Unpacking Technical Assistance (TA) Strategies Within a State-Level Prevention Support System: A Mixed-Method Study in Determining Types and Amount of TA

Abstract

The research-practice gap between evidence-based intervention efficacy and its uptake in real-world contexts remains a central challenge for prevention and implementation science. Providing technical assistance (TA) is considered a crucial support mechanism that can help narrow the gap. However, empirical measurement of TA strategies and their variation is often lacking. The current study unpacks the black box of TA, highlighting different TA strategies, amounts, and their relation to intervention characteristics. First, we qualitatively categorized interactions between TA providers and implementers. Second, we explored how characteristics of implementing organizations and the intervention related to variations in the amount of TA delivered. Using data spanning six years, we analyzed over 10,000 encounters between TA providers and implementers. Content analysis yielded four distinct strategies: Consultation (27.2%), Coordination Logistics (24.5%), Monitoring (16.5%), and Resource Delivery (28.2%). Organizations with prior experience required less monitoring and resource delivery. Additionally, characteristics of the intervention were significantly associated with the amount of consultation, monitoring, coordination logistics, and resource delivery provided. The specific features of the intervention showed significant variation in their relation to TA strategies. These findings provide initial insights into the implications of intervention characteristics in determining how much of which TA strategies are needed to support implementations in real-world settings.

Keywords

technical assistance evidence-based programs implementation support prevention support system prevention capacity evidence-based preventive interventions

Introduction

Over the past three decades, prevention science has built an impressive collection of evidence-based preventive interventions (EBIs) that have proven effective at reducing risk and promoting healthy outcomes; in this article, we use the term EBI to reflect universal prevention, selective, and treatment programs delivered across various community settings. Achieving population-level public health impact requires EBIs to be widely adopted, disseminated, and sustained (Hawkins et al., 2015). However, implementing EBIs across diverse organizational and community contexts introduces several challenges that produce a notable gap between findings from research settings and practice contexts. Outside of research settings, many EBIs encounter implementation variations where the delivery of the program in practice is not done as intended by the designer (Durlak, 2013). Implementation variation introduces challenges to fidelity, quality delivery, and other implementation outcomes (Durlak, 2013; Proctor et al., 2011). Furthermore, the prevention capacity of human service providers also affects the quality implementation of programs (Flaspohler et al., 2008). These challenges contribute to the research-practice gap, where many EBIs fail to replicate findings from efficacy trials, resulting in diminished public health impact (Glasgow et al., 2003; Powell et al., 2015). The research-practice gap between producing EBIs and their uptake in real-world contexts remains a central challenge for prevention and implementation science.

Implementation science aims to address the factors that enhance the uptake and quality delivery of EBIs (Bauer & Kirchner, 2020) and to develop strategies that promote prevention capacity among program providers (Flaspohler et al., 2008). Implementation support is one approach to addressing the challenges that widen the research-practice gap (Durlak & DuPre, 2008; Edmunds et al., 2013; Fixsen et al., 2005). The field’s current state recognizes the need for conceptual and measurement models that move us closer to an evidence base for the effective and efficient delivery of implementation support. Furthermore, a comprehensive, evidence-based framework on technical assistance (TA) mechanisms, techniques, and applications is in its infancy, and even less is known about what strategies are most essential. Thus, a question that remains is how much TA is sufficient and what conditions bolster a particular strategy’s focus. The current investigation contributes to the growing knowledge base on implementation support by empirically classifying TA providers’ activities and examining how EBI characteristics contribute to the type and amount of TA delivered.

The Delivery of Implementation Support through the Support System

The Interactive Systems Framework (ISF), developed by Wandersman and colleagues (2008), provides a conceptual logic model for how coordinated implementation support systems help to narrow the research-practice gap (Hunter et al., 2009a; Katz & Wandersman, 2016; Mitchell et al., 2004). The ISF consists of three interconnected systems: the synthesis and translation system, the support system, and the delivery system. The framework highlights the reciprocal influences among the three systems, where research carried out by the synthesis and translation system informs the support system, and the activities carried out by the support system inform further research on effective implementation strategies and technical assistance needs of the delivery system. The ISF model conceptualizes how quality dissemination and implementation capacity can be built and sustained through ongoing collaboration among key stakeholders across the three systems (Wandersman et al., 2008). We argue that careful examination of the support system may help to unveil how much TA is needed for providers tasked with implementing EBIs.

