Table 1 Themes and examples of factors influencing implementation and de-implementation of the MA BMI report card policy

Aim 1: To explore the reasons for adoption of the BMI report card policy

 Theme: 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

 ⇒ Evidence Base

 ⇒ Source

Role: Other implementation support—Community advisor: “And some of it was, you know, some of the implementation and the sense that this was the right thing to do and that we knew how to do. It was based on the Cambridge Public Schools having done this for several years.”

Role: High-level leader—MDPH: “Now, when you're a strong leader and most of what you do is really good, you can easily get people to just say, not question you, right? To say, Oh, yeah, [she’s] smart, she's good, she's done all these great things. So this is just another one of those things. So we'll go forth…I don't think that they had enough feedback to ask any kind of questions about it. So it passed with flying colors and then as soon as it got implemented, people started going crazy.”

Role: Other implementation support—Community advisor: “But the state was always very clear, as was Cambridge, that surveillance was really at the at the heart of it.”

 Theme: Societal pressure to act on the topic of childhood obesity at the time spurred adoption of the policy

Outer Setting

 ⇒ Societal Pressure

Role: Other implementation support—Community advisor: “But in terms of then the state, so I think, you know, the folks that were at the state at the time were really interested in surveillance. They wanted to be on top of what was going on in terms of increasing levels of overweight and obesity and the disparities and watch the disparity be really cognizant of what was going on to our population and the age of children. I mean, it was it was younger and younger children were being impacted by, you know, moving categories of overweight. It was pretty you know, in those days…it was kind of scary to watch…that change in the body weight of our children and so at its root was really the surveillance piece.”

Role: High-level leader—MDPH: “So it was like you added on each piece as a new health issue arrived and obesity was a big one. That was a big 2007, 2008 and we had a data system demonstrating the increase in type one diabetes, type two diabetes. We certainly had asthma. It's all related…So our data system crossed, I think we had 36 health conditions. We were tracking on 1.2 million students, I would say. So obesity was a big one because we you know, we could prevent a lot of chronic illnesses. And so we were absolutely devoted to doing something about this.”

Aim 2: To identify contextual factors influencing the removal of the BMI report card policy

 Theme: 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

 ⇒ Design

Role: Innovation deliverer—School nurse: “I don't know if they ever consulted school nurses to begin with to find out whether it should have been done. They talk to everybody but school nurses most of the time. I can't tell you how many conversations I've had with DESE [Department of Elementary and Secondary Education], that or a state senator or a representative at some point in the conversation it was, ‘Well, we never thought to talk to the school nurses.’ Why not? Where are the people who are there looking at the kids every single day? We're the ones who have to implement these protocols you put together. Why wouldn't you think to start with us and say, do you recognize a need here? No. So I guess that would be the only thing. And I don't know that they didn't, but I don't know that they did. And their track record is not very good for checking with us first.”

Role: High-level leader—MDPH: “I mean, the level of variation of the implementation of the original reg we heard about anecdotally and meaning not just from parents but also from nursing staff about how things were happening, what they had the bandwidth to do. Like there were requirements for confidentiality and privacy, but we would hear stories both from nurses and from kids and their parents that not really, no that wasn't exactly done that way. Again, I have big, I have pictures in my head of stories that we heard about, about kids being lined up and, like, going behind a curtain together, like with the numbers read out. And it's not private. It's ‘pretend’ private. And I could go anyway. So yeah, there was, whereas in other places tons of resources done very differently. So there was variation.”

Role: High-level leader—MDPH: “But my memory of this is that schools also were there was inconsistency in how they were framing it all, framing the sharing of…information with parents…So theoretically, good framing could minimize stigma, could get parents invested in reducing BMI efforts and in thinking about strategies at home. Like that was the whole idea behind this, right, is that parents, you've got a role in this. Your kids can be healthier.”

Role: High-level leader—MDPH: “So even though parents were hesitant to get these BMI report cards, and they were, oh, one of the other problems almost forgot a major problem with the reporting that was occurring initially was that these report cards, as we call them, were being sent home with kids on the school bus or in their backpacks or whatever. And often other kids would get a hold of them. And there was, as you can imagine, major bullying as a result because kids learned how to identify abnormal those that were overweight and those that were being labeled obese. And so that became a huge public nightmare, public relations nightmare for the school district, but also for us. And so that that became problematic.”

 Theme: The interplay between mass media, societal pressure, and internal pressure and politics was critical to de-implementation

Outer Setting

 ⇒ Societal Pressure

Inner Setting

 ⇒ Tension for Change

Role: Other implementation support—Community advisor: “I do remember this seemed to be a media topic of interest, like the media would like to report on this kind of stuff. And I remember either newspaper or TV report sort of, with parents sort of feeling like this was not information they needed to hear from the schools. That it was an overreach on the part of DPH.”

