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Editorial| Volume 22, ISSUE 11, P2223-2224, November 2021

COVID-19 Vaccination and Implementation Science: How One Can Benefit the Other

DOI:https://doi.org/10.1016/j.jamda.2021.09.018
COVID-19 Vaccination and Implementation Science: How One Can Benefit the Other
Next ArticleLessons in Collaboration from the Management of Pandemic in 2 Large Skilled Nursing Facility Chains
      As of September 16, 2021, more than 5.85 billion doses of the COVID-19 vaccine had been administered across the globe, 383 million of those in the United States.
      Bloomberg
      More than 5.85 billion shots given: Covid-19 tracker.
      https://www.bloomberg.com/graphics/covid-vaccine-tracker-global-distribution/
      Date accessed: September 16, 2021
      Two-thirds of the US adult population have been fully vaccinated, as have almost 83% of persons aged ≥65 years.
      COVID Data Tracker
      COVID-19 vaccinations in the United States.
      https://covid.cdc.gov/covid-data-tracker/#vaccinations_vacc-total-admin-rate-total
      Date accessed: September 16, 2021
      These same numbers are reflected among nursing home staff and residents, 64% and 84% of who have been vaccinated, respectively.
      Data.CMS.gov
      COVID-19 nursing home data.
      https://data.cms.gov/covid-19/covid-19-nursing-home-data
      Date accessed: September 16, 2021
      Vaccination rates have increased in the wake of the Delta variant, but they remain suboptimal.
      JAMDA has published numerous papers on COVID-19 vaccination in recent months, including reasons for vaccine hesitancy,
      • Sadarangani T.R.
      • David D.
      • Travers J.
      Engaging nursing assistants to enhance receptivity to the Coronavirus disease 2019 vaccine.
      J Am Med Dir Assoc. 2021; 22: 1125-1127
      ,
      • Harrison J.
      • Berry S.
      • Mor V.
      • Gifford D.
      Somebody like me": Understanding COVID-19 vaccine hesitancy among staff in skilled nursing facilities.
      J Am Med Dir Assoc. 2021; 22: 1133-1137
      the importance of ease of access,
      • Gharpure R.
      • Yi S.H.
      • Li R.
      • et al.
      COVID-19 vaccine uptake among residents and staff members of assisted living and residential care communities-pharmacy partnership for long-term care program, December 2020-April 2021.
      J Am Med Dir Assoc. 2021; 22: 2016-2020.e2
      the potential utility of diversity/equity/inclusion committees to reduce racial disparities and improve vaccine uptake,
      • Feifer R.A.
      • Bethea L.
      • White E.M.
      Racial disparities in COVID-19 vaccine acceptance: Building trust to protect nursing home staff and residents.
      J Am Med Dir Assoc. 2021; 22: 1853-1855
      increased vaccination rates when requiring it as a condition of employment,
      • Ritter A.Z.
      • Kelly J.
      • Kent R.M.
      • et al.
      Implementation of a Coronavirus disease 2019 vaccination condition of employment in a community nursing home.
      J Am Med Dir Assoc. 2021; 22: 1998-2002
      and the advocacy of AMDA–The Society for Post-Acute and Long-Term Care Medicine in that regard.
      • Dumyati G.
      • Jump R.L.P.
      • Gaur S.
      Mandating COVID-19 vaccine for nursing home staff: An ethical obligation.
      J Am Med Dir Assoc. 2021; 22: 1967-1968
      What is missing from the dialogue, however, is explicit recognition that COVID-19 vaccination—and in fact, all new recommended care practices—require an implementation science lens if they are to be fully adopted and sustained. Implementation science provides a framework to understand the uptake of research evidence into routine practice, with the ultimate goal of improving the quality and effectiveness of health services.
      • Bauer M.S.
      • Damschroder L.
      • Hagedorn H.
      • et al.
      An introduction to implementation science for the non-specialist.
      BMC Psychol. 2015; 3: 32
      Employing this lens underscores why COVID-19 vaccination has been challenging in long-term care and sheds light on the broader context of striving to change any care practice.
      Implementation science lays bare the complexity of “diffusion of innovations”
      • Greenhalgh T.
      • Robert G.
      • Macfarlane F.
      • et al.
      Diffusion of innovations in service organizations: Systematic review and recommendations.
      Milbank Q. 2004; 82: 581-629
      —in this case, the innovation being COVID-19 vaccination. The extent to which any new care practice is adopted relates to numerous considerations, all of which have been evident in the effort to vaccinate persons providing and receiving long-term care.
      • •
        The innovation itself, including its perceived benefits and risks; for COVID-19, the perceived risks have largely centered around safety, efficacy, and length of testing
        • Shekhar R.
        • Sheikh A.B.
        • Upadhyay S.
        • et al.
        COVID-19 vaccine acceptance among health care workers in the United States.
        Vaccines. 2021; 9: 119
        ;
      • •
        Communication and influence, such as the extent to which potential adopters are similar to current adopters; in the case of COVID-19 vaccination, potential adopters tend to have lower education and income than adopters, suggesting a mismatch in communication and influence between the two
