u003e\u003cp\u003e\u003cem\u003e[case vignette\u003c/em\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCollaborative care case vignette\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-Health area\u003csup\u003e\u0026para;\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e-Health district \u003csup\u003e\u0026sect;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCommunity perspectives of the intervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCommunity members and community lay providers perspectives of the program\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eWhat is your reaction to this program?\u003c/p\u003e\u003cp\u003eTo what extent would you support it / participate?\u003c/p\u003e\u003cp\u003eWhat could motivate young people to participate?\u003c/p\u003e\u003cp\u003eCan you think of any challenges to participation?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCollaborative care case vignette\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-Community\u003csup\u003e\u0026yen;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eBOT graph: Behavior over time graph; CMI: Common mental illnesses\u003c/p\u003e\u003cp\u003e\u0026para; Health area participants included health service coordinators\u003c/p\u003e\u003cp\u003e\u0026sect; Health district participants included\u003c/p\u003e\u003cp\u003e\u0026yen; Community participants included young leaders with lived experience with common mental illnesses; religious leader who support young people with CMI; and Maya providers (Maya therapists, traditional birth attendants)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eEthics Statement\u003c/b\u003e\u003c/p\u003e\u003cp\u003e This study was approved by Columbia University Irving Medical Campus (CUIMC) Institutional Review Board (IRB) (Protocol No. 10-2022) and the Guatemala\u0026rsquo;s Ministry of Health and Social Welfare National Health Ethics Committee (IRB-AAAU3592). All participants provided verbal informed consent prior to initiating study procedures.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3. Quantitative phase\u003c/h2\u003e\u003cp\u003e\u003cb\u003eData sources\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe used routinely collected administrative data from municipal health centers and community health posts within 10 municipal health districts in Solol\u0026aacute;, Guatemala from January 2018 to December 2022.The Ministry of Health\u0026rsquo;s Administrative Health Information System (SIGSA, in Spanish) runs and maintains the database for surveillance and administrative purposes (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). However, mental health data is rarely analyzed. Data is collected daily by primary care workers on paper-based standardized forms and it is then entered into an electronic database within the municipal health district on a weekly basis. Finally, data is consolidated monthly and sent to the national-level health information system. The database includes the following information: 1) sociodemographic characteristics (name, age, sex, ethnicity, language, municipality and village), 2) health facility (municipal health district, type of health facility, name of health facility), 3) type of visit (new visit, follow-up), 4) prescribed medication, and 5) diagnosis (name and code) following the International Classification of Disorders version 10 (ICD-10: 2019) (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003eAnalysis: Behavior-over-time (BOT) graphs\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA BOT graph is a systems thinking tool that showcases the behavior of key system-level variables over time. Here, we created BOT graphs showing the number of CMIs by quarter and by year for each municipal health district. Using de-identified SIGSA data, stratified by municipal health district, year and month, we created new diagnosis variables following the ICD-10 classification, grouped as follows: 1) Any health diagnosis, including all primary care visits 2) any neurological mental or substance use illness, including all primary care visits coded for \u0026lsquo;Mental and behavioral disorders\u0026rsquo; (F:00-F:99 codes and sub-codes); and 3) any CMI (depression, anxiety and trauma), including all primary care visits coded for \u0026lsquo;Depressive episode\u0026rsquo; (F:32 codes and sub-codes), \u0026lsquo;Recurrent depressive disorder\u0026rsquo; (F:33 codes and sub-codes), \u0026lsquo;Phobic anxiety disorders\u0026rsquo; (F:40 codes and sub-codes), \u0026lsquo;Other anxiety disorders\u0026rsquo; (F:41 codes and sub-codes), and \u0026lsquo;Reaction to severe stress, and adjustment disorders\u0026rsquo; (F:43 codes and sub-codes). We used R studio and the packages ggplot2, lubridate, and zoo to build the BOT graphs (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). In the qualitative phase, we used our BOT graphs as reference models to elicit systemic factors underlying fluctuations in CMI visits from key system actors (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.4. Qualitative phase\u003c/h2\u003e\u003cp\u003e\u003cb\u003eParticipants\u003c/b\u003e\u003c/p\u003e\u003cp\u003eParticipants included a wide range of stakeholders from Solol\u0026aacute; department and Santiago Atitl\u0026aacute;n, one of the largest rural municipalities with a recognized history of support for public mental health services. Participants included Ministry of Health coordinators in Solol\u0026aacute; (department level); coordinators, primary care providers or mental health providers from Santiago Atitlan (municipal health district); young adult leaders with lived CMI experience; and traditional Maya healers (\u003cb\u003eSee\u003c/b\u003e Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. We used purposive sampling to select potential participants from an \u003cem\u003ea priori\u003c/em\u003e mapping of community leaders. We invited participants who were closely involved in the delivery of mental health services and / or had lived CMI experience, and selected leaders who may become future implementation partners. Eligibility criteria included: 1) working in the Ministry of Health within Solol\u0026aacute; \u003cem\u003eor\u003c/em\u003e living in Santiago Atitlan; and 2) being 18\u0026thinsp;+\u0026thinsp;years of age. All participants provided verbal informed consent prior to initiating study procedures. Our final sample size was based on qualitative saturation.