Integrating Implementation Science In the Evaluation of a Culturally Grounded Stigma‑Reduction Intervention for Indigenous GBM and Traditional Healers In Guatemala

Background and Purpose: Indigenous gay, bisexual, and other men who have sex with men (IGBM) in Guatemala face intersectional stigmas related to HIV, sexual orientation, and Indigenous identity. These stigmas contribute to discrimination that significantly limits access to health services including the HIV care continuum. To address these barriers, we piloted KAWABIL, a stigma-reduction intervention, grounded on socioecological, social cognitive, intergroup contact, and empowerment frameworks, and created shared workshop spaces that promote dialogue, mutual understanding, and collaboration. This study assesses key facilitators and barriers to implementation for future randomized controlled trials (RCT). KAWABIL is the first stigma-reduction intervention in the region to integrate Indigenous traditional healers (ITH), a critical and trusted component of the healthcare system, into efforts to strengthen engagement in the HIV continuum of care.

Methods: Guided by the Consolidated Framework for Implementation Research (CFIR), a qualitative assessment was conducted using purposive sampling among KAWABIL staff members involved in intervention delivery (n = 10), as well as Indigenous gay and bisexual men (IGBM; n = 10) and Indigenous Traditional Healers (ITH; n = 10), to identify individual, contextual, and organizational factors influencing implementation. All interviews were digitally recorded, encrypted, transcribed verbatim, and stored on a secure server. Qualitative data were managed using Dedoose and analyzed thematically.

Results: Across CFIR domains, multiple facilitators and barriers were identified. Regarding intervention characteristics, the inclusion of facilitators from the local community and the cultural appropriateness of KAWABIL were consistently highlighted as major facilitators, fostering trust, openness, and participant engagement. In contrast, theoretical components of the intervention were perceived as less engaging and difficult to sustain participants’ attention, suggesting a need for simplification and more participatory delivery strategies.

Within the outer setting, implementation barriers included long travel distances, limited transportation options, competing work responsibilities, and broader policy constraints affecting funding and continuity of the project. Community interest in the intervention and the provision of economic incentives facilitated recruitment and retention. Within the inner setting, strong compatibility between the intervention and organizational values facilitated implementation and trust-building. However, challenges emerged in the use of REDCap in rural settings, particularly due to connectivity limitations and the complexity of survey instruments. At the individual level, empathetic and highly trained facilitators were identified as central to successful implementation because they promoted trust, emotional safety, and meaningful dialogue.

Regarding the implementation process, effective group interaction strategies, participant incentives, and generally adequate training of survey staff were identified as key facilitators. However, maintaining contact with participants during follow-up emerged as one of the most significant implementation challenges, affecting continuity of engagement and post-intervention communication.

Conclusions and Implications: These findings suggest that culturally grounded facilitation, adaptation of educational content, and flexible implementation strategies are critical for future scale-up of KAWABIL. Next steps will focus on refining intervention content to enhance engagement, adapting data collection tools for rural settings, and developing strategies to improve participant follow-up and retention in preparation for a future randomized controlled trial.