        • Khubchandani J.
        • Sharma S.
        • Price J.H.
        • et al.
        COVID-19 vaccination hesitancy in the United States: A rapid national assessment.
        J Community Health. 2021; 46: 270-277
        ;
      • •
        The outer context, a relevant example being less acceptance of vaccination among those holding certain political beliefs or of certain cultural backgrounds
        • Shekhar R.
        • Sheikh A.B.
        • Upadhyay S.
        • et al.
        COVID-19 vaccine acceptance among health care workers in the United States.
        Vaccines. 2021; 9: 119
        ;
      • •
        System antecedents for the innovation; toward this end, decentralized decision making is known to promote adoption, but nursing homes tend to be centralized organizations
        • Rabig J.
        • Thomas W.
        • Kane R.A.
        • et al.
        Radical redesign of nursing homes: Applying the Green House concept in Tupelo, Mississippi.
        Gerontologist. 2006; 46: 533-539
        ;
      • •
        Linkages, such that if developers are linked to users early on, adoption is more likely—which of course was not the case in vaccine development;
      • •
        System readiness for the innovation, which is promoted by tension for change (certainly true of COVID-19) and also existing practices, policies, and resources; in many ways, efforts related to seasonal influenza vaccination in long-term care have promoted system readiness
        Centers for Disease Control and Prevention
        Menu of state long-term care facility influenza vaccination laws.
        https://www.cdc.gov/phlp/publications/topic/menus/ltcinfluenza/index.html
        Date accessed: September 20, 2021
        ;
      • •
        The adopter himself or herself, such as the desire of long-term care staff to protect their patients and residents;
      • •
        System assimilation, which includes structural changes relating to the innovation, with a recent example being mandates for vaccination
        • Lasek A.
        Require COVID-19 vaccination of all long-term care workers: Experts reach consensus.
        https://www.mcknightsseniorliving.com/home/news/require-covid-19-vaccination-of-all-long-term-care-workers-experts-reach-consensus/
        Date accessed: September 20, 2021
        ; and
      • •
        The implementation process, such as whether frontline workers are involved in decision making, which is not typical of a centralized organization.
      To simplify this complexity, some researchers have consolidated these areas into 5 domains (ie, the Consolidated Framework for Implementation Research): intervention characteristics, outer setting, inner setting, the process of implementation, and the characteristics of the individuals involved.
      • Damschroder L.J.
      • Aron D.C.
      • Keith R.E.
      • et al.
      Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science.
      Implement Sci. 2009; 4: 50
      Despite simplification, each component of implementation is itself complex. At the level of the individual adoptee, for example, the nursing home nursing assistant workforce ranges in age from younger than 20 years of age to older than 65, is almost equally white (42%) and black or African American (38%), and includes 13% who are Hispanic and 21% who are immigrants.
      PHI
      Direct care workers in the United States: Key facts.
      https://phinational.org/national-resource-center/resource/direct-care-workers-in-the-united-states-key-facts-2/
      Date: 2021
      Date accessed: September 20, 2021
      This variability is consequential, because cultural beliefs and norms influence perceptions of disease and also shape behavior
      • Ennis-McMillan M.C.
      • Hedges K.
      Pandemic perspectives: Responding to COVID-19. Open Anthropol 8.
      https://www.americananthro.org/StayInformed/OAArticleDetail.aspx?ItemNumber=25631
      Date accessed: September 20, 2021
      ,
      • Dilworth-Anderson P.
      • Williams I.C.
      • Gibson B.E.
      Issues of race, ethnicity, and culture in caregiving research. A 20-year review (1980–2000).
      Gerontologist. 2002; 42: 237-272
      —take, for example, filial piety (familial allegiance) that is in part attributed to especially high vaccination rates of Native Americans.
      Public Broadcasting Service (PBS)
      American Indians have the highest COVID vaccination rate in the US. PBS.org.
      https://www.pbs.org/wgbh/nova/article/native-americans-highest-covid-vaccination-rate-us/
      Date: 2021
      Date accessed: September 20, 2021
      Cultural adaptation and implementation science are in fact intertwined: implementation science offers the lens to identify what contextual factors influence adoption, and adaptation offers the tools to facilitate successful and equitable implementation.
      • Cabassa L.J.
      • Baumann A.A.
      A two-way street: Bridging implementation science and cultural adaptations of mental health treatments.
      Implement Sci. 2013; 8: 90