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePercentage of visits for common mental illnesses (CMI), depression, anxiety, trauma, and other mental, neurological and substance use illnesses (other MNS) of the total primary care visits by health district in Solol\u0026aacute;, Guatemala\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealth district\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e% CMI visits\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e% Depression visits\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e% Anxiety visits\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e% Trauma visits\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eOther MNS\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.32\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.76\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.28\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.31\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.34\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.09\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.21\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.18\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.09\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTOTAL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.22\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003e*Study health district\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eCollection of semi-structured interviews\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe conducted semi-structured interviews, following PRISM\u0026rsquo;s domains (\u003cb\u003eSee\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). We defined PRISM \u0026lsquo;External Factors\u0026rsquo;, as the community and health system factors influencing the delivery and need for primary care services for CMIs. To capture external factors, we used BOT graphs as boundary objects to guide our conversation (see quantitative phase; (\u003cb\u003eSee Supplementary Material 1)\u003c/b\u003e (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e). For participants with limited reading ability, we asked them to build their own BOT graphs showcasing key external events linked to mental health needs within their communities (\u003cb\u003eSee Supplementary Material 2)\u003c/b\u003e (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e). In the last phase of the interview, we captured PRISM \u0026lsquo;Community\u0026rsquo; and \u0026lsquo;Organizational perspectives of the intervention\u0026rsquo; by presenting participants with a case vignette of a collaborative care program for CMI (\u003cb\u003eSee Supplementary Material 3\u003c/b\u003e). The other three PRISM domains were explored using open-ended questions. We adapted and pilot-tested interview guides among investigators (DS, APA) prior to initiating data collection. Interviews lasted 45\u0026ndash;90 minutes, were audio-recorded and conducted in private spaces, such as public health posts or participants\u0026rsquo; houses. Interviews were conducted in Spanish (APA) or Maya Tz\u0026rsquo;utujil language (DS). Data was collected between March and April 2023 until we reached saturation.\u003c/p\u003e\u003cp\u003e\u003cb\u003eThematic analysis\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThematic analysis was conducted by a Guatemalan implementation and mental health researcher (APA), a Maya Indigenous qualitative researcher (DS), and a mental health researcher (JK). We conducted a deductive-inductive rapid matrix-based thematic analysis (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e). First, we developed verbatim transcripts of interview audio recordings. Then, we extracted data to create interview summaries outlining key results for each PRISM dimension, while allowing for emergent themes and identifying representative quotes (See \u003cb\u003eSupplementary Material 4)\u003c/b\u003e. Two independent analysts reviewed the interview summaries. Finally, we consolidated the interview summaries into a matrix displaying PRISM dimensions and emergent themes in the columns and the four participant sub-groups (Solol\u0026aacute; department, municipal health district, traditional Maya provider, community leader) in the rows. We then reviewed the matrix, comparing and contrasting results between and within participants. Through this process, we identified key factors for the implementation of a collaborative care program for CMIs in the primary care system.\u003c/p\u003e\u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e3.1. Quantitative results\u003c/h2\u003e\u003cp\u003eFrom January 2018 to December 2022, there were 12,447 primary care visits for CMIs in the 10 health districts of Solol\u0026aacute;, which corresponds to 0.30% of all primary care visits (4,215,663) (See Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Similarly, the percentage of CMI primary care visits was lower than 1% at each of the 10 health districts. BOT graphs showcasing the number of primary care CMI visits by 3-month period, from January 2018 to December 2022 and for each Solol\u0026aacute; health district are shown in \u003cb\u003eFig.\u0026nbsp;1.\u003c/b\u003e Study health district 8, where we conducted semi structured interviews, is shown in blue and the rest are shown in orange.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003e3.2. Qualitative results\u003c/h2\u003e\u003cp\u003e\u003cb\u003eParticipants\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe interviewed 20 stakeholders (\u003cb\u003eSee\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Of them, 12 were Ministry of Health workers: four department-level coordinators and eight municipal district-level coordinators and/or providers. Their roles included nurses, physicians, social workers, psychologists and one epidemiologist. The other eight participants were community members: Traditional Maya providers (n\u0026thinsp;=\u0026thinsp;2), religious leaders (n\u0026thinsp;=\u0026thinsp;1), and young adults with lived CMI experience and community leadership (n\u0026thinsp;=\u0026thinsp;5). Traditional Maya providers included a Maya healer (\u003cem\u003eAjq\u0026rsquo;umani\u0026rsquo;eel\u003c/em\u003e in Maya T\u0026rsquo;zutujil; \u003cem\u003eTerapeuta Maya\u003c/em\u003e in Spanish) and a Maya midwife (\u003cem\u003eLy\u0026rsquo;oom\u003c/em\u003e in Maya T\u0026rsquo;zutujil; \u003cem\u003eComadrona\u003c/em\u003e in Spanish). Most participants identified as female (65%) and all, except one, identified as Maya Indigenous of Tz\u0026rsquo;utujil and Kaqchiquel ethnicities.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCharacteristics and numbers of participants for the qualitative phase\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGroup: N\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRoles\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSex: N (Total %)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eEthnicity: N (Total %)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealth area: 4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHealth service and epidemiology coordinators\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale: 3\u003c/p\u003e\u003cp\u003eMale: 1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eKaqchiquel: 3\u003c/p\u003e\u003cp\u003eT\u0026rsquo;zutujil: 0\u003c/p\u003e\u003cp\u003eLadino/a: 1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealth district: 8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHealth service coordinators; primary healthcare providers; mental healthcare providers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale: 6\u003c/p\u003e\u003cp\u003eMale: 2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eKaqchiquel: 3\u003c/p\u003e\u003cp\u003eT\u0026rsquo;zutujil: 5\u003c/p\u003e\u003cp\u003eLadino/a: 