PERSPECTIVE
published: 20 May 2022
doi: 10.3389/frhs.2022.897227
Frontiers in Health Services | www.frontiersin.org 1May 2022 | Volume 2 | Article 897227
Edited by:
Nick Sevdalis,
King’s College London,
United Kingdom
Reviewed by:
Denise F. Lillvis,
University at Buffalo, United States
*Correspondence:
Meagan Pilar
meagan.pilar@wustl.edu
Specialty section:
This article was submitted to
Implementation Science,
a section of the journal
Frontiers in Health Services
Received: 15 March 2022
Accepted: 22 April 2022
Published: 20 May 2022
Citation:
Pilar M, Elwy AR, Lushniak L,
Huang G, McLoughlin GM, Hooley C,
Nadesan-Reddy N, Sandler B,
Moshabela M, Alonge O, Geng E and
Proctor E (2022) A Perspective on
Implementation Outcomes and
Strategies to Promote the Uptake of
COVID-19 Vaccines.
Front. Health Serv. 2:897227.
doi: 10.3389/frhs.2022.897227
A Perspective on Implementation
Outcomes and Strategies to Promote
the Uptake of COVID-19 Vaccines
Meagan Pilar 1
*, A. Rani Elwy 2,3 , Larissa Lushniak 1, Grace Huang 1,
Gabriella M. McLoughlin 4,5 , Cole Hooley 6, Nisha Nadesan-Reddy 7, Brittney Sandler 8,
Mosa Moshabela 7, Olakunle Alonge 9, Elvin Geng 1and Enola Proctor 10
1Department of Infectious Diseases, Washington University School of Medicine, Washington University in St. Louis, St. Louis,
MO, United States, 2Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University,
Providence, RI, United States, 3Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare
System, Bedford, MA, United States, 4College of Public Health, Temple University, Philadelphia, PA, United States,
5Implementation Science Center for Cancer Control and Prevention Research Center, Brown School, Washington University
in St. Louis, St. Louis, MO, United States, 6School of Social Work, Brigham Young University, Provo, UT, United States,
7School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa, 8Bernard Becker Medical Library,
Washington University in St. Louis School of Medicine, St. Louis, MO, United States, 9Department of International Health,
Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States, 10 Shanti K. Khinduka Distinguished
Professor Emerita, Brown School, Washington University in St. Louis, St. Louis, MO, United States
Recent articles have highlighted the importance of incorporating implementation
science concepts into pandemic-related research. However, limited research has been
documented to date regarding implementation outcomes that may be unique to
COVID-19 vaccinations and how to utilize implementation strategies to address vaccine
program-related implementation challenges. To address these gaps, we formed a global
COVID-19 implementation workgroup of implementation scientists who met weekly
for over a year to review the available literature and learn about ongoing research
during the pandemic. We developed a hierarchy to prioritize the applicability of “lessons
learned” from the vaccination-related implementation literature. We identified applications
of existing implementation outcomes as well as identified additional implementation
outcomes. We also mapped implementation strategies to those outcomes. Our
efforts provide rationale for the utility of using implementation outcomes in pandemic-
related research. Furthermore, we identified three additional implementation outcomes:
availability, health equity, and scale-up. Results include a list of COVID-19 relevant
implementation strategies mapped to the implementation outcomes.
Keywords: implementation science, COVID-19, vaccine, implementation outcomes, implementation strategies
INTRODUCTION
The coronavirus disease 2019 (COVID-19) pandemic vividly exemplifies an implementation crisis:
life-saving remedies exist, but their adoption and spread have lagged world-wide. Many longed for
vaccines and heralded their development. However, many medical and public health experts were
surprised at the skepticism, hesitancy, and outright resistance to available vaccines, even as the
pandemic led to sky-rocketing rates of mortality and morbidity and compromised even the most
resource-rich health systems. Despite recommendations from the World Health Organization, we
are still far from achieving the proposed goal of 70% vaccination coverage globally (1). Though
Pilar et al. COVID-19 Implementation Outcomes and Strategies
there is some debate as to whether 70% vaccination is still
sufficient due to the emergence of new variants (2), the challenges
with vaccine program implementation remain.
Implementation science is well-suited to tackle crises like
the COVID-19 pandemic. But what specifically does it offer?
