Implementation Science is a growing field that seeks to accelerate the science into real world practice, an event that can often times take 17 years to achieve. While we are exploring the factors that affect the translation of science, we also need to understand why ineffective practices continue to persist and why effective practices are ended. This is what the study of mis-implementation seeks to answer. In particular, in the United States, it is estimated that only 60% of public health practices are actually evidence based. That leaves the question about what is happening with the other 40% of practices.

In our research published in BMC Public Health, our team conducted a national survey of state health department chronic disease employees to gather more information on how often they felt mis-implementation was occurring in their departments and what could be the possible factors that affect these types of decisions. As the United States has witnessed in the past year, State Health departments are significant drivers of public health interventions. Chronic Diseases are considered a considerable risk factor for cancer and it is estimated that $1.1 billion is annually expended to state cancer control and chronic disease prevention programs. But despite this large number, a small amount of that is actually used towards primary prevention programs such as physical activity and nutritional intervention programs. Given the scarce resources available, it is crucial to know that every dollar is being used towards the most effective and wide-reaching programs. And unfortunately, that may not always be the case.

50.7% of state health department chronic disease employees reported that their work unit sometimes, often or always ended effective programs that should have continued.

From our national survey, we found that 50.7% of state health department chronic disease employees reported that their work unit sometimes, often or always ended effective programs that should have continued. Not surprisingly, the overwhelming reason being funding priorities changed or ended. State Health Department funding is based heavily on time limited grants and it’s not always guaranteed that a successful program will continue to see its funding continue. This is consistent with the literature around evidence-based decision making that engaging with policymakers around programming funding can enhance the sustainment of evidence based programs.

On the flip side of the mis-implementation coin, 48.5% of state health department employees stated that sometimes, often or always continued programs that should have ended. While funding was still a prominent factor with inappropriately continued programs, policymakers and agency leadership were also significant factors in this decision making outcome.

Leadership qualities around perseverance of program implementation and managing change can also have an effect on program continuation outcomes.

When asked further about factors that affect these outcomes, participants revealed that organizational & agency factors have a significant influence. Most significant is that too many organizational layers in a state health agency can impede decision-making. Also leadership qualities around perseverance of program implementation and managing change can also have an effect on program continuation outcomes. Organizational capacity can be a major influence in the success of a programs outcomes. It is simply not enough to have an effective public health program. We also need public health agencies that have the organizational capacity to deliver them effectively and understand when programs should not be continued.

The study team is continuing to build on this initial data by conducting qualitative case studies to highlight the mis-implementation challenges and success that state agencies have been met with in implementing these programs. The team has also partnered with a group at the Brookings Institute to create agent-based models that can help further describe and highlight how these decision-making processes play out in state agencies. These models can eventually be a tool for facilitating better decision-making in the eventual hope that it helps decrease the prevalence of mis-implementation in state health department chronic disease programs.

There is still much to learn about mis-implementation and how implementation science can improve our public health systems. Our study is one of the firsts to really identify these factors across state public health agencies in the United States. We hope that lessons learned from this study can eventually contributed to improved chronic disease health outcomes locally, nationally and globally.