0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCommunity: 8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eTerapeutas; comadronas;\u003c/em\u003e religious leaders; youth leaders with lived experience\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale: 4\u003c/p\u003e\u003cp\u003eMale: 4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eKaqchiquel: 0\u003c/p\u003e\u003cp\u003eT\u0026rsquo;zutujil: 8\u003c/p\u003e\u003cp\u003eLadino/a: 0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal: 20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e--\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale: 13 (65%)\u003c/p\u003e\u003cp\u003eMale: 7 (35%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eKaqchiquel: 6 (30%)\u003c/p\u003e\u003cp\u003eT\u0026rsquo;zutujil: 13 (65%)\u003c/p\u003e\u003cp\u003eLadino: 1 (5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003ePRISM dimensions\u003c/b\u003e\u003c/p\u003e\u003cp\u003eBelow we present qualitative according to each of the six PRISM dimensions. Exemplary quotes for each theme and PRISM dimension, identified through rapid thematic analysis, are provided in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Additionally, \u003cb\u003eFig.\u0026nbsp;2\u003c/b\u003e, showcases an annotated BOT graph summarizing participants\u0026rsquo; contributions and annotations from semi structured interviews. The graph displays overall findings regarding perceived changes in (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) the number of young adults with CMIs, (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) the delivery of primary care mental health services, and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) related community and health system factors from 1990 to the present and into the future in the Santiago Atitlan health district.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eExemplary quotes corresponding to PRISM dimensions and emergent themes from semi structured interviews\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePRISM domain\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTheme\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQuotes\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eOrganizational characteristics\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIdentification, referrals and treatment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e--\"We identify them sometimes during home visits. People tell you 'my daughter \u0026lsquo;or \u0026lsquo;my son', an adolescent, 'doesn't want to go to school, doesn\u0026rsquo;t want to go out, they're afraid to go out'. I quickly think they're afraid, they do need a psychologist\" (\u003c/em\u003eFemale auxiliary nurse, health district)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDocumentation of CMIs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e--\u003cem\u003e\"Everyone registers. For example here, the psychologist registers in her SIGSA form them when they visit her. But also physicians, auxiliaries, professional nurses register, but they leave it like \u0026lsquo;stress disorder\u0026rsquo; or \u0026lsquo;anxiety crisis\u0026rsquo;, \u0026lsquo;nerve crises\u0026rsquo;. There\u0026rsquo;s like three diagnoses. Everyone registers it, but just like that\"\u003c/em\u003e (Female professional nurse, health district)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eImplementation and sustainability Infrastructure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePast initiatives to implement mental health services\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e--\"We wanted to make something more of mental health, make other rural health districts in Solol\u0026aacute; accept it. Even at the national level it was not receiving attention. So, we tried to see how we could support people here in Atitlan, and we achieved it. Then later, the health area hired the other psychologists, 11 more\"\u003c/em\u003e (Male coordinator, health district)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eConcerns about weak infrastructure for the program\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e--\"The administrative barriers would be that psychologists have a [\u003c/em\u003eclinical\u003cem\u003e] profile, lack of educational updates, lack of training of providers. There's always a need to train specialists, right. Also, physical space for mental healthcare. There's space in [\u003c/em\u003ehealth district 9], \u003cem\u003eat least. Also, continuity of human resources. Tools for specialists and medications\"\u003c/em\u003e (Male epidemiology coordinator, health area)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eCommunity characteristics\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLimited mental healthcare seeking\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e--\u003cem\u003e\u0026lsquo;Of 10 people 3 seek help, of those 7 that do not look for help 4 only ask for advice from the 3 that sought professional help, the rest do not look for help because they have nowhere to go to and with time it gets worse\u0026rsquo; (\u003c/em\u003eMale, youth religious leader)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFinancial constraints\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e--\"These problems can affect anyone, the difference is the family's social class and having financial means, as they can quickly look for support because they have the means and has family support, while a person that doesn\u0026rsquo;t have means cannot pay for a treatment, they can't even pay 100 quetzales \"\u003c/em\u003e (Male, leader with CMI experience, community)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStigma and gender roles\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e--\"There is taboo related to psychological support. People that don't accept, people that don't recognize that they have a problem. So they prefer to do nothing about it and that is when they fall into alcoholism and drug use\"\u003c/em\u003e (Female mental HCW, health district)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMedical distrust\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e--\"But if a doctor or nurse receives me with anger or doesn't treat me well, instead of helping me it makes my situation worse. It is about trying to be kind to people. We as providers need to try to be kind all the time to recover the people's trust\"\u003c/em\u003e (Female \u003cem\u003ecomadrona\u003c/em\u003e)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eAccompaniment\u003c/em\u003e from Maya healers and religious leaders\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e--\u003cem\u003e\u0026ldquo;Maya priests, spiritual guides, are dedicated mental health with their own world understanding. Dedicated to overcoming interpersonal and family conflicts, even community problems too. They are like counselors, who are identified as such and are called to intervene. And they are not linked to the healthcare systems and don't have documentation of the cases. Instead, they have their own population, who looks for them due to their recognition and leadership\u003c/em\u003e\" (Male epidemiology coordinator, health area)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInsufficient mental health organizations\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\"Sometimes when I make an appointment the psychologist says, 'I have time in one month'. But if one needs help faster, I communicate with the one nonprofit, and I send them with this nonprofit [...] that has psychologist too, but they charge. But I tell them that they say, 'the auxiliary sent me', sometimes they make a discount and I say, 'thanks God!'