This Perspective article addresses one part of this question by
demonstrating the importance of conceptualizing vaccine roll-
out through the lens of two implementation science concepts:
implementation outcomes and implementation strategies. These
concepts help clarify some of the most pressing questions
about the implementation challenges surrounding vaccination
programs: What needs to be achieved, and how do we
get there? This article is not meant to be an exhaustive
review of current research; rather, it is intended to provide
the reader with guidance on how we might more clearly
conceptualize the implementation outcomes—both anticipated
and actual (3)—that are most relevant for increasing the
uptake of COVID-19 vaccines. Additionally, we will provide
examples of implementation strategies, developed to ensure
successful implementation outcomes, to better aid researchers
and practitioners in evaluating the implementation of COVID-
19 vaccines.
APPLYING AN IMPLEMENTATION
SCIENCE LENS TO THE COVID-19
PANDEMIC
Implementation science is the “study of methods to promote
the systematic uptake of research findings and other evidence-
based practices into routine practice” (4). This field seeks to
provide guidance in cases where evidence-based interventions
exist but are poorly implemented or, in some instances, not
implemented at all. In the case of the COVID-19 pandemic, an
intervention—a vaccine—exists, but it has been underutilized for
myriad reasons (e.g., issues surrounding supply and distribution,
mistrust, misinformation, vaccine hesitancy). Implementation
science provides an opportunity to apply existing methods to
study these challenges and improve the uptake of the COVID-
19 vaccine.
Implementation science is inherently pragmatic and
involves real-world, diverse populations, data collection that is
meaningful and actionable, and a focus on the application of
an evidence-based practice (e.g., vaccination) in local contexts
(5). Thus, ensuring the successful uptake of COVID-19 vaccines
globally requires a pragmatic, low burden assessment of
stakeholders’ perceptions of implementation outcomes related to
vaccination (e.g., acceptability, cost) (6), as well as specific and
operationalized implementation strategies to address barriers to
vaccine uptake (7).
Previous articles have underscored the importance of
incorporating implementation science concepts into pandemic-
related research (8–10). For example, it is vital to engage
stakeholders from project inception and consider context during
implementation, as factors such as available resources, policy
support, health system and population characteristics can impact
the uptake of an intervention (9). Additionally, implementation
science theories and methods can help inform the equitable
development, implementation, and evaluation of interventions
to address health disparities and promote health equity (11–
14). However, there has been a limited research focus to date
regarding implementation outcomes that may be unique to
COVID-19 vaccinations and how to utilize implementation
strategies to address vaccine program-related implementation
challenges. To address these gaps, we formed a global COVID-
19 implementation workgroup of implementation scientists who
met weekly for over a year, to review the available literature
and learn about ongoing research during the pandemic. Our
efforts resulted in a list of implementation outcomes that can
be used to evaluate the implementation of vaccine programs
globally. Likewise, we have compiled a list of implementation
strategies, which can be mapped onto the aforementioned
outcomes to address common challenges related to vaccine
program implementation.
Given this novel disease and the unprecedented times,
evidence directly related to COVID-19 is still developing. As a
result, our recommendation for implementation strategies have
been informed by COVID-19 evidence, as well as previous public
health efforts, which we believe are transferable or applicable to
this pandemic. To aid in this conceptualization of evidence, our
team constructed the following hierarchy by which to prioritize
recommendations and “lessons learned.” We drew from existing
evidence hierarchies [e.g., GRADE (15) and AGREE II (16)] and
used a consensus-based approach among the authors similar to
that espoused for developing guideline recommendations [e.g.,
the DECIDE framework (17–19)]. The implementation science
base of evidence to guide strategy selection for COVID-19
mitigation ranges from scant to very strong.
1. Direct evidence from COVID-19 vaccination: scant and
emergent, especially early in the pandemic.
2. Evidence from other preventative strategies used during
COVID-19 (e.g., masking, social distancing): emergent.
3. Evidence from vaccinations of non-COVID-19 diseases that
are respiratory, novel, or heterogeneous in severity, or during
a pandemic (e.g., influenza): solid to strong.
4. Evidence from vaccination for other infections (e.g., measles,
polio): strong.
5. Evidence from other health conditions: very strong.
IMPLEMENTATION OUTCOMES
Implementation outcomes provide a means to evaluate the
implementation success of interventions, treatments, policies,
and protocols and are distinct from other, traditionally measured
outcomes, such as service system and clinical outcomes (6).
