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
Implementation Science Communications volume 4, Article number: 63 (2023)
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.
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.
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.
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.
The implementation of evidence-based policy interventions is essential to advancing population health, but an equally important consideration is how to de-implement policies that do not work or have harmful consequences. De-implementation, a relatively new concept with emerging theoretical constructs and methods in the implementation science field, involves the discontinuation or removal of interventions from practice . McKay and colleagues proposed several criteria for de-implementation, including (1) if an intervention is ineffective or harmful, (2) if an alternative intervention is identified that makes better use of resources or is more effective, or (3) if the targeted health issue is no longer a priority . The use of these criteria for considering de-implementation may be particularly useful to policymakers and practitioners in public health practice, where available funds for public health initiatives are often minimal , in order to maximize impacts on health outcomes.
Gaps in evidence for de-implementation remain for several key areas. First, it has been suggested that factors influencing policy adoption may not be the same as those for de-implementation ; however, examples of these differences are limited. Another knowledge gap is what the de-implementation process looks like for public health policies since the de-implementation literature has focused primarily on low-value care in clinical settings [4-7]. Evidence is also limited for how perspectives of de-implementation compare and contrast  by the roles of the individuals involved with the policy implementation.
Body mass index (BMI) report cards, state-level policies requiring schools to distribute “report cards” of weight status to parents/guardians (distinct from state policies that require schools to collect heights and weights for surveillance purposes, but involve anonymous data collection and no report-backs to parents), have been cited as a potential candidate for de-implementation [8-10]. BMI report cards were initially proposed in the early 2000s as a strategy for childhood obesity prevention . Eleven states adopted this policy in the past 20 years, whereas another 14 states implemented screening-only policies for public health surveillance [12, 13]. Initially, there was little evidence for the impacts of BMI report cards on their intended purpose of reducing childhood obesity with several earlier reviews noting that existing evidence for an impact on behaviors was mixed  and that there was little evidence for an impact on obesity prevalence [12, 15]. However, as time has passed, and this policy has been able to be further evaluated, evidence from a well-designed randomized controlled trial in 2021  and natural experiment in 2011  has shown BMI report cards do not prevent or reduce childhood obesity. Additionally, evidence indicates BMI report cards have received negative feedback from parents [17, 18] and may increase weight dissatisfaction among participating children  which is a risk factor for the use of unhealthy weight control behaviors [19, 20].
Our study used qualitative interviews, guided by the Consolidated Framework for Implementation Research (CFIR 2.0) , to understand the process by which policymakers, practitioners, and community advisors adopted and then de-implemented a BMI report card policy in Massachusetts (MA). We had three study aims: (1) to explore the reasons for policy adoption, (2) to identify the contextual factors that influenced removing the policy from practice, and (3) to understand the acceptability and feasibility of de-implementation of the policy and the de-implementation process .
Study design and sample
This qualitative study employed semi-structured interviews of individuals involved with the MA BMI report card policy implementation between April 2009 and October 2013 and/or policy de-implementation in October 2013 (see Fig. 1).
In 2009, the MA Public Health Council amended regulations governing physical examination of students (105 CMR 200.00) to include a provision for BMI report cards . The “adoption” of the BMI report card policy involved a policy amendment to eliminate the existing requirement for annual height and weight surveillance in public schools and instead required BMI screening and reporting for students in grades 1, 4, 7, and 10. BMI screening refers to two components: (1) the assessment of student height, weight, and BMI at school and (2) the reporting of aggregate BMI results to the MA Department of Public Health (MDPH) to track obesity prevalence. BMI reporting refers to the requirement for BMI results to be delivered to parents/guardians as a “report card” along with nutrition and physical activity resources. De-implementation of the BMI report cards occurred in October 2013 when the MA Public Health Council amended the regulations (105 CMR 200.00) to exclude BMI report cards for parents/guardians; however, the council preserved provisions for BMI screening and aggregate reporting of results to MDPH .
We purposively sampled participants representing major roles of those involved with the implementation and de-implementation of the BMI report card policy, including (1) members of the MA Public Health Council which oversees state public health policies ; (2) leadership from MDPH, the entity responsible for policy implementation; (3) representatives from partner agencies involved with program development; and (4) school nurses responsible for program delivery. In February 2022, we reviewed historical documents, including MDPH program manuals and MA Public Health Council meeting minutes, to generate a sampling frame of potential participants (n = 43). Additional suggestions for individuals to recruit were obtained from study participants (n = 7). We also created a timeline of key events from our review of the historical documents (see Fig. 1) and verified it for accuracy with key personnel involved with the policy implementation and de-implementation.
