Abstract
BackgroundMis-implementation, the inappropriate continuation of programs or policies that are not evidence-based or the inappropriate termination of evidence-based programs and policies, can lead to the inefficient use of scarce resources in public health agencies and decrease the ability of these agencies to deliver effective programs and improve population health. Little is known about why mis-implementation occurs, which is needed to understand how to address it. This study sought to understand the state health department practitioners’ perspectives about what makes programs ineffective and the reasons why ineffective programs continue.MethodsEight state health departments (SHDs) were selected to participate in telephone-administered qualitative interviews about decision-making around ending or continuing programs. States were selected based on geographic representation and on their level of mis-implementation (low and high) categorized from our previous national survey. Forty-four SHD chronic disease staff participated in interviews, which were audio-recorded and transcribed verbatim. Transcripts were consensus coded, and themes were identified and summarized. This paper presents two sets of themes, related to (1) what makes a program ineffective and (2) why ineffective programs continue to be implemented according to SHD staff.ResultsParticipants considered programs ineffective if they were not evidence-based or if they did not fit well within the population; could not be implemented well due to program restraints or a lack of staff time and resources; did not reach those who could most benefit from the program; or did not show the expected program outcomes through evaluation. Practitioners described several reasons why ineffective programs continued to be implemented, including concerns about damaging the relationships with partner organizations, the presence of program champions, agency capacity, and funding restrictions.ConclusionsThe continued implementation of ineffective programs occurs due to a number of interrelated organizational, relational, human resources, and economic factors. Efforts should focus on preventing mis-implementation since it limits public health agencies’ ability to conduct evidence-based public health, implement evidence-based programs effectively, and reduce the high burden of chronic diseases. The use of evidence-based decision-making in public health agencies and supporting adaptation of programs to improve their fit may prevent mis-implementation. Future work should identify effective strategies to reduce mis-implementation, which can optimize public health practice and improve population health.
Highlights
Chronic diseases such as cardiovascular disease, cancer, and diabetes cause the majority of deaths worldwide and are costly to individuals, healthcare systems, and communities [1,2,3]
To understand how public health practitioners perceive ineffective programs and what they think contributes to the continuation of ineffective programs, we conducted in-depth interviews with 44 state health department practitioners working in chronic disease prevention and control
Governmental public health systems have been tasked with addressing the burden of chronic diseases by using evidence-based approaches to implement evidence-based programs and policies (EBPPs) that can improve modifiable chronic disease risk factors [4,5,6,7]
Summary
Chronic diseases such as cardiovascular disease, cancer, and diabetes cause the majority of deaths worldwide and are costly to individuals, healthcare systems, and communities [1,2,3]. Governmental public health systems have been tasked with addressing the burden of chronic diseases by using evidence-based approaches to implement evidence-based programs and policies (EBPPs) that can improve modifiable chronic disease risk factors [4,5,6,7]. SHDs receive funds from national public health agencies, state-level legislatures, and other funders to implement chronic disease prevention and management programs and policies [14]. SHDs often act as the granting agency for local partners (e.g., local health departments, community-based organizations), which are responsible for delivering programs to individuals and communities. Decisionmaking in SHDs about implementing programs and policies is complex and varies by state but typically includes top leadership (e.g., department or division directors), middle managers, and programmatic staff.
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