\u003c/em\u003e\" (Female auxiliary nurse, health district)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExternal environment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCommunity factors influencing CMIs and primary care services for CMIs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eSee Fig.\u0026nbsp;2.2\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eOrganizational perspectives of the intervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePositive to mixed reactions to the program\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\"I truly see it as very good; it would truly see it as a dream if it were to be here. It would really help us a lot with comprehensive care, which is what we want right, it is what we really want\"\u003c/em\u003e (Mental HCW, health district)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMixed reactions about program\u0026rsquo;s feasibility\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\"\u003cem\u003eI would be a little bit worried about the system. And having enough time. Because auxiliary nurses have a lot to do and paperwork\u003c/em\u003e\" (Male social work coordinator, health area)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eCommunity perspectives of the intervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePositive reactions to the program\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\"Is there any possibility of having this program here in Guatemala? Because I see that it is very necessary for the mental problems that we have\"\u003c/em\u003e (Female youth leader)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eConcerns about participation and health system\u0026rsquo;s capacity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\"M\u003cem\u003eaybe the fear [\u003c/em\u003ewould hinder participation\u003cem\u003e]... the fear of sharing their truth\u003c/em\u003e\" (Female school teacher)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003ePRISM: Organizational Characteristics\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eIdentification, referrals and treatment of CMIs\u003c/strong\u003e\u003cp\u003eParticipants indicated that frontline primary care workers are the ones who identify young adults with CMIs during health promotion activities, home visits and primary care visits. Those working at the community level, like \u003cem\u003erastreadores (\u003c/em\u003etracers) and auxiliary nurses, are the first ones to detect, followed by those working within primary care facilities, like professional nurses and general physicians. Providers and coordinators highlighted the need for having detection checklists and training in brief counseling skills. Currently, providers detect people based on their appearance (e.g. neglected look), attitude (e.g. sad, angry, desperate, afraid), conversation topics (e.g. family or financial problems), and multiple primary care visits with limited improvement despite medical treatment. When the CMI seems mild to the provider, they aim to provide emotional support through brief conversations. If it seems severe, primary care providers direct the person and their relatives to the one public primary care psychologist, who may provide psychoeducation and psychotherapy. However, there are long waiting times (2\u0026ndash;3 months), which providers and community members identified as a significant barrier and source of frustration. Since there are no public psychiatrists in Solol\u0026aacute;, most people who need pharmacotherapy have to be referred to the National Psychiatric Hospital in Guatemala City, which is six to eight hours away and significantly reduced outpatient services since the COVID-19 pandemic.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eDocumentation of CMIs in the health information system\u003c/strong\u003e\u003cp\u003eHealth coordinators expressed concerned about the under-registration of CMIs within primary care, mainly due to the limited mental health training of primary care workers. For instance, auxiliary nurses frequently register anxiety disorders as \u0026lsquo;nerve crisis\u0026rsquo; (\u003cem\u003ecrisis nerviosa, nervios)\u003c/em\u003e in the SIGSA system. While psychologists use more specific terms, such as \u0026lsquo;post-traumatic stress disorder\u0026rsquo;, their information system is independent and does not feed into SIGSA. Providers and coordinators expressed the need for a unified information system and a set of standardized indicators to monitor mental health diagnosis and services, similar to prioritized programs (e.g. immunization).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003ePRISM: Implementation and sustainability infrastructure\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003ePast mental health service initiatives\u003c/strong\u003e\u003cp\u003eMinistry of Health workers emphasized that Santiago Atitl\u0026aacute;n was the first municipal health district in Solol\u0026aacute; to have a psychologist, due to the leadership of the district director and decades-long mental health advocacy (See \u003cb\u003eFig.\u0026nbsp;2\u003c/b\u003e). While providers indicated that having a psychologist within the health district was very helpful, they also emphasized the need for Tz\u0026rsquo;utujil-speaking specialists. One provider indicated that the Inclusive Health System model \u003cem\u003e(Modelo Incluyente en Salud, MIS)\u003c/em\u003e, was a primary care strengthening program that temporarily improved mental health services by providing training primary care workers in the detection and treatment of mental illnesses (See \u003cb\u003eFig.\u0026nbsp;2)\u003c/b\u003e.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConcerns about weak infrastructure for the collaborative care program\u003c/strong\u003e\u003cp\u003eMost Ministry of Health workers highlighted infrastructural weaknesses within the health system that would need to be addressed for the collaborative care program to be implemented. Limitations included mental health being a low priority for most Ministry of Health leaders at the national- and department-level; insufficient mental health training and rising burnout among primary care workers (especially post-COVID-19); scarce mental health specialists and psychotropic medications in primary care; and a lack of legal policies to support mental health resources and supplies.