From April to July 2022, we recruited participants by email or list serv and offered a $25 gift card incentive. We prioritized and contacted 21 individuals based on their roles and level of involvement with implementation and de-implementation. Of these, 2 declined and 4 did not respond after 3 communication attempts. After recruiting and conducting 15 interviews with representation from key stakeholder groups, we reached saturation of themes by having adequate information power  to accomplish our study aims and sample specificity. This study was determined exempt by the Institutional Review Board at the Harvard T.H. Chan School of Public Health. Data were reported according to the Standards for Reporting Qualitative Research checklist (see Additional file 1).
We conducted semi-structured interviews using interview questions guided by CFIR 2.0  and by interview questions from our team’s prior work  informed by the original CFIR  and publicly available CFIR questions . The CFIR 2.0 features constructs that are associated with effective implementation across five domains: (1) the Innovation, meaning the intervention or service being implemented; (2) the Inner Setting where the intervention is implemented; (3) the Outer Setting where the Inner Setting is situated; (4) the Individuals involved and how they relate to implementation; and (5) the Implementation Process . Three study authors (RL, EK, MKP) collaborated on the development of the interview questions and protocols. The open-ended interview questions asked about the participant’s role and key determinants for implementation [21, 25], including the factors influencing policy implementation and de-implementation, perceptions of the policy, impact, and feasibility of steps for implementation and de-implementation (see Additional file 2 for interview questions).
Based on our verified timeline of historical events, we included our definitions of the timing for “implementation” (April 2009 to October 2013) and “de-implementation” (October 2013) in the study recruitment materials, consent script, and interview questions to help remind participants of the timeline. We also organized our interview questions by these periods of time to distinguish between data for implementation and de-implementation.
All study authors conducted and audio-recorded the 45- to 60-min interviews using Zoom. We used Sonix software  to transcribe interview audio files to text and checked the transcripts for accuracy.
We imported transcripts into NViVo qualitative software  to conduct a thematic analysis informed by CFIR 2.0 to characterize factors influencing policy implementation and de-implementation . Two study authors (MKP, KK) used a deductive approach to develop a codebook of CFIR constructs across four CFIR 2.0 domains: Innovation, Inner Setting, Outer Setting, and Individuals/Roles subdomain (Fig. 2). The two study authors independently coded the same transcripts from two interviews using a line by line analysis. They also reviewed the transcripts to determine if any new inductive codes beyond the CFIR framework were needed. Next, they compared coded text, reached consensus on codes, and adjusted the codebook following discussions with all study authors. Codebook revisions included the omission of repetitive codes and the clarification of when certain codes should be applied to text. No codes were added. The two study authors used the revised codebook to modify their coding of the same two transcripts, and then they double coded three additional transcripts (26%). The process of comparing codes, reaching consensus, and meeting with all study authors was repeated. The two study authors then divided and independently coded the remaining 11 interviews using the revised codebook and met to discuss areas of uncertainty before finalizing the coded transcripts and summarizing the coded data by CFIR domains. All study authors then independently reviewed the summarized codes and text to identify preliminary themes within and across CFIR domains. The team met to share and refine preliminary themes, discuss additional themes, and reach consensus on themes.
Throughout the process of conducting interviews, developing the codebook, and analyzing and interpreting the data, the authors (MKP, RL, KK, EK) acknowledged how their life experiences and identities related to the data. MKP, a former 4-year MA resident, is a researcher and prior public health practitioner with experience implementing school-based childhood obesity prevention initiatives, including in a state with BMI report cards. RL, a lifelong MA resident, conducts research on childhood obesity prevention, weight stigma, and implementation science and has partnerships with MA government agencies. KK, a 2-year MA resident, is a researcher and former public health practitioner with experience implementing school-based nutrition initiatives. EK, a long-time MA resident whose family members have attended MA public schools across three generations conducts research on childhood obesity prevention and weight stigma.
Of the n = 15 interview participants, five were current or former staff at MDPH; one was a former member of the MA Public Health Council; three were school nurses; and six were community advisors/practitioners. Identified themes are organized by our original study aims below; examples of representative quotations are provided with the associated CFIR 2.0 domains and constructs listed in parenthesis. Additional quotations are displayed in Table 1.
Findings for Aim 1: To explore the reasons for adoption of the BMI report card policy
We identified two themes for adoption of the BMI report card policy. The first theme was that the evidence base was not the primary motivator for adoption—instead, the fact that the BMI report cards came from trusted sources mattered more (Innovation domain: Evidence-base, Source). One MDPH respondent noted, “But an interesting factoid in terms of how policies are made, it's not really when we always say follow the science.” Instead, participants expressed that seeing a pilot program with vocal champions in the nearby Cambridge Public Schools, and policies in other states, convinced public health leaders to adopt the policy. There was also a sense of trust within MDPH and among the MA Public Health Council of having good intentions and selecting the best available strategies for childhood obesity (see Table 1).
