key: cord-0913385-ivygj74r authors: Zimmerman, Sheryl; Gaugler, Joseph E.; Nkimbeng, Manka title: COVID-19 Vaccination and Implementation Science: How One Can Benefit the Other date: 2021-10-26 journal: J Am Med Dir Assoc DOI: 10.1016/j.jamda.2021.09.018 sha: 8995b63cbd10da1ffe0ad5891390b9471c6a8b62 doc_id: 913385 cord_uid: ivygj74r nan education and income than adopters, suggesting a mismatch in communication and influence between the two 13 ; The outer context, a relevant example being less acceptance of vaccination among those holding certain political beliefs or of certain cultural backgrounds 12 ; System antecedents for the innovation; toward this end, decentralized decision making is known to promote adoption, but nursing homes tend to be centralized organizations 14 ; Linkages, such that if developers are linked to users early on, adoption is more likelydwhich 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 15 ; 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 16 ; 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. 17 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. 18 This variability is consequential, because cultural beliefs and norms influence perceptions of disease and also shape behavior 19, 20 dtake, for example, filial piety (familial allegiance) that is in part attributed to especially high vaccination rates of Native Americans. 21 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. 22 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. 23, 24 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. 25 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, 26 deprescribing, 27 antibiotic stewardship, 28 palliative care, 29 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. 30 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 overcomedincluding 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. More than 5.85 billion shots given: Covid-19 tracker COVID-19 vaccinations in the United States COVID-19 nursing home data Engaging nursing assistants to enhance receptivity to the Coronavirus disease 2019 vaccine Somebody like me": Understanding COVID-19 vaccine hesitancy among staff in skilled nursing facilities COVID-19 vaccine uptake among residents and staff members of assisted living and residential care communities-pharmacy partnership for long-term care program Racial disparities in COVID-19 vaccine acceptance: Building trust to protect nursing home staff and residents Implementation of a Coronavirus disease 2019 vaccination condition of employment in a community nursing home Mandating COVID-19 vaccine for nursing home staff: An ethical obligation An introduction to implementation science for the non-specialist Diffusion of innovations in service organizations: Systematic review and recommendations COVID-19 vaccine acceptance among health care workers in the United States COVID-19 vaccination hesitancy in the United States: A rapid national assessment Radical redesign of nursing homes: Applying the Green House Menu of state long-term care facility influenza vaccination laws Require COVID-19 vaccination of all long-term care workers: Experts reach consensus. McKnight's Senior Living Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science Direct care workers in the United States: Key facts Pandemic perspectives: Responding to COVID-19 Issues of race, ethnicity, and culture in caregiving research. A 20-year review American Indians have the highest COVID vaccination rate in the US A two-way street: Bridging implementation science and cultural adaptations of mental health treatments Culturally-tailored interventions for chronic disease selfmanagement among Chinese Americans: A systematic review A portfolio analysis of culturally tailored trials to address health and healthcare disparities Agency for Healthcare Research and Quality. Spotlight on vaccine confidence A model quality improvement program for the management of falls in nursing homes Deprescribing as a clinical improvement focus Nurse decision-making for suspected urinary tract infections in nursing homes: Potential targets to reduce antibiotic overuse Palliative care implementation in long-term care facilities: European Association for palliative care white paper Dissemination and Implementation Research in Health: Translating Science to Practice Table 1 Expert Recommendations for Implementing Change (ERIC) 30