In the case of COVID-19 prevention and treatment, service
system outcomes include the timeliness and efficiency of the
health system, and perceived equity and patient-centeredness of
treatments, while clinical outcomes reflect population and patient
health and safety, as well as satisfaction with treatment options,
including vaccines.
In 2011, Proctor and colleagues developed the
Implementation Outcomes Framework as a way to conceptualize
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Pilar et al. COVID-19 Implementation Outcomes and Strategies
and measure eight distinct implementation outcomes—
acceptability, adoption, appropriateness, cost, feasibility, fidelity,
penetration, and sustainability (6). This framework has since
been widely cited and applied within the implementation science
community. However, based on our review of the literature,
there are additional outcomes that could—and should—be
considered within the context of the COVID-19 pandemic to
provide a more comprehensive evaluation of implemenation
of vaccine programs. As a result, we have operationalized the
eight well-known implementation outcomes based on their
relevance to the COVID-19 pandemic and have proposed three
additional outcomes (availability, health equity, and scale-up)
for consideration (Table 1).
Evaluations of COVID-19 mitigation efforts could have
been—and still have potential to be—more precise and robust
with a greater focus on implementation outcomes. These
outcomes can play three important roles in relation to COVID-
19 control. First, they allow researchers and implementers to
focus efforts on assessing the baseline or starting point, thereby
quantifying the gap between desired and achieved outcomes.
Vaccines need to “have an efficacy of at least 70% to prevent an
epidemic and of at least 80% to largely extinguish an epidemic
without any other measures (e.g., social distancing)” (29). Within
the context of COVID-19 vaccination, where many countries
included other mitigation measures in their efforts to control
the pandemic, such as mask wearing and social distancing,
this could include monitoring the vaccination status of a
population. In addition to quantifying gaps in implementation,
incorporating implementation outcomes into vaccine program
planning and evaluation also provides a source of accountability
for implementers at the national-, state-, or local-levels. The
additional implementation outcomes of availability and health
equity are essential for increasing vaccine uptake. Vaccines can
be utilized only when they are available, and the sufficiency of
their availability depends on supply, the size of population to
be covered, and the size of priority groups receiving vaccines.
Similarly, vaccine equity requires consideration of sub-groups,
including groups with priority needs for vaccination and those
that differ by social, economic, demographic, and geographical
factors linked to systemic disadvantage.
Second, implementation outcomes provide a direction for
implementation efforts. For instance, factors such as the
feasibility and sustainability of public health programs may be
prioritized when implementation outcomes are incorporated into
the planning and evaluation process. These outcomes can also
highlight potential barriers or facilitators that may arise during
implementation and help researchers identify implementation
strategies to address potential challenges. As we have seen over
the past 2 years, myriad challenges can arise during vaccine
development, distribution, and implementation. For example,
factors such as unfamiliar technology or a lack of staff buy-in may
decrease the feasibility of implementing a COVID-19 vaccine
program. The additional implementation outcome of scale-up
we have defined illustrates how vaccine scale-up is affected by
factors such as vaccine hesitancy, supply shortages, financial
and technological resources, and existing infrastructure (e.g.,
cold-chain system infrastructure and ample workforce). Scale-up
differs from the original penetration implementation outcome,
which refers to the degree to which an intervention has infiltrated
a service system. Scale-up, on the hand, is broader, encompassing
multiple service systems thereby requiring different strategies
at higher socioecological levels. Additionally, the deluge of
information disseminated through social media has increasingly
delivered misinformation impacting acceptability of COVID-
19 vaccines globally. As a result, specific strategies can be
selected based on the implementation context. Challenges with
technology could be addressed through the provision of technical
assistance, while buy-in could be encouraged by identifying
champions within the organization. Finally, vaccine-related
misinformation could be counteracted through a targeted public
health campaign emphasizing the transparency of the vaccine
development process, and using jargon-free messaging that takes
into account socioeconomic and cultural factors, as well as
personal and media sources needed for communicating with
specific populations (30).