Role: Innovation deliverer—School nurse: “But when it was being eliminated…I do remember letters to the editor. I remember discussions on the news, interviews with medical professionals as well as nurses, school nurses and parents. So, yeah, I do remember that by the time it was getting eliminated, there were a lot of people who were very upset over it.”

Role: Innovation deliverer—School nurse: “I definitely remember receiving phone calls from parents, you know, but I was really fortunate because when I explained the purpose of this and what was happening, I have to say that I really didn't have any continued backlash about it.”

Role: High-level leader—MDPH: “We didn't get complaints, a lot of complaints from parents.”

Role: High-level leader—MDPH: “So, you know, this department of public health that was rocked by scandal, two different scandals…And so…that had happened, then losing stable leadership, and then Saturday Night Live making fun of the school nutrition regs. 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.”

Role: High-level leader—MDPH: “And so the Department of Public Health was in this kind of free fall where the public had questions…So we were in a bad light in the public with the legislature and with the governor.”

Role: High-level leader—MDPH: “The timing thing, too. There was emerging evidence in that a study had just been published, which I don't remember any of the details about it now suggesting that the like nutrition regs and the BMI reg in and of themselves weren't the problem, but this parental notification was not evidence based. And third, in complete transparency, the political pressure made it necessary…to move much faster on addressing that regulatory problem than I think would have happened otherwise. So in other words, I think I do think without the kind of political and communications problem, like health communication problem that was coming because of the how much publicity there was about the letter, like ‘fat letters,’ it meant that he [the governor] had to work faster than it normally would in changing a regulation because the evidence was still emerging that it was not good to do.”

Role: High-level leader—MDPH: “Through some other evidence-based research that was being done at the time–I know specifically a California study was being cited– it was determined that we needed to change the effort from an individual child report to a more community wide report, so a more school-based report versus individual child. So that's when that change started to come about towards the probably the end of 2012. I'll say that we started to look at the data that we had and the fact that it really wasn't working that well in the individual child…But in the process of all of this, it started to come out that parents weren't happy with the reporting structure.”

 Theme: 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

 ⇒ Mission Alignment

Role: Innovation deliverer—School nurse: “[I] don’t know that other school staff are concerned about anything, but I do know that some of the nursing staff were concerned about it being their responsibility and they weren’t comfortable with that. So the reasons that I have already talked about that the feeling was that this was something that should be done by a primary care provider in that type of setting so that that and that students were already having physicals, so they were already having their weights done and if they needed a referral to PCP was already doing that.”

Role: High-level leader—MDPH: “I remember approaching pediatricians and they really did not want to do what they pediatricians are reluctant to add anything to their plate when it comes to doing initial screenings.”

Role: Other implementation support—Community advisor: “And particularly in those early days, I mean, the pediatricians were not yet giving this information back to students. And I think that was a lot of the impetus behind the state is that they really wanted a surveillance system.”

 Theme: Communication breakdown contributed to inconsistent implementation

Inner Setting

 ⇒ Communication

Role: High-level leader—MDPH: “I wasn't aware if there was any required reporting to the school, like to our school nurse part of the department around what they did, how they distributed the information. All we had was anecdotal and I think that's what all of our folks had.”

Role: Other implementation support—Community advisor: “And I don't believe that we had any formalized reporting structure. So I don't think, for example, on the report card, like there was something that said, you know, if you have any concerns about this information, please contact this number or send us an email. So I don't think there was if there was flak from parents or teachers or school nurses or whatever, I don't think we had a well-organized reporting structure. So [it] would have all been at the local level that people if parents were upset, it would be a school committee or school board kind of complaint. So I don't think there was anything that was designed to capture that information. So I don't think we were necessarily in a good place to be systematic in understanding whether there were negative consequences of any importance or prevalent or common commonly experience.”

Role: Other implementation support—Community advisor: “And then parents got this letter that just said, ‘Your kid’s over, by the BMI chart, your kid is overweight.’ [It] didn't take into account, I don't think the letter said anything about well, what this means is if your child is athletic, they may not. And we didn't do any real great education around it. And so it was, it landed with a thud, essentially.”

 Theme: 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

 ⇒ Access to Knowledge

Role: High-level leader—MDPH: “We hired a staff member whose job was 40 h a week was to go around to school districts and train school nurses and the others that were going to be involved. As I said, they often had the physical education teachers or others involved in their screenings. We went around and she literally went to individual schools and districts and did extensive training on a daily basis for, oh, 6 to 8, maybe 9 months. That's all she did. And so and we reached…I think we did the entire state. I don't think anybody said no to offering this. Obviously, it was a free training and we went in and brought the equipment in.”

