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

Abstract

Background: Social determinants of health have been shown to influence individual mental health and overall well-being. Additionally, populations that experience stigma and/or discrimination because of race, class, gender, or another identity group experience disproportionately higher rates of mental health disorders than populations that do not experience such marginalization. One way to address upstream social determinants that influence mental health is through systems change initiatives. In 2019, Indiana implemented a statewide Regional Prevention System (RPS) focused on systems change to promote mental health and prevent substance misuse. Methods: We developed a semi-structured interview guide to collect insights about the RPS implementation and sustainability. Potential participants were identified based on their role as an active regional coordinator (n = 9). We conducted qualitative interviews with all 9 regional coordinators in Indiana. Interview recordings were transcribed and coded using an a priori coding framework based on constructs from the Theory of Innovation Implementation and the Consolidated Framework for Implementation Research. Results: Insights about the RPS implementation process are presented across four domains: innovation, system-level, organization-level, and sustainability. In terms of implementation barriers, coordinators encountered hesitancy and distrust from community members, which they had to overcome to gain buy-in. They also described stigma, including community and individual social norms towards mental health and substance misuse, as barriers that challenged efforts to engage community members in the RPS. Facilitators of implementation included having established community infrastructure and external partnerships. In communities without existing infrastructure to support prevention efforts, particularly rural communities, the implementation process took longer but community members welcomed the additional support and valued the new communication platforms created by the RPS. On sustainability, coordinators provided examples of communities that were able to obtain grant funding in support of prevention initiatives launched through the RPS. Conclusion: The process of implementing and sustaining prevention efforts through the RPS varied across communities. Prioritizing the delivery of systems-change efforts in underserved communities that are ready for change, rather than statewide efforts, may offer a better strategy for addressing disparities in the social determinants of health that influence mental health and substance misuse.