Third, implementation outcomes can increase the precision
of evaluation efforts surrounding public health programs. Too
often, public health systems’ data collection is limited to clinical
outcomes (e.g., number of COVID-19 cases, hospitalizations,
and mortality). However, measuring intermediate outcomes,
such as acceptabilty, adoption and fidelity, paints a more
complete picture of program implementation and illuminates
the challenges to current implementation efforts. For example,
several global surveys conducted throughout the pandemic have
assessed the degrees of acceptability of COVID-19 vaccines
over time (31,32). Important findings from these surveys have
revealed that those who trust their governments and their
messaging (31) and receive information and guidance from
healthcare providers (32) reported that they will be more likely
to become vaccinated against COVID-19. In another project,
COVID-19 vaccine acceptability among patients and employees
of a large integrated healthcare system in the United States
was assessed through surveys (33) and interviews (34). Specific,
tailored communication strategies were then created to overcome
identified barriers to receiving a vaccine and were disseminated
widely across the healthcare system, for use in one-to-one
conversations between trusted providers and patients, and
among employees (34). The additional information regarding,
for example, program acceptability can enable implementers to
better evaluate program efforts and adapt practices to promote
the uptake of COVID-19 vaccines.
IMPLEMENTATION STRATEGIES
Implementation strategies are defined as “methods or techniques
used to enhance the adoption, implementation, and sustainability
of a clinical program or practice” (7). Implementation scientists
have emphasized the importance of identifying and compiling
evidence-based strategies (35), selecting strategies based on
implementation context and barriers (36), and specifying the
use of implementation strategies in research (7). Building on
this body of work, our team set out to map implementation
strategies onto specific implementation outcomes and challenges
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Pilar et al. COVID-19 Implementation Outcomes and Strategies
TABLE 1 | Operationalization and addition of implementation outcomes unique to COVID-19.
Implementation outcome Definition Application to COVID-19
Acceptability*The perception among stakeholders that a given treatment,
service, practice, or innovation is agreeable, palatable, or
satisfactory
Vaccine implementation requires a minimum level of acceptability among
policy makers, healthcare providers, community leaders,
parents/caregivers, and those eligible for the vaccine. Vaccine acceptability
is undermined by misinformation, lack of trust in governments and health
systems, and anti-vaccine beliefs and attitudes.
Adoption*The intention, initial decision, or action to try or employ a new
treatment or innovation—also referred to as “uptake”
Vaccine adoption can be impacted by external mandates, vaccine supply,
organizational culture and climate, and healthcare providers’ willingness to
recommend and administer the vaccine.
Appropriateness*The perceived fit, relevance, or compatibility of the treatment
or innovation for a given practice setting, provider, or
consumer; and/or the perceived fit of the innovation to
address a particular issue or problem
The appropriateness of vaccines is influenced by organizational- and
individual-level factors, such as existing resources within an organization,
healthcare providers’ knowledge and perceptions of the vaccine, and
patients’ ability and willingness to receive the vaccine.
Availability** The supply of a new treatment or innovation at any one time Vaccines can be utilized only when they are available, and the sufficiency of
their availability depends on supply, the size of population to be covered,
and the size of priority groups receiving vaccines.
Cost*The cost impact of an implementation effort The cost of vaccine implementation includes multiple levels, such as the
cost to procure vaccine doses (e.g., national financing), administer doses
(e.g., organizations’ costs to pay employees, restructure existing processes,
etc.), incentivize doses (e.g., organizations paying employees to be
vaccinated), and receive doses (e.g., individuals’ costs to travel, take time
off work, etc.).
Feasibility*The extent to which a new treatment or innovation can be
successfully used or carried out in a given setting
The feasibility of vaccine implementation is affected by supply, as well as
geographic factors, transportation and storage structures, and the
capabilities, time, and training of vaccine providers.
Fidelity*The degree to which a treatment or innovation was
implemented as it was prescribed in the original protocol or
as was intended by program developer
Vaccines must be stored, distributed, and delivered with strict fidelity to
dosing and safety requirements.
Health Equity** Fair access to a treatment or innovation without avoidable or
remediable differences among groups of people
Vaccine equity requires consideration of sub-groups, including groups with
priority needs and those that differ by social, economic, demographic, and
geographical factors linked to systemic disadvantage.
Penetration*The integration of a treatment or innovation within a service
setting and its subsystem
The penetration of a vaccine program is impacted by myriad factors,
including policies, organizational culture, personal beliefs, and the supply of
the vaccine itself.