Operationalizing Technical Assistance via the Evidence-based System for Innovation Support

While the ISF establishes a structural framework contextualizing systems needed for diffusing EBIs, Wandersman and colleagues (2008) noted that the real work of bridging the research-practice gap is actualized within the “arrows” that connect the interactive systems. In later work, Wandersman and colleagues (2012) provided a more granular conceptual lens for how support is executed via the Evidence-based System for Innovation Support (EBSIS). The EBSIS logic model augments the ISF by zooming into the “black box” of how the support system provides various forms of implementation support to delivery systems, introducing a conceptual basis for theory, research, and application. The first step in the EBSIS model involves performing a needs assessment evaluating the delivery system’s current capacity level and support needs. Next, the model describes four sequential components that characterize implementation support—tools, training, TA, and quality assurance and quality improvement (QA/QI). Therefore, support systems help delivery systems achieve prevention capacity and implementation outcomes by applying all four components within the EBSIS model. The provision of tools, training, TA, and QA/QI is both iterative and additive, such that each component builds on, enhances, and reinforces the others in a reciprocal and feedback-loop fashion.

Wandersman and colleagues (2012) emphasized the need for further operationalization, measurement, and empirical investigation of support components as an essential next step in substantiating an evidence base for the practice and effectiveness of implementation support. The current study is a response to this call. We aim to further unpack implementation support by examining the application of TA, specifically within the context of a state-level support system. We believe that implementation support components can be further unpacked to illuminate specific strategies that characterize the components of support (Albers et al., 2021; Chinman et al., 2018; Metz et al., 2021).

The current study highlights the support system as a viable system that may be used to unpack the facets of implementation support, specifically regarding technical assistance strategies. The support system functions to build prevention capacity among program implementers and to foster collaboration and networking between and within the synthesis and translation, and delivery systems (Chinman et al., 2008; Hunter et al., 2009b; Mitchell et al., 2004; Rhoades et al., 2012). Our current investigation focuses on classifying different TA strategies delivered within a state-level support system.

Unpacking Implementation Support through Examination of Technical Assistance Strategies

Katz and Wandersman (2016) conceptualized TA as an “individualized hands-on approach to capacity building in organizations and communities” (p. 418). Notably, TA is one of the four components of implementation support (Wandersman et al., 2012), and TA is usually ongoing following initial training (Durlak & DuPre, 2008; Fixsen et al., 2009). Technical assistance providers use various strategies such as training, consultation, program monitoring, implementation tools, peer networking activities, and others to enhance prevention capacity (Fagan et al., 2012, 2019; Farrell et al., 2019; Feinberg et al., 2004; Hunter et al., 2009b). Therefore, various TA strategies may be required to achieve desired implementation outcomes. What is known is that by receiving structured, tailored, and ongoing implementation support, program implementers become equipped with knowledge, skills, tools, and competencies that enable them to adopt EBIs, deliver them with quality and fidelity, and sustain them (Fixsen et al., 2013; Katz & Wandersman, 2016; Wandersman, 2009; Wandersman et al., 2012). The pressing question remains: how much of which TA strategies are necessary, and under what conditions?

How Much TA is Needed: For Which Strategies and Under What Conditions?

Fixsen et al. (2005) highlighted the diverse influences of multiple contexts on implementation processes, ranging from external factors within different systems to organizational characters and core implementation components. It is essential to understand the various factors that affect implementation outcomes, be they external or internal to the implementation context. They may directly relate to how much TA is needed to aid program implementers with EBI delivery.

Evidence-based preventive interventions vary in design, quality, complexity, and resources available from the program developer (Damschroder et al., 2015; Damschroder et al., 2009). As a result, the amount of TA necessary may vary considerably, especially given these different contextual factors. The Consolidated Framework for Implementation Research (CFIR) provides a comprehensive framework for understanding and evaluating complex interventions in healthcare, social services, and other fields (Damschroder et al., 2009). The CFIR model is useful for illuminating how intervention characteristics contribute to variations in which TA strategies are delivered. For example, in a case study, Engell and colleagues (2021) used the CFIR to show that intervention content and design characteristics contributed to the implementability of the Enhanced Academic Support program. Engell et al. found that content designed with more flexible structure, integration, and tailoring processes had greater implementability, requiring less follow-up training and additional implementation support. Eisman and colleagues examined the implementability of state-adopted health curriculums in school-based settings and found that intervention design characteristics related to acceptability, program-context fit, and adaptability (Eisman et al., 2022) and teacher previous experiences with program components (Eisman et al., 2020) were related to program fidelity and implementation quality. The aforementioned studies, as with much of CFIR research (Kirk et al., 2016), show how factors related to intervention characteristics influence implementation outcomes; these factors also likely relate to the degree of TA that is delivered to support organizations implementing EBIs.