      Nonetheless, attempts to incorporate cultural adaptation into vaccine outreach and education are limited and could be bolstered by messaging that reflects differences in language and context to make it compatible with the cultural patterns, meanings, and values of a given population.
      • Huang Y.-C.
      • Garcia A.A.
      Culturally-tailored interventions for chronic disease self-management among Chinese Americans: A systematic review.
      Ethn Health. 2020; 25: 465-484
      ,
      • Torres-Ruiz M.
      • Robinson-Ector K.
      • Attinson D.
      • et al.
      A portfolio analysis of culturally tailored trials to address health and healthcare disparities.
      Int J Environ Res. 2018; 15
      Toward that end, the Agency for Healthcare Research and Quality (AHRQ) has materials available under their “Spotlight on Vaccine Confidence” website that among other implementation components address individual differences in vaccine trust and diverse strategies to increase vaccination rates among nursing assistants.
      Agency for Healthcare Research and Quality
      Spotlight on vaccine confidence.
      https://www.ahrq.gov/nursing-home/spotlight/index.html
      Date accessed: September 20, 2021
      Thus, understanding the challenges of COVID-19 in the context of implementation science both underscores the complexity of changing care practices and provides a framework for the adoption of any new care practice. Such a framework can benefit adoption of innovations related to falls reduction,
      • Taylor J.A.
      • Parmelee P.
      • Brown H.
      • et al.
      A model quality improvement program for the management of falls in nursing homes.
      J Am Med Dir Assoc. 2007; 8: S26-S36
      deprescribing,
      • Dharmarajan T.S.
      • Choi H.
      • Hossain N.
      • et al.
      Deprescribing as a clinical improvement focus.
      J Am Med Dir Assoc. 2020; 21: 355-360
      antibiotic stewardship,
      • Beeber A.S.
      • Kistler C.E.
      • Zimmerman S.
      • et al.
      Nurse decision-making for suspected urinary tract infections in nursing homes: Potential targets to reduce antibiotic overuse.
      J Am Med Dir Assoc. 2021; 22: 156-163
      palliative care,
      • Froggatt K.A.
      • Moore D.C.
      • Van den Block L.
      • et al.
      Palliative care implementation in long-term care facilities: European Association for palliative care white paper.
      J Am Med Dir Assoc. 2020; 21: 1051-1057
      and virtually any other practice, because in all instances, intervention characteristics, the outer setting, the inner setting, the process of implementation, and the characteristics of individuals are influential. It is for this reason that a major effort of implementation science is to consolidate the overwhelming number of strategies to better guide how innovations are implemented into various health care and clinical contexts. Implementation science has much to contribute in terms of understanding the often complex ecosystem in which many long-term care settings operate, and offers a number of strategies and evaluation insights that can help better inform and tailor effective adoption of innovation in nursing homes, assisted living communities, and similar environments. For example, consider the Expert Recommendations for Implementing Change (ERIC) shown in Table 1. The 9 ERIC categories include numerous specific strategies to guide implementation efforts (including quality improvement) to facilitate adoption of evidence-based innovations.
      • Kirchner J.E.
      • Waltz T.J.
      • Powell B.J.
      • et al.
      Implementation strategies.
      in: Brownson R.C. Colditz G.A. Proctor E.K. Dissemination and Implementation Research in Health: Translating Science to Practice. 2nd Ed. Oxford University Press, New York2017
      Table 1Expert Recommendations for Implementing Change (ERIC)
      • Kirchner J.E.
      • Waltz T.J.
      • Powell B.J.
      • et al.
      Implementation strategies.
      in: Brownson R.C. Colditz G.A. Proctor E.K. Dissemination and Implementation Research in Health: Translating Science to Practice. 2nd Ed. Oxford University Press, New York2017
      • 1.
        Use evaluative and iterative strategies
      • 2.
        Provide interactive assistance
      • 3.
        Adapt and tailor to context
      • 4.
        Develop stakeholder interrelationships
      • 5.
        Train and educate stakeholders
      • 6.
        Support clinicians
      • 7.
        Engage consumers
      • 8.
        Utilize financial strategies
      • 9.
        Change infrastructure
      In focusing on how implementation science elements could have been better harnessed to improve vaccination uptake in long-term care, it is important to recognize that the unprecedented nature of the COVID-19 pandemic and its catastrophic effects highlight structural and social challenges that no implementation approach could likely overcome—including the extreme political polarization contributing to individuals’ decisions to remain unvaccinated, as well as media that actively traffic misinformation. In fact, it is for these and related reasons that it is essential to appreciate the complexity of changing care practices; in sum, COVID-19 vaccination is a global case study of implementation science.