Scale-up** Deliberate efforts to increase the impact of successfully
tested health innovations so as to benefit more people and to
foster policy and program development on a lasting basis (20)
The potential for scale-up is affected by factors such as vaccine hesitancy,
supply shortages, financial and technological resources, political will, and
existing infrastructure (e.g., cold-chain system infrastructure and ample
workforce).
Sustainability*The extent to which a treatment or innovation is maintained or
institutionalized within a service setting’s ongoing, stable
operation
The sustainability of vaccination efforts and programs must be incorporated
into existing both national and organizational structures (e.g., allocating
financial and human resources), workflows (e.g., restructuring employee
roles and responsibilities), and/or programs (e.g., bundling with existing
programs).
*Definitions are adapted from the Proctor et al. 2011 paper (6). **Team added constructs—availability (21–24), health equity (25–27), and scale-up (28)—based on theoretical and
practical application.
to provide guidance for researchers and practitioners to increase
the uptake of vaccines and aid in the scale-up and spread of
successful vaccination programs.
After identifying and conceptualizing critical implementation
outcomes to assess to determine the effectiveness of COVID-
19 vaccine implementation globally (Table 1), our research
group considered some of the most common challenges
encountered during vaccine program implementation (e.g.,
mistrust, misinformation, vaccine hesitancy, supply issues).
We then compiled a range of implementation strategies to
determine which of these may be most useful in overcoming
common implementation challenges and increasing uptake of
COVID-19 vaccines. We present the implementation outcomes,
implementation challenges, and the implementation strategies
our team identified, and details on these strategies (e.g.,
specified actions or tools) identified in the literature to improve
implementation success (Table 2).
In many cases, we found that several implementation
strategies were needed to address these complex, multi-
level implementation challenges (5), especially prevalent in
vaccination programs. For example, Rajkumari and colleagues
identified two barriers related to the uptake of a measles-
rubella vaccine in India—limited knowledge of the vaccine
and geographic inaccessibility—which impacted the vaccine
program’s acceptability and feasibility, respectively (43). As a
result, the team selected implementation strategies to address
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TABLE 2 | Implementation outcomes, challenges, and strategies applicable to the COVID-19 vaccine program implementation.
Implementation
outcome
Implementation challenge Implementation strategy Example
Acceptability Vaccine hesitancy (broad) Plan: Identify hesitancy in the
population or subgroups and tailor
intervention efforts to reach them
Used the Guide to Tailoring Immunization Programs
(37,38) to identify subgroups with low immunization
rates, diagnose factors impacting vaccine hesitancy, and
tailor programs to addresses the factors leading to low
vaccine acceptance in the subgroup (39)
Used the Social Mobilization Network (SMNet) to target
resistance at multiple levels through effective,
personalized health communication (40)
Low vaccine demand Educate: Receive recommendation
from a trusted source
Promoted demand for vaccines through a personalized
recommendation from a trusted healthcare provider in
communities of color (41)
Limited knowledge or awareness of
vaccines
Plan: Design and implement a health
campaign
Created a vaccination program through the Cameroon
Baptist Convention Health Services that targeted
schools, clinics, churches, and regarding HPV and
cervical cancer (42)
Implemented a national vaccination campaign through
school and community outreach sessions (43)
Used nation-wide campaign, National Immunization
Days (NIDs), to administer vaccines in locations across
the country (44)
Adoption Low levels of vaccine awareness Educate: Train health
workers/community volunteers in
information, education and
communication tactics
Harnessed the power of social networks and trained
community volunteers to and increase awareness of and
support for HIV vaccine research in minority populations
(45)
Misconceptions about the vaccine
and its effects
Plan/Educate: Use health
communication strategies to address
mistrust
Recommendations to create positive vaccine narratives
and use positive emotional appeals (e.g., hope and job in
receiving a vaccine) to counteract negative emotions
(e.g., fear, anger, mistrust) surrounding vaccination (46)
Conducted a series of town hall meetings to address
concerns and misinformation raised by healthcare
workers and staff (47)
Vaccine hesitancy (mistrust in science
or the vaccine)
Plan/Educate: Create health
communication materials
Created a digital infographic to promote trust in science,
reduce the believability of misinformed narratives, and
increase the likelihood of engaging in preventive
behaviors (48)
Appropriateness Low vaccine demand and mistrust in
the community
Plan: Tailor outreach efforts and
communication strategies to
subgroups (e.g., race/ethnicity,
gender, rural areas)
Recommendations regarding outreach—Efforts should
be led by physicians reflecting the diversity of the
subgroups (e.g., Black physicians affiliated with
historically Black medical institutions to target
communities of color; physicians from well-respected
medical institutions in Republican-leaning states to target