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003ePRISM: Community characteristics\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eLimited mental health support seeking\u003c/strong\u003e\u003cp\u003eParticipants reported that most young adults do not seek mental health care when needed, typically only doing so once they face considerable impairment in daily functioning and after experiencing symptoms for two to three years. Early help-seeking is often attributed to encouragement and support from friends and family members, particularly parents. Many young adults prefer to manage CMI symptoms by participating in sports or seeking guidance and assistance from friends or Maya providers. Both community members and healthcare providers expressed ongoing concern regarding problematic coping strategies, such as self-medication or the use of alcohol and drugs, which frequently result in substance use disorders or the escalation of CMIs.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eFinancial constraints limit mental healthcare seeking\u003c/strong\u003e\u003cp\u003eYoung adults with lived CMI experience indicated that financial limitations are a significant barrier to accessing mental health services. This is because most are not aware of the availability and role of the public primary care psychologist. Also, while local private and nonprofit offering psychotherapy have increased, these services remain unaffordable for most people. According to one community participant, financial barriers to mental healthcare have contributed to suicide cases among young adults.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eStigma and gender roles limit mental healthcare seeking\u003c/strong\u003e\u003cp\u003eMost Ministry of Health and community participants noted that widespread attitudes toward mental health play a significant role in limiting healthcare-seeking behaviors within the community. Cultural norms discourage people from sharing their feelings and emotions, and make mental health an \u0026lsquo;unspoken\u0026rsquo; or \u0026lsquo;taboo\u0026rsquo; topic. Men are particularly affected, as multiple female participants indicated that a strong \u0026lsquo;\u003cem\u003emachista\u0026rsquo;\u003c/em\u003e makes them hesitant to share and show their feelings. In addition, there is a widespread perception that those who seek mental healthcare are \u0026lsquo;crazy\u0026rsquo; or \u0026lsquo;mad\u0026rsquo;.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMedical distrust and the role of Maya providers and religious leaders\u003c/strong\u003e\u003cp\u003eCommunity members and Maya providers noted that negative past experiences with primary care providers limit mental healthcare seeking. Mistreatment and lack of understanding of cultural norms and available resources by primary care providers lead to distrust and make people afraid to seek care. Moreover, a Maya midwife narrated examples of people who experienced worsening CMI symptoms after interacting with an unempathetic and uncaring provider.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eAccompaniment from Maya providers and religious leaders\u003c/strong\u003e\u003cp\u003e Many participants indicated that traditional Maya providers, including therapists and midwives, provide culturally appropriate, trusted and continuous support to young adults with CMIs. Their support differs from Western approaches, as it is based on spirituality, energy balance and Maya cosmovision. For instance, a health coordinator described that Maya healers\u0026rsquo; perform rituals to find the person\u0026rsquo;s loss soul in \u0026lsquo;\u003cem\u003eperdida del alma\u0026rsquo;\u003c/em\u003e, which translates to \u0026lsquo;soul loss\u0026rsquo; and is a culturally grounded illness that resembles what psychiatry may diagnose as post-traumatic stress disorder (PTSD). Several participants used the Spanish term \u0026lsquo;\u003cem\u003eacompa\u0026ntilde;amiento\u0026rsquo;\u003c/em\u003e, which translates to \u003cem\u003eaccompaniment\u003c/em\u003e when referring to Maya traditional support, a process in which the provider \u0026lsquo;walks along\u0026rsquo; with the person over time, listening closely to understand their problems, providing advice and natural remedies, encouraging them to \u0026lsquo;go out\u0026rsquo; and \u0026lsquo;be active\u0026rsquo; and involving family members in their care. \u003cem\u003eAccompaniment\u003c/em\u003e lasts until the person is feeling better, usually for 2\u0026ndash;3 months. Similarly, religious leaders provide support by listening, encouraging reflection and providing religious advice.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eInsufficient mental health organizations\u003c/strong\u003e\u003cp\u003eMost participants indicated that there is a lack of and urgent need for organizations beyond the Ministry of Health to support people living with CMIs who are unable to afford private mental health services.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003ePRISM: External environment\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eFactors influencing the need for and delivery of primary care mental health services\u003c/strong\u003e\u003cp\u003eParticipants referred to external factors that have increased the number of young adults with CMIs, including historical events, such as the civil war during and natural disasters, as well as the recent increase in interpersonal violence and drug use and unemployment within the community (See \u003cb\u003eFig.\u0026nbsp;2).\u003c/b\u003e Advocacy for mental health and the deployment of the Inclusive Health Model (MIS) increased the delivery of primary care mental health services in the past. However, the COVID-19 pandemic both increased the mental health needs within the community, while leading to a sudden decrease in primary care mental health services (See \u003cb\u003eFig.\u0026nbsp;2).\u003c/b\u003e\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003ePRISM: Organizational perspectives of the intervention (Collaborative care program for CMIs)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003ePositive to mixed reactions to the program\u003c/strong\u003e\u003cp\u003eEvery Ministry of Health worker saw the program as a potentially useful and helpful, and most strongly supported it. Participants indicated that the program would be effective at increasing the number of primary mental health visits in the future. Participants highlighted its stepped-care nature, as it could both facilitate the detection and treatment of people with CMIs, while helping to save limited resources. Its multidisciplinary approach could facilitate the delivery of integrated and comprehensive mental health services by involving multiple types of providers at different community and health system levels. The program could also reduce the work overload of psychologists.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMixed reactions about program\u0026rsquo;s feasibility\u003c/strong\u003e\u003cp\u003eMost Ministry of Health workers considered the program to be feasible, except for ensuring the availability of psychotropic medications. Other concerns included the feasibility of training primary care workers in mental health, due to time limitations and high staff turnover, and the feasibility of ensuring health users\u0026rsquo; right to privacy, which would need to be addressed through specific training. Coordinators were especially concerned about the feasibility of delivering mental health services on top of other primary care programs, such as maternal and child health. To address this challenge, coordinators and providers recommended integrating the program into existing ones, such as prenatal care and chronic diseases care (e.g. diabetes).