Additionally, public health specialists have pointed out that some EBIs may encounter implementation obstacles given the complexity of design, high costs, and a narrow focus that does not align with communities’ needs (Green & Mercer, 2001). Instances in which program implementers encounter these obstacles with their selected EBIs may necessitate the effective initiation and maintenance of considerable resources and infrastructure for the long haul (Aarons et al., 2009; Brownson et al., 2018). Thus, in such instances, a greater need for and reliance on various TA strategies may be warranted. Other factors, such as the differences in the length or intensity of the delivery of an EBI (Codding et al., 2022; Fallon et al., 2022) can also impact implementation capacity and, thus, TA needs. The aforementioned studies and other related work highlight how factors relating to EBI resources, other infrastructure supports, and their complexity can contribute to a provider’s capacity to deliver a program with fidelity, which may relate to how much TA is needed.

The Current Study

The current study examines the amount of TA delivered to support program implementation for a variety of EBIs. Our overarching goal is to delineate how much of different types of TA strategies are employed given different EBI conditions. We address our goal via two interrelated sub-studies where we empirically classify different TA strategies and determine how often they occur within a state-level support system. In Study 1, we classify TA providers’ strategies to support human service organizations delivering EBIs. We identify specific TA strategies supported by existing evidence (Le et al., 2016) and aligned with the standard methods employed by a training and technical assistance center (Rhoades et al., 2012) to aid human service organizations delivering EBIs; these include consultation, coaching, coordination logistics, monitoring, resource delivery, and networking coordination. In Study 2, we explore how intervention and provider characteristics are associated with the amount of TA delivered. We examine associations among characteristics of EBI quality and design. Design characteristics examined in this study include the intervention continuum of care (Elliott, 2016), focus of the intervention content (e.g., family-focused; Bailey et al., 1986), characteristics of delivery settings, including the system setting (e.g., school-based) and the respondent mode of delivery (e.g., group-based). Quality characteristics include the amount of external support the program developer provides and the evidence rating for the EBI. Based on personal communications with TA providers, we had some expectations on how EBI characteristics might be related to the quantity of TA delivered. For instance, we hypothesized that more complex programs with greater content focus (i.e., Treatment vs. Universal) would be associated with more significant amounts of TA. We also hypothesized that more TA would be found for EBIs that were family-focused programs than non-family-focused and school-based settings compared to other settings. We also hypothesized that more significant amounts of developer support, measured by developer-provided tools, training, and resources, would be associated with a smaller quantity of TA delivered.

Study 1: Classifying Implementation Support Activities

Method

In the first study, the unit of analysis is the nature of TA encounters between implementation support specialists and TA recipients.

Data Source

Fourteen implementation specialists reported on over 11,685 TA encounters provided to 168 different human service organizations delivering EBIs (310 program implementations; 16 different EBIs) across Pennsylvania communities. Information about TA provision to support EBI implementation was tracked using a reporting form, starting in 2011, when the tracking system was first implemented, and going through 2017, when the ACCESS tracking system became defunct. Implementation specialists completed the reporting form after each TA encounter.

Measures

TA Contact Form

Implementation support activities were assessed via a TA contact form created in Microsoft Access. Implementation specialists reported their direct contact with human service organizations, including date of reference, modality, organization name(s), EBI, the number who received support, TA strategy, and an open-ended general notes section. The TA category and the open-ended notes were used to code implementation support activities.

Analysis Plan

To address the first research question, each instance of TA contact was qualitatively coded into one of the six content codes conceptually defined by the research team. The remaining TA contact encounters not selected during coder training were divided among two research assistants. Once all TA contact encounters were coded, each content code was summed across all years, EBIs, and organizations. Descriptive statistics were computed for each TA strategy and across EBIs, and years.

Data Reduction Procedures

The number of encounters in the dataset was reduced using three exclusion criteria:

(1) Any instance that took place during or after 2018 (3 TA encounters were removed); (2) if the total count of encounters reported for a given EBI was less than 300 (these included EBIs that had not been supported across all years of data collection; 677 TA encounters and 6 EBIs were removed); and, (3) any instance where there was not enough descriptive information included to code the reported contact (74 TA encounters). Once delimited, the dataset yielded 10,931 TA encounters, with 145 human service organizations delivering 341 programs reflecting 10 different EBIs.

