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      De-implementing public health policies: a qualitative study of the process of implementing and then removing body mass index (BMI) report cards in Massachusetts public schools

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          Abstract

          Background

          This study explored reasons for the adoption of a policy to distribute report cards to parents about children’s weight status (“BMI report cards”) in Massachusetts (MA) public schools in 2009 and the contextual factors influencing the policy removal in 2013.

          Methods

          We conducted semi-structured, qualitative interviews with 15 key decision-makers and practitioners involved with implementing and de-implementing the MA BMI report card policy. We analyzed interview data using a thematic analytic approach guided by the Consolidated Framework for Implementation Research (CFIR) 2.0.

          Results

          Primary themes were that (1) factors other than scientific evidence mattered more for policy adoption, (2) societal pressure spurred policy adoption, (3) problems with the policy design contributed to inconsistent implementation and dissatisfaction, and (4) media coverage, societal pressure, and organizational politics and pressure largely prompted de-implementation.

          Conclusions

          Numerous factors contributed to the de-implementation of the policy. An orderly process for the de-implementation of a policy in public health practice that manages drivers of de-implementation may not yet exist. Public health research should further focus on how to de-implement policy interventions when evidence is lacking or there is potential for harm.

          Supplementary Information

          The online version contains supplementary material available at 10.1186/s43058-023-00443-1.

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          Most cited references27

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          Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science

          Background Many interventions found to be effective in health services research studies fail to translate into meaningful patient care outcomes across multiple contexts. Health services researchers recognize the need to evaluate not only summative outcomes but also formative outcomes to assess the extent to which implementation is effective in a specific setting, prolongs sustainability, and promotes dissemination into other settings. Many implementation theories have been published to help promote effective implementation. However, they overlap considerably in the constructs included in individual theories, and a comparison of theories reveals that each is missing important constructs included in other theories. In addition, terminology and definitions are not consistent across theories. We describe the Consolidated Framework For Implementation Research (CFIR) that offers an overarching typology to promote implementation theory development and verification about what works where and why across multiple contexts. Methods We used a snowball sampling approach to identify published theories that were evaluated to identify constructs based on strength of conceptual or empirical support for influence on implementation, consistency in definitions, alignment with our own findings, and potential for measurement. We combined constructs across published theories that had different labels but were redundant or overlapping in definition, and we parsed apart constructs that conflated underlying concepts. Results The CFIR is composed of five major domains: intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and the process of implementation. Eight constructs were identified related to the intervention (e.g., evidence strength and quality), four constructs were identified related to outer setting (e.g., patient needs and resources), 12 constructs were identified related to inner setting (e.g., culture, leadership engagement), five constructs were identified related to individual characteristics, and eight constructs were identified related to process (e.g., plan, evaluate, and reflect). We present explicit definitions for each construct. Conclusion The CFIR provides a pragmatic structure for approaching complex, interacting, multi-level, and transient states of constructs in the real world by embracing, consolidating, and unifying key constructs from published implementation theories. It can be used to guide formative evaluations and build the implementation knowledge base across multiple studies and settings.
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            Sample Size in Qualitative Interview Studies: Guided by Information Power

            Sample sizes must be ascertained in qualitative studies like in quantitative studies but not by the same means. The prevailing concept for sample size in qualitative studies is "saturation." Saturation is closely tied to a specific methodology, and the term is inconsistently applied. We propose the concept "information power" to guide adequate sample size for qualitative studies. Information power indicates that the more information the sample holds, relevant for the actual study, the lower amount of participants is needed. We suggest that the size of a sample with sufficient information power depends on (a) the aim of the study, (b) sample specificity, (c) use of established theory, (d) quality of dialogue, and (e) analysis strategy. We present a model where these elements of information and their relevant dimensions are related to information power. Application of this model in the planning and during data collection of a qualitative study is discussed.
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              The updated Consolidated Framework for Implementation Research based on user feedback

              Background Many implementation efforts fail, even with highly developed plans for execution, because contextual factors can be powerful forces working against implementation in the real world. The Consolidated Framework for Implementation Research (CFIR) is one of the most commonly used determinant frameworks to assess these contextual factors; however, it has been over 10 years since publication and there is a need for updates. The purpose of this project was to elicit feedback from experienced CFIR users to inform updates to the framework. Methods User feedback was obtained from two sources: (1) a literature review with a systematic search; and (2) a survey of authors who used the CFIR in a published study. Data were combined across both sources and reviewed to identify themes; a consensus approach was used to finalize all CFIR updates. The VA Ann Arbor Healthcare System IRB declared this study exempt from the requirements of 38 CFR 16 based on category 2. Results The systematic search yielded 376 articles that contained the CFIR in the title and/or abstract and 334 unique authors with contact information; 59 articles included feedback on the CFIR. Forty percent (n = 134/334) of authors completed the survey. The CFIR received positive ratings on most framework sensibility items (e.g., applicability, usability), but respondents also provided recommendations for changes. Overall, updates to the CFIR include revisions to existing domains and constructs as well as the addition, removal, or relocation of constructs. These changes address important critiques of the CFIR, including better centering innovation recipients and adding determinants to equity in implementation. Conclusion The updates in the CFIR reflect feedback from a growing community of CFIR users. Although there are many updates, constructs can be mapped back to the original CFIR to ensure longitudinal consistency. We encourage users to continue critiquing the CFIR, facilitating the evolution of the framework as implementation science advances. Supplementary Information The online version contains supplementary material available at 10.1186/s13012-022-01245-0.
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                Author and article information

                Contributors
                mkp984@g.harvard.edu
                Journal
                Implement Sci Commun
                Implement Sci Commun
                Implementation Science Communications
                BioMed Central (London )
                2662-2211
                9 June 2023
                9 June 2023
                2023
                : 4
                : 63
                Affiliations
                [1 ]GRID grid.38142.3c, ISNI 000000041936754X, Department of Nutrition, , Harvard T.H. Chan School of Public Health, ; 665 Huntington Avenue, Boston, MA 02115 USA
                [2 ]GRID grid.38142.3c, ISNI 000000041936754X, Department of Social and Behavioral Sciences, , Harvard T.H. Chan School of Public Health, ; 677 Huntington Avenue, Boston, MA 02115 USA
                Author information
                http://orcid.org/0000-0003-3466-8650
                Article
                443
                10.1186/s43058-023-00443-1
                10251595
                37296487
                8701ba5f-23a0-4b3e-b225-b611fea32f62
                © The Author(s) 2023

                Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

                History
                : 14 February 2023
                : 25 May 2023
                Funding
                Funded by: The JPB Foundation
                Funded by: FundRef http://dx.doi.org/10.13039/100000054, National Cancer Institute;
                Award ID: P50 CA244433
                Award Recipient :
                Funded by: FundRef http://dx.doi.org/10.13039/100000867, Robert Wood Johnson Foundation;
                Award ID: 2833590
                Award Recipient :
                Funded by: FundRef http://dx.doi.org/10.13039/100000050, National Heart, Lung, and Blood Institute;
                Award ID: 1F31HL162250-01A1
                Award Recipient :
                Categories
                Research
                Custom metadata
                © BioMed Central Ltd. 2023

                de-implementation,implementation science,public health,public policy

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