Table 3.

Meta Salud diabetes implementation study coding framework and themes.

Contextual factors	Implementation questions	Emerging themes and illustrative quotes
MANAGEMENT
Availability, skills, motivation, and experience of local leadership	•Does management have power or leadership and resources to change aspects of the organization's structure and function to positively influence the impact of the intervention? (i.e., provide time for training; ensure staffing; support change; support teams)	•Many of the health centers had new directors due to a change in state government and there was frequent turnover of GAM facilitators, which meant a lack of continuity. •Health center directors varied in who and how many people they sent to MSD training (i.e., nurse, psychologist, community health worker, intern).“The nurse in charge of the GAM should not change every 6 months. When a new nurse comes in [GAM], participants stop coming. The new person does not receive training. They just repeat topics without any continuity. You also need tro train the director and the head of nursing so they know what's being done.” (GAM facilitator, MSD feedback meeting)
Performance monitoring and feedback	•What data is being monitored and how is it used for planning? •Is there a GAM annual work plan and is it being monitored? Who is responsible for it?	•Although the Ministry of Health required submission of an annual plan for the GAM, facilitators did not receive feedback. •The health centers submitted patient data from their registries to accredit their GAMs, but there was no process to verify the data.“[We need to] change the mindset that things aren't going to work out. There are many support programs [for patients] but no one's paying attention to quality.” (GAM facilitator, MSD feedback meetings)
Established institutional culture or behavioral norms that affect potential for change	•What is the view of health promotion? •How do providers perceive patients? How do staff communicate with patients?	•Health center directors felt that the intervention could be of great benefit to the staff and patients. Some health center directors were not familiar with GAM purpose or guidelines.“The director trusted us completely to work on the [MSD] project, he gave us the freedom to do it, but we didn't sense that he was interested in taking part or being informed of the progress of the program. It ended up being ‘Do it however you want to do it, but do it’.” (GAM facilitator, MSD feedback meeting)
STAFFING
Availability of human resources and this is affected by staff turnover, pay, and incentives	•How are staff supported and incentivized? (i.e., trainings, travel support, clear job role, control over one's own work) What contributes to high turnover?	•GAM facilitators were supported by interns who are not available in the long run. •GAM facilitators and other staff did not receive regular health promotion training.“Since there is very little staff [in the health center], each one of us has their own program, right? So there's a head of immunizaions, but if she has to do immunizations we have to help her out, so all of us help her out. And is if someone else [from another program] needs help we get it, but that's it. For example, I'm the head [of the GAM] right now, so I'm the one that's with [the group], but if at some point I can't do it or something, one of the girls can come and give them the talk.” (GAM facilitator, case study interview)
Skills and knowledge	•Is there induction training for GAMS? •Ongoing supervision and in-service training? •How many people are trained in GAMs?	•Some GAM facilitators had never received health promotion training, particularly on chronic disease. •Facilitators were enthusiastic about in-person training.“Our bosses are always coming and going to trainings in other places and don't necessarily replicate the training when they come back. Before they used to send other health center staff to the trainings but now they don't.” (GAM facilitator, MSD facilitator feedback meeting)
Personal motivation and agency to affect change in the health center	•How are GAMS perceived by staff? •How are changes communicated and supervised?	•In some Centers, the GAM facilitator was assigned because no one wanted the responsibility. •In other Centers, the GAM facilitator had been in the position for years and had strong ties with participants, which encouraged motivation and agency.“I can take the handbook and follow the instructions, but if I don't go the extra mile for the patient, so I can feel that I'm helping the patient, it's just going to be a regular work day. The attitude of the staff, that's what's going to determine if it works or not, if a program like this one is relevant or not.” (MSD assistant facilitator, case study interview)
LOCAL ENVIRONMENT
Patient and community factors that constrain health personnel such as language, cultural expectations, poverty	•What are the positive health seeking behaviors exhibited by patients and how can they be influenced? •How do patients perceive the GAMS?	•Patients faced economic challenges. •The patients had difficulty accessing care because of the health center's location and the lack of public transit. •The GAM participants were not interested in physical activity. •GAM participants wanted their family to participate in the GAM.“Unfortunately [because of], our cultural roots we have to motivate the patients to participate, motivate them in any way. If they see something that motivates them they start to come to their groups. Particularly the facilitator, that's why the profile [of the GAM facilitator] that you mentioned is important. It has to be someone who's very dynamic and that above all else has a lot of communication with the patient and treats them as they should be treated.” (Health Center Director, case study interview)
Lack of medication and material resources	•What are the constraints to care facing centers? GAMS facilitators? •How do we adapt to resources available?	•Staff at some health centers requested assistance obtaining diabetes medication. •Many GAMs had inadequate access to measurement equipment, including strips for glucometers.“For GAM use, they share the baumanometer and scale they use for outpatient services, they do not have measuring tapes, and usually there are not enough test strips for the glucometer they use.” (Health center evaluation)
Parallel and competing health system interventions from the state and federal level	•Are there any conflicting or concurrent policies, initiatives or programs that might positively or negatively impact the intervention? Overtax the staff? •What are the competing external factors on implementation of the program?	•Health promotion staff confront dueling priorities.“[The GAM facilitator] mentioned that the Health Center was giving priority to other activities before the GAM, immunizations for example.” (MSD observation)