Coding Procedures

The Interactive Systems Framework (Wandersman et al., 2008), the Evidence-based Prevention and Intervention Support logic model (EPIS; Rhoades et al., 2012), and an extensive literature review on TA were used to develop a coding classification system for TA activities. The co-authors developed, reviewed, and revised content codes. The codes were crosswalked with existing TA categories in the EPIS logic model and performance metric reporting system, resulting in a standardized codebook. A coding manual was created with content code descriptions. Next, the first author randomly selected and coded a subset of the 11,685 reported contacts before the initial data reduction (1115 encounters, 9.5% of the sample). Table 1 shows the coding scheme for six content codes used to classify the hypothesized TA interactions. Two research assistants were trained to review and organize primary support activities using the content codes. Training included discussing code meanings and practicing coding. The research assistants coded the “gold standard” encounters coded by the first author. Coding consensus meetings were held after each iteration, resulting in revisions to the coding manual and code descriptions. The training involved two phases. In phase one, research assistants coded the “gold standard” encounters separately from the first author.

Table 1.

Coded Activities, EBSIS Component, Descriptions, Brief Coding Instructions and Qualitative Text Examples From TA Records

Strategy	EBSIS component	Description	Brief coding Instruction	Example
Consultation	TA	Provide expert advice, information, and/or opinions, regarding general and program-specific implementation capacity needs.	IS provides information to help troubleshoot, resolve, or navigate a practitioner’s concerns, challenges, and needs regarding implementation.	“Discussed…developer’s call and certification process for facilitators. Identified next steps and set date for follow-up call…”
Coordination Logistics	QA/QI	Support organizing/tracking program logistical needs across implementation stages—i.e., scheduling, planning, and coordinating multiple activities including fidelity verification, facilitator training, staff hiring, etc.	IS coordinates efforts or activities such as model-specific trainings, general prevention trainings, networking, or new grantee orientations.	“Aided [PDS Coordinator] in scheduling [program] facilitator training with [program developer consultant]”.
Coordination Logistics	TA
Monitoring	QA/QI	Observe/check the progress of implementation activities, reporting and grantee compliance activities, and maintain regular and systematic review and oversight ensuring grant recipients meet all program and funder deliverables.	IS reviews reports/documents prior to submission, asking providers to rerun reports, add information or correct errors.	“Contacted [Coordinator] grantee about missing spreadsheet in Egrants. [Coordinator] will submit within the week.”
Monitoring	TA
Resource Delivery	Tools	Distribute, create, and update materials/tools to enhance skills, knowledge, and practices for program implementation; resources could be general prevention or program-specific tools.	IS distributes knowledge building tools and resources to support program implementation, fidelity monitoring and valid impact assessment.	“Emailed new fidelity tool and instructions for use to all [program grant recipients].”
	QA/QI
	TA
Networking Cooordination	Relationships	Facilitates interagency collaboration, peer-to-peer networking, fosters networking and mediates introductions amongst systems, and across different stakeholder agencies.	IS facilitates or coordinates PDS learning communities and communication across interactive systems.	“Phone call and email support [provider] who is setting up a county stakeholder meeting to address barriers to sustainability.”
Networking Cooordination	QA/QI
Coaching	TA	Provide guidance or on the spot training to support practitioners in achieving skill-based and professional goals, enables learning and development within a mentoring context.	IS and practitioner actively engage in discussing problems and identifying solutions for barriers or concerns a site may be facing.	“Site requested TA to discuss financial roadblocks and identify problem-solving strategies”

Note. TA = Technical Assistance; QA/QI = Quality Assurance/Quality Improvement; IS = Implementation Specialist; PDS = Prevention Delivery System.

Coding was done iteratively, with each coder assigned a random 20% of the 731 gold standard cases per iteration (about 146 encounters per coder). After each iteration, coding consensus meetings were held to address discrepancies between the coder and the gold standard codes. In phase one, the coding manual and descriptions were revised for clarity and distinctiveness. Phase one was considered complete once each coder achieved 80% or greater agreement with the “gold standard" codes. Inter-rater agreement was assessed using Cohen’s kappa with weighted disagreements in large samples (Fleiss et al., 1969). Interrater reliability was moderate to strong for phase one (McHugh, 2012), averaging 88%, ranging from 76% to 85% across the three coding iterations. In the second phase, another random subset of TA encounters were coded by each coder (546 encounters, 5% of the sample). This process was repeated twice with a new random subset of encounters. Phase two coding consensus meetings were held after each iteration to review discrepancies and reach a consensus. Phase two completion was reached when the two coders achieved at least 80% agreement for the three subsets of TA contact encounters; phase two interrater reliability was strong to almost perfect (McHugh, 2012), demonstrating high percent agreement among the coders (κ = .92).

