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)
	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)
	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)