      References

        • Bloomberg
        More than 5.85 billion shots given: Covid-19 tracker.
        (Available at:)
        https://www.bloomberg.com/graphics/covid-vaccine-tracker-global-distribution/
        Date accessed: September 16, 2021
        View in Article
        • COVID Data Tracker
        COVID-19 vaccinations in the United States.
        (Available at:)
        https://covid.cdc.gov/covid-data-tracker/#vaccinations_vacc-total-admin-rate-total
        Date accessed: September 16, 2021
        View in Article
        • Data.CMS.gov
        COVID-19 nursing home data.
        (Available at:)
        https://data.cms.gov/covid-19/covid-19-nursing-home-data
        Date accessed: September 16, 2021
        View in Article
        • Sadarangani T.R.
        • David D.
        • Travers J.
        Engaging nursing assistants to enhance receptivity to the Coronavirus disease 2019 vaccine.
        J Am Med Dir Assoc. 2021; 22: 1125-1127
        View in Article
        • Harrison J.
        • Berry S.
        • Mor V.
        • Gifford D.
        Somebody like me": Understanding COVID-19 vaccine hesitancy among staff in skilled nursing facilities.
        J Am Med Dir Assoc. 2021; 22: 1133-1137
        View in Article
        • Gharpure R.
        • Yi S.H.
        • Li R.
        • et al.
        COVID-19 vaccine uptake among residents and staff members of assisted living and residential care communities-pharmacy partnership for long-term care program, December 2020-April 2021.
        J Am Med Dir Assoc. 2021; 22: 2016-2020.e2
        View in Article
        • Feifer R.A.
        • Bethea L.
        • White E.M.
        Racial disparities in COVID-19 vaccine acceptance: Building trust to protect nursing home staff and residents.
        J Am Med Dir Assoc. 2021; 22: 1853-1855
        View in Article
        • Ritter A.Z.
        • Kelly J.
        • Kent R.M.
        • et al.
        Implementation of a Coronavirus disease 2019 vaccination condition of employment in a community nursing home.
        J Am Med Dir Assoc. 2021; 22: 1998-2002
        View in Article
        • Dumyati G.
        • Jump R.L.P.
        • Gaur S.
        Mandating COVID-19 vaccine for nursing home staff: An ethical obligation.
        J Am Med Dir Assoc. 2021; 22: 1967-1968
        View in Article
        • Bauer M.S.
        • Damschroder L.
        • Hagedorn H.
        • et al.
        An introduction to implementation science for the non-specialist.
        BMC Psychol. 2015; 3: 32
        View in Article
        • Greenhalgh T.
        • Robert G.
        • Macfarlane F.
        • et al.
        Diffusion of innovations in service organizations: Systematic review and recommendations.
        Milbank Q. 2004; 82: 581-629
        View in Article
        • Shekhar R.
        • Sheikh A.B.
        • Upadhyay S.
        • et al.
        COVID-19 vaccine acceptance among health care workers in the United States.
        Vaccines. 2021; 9: 119
        View in Article
        • Khubchandani J.
        • Sharma S.
        • Price J.H.
        • et al.
        COVID-19 vaccination hesitancy in the United States: A rapid national assessment.
        J Community Health. 2021; 46: 270-277
        View in Article
        • Rabig J.
        • Thomas W.
        • Kane R.A.
        • et al.
        Radical redesign of nursing homes: Applying the Green House concept in Tupelo, Mississippi.
        Gerontologist. 2006; 46: 533-539
        View in Article
        • Centers for Disease Control and Prevention
        Menu of state long-term care facility influenza vaccination laws.
        (Available at:)
        https://www.cdc.gov/phlp/publications/topic/menus/ltcinfluenza/index.html
        Date accessed: September 20, 2021
        View in Article
        • Lasek A.
        Require COVID-19 vaccination of all long-term care workers: Experts reach consensus.
        (McKnight’s Senior Living. Available at:)
        https://www.mcknightsseniorliving.com/home/news/require-covid-19-vaccination-of-all-long-term-care-workers-experts-reach-consensus/