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003ePRISM: Community perspectives of the intervention (Collaborative care program for CMIs)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003ePositive reactions to the program\u003c/strong\u003e\u003cp\u003eMost community participants expressed strong support and enthusiasm for the program, with some expressing strong encouragement for its prompt implementation. Most participants liked the program overall, its multidisciplinary nature, and though it would address a significant treatment gap among the growing population with CMIs. Some participants emphasized that Maya providers and religious leaders would need to be involved in the program, in coordination but not together with primary care providers. Most participants highlighted the need to involve family members to achieve long-lasting recovery from CMIs.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConcerns about the health system\u0026rsquo;s infrastructure and community participation\u003c/strong\u003e\u003cp\u003eA common concern about the program was the potential barriers to young adult participation in services. Participants noted that gossip (\u003cem\u003echismes)\u003c/em\u003e and lack of confidentiality from providers could discourage engagement. Others mentioned the fear of sharing personal problems might limit participation. Finally, one community participant expressed skepticism about the public health system\u0026rsquo;s capacity and the availability of financial resources to successfully implement the program.\u003c/p\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003e This multi-methods study assessed the health system- and community-level factors relevant to the implementation of a collaborative care program for Maya Indigenous young adults living with CMIs in rural Guatemala. We utilized systems thinking tools, BOT graphs and an implementation science framework, PRISM, to explore the dynamic behavior of public primary care mental health services and key factors to implement a collaborative care program for CMIs. Two important findings emerged from this study. First, the current number of primary care visits for CMIs is largely insufficient to address the community needs. To address community needs, the number of mental health visits would need to significantly increase over time. Second, a collaborative care program help to increase the number of common mental illness visits. To ensure the program\u0026rsquo;s fit, it would need to include strategies designed to address contextual factors, such as addressing the users\u0026rsquo; right to privacy and engaging Maya healers. Infrastructural gaps, such as the lack availability of psychotropic medications and limited mental health funding, would need to be address through short- and long-term strategies.\u003c/p\u003e\u003cp\u003eOur first finding, the low percentage of primary care CMI visits in Solol\u0026aacute;, Guatemala (less than 1% of all primary care visits) is consistent with other studies indicating a large national mental health treatment gap (\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e). The National Mental Health Survey 2009 showed that just over 2% of people with mental illnesses access mental health services of any type (\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e). Similarly, a secondary analysis of the National Disability Survey 2016, showed that less than 6% of Guatemalans with anxiety or depression received psychotropic medications in the past 12 months (\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e). Our study confirmed that the mental health treatment gap in Guatemala is partially driven by the limited availability of primary care mental health services. As expected, the number of CMI visits evolved over time, being at the lowest during the COVID-19 pandemic. Qualitative data shed light on other factors that may have led to fluctuations in the number of primary care visits for CMIs. External factors, such as a natural disaster in 2005 simultaneously increased the mental health needs among young adults and the mental health awareness, leading to advocacy for additional resources within primary care to provide mental health services. Internal health district factors, such as the overreliance on mental health specialists, may be unintentionally separating the delivery of mental health services from the rest of primary care services. Our qualitative findings also pointed at the need to improve the documentation of CMIs, which is an essential component of collaborative care programs and a gap in other LMICs (\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe collaborative care program for CMIs was perceived as a potentially acceptable and effective intervention among young adults. However, most subgroups of participants expressed concerns about the health system\u0026rsquo;s infrastructural support for the program and the program\u0026rsquo;s fit within the system (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). Fit is considered essential to the successful implementation and sustainability of programs. To increase fit, implementation strategies (the \u0026lsquo;how\u0026rsquo;) and the delivered interventions (the \u0026lsquo;what\u0026rsquo;) should be tailored to the health system and community contexts. Based on our findings, health system-level implementation strategies should address the need for training primary care providers in the detection, brief counseling, and documentation of CMIs, while training mental health specialists in supervision and ongoing consultations in coordination with primary care workers. Community strategies should involve Maya People\u0026rsquo;s explanatory models of mental health and engage traditional Maya providers and religious leaders who are trusted by the community and already support those with CMIs. A strategy could, for example, provide Maya healers, midwives and religious leaders with tools to better screen and \u003cem\u003eaccompany\u003c/em\u003e young adults with CMI in coordination with primary care and mental health providers. Enhancing fit also requires strengthening the health system\u0026rsquo;s implementation and sustainability infrastructure through longer term strategies. For instance, ensuring administrative support for the program could facilitate the availability of psychotropic medications within primary care facilities. Finally, strategies should address the stigma against people with CMIs and mental health services. External factors, such as high unemployment levels and historical exposure to violence, cannot not be addressed through primary care services only, but need to be acknowledged when designing and implementing the collaborative care program for CMIs. Longer-term and wider multi-sectoral mental health initiatives could address the social determinants of mental health.