Table 2.

Key implementation questions, outcomes, methods, and strategies for evidence-based COVID-19 interventions, at different stages of the pandemic.

	Evidence-based intervention for COVID-19 control	Implementation question	Implementation outcome in question	Methods for addressing question	Implementation strategies with promise to address question
Reflecting backward: opportunities for future emergency preparedness process/systems improvement	PPE	How can systems for stockpiling and subsequently distributing PPE be more automated and less reactive?	Sustainability	Process mapping (3, 4), stakeholder engagement (5), microplanning (6–8)	• Purposefully re-examine implementation (e.g., understand current processes and adjust as necessary) • Model and simulate change (e.g., identify scenarios with greatest efficiency) • Promote adaptability (e.g., tweak planning and supply chains to accommodate new processes)
	PPE	How can we ensure that every health worker has access to, and appropriately dons, PPE?	Adoption, acceptability, fidelity	Stakeholder engagement, social marketing and education (9, 10)	• Develop and distribute educational materials (e.g., social media videos of hand washing techniques, open source patterns for crafting masks on public health websites) • Role revision (e.g., role designated to distribute PPE and ensure appropriate donning)
	Intensive care management	How can we rapidly and efficiently deploy a massive volunteer health force (e.g., doctors and nurses in NYC, or a public health corps)?	Feasibility, penetration	Process mapping, stakeholder engagement, optimization modeling (11, 12), policy analysis (13)	• Role revision and liability laws (e.g., legislation to allow non-ICU health care workers to serve in certain capacities in times of pandemic)
	Intensive care management	How can we ensure that BIPOC communities are receiving equitable screening, testing, and intensive care management? How do we proactively monitor whether tailored responses are equitable for marginalized communities and change our approaches when data reveals inequitable responses?	Adoption, fidelity	Surveillance and data systems (14), policy analysis, quality improvement (15), stakeholder engagement	• Educational meetings and outreach visits (e.g., educating health workers on root causes of inequity, identifying, and rectifying implicit biases) • Involve patients and family members, obtain and use patient and family feedback (e.g., prioritize solutions in partnership with affected communities) • Change service sites (e.g., neighborhoods in which testing and services are available) • Alter patient fee structure (e.g., revise insurance system) • Rapid iterative tests of change, purposely re-examine the implementation, audit and feedback (e.g., disaggregate data sources by race to enable assessments of inequity and track whether interventions are having impact)
	Intensive care management	How can we meet the infrastructure needs required to accommodate patient surges?	Cost, feasibility, penetration	Economic evaluation, optimization modeling	• Change physical structure or equipment (e.g., shift elective areas of hospital into COVID-19 specific wards, convert stadiums and tents into hospitals)
Acting now: enhancing adoption, fidelity, and sustainment of behavioral public health interventions	Social distancing	What kinds of approaches are most effective for increasing fidelity to social distancing? How do we measure and use context to improve transferability of early learnings?	Fidelity	Social marketing, rapid ethnography to understand implementation contexts (16, 17)	• Identify early adopters, inform local leaders, Mandate change (e.g., regional policies) • Alter incentives (e.g., use technology to monitor mobility and integrate individual incentives for high fidelity)
	Social distancing	Are there small tweaks to social distancing policies that improve their effectiveness by making it easier to comply with and sustain?	Acceptability, fidelity, sustainability	Policy analysis, rapid cycle quality improvement	• Promote adaptability and tailor strategies (e.g., retain core element of 6 feet apart distance, but tailor guidance to allow walking 6 feet apart in pairs)
	Social distancing	How does community fidelity to social distancing impact epidemic duration?	Acceptability, fidelity	Qualitative data collection and rapid analysis (18), Network-based models (19), surveillance and data systems	• Use data experts (e.g., utilize passive data, like GPS mobility data aggregated by Google, to inform fidelity near real-time with regional specificity)
	Community behavior change	How does public trust of government officials impact community level compliance with new COVID-19 policies?	Adoption, appropriateness, Fidelity	System dynamics modeling (20), policy analysis	• Educational meetings and outreach visits (e.g., “Town Hall” style meetings with public officials and public health institutions)
	Community behavior change	How can marginalized communities—especially incarcerated or detained persons, persons experiencing homelessness—be enabled to participate in social distancing and other community behavior change activities?	Adoption, appropriateness, fidelity	Policy analysis, stakeholder engagement	• Change physical structure or equipment (e.g., provide free and stable housing, release incarcerated persons from prisons and jails and detention centers) • Mandate change (e.g., regional level executive orders to enable administrative release, legislative change to allow for release during times of pandemic) • Involve patients and family members, obtain and use patient and family feedback (e.g., prioritize solutions in partnership with affected communities through establishment of advisory boards) • Alter incentive structures (e.g., when release is not possible, remove punitive actions associated with quarantine by allowing access to phone, email, etc.) • Role revision (e.g., when release is not possible, retain smaller skeleton staffing that lives on prison campus to minimize external exposure)
	Hand washing and Mask wearing in public spaces	How can we increase coverage of non-medical mask usage in public spaces? Which communication strategies regarding proper hand washing and mask use result in high accuracy and behavioral maintenance on the individual level?	Acceptability, adoption, fidelity, sustainability	Social marketing	• Use mass media, Start a dissemination organization, Develop and distribute educational materials (e.g., social media videos of hand washing techniques, open source patterns for crafting masks on public health websites)
