Definitions and determinants: Use of Participatory System Dynamics to understand de-implementation, consensus, and buy-in
This study demonstrates that Participatory System Dynamics (PSD) is an effective method for engaging community practitioners to develop shared definitions, consensus, and buy-in for the complex process of policy de-implementation, revealing a preference for modifying rather than fully dismantling punitive policies.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
In the world of public health, there is a growing recognition that some rules meant to help people are actually causing harm. This field, known as implementation science, studies how to get good ideas into practice and, just as importantly, how to stop bad ones. A specific challenge arises when trying to remove policies that punish people for substance use during pregnancy. These policies often force doctors and social workers to report mothers to authorities, which can lead to family separation and deter people from seeking treatment. The problem is complex: the rules are tangled with politics, funding, and deep-seated fears about safety. To fix them, experts need to understand not just what the rules are, but how the people who enforce them see the world. They need to know if these practitioners believe the rules should be changed, and if they feel capable of making those changes happen.
A team of researchers from universities in North Carolina and Kentucky decided to test a new way of solving this puzzle. They gathered twenty-one community practitioners—doctors, clinic directors, social workers, and policy advocates—and asked them to map out the problem together. Instead of just filling out a survey, the group spent two days in a workshop using a method called participatory system dynamics. This approach treats a problem like a web of connected causes and effects. The participants drew diagrams showing how different factors, like funding or stigma, push and pull on each other over time. The goal was to see if this collaborative drawing process could help the group agree on what the problem actually is, and whether it could shift their minds toward supporting the removal of harmful policies.
The researchers found that the process worked. Before the workshop, when asked what actions were needed to fix the system, the participants mostly suggested individual-level changes, like training staff or educating patients. After they spent time mapping out the entire system together, their focus shifted. They began to prioritize structural changes, such as securing better funding, translating medical evidence into law, and changing the policies themselves. The group moved from thinking about small fixes to understanding the larger machinery of the system. They realized that to stop harmful practices, they needed to change how money flows and how evidence is used to make laws, rather than just trying to change individual behaviors.
A key discovery was how the participants viewed the idea of "de-implementation," or removing a policy. They did not mostly want to tear down the entire system. Instead, they preferred to modify existing rules to make them less punitive. For example, rather than demanding the total removal of testing for drug use, they suggested changing the rules so that a positive test result from a prescribed medication did not automatically trigger a report to child protective services. They wanted to tweak the enforcement mechanisms to stop punishing people who were seeking help. This nuance was important: the practitioners saw that a complete dismantling of policies might be too politically difficult, but modifying them to be more supportive of recovery was a realistic and necessary step.
The study also measured how much the participants "bought in" to the idea of changing these policies. This buy-in was broken down into three parts: whether they believed the change was good, whether they felt motivated to do it, and whether they felt capable of making it happen. The results showed that the workshop helped increase their belief that the changes were necessary and their motivation to pursue them. However, their confidence in their own ability to make the changes happen remained lower. This suggests that while the group agreed on the goal, they still felt some hesitation about their power to achieve it, especially in states where the political environment was more restrictive.
The researchers also noticed that the participants' views depended heavily on their job and where they lived. In Kentucky, where punitive policies were already in place, the practitioners had more mixed feelings about whether certain rules were truly harmful. Some social workers and child welfare staff, who deal with the reporting process daily, were less likely to agree that reporting was purely punitive, often because they saw it as a way to connect families with treatment. In North Carolina, where such policies were less common, the group was more unified in seeing the rules as harmful. This showed that a person's daily experience and the political context of their state shaped how they defined the problem.
To ensure the group was truly agreeing on the system map they built, the researchers used a technique to track who spoke up and who nodded in agreement during the sessions. They found that the themes the group agreed on most strongly matched the main loops in their final diagram. This confirmed that the visual model they created was a true reflection of their shared understanding. The process did not just produce a drawing; it produced a consensus. The participants left the workshop with a clearer, shared definition of the problem and a stronger sense of what needed to be done, even if they still felt some uncertainty about their ability to force those changes through the political system.
Ultimately, this study demonstrated that bringing practitioners together to map out a complex system can change how they think about policy. It moved them from a mindset of individual education to one of structural reform. It showed that people are often willing to modify harmful rules rather than destroy them entirely, and that their willingness to act is deeply tied to their role and their political environment. The researchers concluded that for de-implementation to succeed, it cannot be done by experts alone. It requires engaging the people on the front lines in a process that helps them see the whole picture, agree on the solution, and find the motivation to push for change. Without this kind of shared understanding and buy-in, efforts to remove harmful policies may stall before they even begin.
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