Role: Other implementation support—Community advisor: “I was involved in a survey that we did with school nurses, and they [school nurses/staff] weren't prepared whether we did any training or not. I don't really remember, honestly, but they were not prepared. And nobody, I don't think, still is prepared to figure out how to talk about overweight in a way that is, I mean, it's a stigmatizing condition that we have as a society…have allowed to stigmatize too, in my opinion. But you know, they were not prepared and they hated it, and because they were on the front line having to talk to parents and deal with parents.”

Role: Innovation deliverer—School nurse: “And I remember them [MDPH] offering the trainings and we had regional nurse leader meetings as well. And I'm pretty sure that we…reviewed the change in the in the regulation at the regional meetings and they did offer trainings.”

Aim 3: To understand the acceptability and feasibility for policy de-implementation

 Theme: The acceptability of de-implementation was not universal

Innovation

 ⇒ Design

Outer Setting

 ⇒ Local Attitudes

Inner Setting

 ⇒ Relative Priority

Role: Innovation deliverer—School nurse: “I think like some nurses were just glad to not do it and I'm sure there were other nurses like myself. I was, I would say, indifferent or ambivalent is the right word. But it wasn't like, ‘Oh, we really need to do this kind of a thing.’ It was just kind of like, ‘Oh, okay, we're not going to do that anymore.’

Role: Innovation deliverer—School nurse: “I didn't think it was an effective tool to begin with. So when they said it was being de-implemented, I was very good with that…All it's providing is some statistics that I'm not even sure of the value of the statistics, because we're not taking into account the entire person and what's going on. And so I think for me personally, it was a relief to not have to send that home anymore.”

Role: Other implementation support—Community advisor: “I don't see a downside from it being discontinued except…our heads went back into the sand, and there was now… no information on the health of a child and the dangers of overweight/obesity unless they have some nutrition education in their schools.”

Role: High-level leader—MDPH: “And I think parents’ priorities and perspectives all changed that time because everybody was so focused on these SBIRT [Screening, Brief Intervention, and Referral to Treatment] screening…BMI and postural kind of got downplayed in priorities not only among schools, but among parents. And so we rarely had any complaints from that, but they were still being done.”

Role: High-level leader—MDPH: “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. But none of the results were being told to parents…And it became a huge nightmare for the school districts…And we gave that feedback to the department in 2013, 2014 that this wasn't working this procedural way that they had determined was not working.”

Role: High-level leader—MDPH: “Yeah, I think I think it went pretty easily…There are portals for all parents and students to go into. So the letter was in, I believe in the portal and they could access it if they wanted it and not if they didn't want it…Each school, I think, made a different decision. Some of them didn't post them at all—the parent had to request it and had them post it in a place that they could get access to…So I think that each school had hearings about what the tenor of their community around, whether they wanted to know it or not. I would say most they just easily got posted on the portal.”

 Theme: Perspectives of how childhood obesity can be prevented have evolved since the time of the MA BMI report card policy

Innovation

 ⇒ Design

Role: High-level leader—MDPH: “Well, I do want to say I want to make it clear from my perspective that the original initiative in 2008, as well intentioned as it was and based upon the research that we had at that time, was flawed in that what we learned between 2008 and 2013 is that it does have to be a community-wide approach. You cannot approach obesity in public health from an individual perspective. That will never work. And I think that was a key lesson learned here, that in the transition between the two got lost, that this is what we are trying to do. Even though school nurses, as I mentioned, had been doing a lot of physical activity initiatives, something to promote that active living and certainly healthy eating during this time. What the message that was getting lost is this takes all of us to if we're going to reduce obesity among our school age children. And that's I'm sorry that that message got lost because that's an important message. It takes a community, a village to fix this.”

Role: Other implementation support—Community advisor: “I mean, we all knew it was like such a bigger problem than what a parent was going to solve overnight or that a kid could take on. But that awareness is part of any kind of strategy and bringing that level of awareness. I'll tell you what it got. It got on people's radars where it wasn't before and the report cards probably weren't particularly impactful at an individual level, but they did raise awareness, I would say, at a community level. Not all of it maybe been positive, but it did bring that attention really forward.”

 Theme: Not all components of the policy were perceived as needing to be de-implemented

Innovation

 ⇒ Design

 ⇒ Relative Advantage

Role: High-level leader—MDPH: “Because for surveillance…as well as trying to understand what was working in efforts to address obesity, and so it was…important to maintain the BMI measurement. And so there was this dual goal and of wanting to keep something that was an important part of the regulation and having to move very quickly on something that it was not clear was an important part of the regulation. In fact, the study that was literally published as the regulation was being revisited—they came out was that this piece of the reg was not evidence based.”

Role: Other implementation support—Community advisor: “It's just not worth the…it's not so clear that it has like this amazing impact…and we can continue with the surveillance.”