	Cross-cutting	How do we prioritize which policies to deploy (e.g., improve social distancing, mask usage, contact tracing and quarantine, virologic testing coverage, etc.)? How do these decisions change for a resource-limited setting?	Cost, adoption, penetration, sustainability	Simulation models (21), cost-effectiveness analysis, budget impact analysis (22)	• Conduct local needs assessment (e.g., differentiate policies that are engendering targeted behavior changes, by region)
Moving forward: integrating new evidence into decision-making and programming	Testing	How can laboratory testing networks be optimally designed to receive samples within a geographic network and quickly share results back to providers and individuals? How can we ensure that turnaround time is not only fast, but equitable in reaching the multiple, diverse communities who are marginalized?	Appropriateness (practicability), feasibility	Simulation modeling (e.g., queuing, discrete event simulation), surveillance and data systems	• Model and simulate change, change service sites (e.g., consider hub-and-spoke model, disaggregate data sources and model outputs to enable assessments of inequity and prioritize equity in modeled scenarios) • Develop a formal implementation blueprint, Develop and organize quality monitoring systems (e.g., continue to assess test turnaround time and receipt) • Facilitate relay of clinical data to providers (e.g., automated portal for test results sharing, consider sharing directly with patients using portal or text messages) • Use data experts (e.g., outsource creation and management of portal system and automation)
	Testing	What is the most efficient approach to conducting drive-through sample collection for testing? What structural tweaks can be made to this infrastructure to equitably serve populations with diversity in neighborhood, income, wealth, and access to cars?	Appropriateness (practicability), feasibility	Operations research (23), flow mapping, quality improvement, discrete event simulation modeling, optimization modeling	• Rapid iterative tests of change, stage implementation scale up, purposely re-examine the implementation, audit and feedback, develop and organize quality monitoring systems (e.g., continue to assess time spent waiting for sample collection, turnaround time, flow of cars through system and bottlenecks, assess metrics disaggregated by neighborhood and socio-economic status and optimize to ensure equity for each group) • Local knowledge sharing networks, promote network weaving, visit other sites, use train-the-trainer strategies, provide ongoing consultation (e.g., connect new sites with existing expert sites for troubleshooting)
	Testing	How can we overcome structural barriers to testing at the individual and provider levels? How are structural barriers magnified for marginalized communities, including BIPOC, undocumented persons, incarcerated persons, and persons experiencing homelessness? How can structural barriers be mitigated for diverse communities?	Adoption	Policy analysis, costing and cost-effectiveness, Social marketing	• Alter patient fee structure (e.g., insurance, copays, etc.) • Place innovation on fee for service list (e.g., legislation to reimburse telehealth visits at the same rate) • Change service sites (e.g., drive through testing, home-based testing) • Involve patients and family members, obtain and use patient and family feedback (e.g., prioritize solutions in partnership with affected communities)
	Testing	How can clinicians know who to test and how often in a setting of rapidly evolving guidance on test eligibility?	Adoption, fidelity	Policy analysis and leadership engagement, quality improvement	• Remind clinicians and use data warehousing techniques (e.g., integrate symptom check and relevant questions in integrated EMR with automatic flag for test eligibility and prompt to order, harmonize EMR platforms across hospital networks) • Provide local technical assistance, centralize technical assistance (e.g., phone call in line at state public health level for clinicians or county-level public health to clarify protocols)
	Case contact tracing	How can we staff the aggressively high coverage of contact tracing required to relax social distancing policies within a geographic area?	Cost, feasibility, penetration	Cost-effectiveness analysis, policy analysis, Stakeholder mapping and engagement	• Shadow other experts, revise professional roles (e.g., allow expanded lay workforce with training to do contact tracing)
	Case contact tracing	How can a public health response acknowledge the historic injustices that leave diverse marginalized communities differently and disproportionately affected, and adapt their intensive contact tracing approach to be compatible with varied trust in public systems and concerns about privacy?	Acceptability	Social marketing, qualitative data, dissemination science (24, 25)	• Intervene with patients to enhance uptake and adherence, involve patients and family members, Obtain and use patient and family feedback, prepare patients to be active participants, local consensus discussions (e.g., develop communication strategies in partnership with patient populations) • Use mass media, start a dissemination organization • Develop and distribute educational materials
	Future vaccine	In the case of initially limited vaccine availability, how do we prioritize and operationalize vaccination for the most vulnerable? How does that approach and system shift as supplies become more readily available?	Appropriateness (practicability), feasibility, penetration	System dynamics modeling, stakeholder engagement, process mapping	• Assess for readiness and identify barriers and facilitators, facilitate relay of clinical data to providers (e.g., to ensure that standardized approaches are used to identify and prioritize patients)
	Future medication for prophylaxis or treatment	When efficacious medications have been identified for broad prevention, post-exposure prophylaxis, and case treatment, how do we update guidelines for use and broadly distribute?	Adoption, penetration	Social marketing, qualitative data, dissemination science	• Provide clinical supervision, provide ongoing consultation • Increase demand • Intervene with patients/consumers to enhance uptake and adherence • Place innovation on fee for service lists/formularies
	Reducing usage of medications/interventions that are not evidence-based	How can we inhibit or reverse adoption of value-neutral or negative interventions?	De-implementation, adoption	Social marketing, qualitative data, dissemination science	• Remind clinicians and use data warehousing techniques (e.g., integrate diagnosis and treatment check in EMR with automatic flag for test eligibility and prompt to order) • Alter incentives • Local consensus discussions, engage patients