A cross-country study of mis-implementation in public health practice

Karishma S Furtado,Rebecca Armstrong,Zhaoxin Wang,Pauline Sung-Chan,Ross C Brownson,Tahna Pettman,Elizabeth L Budd,Rodrigo Reis

doi:10.1186/s12889-019-6591-x

Abstract

BackgroundMis-implementation (i.e., the premature termination or inappropriate continuation of public health programs) contributes to the misallocation of limited public health resources and the sub-optimal response to the growing global burden of chronic disease. This study seeks to describe the occurrence of mis-implementation in four countries of differing sizes, wealth, and experience with evidence-based chronic disease prevention (EBCDP).MethodsA cross-sectional study of 400 local public health practitioners in Australia, Brazil, China, and the United States was conducted from November 2015 to April 2016. Online survey questions focused on how often mis-termination and mis-continuation occur and the most common reasons programs end and continue.ResultsWe found significant differences in knowledge of EBCDP across countries with upwards of 75% of participants from Australia (n = 91/121) and the United States (n = 83/101) reporting being moderately to extremely knowledgeable compared with roughly 60% (n = 47/76) from Brazil and 20% (n = 21/102) from China (p < 0.05). Far greater proportions of participants from China thought effective programs were never mis-terminated (12.2% (n = 12/102) vs. 1% (n = 2/121) in Australia, 2.6% (n = 2/76) in Brazil, and 1.0% (n = 1/101) in the United States; p < 0.05) or were unable to estimate how frequently this happened (45.9% (n = 47/102) vs. 7.1% (n = 7/101) in the United States, 10.5% (n = 8/76) in Brazil, and 1.7% (n = 2/121) in Australia; p < 0.05). The plurality of participants from Australia (58.0%, n = 70/121) and the United States (36.8%, n = 37/101) reported that programs often mis-continued whereas most participants from Brazil (60.5%, n = 46/76) and one third (n = 37/102) of participants from China believed this happened only sometimes (p < 0.05). The availability of funding and support from political authorities, agency leadership, and the general public were common reasons programs continued and ended across all countries. A program’s effectiveness or evidence-base—or lack thereof—were rarely reasons for program continuation and termination.ConclusionsDecisions about continuing or ending a program were often seen as a function of program popularity and funding availability as opposed to effectiveness. Policies and practices pertaining to programmatic decision-making should be improved in light of these findings. Future studies are needed to understand and minimize the individual, organizational, and political-level drivers of mis-implementation.

Highlights

Mis-implementation contributes to the misallocation of limited public health resources and the sub-optimal response to the growing global burden of chronic disease
Survey Development A 22-question, cross-sectional survey was developed based on a literature review of existing measures in evidence-based chronic disease prevention (EBCDP), [23, 39,40,41], a guiding frame work based on previous work of the research team, [16, 41] as well as information gathered from 50 qualitative interviews of local public health practitioners across the four countries [24, 42]
Evidence-based knowledge and Mis-implementation frequency by country (Table 2) We found significant differences in knowledge of EBCDP across countries with upwards of 75% of participants from Australia (n = 91/121) and the United States (n = 83/101) reporting being moderately to extremely knowledgeable compared with roughly 60% (n = 47/76) from Brazil and 20% (n = 21/102) from China (Table 2)

Summary

Introduction

Mis-implementation (i.e., the premature termination or inappropriate continuation of public health programs) contributes to the misallocation of limited public health resources and the sub-optimal response to the growing global burden of chronic disease. This study seeks to describe the occurrence of mis-implementation in four countries of differing sizes, wealth, and experience with evidence-based chronic disease prevention (EBCDP). The field of evidence-based public health, [3,4,5,6] namely evidence-based chronic disease prevention (EBCDP) seeks to address the challenge of chronic disease prevention by using the best available scientific evidence, applying program-planning frameworks, engaging the community in decision making, using data and information systems systematically, conducting sound evaluation, and disseminating what is learned [7, 8]. Studies have identified barriers impeding evidence-based public health practice at the individual (e.g., lack of EBCDP knowledge), agency/organizational (e.g., absence of leadership support for EBCDP), community (e.g., absence of critical community-based partnerships), sociocultural (e.g., lack of societal demand for evidence-based programs), and political (e.g., lack of buy-in from policymakers) levels in the United States as well as in other developed and developing countries [14,15,16,17]

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Discussion

Conclusion