\u003c/p\u003e\u003cp\u003eThis study responded to multiple calls for using systems science methods to assess multi-level dynamic context in implementation science (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). In implementation research, qualitative methods are often utilized to capture the perspectives of stakeholders prior, during and after an implementation effort (\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e). Qualitative systems thinking methodologies have been used in systematic reviews to describe the drivers of complex public health problems (\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e) and the multi-level factors influencing the sustainability of mental health services in LMICs (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). In this study, we used BOT graphs as boundary objects to capture the systems perspectives of stakeholders (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e), including the dynamic health system and community factors that have influenced the implementation of mental health services and the mental health needs among the community. Our study showed that it is feasible to use data collected through Guatemala\u0026rsquo;s Ministry of Health\u0026rsquo;s information system to explore the behavior of key indicators of primary care services over time, which is an underutilized but powerful source of information. We completed the first phase of the tailoring of implementation strategies of a collaborative care program for CMIs within the public primary care system in Guatemala. The second phase, the selection of implementation strategies, will be published in a separate manuscript.\u003c/p\u003e\u003cp\u003eResults from this study should be interpreted considering three main limitations. First, our purposive sampling of participants took place in one department, Solol\u0026aacute;, and one of ten rural health districts, Santiago Atitlan. Stakeholders\u0026rsquo; perceptions may be different in other settings and continue to evolve as they experience the program\u0026rsquo;s implementation (\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e). Second, results from this setting may not be generalizable to other departments and health districts in Guatemala. However, given that the public health system structure is similar across the country our study may provide guidance to other settings looking to assess context and initiate implementation initiatives with the primary care system. Importantly, other rapid qualitative analysis should be conducted in a set of health districts across the country to validate and enrich our results. Third, health information systems in Guatemala and other LMICs, particularly the indicators related to mental health services, may have important limitations. Issues include under-reporting by health care providers and lack of information about health service coverage and population sizes. Future studies should focus on assessing and making recommendations related to the documentation and analysis of routinely collected mental health data within Guatemala\u0026rsquo;s public primary care system.\u003c/p\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eOur rapid multi-methods study assessed relevant contextual factors for the implementation of a collaborative care program for CMIs in rural Guatemala. Guided by an systems thinking tools and an implementation science framework, PRISM, we identified key contextual factors that may guide the future selection and development of implementation strategies. For example, a context of medical pluralism, with traditional Maya and Western health practices, calls for strategies that respond to diverse mental health explanatory models and involve traditional Maya providers and religious providers. Through systems thinking tools, we captured the dynamic behavior of primary care mental health visits over time. For example, our BOT graphs showed that the primary care system is still experiencing the aftermath of the COVID-19 pandemic, with decreased delivery of primary care services and trust from community members. Implementation strategies should address key dynamic contextual factors, such as distrust from the community coupled with a heightened awareness of the mental health needs within the community. This study sets the foundation for the future selection of implementation strategies for a collaborative care program for CMIs in rural Guatemala, which will be described in a separate manuscript. Our methodologies may aid other global health implementation researchers preparing for the implementation of primary care interventions in Central America and other LMICs.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBOT graphs \u0026ndash; Behavior-over-time graphs\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCMIs \u0026ndash; Common mental illnesses\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eICD - International Classification of Disorders\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLMICs \u0026ndash; Low and middle income countries\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePRISM - Practical, Robust Implementation and Sustainability Model\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSIGSA \u0026ndash; Spanish translation of \u0026lsquo;Ministry of Health\u0026rsquo;s Administrative Health Information System\u0026rsquo;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWHO - World Health Organization\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eThis study was approved by Columbia University Irving Medical Campus (CUIMC) Institutional Review Board (IRB) (Protocol No. 10-2022) and the Guatemala’s Ministry of Health and Social Welfare National Health Ethics Committee (IRB-AAAU3592). All participants provided verbal informed consent prior to initiating study procedures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e: Not applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eData will be shared upon reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e: The authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThe authors received no financial support for the research, authorship, and/or publication of this article.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions: APA –\u0026nbsp;\u003c/strong\u003eConceptualization, Formal Analysis, Investigation, Resources, Data curation, Project Administration, Writing – Original Draft, Writing – Review and Editing; \u003cstrong\u003eCB –\u0026nbsp;\u003c/strong\u003eConceptualization, Supervision, Review and Editing; \u003cstrong\u003eMPF –\u0026nbsp;\u003c/strong\u003eConceptualization, Supervision, Review and Editing; \u003cstrong\u003eEZ –\u0026nbsp;\u003c/strong\u003eConceptualization, Supervision, Review and Editing; \u003cstrong\u003eDS –\u0026nbsp;\u003c/strong\u003eMethodology, Formal Analysis, Investigation, Resources, Writing – Review and Editing; \u003cstrong\u003eLT –\u0026nbsp;\u003c/strong\u003eConceptualization, Writing - Review and Editing; \u003cstrong\u003eRS –\u0026nbsp;\u003c/strong\u003eConceptualization, Supervision, Writing - Review and Editing; \u003cstrong\u003eJK -\u0026nbsp;\u003c/strong\u003eConceptualization, Supervision, Writing – Original Draft, Writing - Review and Editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e: We would like to acknowledge our partners: the Program for Mental Health at the Ministry of Health and Social Welfare in Guatemala, particularly Dr. Aracely Tellez; and the Inclusive Health Institute in Guatemala, particularly Dr. Juan Carlos Verdugo and Dr. Lidia Morales. We would also like to acknowledge the Sololá Health Area and the Study Health District, particularly Dr. Juan Chumil. Finally, we would like to recognize and express our enormous gratitude to the community co-facilitators and the study participants who shared their time, experiences and ideas with us.