conservative states) (49)
Vaccine hesitancy (broad) Plan: Create persuasive public health
communication plans tailored to an
individual’s level of vaccine hesitancy
Segmented portions of the population and target health
communication efforts to their identified barriers (50)
Utilized vaccine messaging that address the personal
benefits of vaccination (e.g., prevention of chronic illness)
to target the hesitant population (51)
Vaccine hesitancy (broad) Plan: Use effective mass
communication strategies
Recommendations to emphasize transparency regarding
vaccine-related health communications (e.g., safety,
efficacy, vaccine development, distribution, and cost) (52)
Vaccine hesitancy (mistrust in science
or the vaccine)
Educate: Provide training to promote
cultural competence
Recommendations to train and equip healthcare
providers, particularly when working with historically
marginalized groups (53)
Availability Limited number of suppliers Finance; Alter incentive structure by
developing advance purchase
commitments
Need an integrated policy approach that preserves
incentives for market entry and innovation in the vaccine
industry while addressing vaccine concerns and
increasing immunization funding and reimbursement for
both providers and patients (54)
High research and development and
production costs
Finance: Access new funding through
government subsidies for basic
vaccine research
Increased funding through the US Biomedical Research
and Development Authority, resulting in over $19.3 billion
to facilitate COVID-19 vaccine development (55)
(Continued)
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TABLE 2 | Continued
Implementation
outcome
Implementation challenge Implementation strategy Example
Safety problems leading to increased
regulatory requirements.
Policy context: Change liability laws to
provide protection for manufacturers
Established a COVID-19 vaccine injury no-fault
compensation scheme in South Africa to facilitate
COVID-19 vaccine rollout (56)
Storage availability Policy context: Identify barriers and
facilitators and test new workflows
Increased the frequency of transport capacity to reduce
storage bottlenecks and increase vaccine availability (57)
Cost Limited economic resources Finance: Engage and mobilize
stakeholders and payers
Recommendations to ensure adequate operational
funds are mobilized in readiness for the vaccination
exercise based on the country micro-plans (58)
Limited economic resources Finance: Include COVID-19 vaccine
strategy government budgets
Recommendations to estimate funding needs and align
cost plans with existing resources while minimizing
fragmentation for existing programs (58)
Limited economic resources Finance: Provide financial incentives
(in settings with low immunization
coverage)
Utilized trusted vaccine “ambassadors,” SMS reminders,
and low-cost incentives (i.e., mobile phone credit) to
increase vaccine uptake (59)
Limited economic resources Finance: Identify potential new
sources of revenue
Recommendations to facilitate dialogue and alignment
with the budget and planning departments of the
Ministry of Health, Ministry of Finance, and the funding
partners (58)
Feasibility Low vaccine demand Restructure: Bundle vaccine efforts
with existing community programs
Recommendations regarding how vaccination programs
could be offered alongside existing services and valued
community initiatives, such as nutritional support and
food supplementation programs (60)
Recommendations to consider other factors when
bundling programs: similarities in target groups, logistical
requirements, skill levels required for healthcare staff (61)
Geographic inaccessibility Restructure: Decrease geographic
barriers to vaccine uptake
Included community organizations, such as schools, as
centers for vaccine campaign administration (43)
Employed strategies such as door-to-door visits to
spread awareness of vaccine program goals and local
vaccination sites (60)
Fidelity Compliance with public health
recommendations
Policy context: Develop enforcement
policies regarding vaccination
Recommendations to consider factors such as control
aversion, trust in the government, and the degree of
enforcement when designing enforcement vs. voluntary
policies (62)
Recommendations for policymakers to develop
programs that optimize identification and treatment of
those with disease while minimizing the use of invasive
measures, such as involntary detention of noncompliant
patients or forced administration of vaccinations (63)
Fidelity Inability to track disease spread and
report cases
Quality management: Strengthen
surveillance systems and establish
robust system for capturing and
tracking cases
Examples: Provide supervision; use
desk and field reviews to assess
quality of AFP surveillance
Recommendations to improve surveillance system’s
functioning, sensitivity, and quality despite challenges
such as a large national geographic expanse, zones with
chronic insecurity and inaccessibility, and a lack of
capacity and infrastructure (64)
Health equity Structural racism Educate: Provide equity training for
implementers
Recommendations to provide training, education, or
opportunities for reflection in health equity, addressing
structural racism, and/or promoting antiracism
approaches with respect to our research, institutions,
and community partnerships (e.g., Public Health Critical
Race Praxis) (65)
Unequal power dynamics with
stakeholders
Plan: Include early and ongoing
engagement with stakeholders in
both decision-making and
prioritization
Recommendations to promote transparency,
consideration of power dynamics, equitable sharing of