The second theme was that societal pressure to act on the topic of childhood obesity at the time spurred adoption of the policy (Outer Setting domain: Societal Pressure). Participants described how childhood obesity had become an urgent topic, and thus, MDPH felt pressure to implement interventions, even if strong evidence for their effectiveness was not available yet (see Table 1). One MDPH respondent said, “[It] was a full-fledged priority. That’s what it was. There was a priority at the department at the time to respond to the growing epidemic,” and another noted, “We also knew that we didn’t know enough about the obesity epidemic and we didn’t know about effective, evidence-based strategies for the epidemic at the time.”
Findings for Aim 2: To identify contextual factors influencing the removal of the BMI report card policy
We identified five themes related to factors influencing de-implementation of the BMI report card policy. One theme was that the reported poor design of the policy—including a perceived lack of involvement of key stakeholders in planning—led to inconsistent implementation and overall dissatisfaction which ultimately enabled de-implementation (Innovation domain: Design). Reported minimal involvement of school nurses in the planning of the implementation process—despite being responsible for program delivery—may have led to inconsistencies in how schools conducted BMI screening and/or reporting. An MDPH participant commented, “We had a lot of difficulties in maintaining consistency and standards.” Under representation of school nurses in program design may have also contributed to dissatisfaction with the policy (see Table 1).
Another factor identified was that the interplay between mass media, societal pressure, and internal pressure and politics was critical to de-implementation (Outer Setting domain: Societal Pressure; Inner Setting domain: Tension for Change). Just as societal pressure influenced policy adoption, external pressures to reconsider the policy were major catalysts in its reversal. Some MDPH leaders described learning BMI report cards may not be effective through internal review of the surveillance data and a 2011 study ; however, this did not prompt de-implementation. Instead, participants recalled how BMI report cards were mocked as “fat letters” during an episode of the television show Saturday Night Live, and that this accelerated de-implementation. One MDPH staff noted, “And so it hit the news waves. It was on CNN. Saturday Night Live did a little skit about the ‘fat letter’. And all of a sudden I’m in the governor’s office: ‘get rid of BMI’.” Additional news stories featuring upset parents made the governor work quickly to de-implement it (see Table 2 for media examples). Parental concerns raised in the media mirrored the occasional complaints reported by school nurses though MDPH staff voiced mixed perspectives on the volume of parent complaints received since implementation (see Table 1). This societal pressure to end the policy coincided with a challenging time at MDPH, which had recently experienced changes in leadership and staffing following the department’s involvement in several incidents of misconduct unrelated to the BMI report cards. MDPH, in an effort to re-gain favor with the public, felt a responsibility to respond to the public outcry over BMI report cards. One MDPH staff noted, “We have a brand-new commissioner and are trying to make decisions about what's best for children. It was very complex, heightened, heated, terrible.”
Perceptions that BMI reporting to parents was not necessary and not appropriate for schools to be doing contributed to dissatisfaction among some participants (Inner Setting domain: Mission Alignment). Specifically, there was a perceived mismatch between the role of schools versus pediatricians’ offices in collecting and discussing BMI with families. Some respondents believed addressing BMI with parents was best suited for pediatricians and/or that pediatricians were already screening BMI. One school nurse said, “I don’t see any reason why schools need to be involved in this issue…[It’s] doubling up on information that we already have.” However, other respondents felt that pediatricians were not actually discussing BMI with families, and thus this intervention was needed (see Table 1).
A fourth catalyst for de-implementation was communication breakdown contributed to inconsistent implementation (Inner Setting domain: Communication). Respondents expressed disconnects between policymakers, practitioners, and families impacted by the policy. Some involved with developing the policy procedures reported having minimal opportunity for feedback from those affected by the policy. One such community advisor said, “I don’t think we had a well-organized reporting structure…So I don’t think we were necessarily in a good place to be systematic in understanding whether there were negative consequences.” Similarly, there were miscommunications about the intention of the report cards between those who designed or delivered the intervention and the families (see Table 1). One MDPH participant remarked,
And one of the things we had to keep stressing…that this is simply a screening, it is not a diagnostic tool… So it was kind of like you were calling them obese, but not really. So there's a lot of confusion. And school nurses were confused by it, too.