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eFerrari A. Global, regional, and national burden of 12 mental disorders in 204 countries and territories, 1990\u0026ndash;2019: a systematic analysis for the Global Burden of Disease Study 2019. The Lancet Psychiatry. 2022 Feb 1;9(2):137\u0026ndash;50. \u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Depression and Other Common Mental Disorders: Global Health Estimates. Geneva; 2017. \u003c/li\u003e\n\u003cli\u003eKohn R, Saxena S, Levav I, Saraceno B. The treatment gap in mental health care. 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PRIME: A Programme to Reduce the Treatment Gap for Mental Disorders in Five Low- and Middle-Income Countries. PLOS Medicine. 2012 Dec;9(12):e1001359. \u003c/li\u003e\n\u003cli\u003eHamilton AB, Finley EP. Qualitative Methods in Implementation Research: An Introduction. Psychiatry research. 2019 Oct 1;280:112516. \u003c/li\u003e\n\u003cli\u003eKiekens A, de Casterl\u0026eacute; BD, Vandamme AM. Qualitative systems mapping for complex public health problems: A practical guide. PLOS ONE. 2022 Feb 1;17(2):e0264463. \u003c/li\u003e\n\u003cli\u003eChambers DA, Glasgow RE, Stange KC. The dynamic sustainability framework: Addressing the paradox of sustainment amid ongoing change. Implementation Science. 2013 Oct 2;8(1):117. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"implementation-science-communications","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"iscm","sideBox":"Learn more about [Implementation Science Communications](https://implementationsciencecomms.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ISCM/default.aspx","title":"Implementation Science Communications","twitterHandle":"@ImplementSci","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Implementation context, systems science, global mental health, depression, anxiety, health system, collaborative care, primary care, Indigenous People, Guatemala","lastPublishedDoi":"10.21203/rs.3.rs-7199908/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7199908/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Collaborative care programs are effective at improving common mental illnesses (CMIs) outcomes in many low- and middle-income countries (LMICs). However, their routine implementation within primary care and communities is limited. To enhance implementation outcomes, strategies of evidence-informed interventions should be carefully tailored to context. Here, we conducted a contextual assessment to identify key community and health system factors prior to selecting implementation strategies for the first collaborative care program for Maya Indigenous People living with CMIs in Guatemala.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: This multi methods study combined systems thinking and implementation science tools. We used routinely collected administrative data to create behavior-over-time (BOT) graphs showcasing the number of primary care visits for CMIs in 10 municipal health districts (2018-2022). We conducted semi-structured interviews at one municipal health district following the ‘Practical, Robust Implementation and Sustainability Model’ (PRISM) framework. Participants (n=20) were Ministry of Health coordinators and providers, community leaders with CMIs, and traditional Maya providers. We conducted rapid matrix-based thematic analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: BOT graphs showed fluctuations in CMI visits, which participants linked to health system and community factors. For instance, historical advocacy for mental health and the training of primary care workers in mental health had increased the number of CMI visits, while the COVID-19 pandemic suddenly decreased CMI visits in 2020. Overall, less than 1% of primary care visits addressed CMIs, which participants indicated did not meet the large and increasing need for mental health services. Civil war violence, natural disasters and alcohol use have increased the mental health needs of young adults over time. Participants indicated that a collaborative care program could increase CMI visits, if implementation strategies address health system and community factors, such as ensuring access to psychotropic medications, and engaging Maya traditional providers in mental health services.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eBy combining BOT graphs, a systems thinking tool, with PRISM we identified dynamic health system and community factors that may influence the implementation of a collaborative care program for CMIs. This is an example on how to conduct pragmatic contextual assessments with readily accessible administrative data and rapid qualitative methods prior to selecting implementation strategies of evidence-informed interventions.\u003c/p\u003e","manuscriptTitle":"Collaborative care programs for common mental illnesses in low- and middle-income countries: A multi-methods assessment of implementation context in Guatemala","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-17 14:16:46","doi":"10.21203/rs.3.rs-7199908/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2025-10-03T15:50:55+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2025-08-13T14:37:00+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-08T14:58:06+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-25T01:43:07+00:00","index":"","fulltext":""},{"type":"submitted","content":"Implementation Science Communications","date":"2025-07-23T18:23:43+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"implementation-science-communications","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"iscm","sideBox":"Learn more about [Implementation Science Communications](https://implementationsciencecomms.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ISCM/default.aspx","title":"Implementation Science Communications","twitterHandle":"@ImplementSci","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9761aa6a-a9ad-4141-bc19-7d5345a26ec5","owner":[],"postedDate":"August 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2025-10-03T19:52:04+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-17 14:16:46","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7199908","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7199908","identity":"rs-7199908","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}