resources, respect of community values, and inclusion of
racially/ethnically diverse partners as equitable
decision-makers early and often (65)
(Continued)
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TABLE 2 | Continued
Implementation
outcome
Implementation challenge Implementation strategy Example
Vaccine hesitancy (broad) Plan: Engage community partners to
promote vaccine-related
information-sharing and build trust
with marginalized communities
Increased vaccine acceptance by waiting for safety data
to be more robust, knowing more about the vaccine, and
receiving a recommendation to take the vaccine from a
trusted healthcare provider (41)
Engaged youth group members and significantly
enhanced the ability of vaccination teams to vaccinate
chronically missed children (66)
Engaged pastors as trusted messengers; created
partnerships with shared responsibility and power; and
co-created solutions with faith leaders and their
community, governments and institutions (67)
Utilized local community members to spread information
about vaccination events, which was more effective than
mass media advertisements (68)
Low vaccine demand Vaccine
hesitancy (mistrust in science or
the vaccine)
Plan: Create micro-plans with
hard-to-reach communities at center
of plans
Elicited immunization preferences for six program
characteristics (e.g., location, use of incentives, bundling
with existing services) to create a targeted approach for
implementation (60)
Utilized local and religious leaders to enhance
community knowledge of vaccination campaigns (43)
Low vaccine demand Plan: Utilize social networks to
increase reach and uptake
Used social network methods to identify and recruit to
provide access to high-risk youth who may be critical
recipients of a future vaccine (38)
Penetration Low vaccine demand Restructure: Enable community
health workers to promote vaccine
uptake
Utilized existing community structures such as churches
to spread preventive care messages and facilitate
vaccine promotion (69)
Low vaccine demand Quality management: Use
patient-held web-based portals and
computerized reminders increase
immunization coverage rates
Used text messaging, immunization campaign websites,
patient-held web-based portals, and computerized
reminders and standing orders for physicians to increase
immunization coverage rates (70)
Limited advocacy for an
implementation
Plan/Quality management: Identify
and engage policy entrepreneurs and
champions in various levels of
government, user organizations, and
the broader community
Recruited individuals who were highly motivated to move
forward with innovations and advocate for their
promotion and adaptation at organizational or
bureaucratic levels (20)
Scale-up Lack of dynamic partnerships Quality management: Assess the
strengths and weaknesses of the user
organization (e.g., public sector
health service system, NGO, etc.) and
develop strategies to build capacity
Recommendations to identify how user organizations’
resources, staffing, organizational culture, and leadership
structures will affect program scale-up (20)
Limited organizational capacity to
implement
Plan/Educate: Ensure the team has
necessary skills and capacities to
implement a vaccine program
Recommendations to conduct program evaluation,
management, training, economic evaluation, fundraising,
health communication, and writing while emphasizing
the importance of cultural knowledge (20)
Limited consideration of external
influences when developing
implementation program goals
Quality management/Restructure:
Identify the environmental factors
influencing scaling up and understand
how they affect the process
Recommendations to consider how policy/politics,
bureaucracy, and socio-economic/cultural contexts will
directly impact vaccination program scale-up prior to
implementation (20)
Sustainability Vaccine hesitancy (broad) Plan/Educate: Prepare materials for
healthcare workers to better integrate
into routine practice
Recommendations to (1) prepare a list of common
vaccine questions; (2) develop a list of effective
responses; and (3) train and practice with staff to
response to patients’ concerns (50)
Limited organizational capacity to
implement
Restructure: Bundle vaccine efforts
with existing community programs
Recommendations to consider multi-level factors when
bundling programs: similarities in the availability of
funding, logistical requirements, political support, and
level of burden (i.e., to ensure that bundling does not
disrupt service delivery) (61)
Low vaccine demand Vaccine
hesitancy (mistrust in science or
the vaccine)
Plan: Build buy-in with stakeholders Engaged trusted community figures, such as community
influencers, local religious leaders, healthcare providers,
and parents (41,49,52,71)
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Pilar et al. COVID-19 Implementation Outcomes and Strategies
these barriers, which included creating a national health
campaign and administering vaccines through community
organizations, such as schools (43). Momplaisir et al., explored
attitudes and beliefs related to COVID-19 vaccinations
within Black communities in the United States (41). Though
participants reported low demand and high levels of vaccine
hesitancy, they also identified that recommendations from
a healthcare provider might increase their trust in the
vaccine’s safety and efficacy (41). These findings illustrate
the importance of engaging community partners and promoting
trust, particularly in historically underserved communities,
to increase the acceptability and equitable distribution of the
COVID-19 vaccine.