A fifth catalyst was that uptake of and access to appropriate training, as well as reported gaps in the content of available training, contributed to inconsistent implementation and discomfort (Inner Setting domain: Access to Knowledge) (see Table 1). While one MDPH leader reported providing exhaustive training, a school nurse said, “I know I never received any training.” Another public health practitioner involved in supporting implementation characterized the training as not helping nurses address the sensitive nature of reporting children’s BMI, saying, “We didn’t provide the appropriate training for school nurses, the appropriate sensitivity training, culturally appropriate training, the whole gamut…it was just height, weight.”
Findings for Aim 3: To understand the acceptability and feasibility of policy de-implementation
We identified two themes related to acceptability. The first theme is that acceptability of de-implementation was not universal (Innovation domain: Design; Outer Setting domain: Local Attitudes; Inner Setting domain: Relative Priority). One school nurse reflected, “I think as a collective group, we [school nurses] felt relieved that we…no longer have to do that,” whereas others disagreed (see Table 1). In the school year following de-implementation, one MDPH participant recalled a surge in complaints about why schools were collecting student BMI, but not reporting it to parents/guardians: “But parents became very upset that they weren’t getting this information and that their children were coming home and told that they were being weighed.”
The second theme for acceptability is that when reflecting on de-implementation, some within the MDPH, the Public Health Council, and community advisory groups remarked how perspectives of how childhood obesity can be prevented have changed since the time of the MA BMI report card policy (Innovation domain: Design). Respondents described how the public health field has evolved to consider the social, structural, and economic determinants of health when addressing obesity rather than focusing solely on individual behavior change (see Table 1). A member of the MA Public Health Council said:
The idea of approaching a problem like obesity with such an individual focused intervention just really flies in the face of everything we know about the structural issues that are responsible for obesity. And so it seems very obvious to me now that this is like using a hammer on I don’t know, something that’s not a nail.
We identified one theme for the feasibility of policy de-implementation in that not all components of the policy were perceived as needing to be de-implemented (Innovation: Design, Relative Advantage). There was agreement that it was favorable to retain the BMI surveillance component to allow for public health planning and evaluation. One MDPH participant said,
You know, I think surveillance is a very important thing. And I think that if we were to lose the ability to track the impact of the whole range of prevention and health promotion strategies that were happening, both in schools and outside of schools through this through BMI measurement and reporting would have been not good.
By retaining BMI measurement and reporting to MDPH only, leaders were able to optimize acceptability, particularly within the MDPH, and feasibility, lessening the burden on individual schools (see Table 1).
Our qualitative study of the MA BMI report card policy identified multiple themes about why the policy was implemented in 2009 and what catalyzed its de-implementation in 2013. Our findings align primarily with one criterion for de-implementation proposed by McKay et al.: the intervention is found to be ineffective or harmful . However, several factors may matter more than the evidence of an intervention’s effectiveness for implementation and de-implementation, especially when there is tension between the Inner and Outer Setting domains. It appeared that societal pressure for public health leaders to quickly address childhood obesity, before there was ample research, meant that leaders were spurred to implement a policy without strong evidence behind it. Yet the policy was still not de-implemented when evidence had emerged at that time suggesting it was not effective  or that it could exacerbate body image concerns  and unhealthy weight management behaviors . Instead, societal pressure again played a pivotal role when state leadership received national attention and political pressure to de-implement increased. MDPH’s concerns about reputation at the time and the ongoing reorganization of staff added a layer of internal pressure for de-implementation. Initial problems with implementation, including perceptions of limited engagement of school nurses in program planning, miscommunication, training gaps, and a sense of mission misalignment, contributed to tepid support, which may have also allowed it to be more easily de-implemented.
Consistent with Prusaczyk’s hypothesis that factors influencing implementation may differ from those for de-implementation , our findings offer an applied example of such differences for a public health policy. Innovation design, internal pressure in the Inner Setting, and societal pressure in the Outer Setting, and their interaction, were highly influential for prompting policy adoption and de-implementation. However, pressure appeared to be much higher across both levels of the Inner Setting (MDPH and schools) and the Outer Setting for de-implementation. We also found differences in the acceptability and feasibility of de-implementation for the practice of BMI report cards versus the process of de-implementation . Opinions were mixed on the decision to de-implement the policy based on considerations for the Innovation, Inner Setting, and Outer Setting domains. The process for de-implementation, however, appeared to be straightforward, although some felt there could have been more efforts to first test the model of BMI screening only. A final consistency with Prusaczyk’s conceptual paper  is that we observed variation in respondent perspectives within and between roles and by policy implementation and de-implementation which could in theory contribute to incomplete de-implementation. In this case, however, it does appear that de-implementation was successful, especially since school nurses expressed a sense of relief for no longer having to issue BMI report cards. However, our study team did encounter several instances in our formative research where it was unclear from online materials or communications with school professionals about whether schools were still required to implement the BMI report card component. Replication of information from outdated websites, especially when only part of the original intervention is de-implemented, could present challenges to complete de-implementation of public health policies.