        Date accessed: September 20, 2021
        View in Article
        • Damschroder L.J.
        • Aron D.C.
        • Keith R.E.
        • et al.
        Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science.
        Implement Sci. 2009; 4: 50
        View in Article
        • PHI
        Direct care workers in the United States: Key facts.
        (Available at:)
        https://phinational.org/national-resource-center/resource/direct-care-workers-in-the-united-states-key-facts-2/
        Date: 2021
        Date accessed: September 20, 2021
        View in Article
        • Ennis-McMillan M.C.
        • Hedges K.
        Pandemic perspectives: Responding to COVID-19. Open Anthropol 8.
        (Available at:)
        https://www.americananthro.org/StayInformed/OAArticleDetail.aspx?ItemNumber=25631
        Date accessed: September 20, 2021
        View in Article
        • Dilworth-Anderson P.
        • Williams I.C.
        • Gibson B.E.
        Issues of race, ethnicity, and culture in caregiving research. A 20-year review (1980–2000).
        Gerontologist. 2002; 42: 237-272
        View in Article
        • Public Broadcasting Service (PBS)
        American Indians have the highest COVID vaccination rate in the US. PBS.org.
        (Available at:)
        https://www.pbs.org/wgbh/nova/article/native-americans-highest-covid-vaccination-rate-us/
        Date: 2021
        Date accessed: September 20, 2021
        View in Article
        • Cabassa L.J.
        • Baumann A.A.
        A two-way street: Bridging implementation science and cultural adaptations of mental health treatments.
        Implement Sci. 2013; 8: 90
        View in Article
        • Huang Y.-C.
        • Garcia A.A.
        Culturally-tailored interventions for chronic disease self-management among Chinese Americans: A systematic review.
        Ethn Health. 2020; 25: 465-484
        View in Article
        • Torres-Ruiz M.
        • Robinson-Ector K.
        • Attinson D.
        • et al.
        A portfolio analysis of culturally tailored trials to address health and healthcare disparities.
        Int J Environ Res. 2018; 15
        View in Article
        • Agency for Healthcare Research and Quality
        Spotlight on vaccine confidence.
        (Available at:)
        https://www.ahrq.gov/nursing-home/spotlight/index.html
        Date accessed: September 20, 2021
        View in Article
        • Taylor J.A.
        • Parmelee P.
        • Brown H.
        • et al.
        A model quality improvement program for the management of falls in nursing homes.
        J Am Med Dir Assoc. 2007; 8: S26-S36
        View in Article
        • Dharmarajan T.S.
        • Choi H.
        • Hossain N.
        • et al.
        Deprescribing as a clinical improvement focus.
        J Am Med Dir Assoc. 2020; 21: 355-360
        View in Article
        • Beeber A.S.
        • Kistler C.E.
        • Zimmerman S.
        • et al.
        Nurse decision-making for suspected urinary tract infections in nursing homes: Potential targets to reduce antibiotic overuse.
        J Am Med Dir Assoc. 2021; 22: 156-163
        View in Article
        • Froggatt K.A.
        • Moore D.C.
        • Van den Block L.
        • et al.
        Palliative care implementation in long-term care facilities: European Association for palliative care white paper.
        J Am Med Dir Assoc. 2020; 21: 1051-1057
        View in Article
        • Kirchner J.E.
        • Waltz T.J.
        • Powell B.J.
        • et al.
        Implementation strategies.
        in: Brownson R.C. Colditz G.A. Proctor E.K. Dissemination and Implementation Research in Health: Translating Science to Practice. 2nd Ed. Oxford University Press, New York2017
        View in Article

      Article info

      Identification

      DOI: https://doi.org/10.1016/j.jamda.2021.09.018

      Copyright

      © 2021 AMDA - The Society for Post-Acute and Long-Term Care Medicine.

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