DISCUSSION
The COVID-19 pandemic is an evolving situation, and
implementation science needs to respond accordingly. Many of
our theories and study designs have an implicit long period of
time that’s required to assess implementation (72). However, this
situation requires rapid assessments and evaluations, as well as
the measurement of implementation outcomes that may have
been previously overlooked (73).
Our team’s activity provided evidence that the original Proctor
implementation outcomes are still essential for examining the
success of COVID-19 vaccination programs globally; yet three
outcomes—those of availability, health equity and scale-up—are
welcome additions to the implementation outcomes framework.
Addressing implementation challenges related to availability, for
example, allows governments and policymakers to focus on the
earlier, or pre-implementation, factors that support widespread
vaccine scale-up, such as increasing vaccine suppliers and
providing incentives and additional funding structures to address
high research and development costs. In certain contexts, policies
may also need to change regarding manufacturing liability, which
is essential for increasing the availability and eventual scale-up of
vaccines. Vaccine availability is also impacted by storage issues
and can be mitigated by additional infrastructure support, such
as increasing transportation, which is needed for future scale-up.
Health equity, a critical part of implementation science,
and fair access to COVID-19 vaccines has been a continual
challenge globally. Health equity is also closely related to
the implementation outcomes of availability and scale-up. For
example, when there is limited vaccine supply or organizational
capacity for vaccine program implementation, power struggles
that exist among stakeholders with varying social, economic,
demographic, and geographical differences may lead to an
inequitable distribution of vaccines (e.g., vaccines only being
available to groups whose power aligns with the organizations
distributing vaccines). Additionally, greater distrust in science
and vaccines within historically underserved populations may
further impede vaccine acceptance and uptake. This underscores
the importance of considering the myriad external influences that
lead to misinformation campaigns and distrust when assessing
the potential for vaccine program scale-up.
Through engagement of a collaborative working group on
global vaccine implementation, our team was able to apply a well-
known implementation science framework to current and past
literature, policies, and country-level knowledge about vaccines.
As a result, we identified three additional implementation
outcomes and compiled a list of specific implementation
strategies that can be applied at multiple levels to increase
vaccine uptake.
DATA AVAILABILITY STATEMENT
The original contributions presented in the study are included
in the article/supplementary material, further inquiries can be
directed to the corresponding author/s.
AUTHOR CONTRIBUTIONS
EP, EG, MM, and OA contributed to conception of the study.
MP, AE, and EP wrote the first draft of the manuscript. GH and
LL wrote portions of the manuscript. All authors contributed to
manuscript revision, read, and approved the submitted version.
FUNDING
This work was supported in part by the National Institute of
Allergy and Infectious Diseases (No. K24AI134413). EP effort
was supported by the Implementation Science-Entrepreneurship
Unit of the Washington University Institute of Clinical
and Translational Sciences (No. UL1TR002345) from the
National Center for Advancing Translational Sciences of the
National Institutes of Health; the National Institute of Mental
Health (No. R25MH080916); National Cancer Institute (No.
P50CA244431); National Institute of Mental Health (No.
5P50MH113662); Patient-Centered Outcomes Research Institute
Award (No. TRD-1511-33321).
ACKNOWLEDGMENTS
We would like to acknowledge the support of the Washington
University Center for Dissemination and Implementation.
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