Weno et al. developed a taxonomy of strategies for de-implementation of public health programs . The first strategy is to use evaluation data for decision-making. While some participants noted being aware of new evidence and state data showing BMI report cards were not decreasing childhood obesity, this was not a primary catalyst for de-implementation. A second strategy, to consider if any program components can be saved, did take place; MDPH maintained the requirement to measure BMI at school and report aggregate data to MDPH while removing report cards. A third strategy, to transparently communicate and discuss program adjustments, was not fully utilized. While the policy amendment was presented at an MA Public Health Council meeting prior to de-implementation, some participants believed the revised policy should have been piloted before de-implementation occurred statewide to test acceptability and avoid unintended consequences. The additional strategies suggested by Weno et al.—respect partner relationships and communicate effectively—do not appear to have been primary strategies used for de-implementation. This is unsurprising since this de-implementation framework did not exist in 2013; however, this raises a larger question of what types of processes decision-makers use to de-implement public health interventions that have fallen out of favor and whether there are ideal processes for de-implementation. Our results suggest, at least in considering public health policies specifically, it may be useful to apply Kingdon’s policy window model, which posits the need for alignment of three streams for policies to be implemented: problem, policy, and politics . Our findings indicate this window of opportunity may also be present in policy de-implementation, particularly when de-implementation occurs in response to external factors rather than being planned.
As research evolves and commonly used interventions are found to be ineffective, the question of how to de-implement is important. Public health practitioners, in response to urgent public health problems, may need to act before evidence for action is available. Thus, practices may become incorporated into an institution’s work and be difficult to change. Our study suggests there is not a well-defined process for de-implementing interventions driven by policy change; rather, the de-implementation of this policy depended largely on chance and political processes. Future research should identify effective de-implementation strategies for interventions that can be easily used by public health leaders. The de-implementation of ineffective interventions has the added benefit of freeing up resources for effective ones, a critical issue considering the limited availability of public health dollars. Surprisingly, costs were not reported as a consideration for de-implementation in this study. BMI report cards are relatively inexpensive per student [10, 33], but the labor time required for school nurses to implement BMI report cards over time is not insignificant  which was echoed in some school nurse interviews.
This study had several limitations. Our sample size was small and may not have represented all perspectives on the implementation and de-implementation of the MA BMI report card policy. Our focus on state-level processes meant we could not incorporate the perspectives of those who were most directly affected by the intervention (i.e., students and parents/guardians). However, we did include perspectives of an array of individuals involved in policy adoption, implementation, and de-implementation. The results of our study may be limited by the time gap between the implementation of the policy in 2009, de-implementation in 2013, and our interviews in 2022. While we verified key events with a review of historical documents and reminded participants of the timeline for implementation and de-implementation as part of the interview script, participants were not asked to review our study results which could have strengthened the validity of our findings. Additionally, it is possible that currently held beliefs and experiences could have biased participant recall; however, we included an interview question that asked explicitly for interviewees to contrast their current perspectives with those from the time of the MA BMI report card policy.
Societal pressure, political pressure, and problems with initial design and implementation were key catalysts for the de-implementation of the MA BMI report card policy. Public health research should further focus on developing strategic processes to de-implement ineffective policies and interventions that adequately address the drivers of policy de-implementation.
Availability of data and materials
Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.
Body mass index
Massachusetts Department of Public Health
Consolidated Framework for Implementation Research
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We would like to thank and acknowledge the study participants for contributing their time and insight into this topic.
This study was supported by grants from Healthy Eating Research, a national program of the Robert Wood Johnson Foundation (2833590) and The JPB Foundation, as well as a Ruth L. Kirschstein Predoctoral Individual National Research Service Award (1F31HL162250-01A1) of the National Heart, Lung, and Blood Institute of the National Institutes of Health, and the Implementation Science Center for Cancer Control Equity, a National Cancer Institute-funded program (P50 CA244433). The content is solely the responsibility of the authors and does not necessarily represent the official views of these agencies.
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Poole, M.K., Lee, R.M., Kinderknecht, K.L. et al. 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. Implement Sci Commun 4, 63 (2023). https://doi.org/10.1186/s43058-023-00443-1
- Implementation science
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- Public policy