Results

The first study shows qualitative content analyses’ findings classifying TA providers' different strategies. Table 1 shows the six TA strategy codes, their descriptions, and example text used to classify TA provider activities—consultation, coaching, coordination logistics, monitoring, resource delivery, and networking coordination. All six hypothesized implementation support practices were classified via the content analysis, but there was considerable variation in the frequency of content codes assigned across the different strategies. Table 2 shows the coding frequencies and averages across years, EBIs, and human service organizations. The most frequently occurring TA encounters were Resource Delivery (28.2%), Consultation (27.2), Coordination Logistics (24.5), and Monitoring (16.5). Together, these accounted for more than 95% of the content coded. Networking Coordination and Coaching were infrequently coded, occurring less than 5% across all content.

Table 2.

Frequencies and Distribution of the Implementation Support Activity Codes

Codes	Overall		Avg. Per year		Avg. Per program		Avg. Per org
Codes	N	%	M	SD	M	SD	M	SD
Consultation	2969	27.2	438.1	163.29	285	171.48	25.2	27.83
Coordination Logistics	2682	24.5	381.1	162.31	248.9	207.02	21.5	25.50
Monitoring	1801	16.5	421.6	387.67	169.2	184.13	25.5	30.80
Resource delivery	3080	28.2	256.6	167.19	283.2	305.91	15.8	15.86
Netwoking Coordination	273	2.5	37.4	33.69	25.3	25.81	3.6	4.67
Coaching	126	1.2	18.9	11.36	12	12.23	2.4	2.10
Total	10931	100	1564.3	839.79	1030.9	850.37	85.4	94.89

Note. Avg. = Average; Org = Human service organization.

Discussion

Study 1 findings show that TA providers employed resource delivery, consultation, coordination logistics, and monitoring strategies in their encounters with EBI implementers. Each of these four strategies was ongoing during EBI implementation. Some strategies, mainly resource delivery and consultation, occurred more frequently than others. Our findings support those offered in the existing literature, indicating that the process of TA provision is ongoing and multifaceted and requires tailoring (Katz & Wandersman, 2016), and the amount needed may vary across strategies to efficiently deliver a sufficient degree of support to the program implementers (Feinberg et al., 2004, 2008). Coaching and networking coordination were the least common strategies. However, coaching is often considered the overall approach through which TA strategies take place (Nadeem et al., 2013; Strompolis et al., 2020). Thus, it is possible that a coaching approach was employed in delivering multiple different TA strategies; this may be the case, particularly in TA encounters where consultation was provided (Nadeem et al., 2013). Although networking coordination was not a substantial facet of TA provision in our findings, its delivery may have occurred nonetheless. Networking coordination involves facilitating and meditating interagency collaboration, connecting systems, and fostering peer-to-peer learning communities (Leeman et al., 2015, 2017). It is possible that instances of networking coordination were recorded via other TA reporting metrics by the implementation specialists that were not examined in the current study. Furthermore, Leeman and colleagues (2015) expanded on the original EBSIS framework by introducing additional capacity-building strategies, such as peer networking, that also occur within the context of TA and implementation support, warranting further investigation of this process as an implementation support strategy. Table 1 also identifies how each TA strategy maps onto the implementation support components described within the EBSIS model proposed by Wandersman and colleagues (2012). In some instances, a strategy is conceptually mapped onto more than one EBSIS component, given the activities being executed. While we believe this is an important area to explore further, it was beyond the scope of the current investigation.

Our findings support existing literature on TA strategies used to promote prevention capacity among service providers. Consultation described activities where TA providers gave the program provider expert advice, knowledge, or guidance (Edmunds et al., 2013; Nadeem et al., 2013; Schoenwald et al., 2004). Consultation is considered unidirectional because information flows from the TA provider to the program implementer. In contrast, coaching involves a collaborative approach between the TA provider and the implementer, where guidance is provided through motivation and shared learning (Dusenbury et al., 2010; Gunderson et al., 2018). Coordination logistics described how TA providers organized and tracked program logistical needs across the stages of implementation (Nowell, 2009). Monitoring described instances when TA providers gave systematic review and oversight of implementation activities (Chalmers et al., 2003; Saunders, 2022). Resource delivery described instances when TA providers created, distributed, and disseminated tools/materials relevant to program implementation and building prevention capacity (Dunst et al., 2019; Le et al., 2016; Yazejian et al., 2019).

Study 2 Associations Among Intervention Characteristics and Amount of Technical Assistance

Method

In the second study, the unit of analysis is the unique EBI implementation. The unique implementation reflects a specific cohort, or cohorts, of EBI delivery for a given human service organization within a particular grant period. More information about the data structure and measures developed for this study is described below.

Data Source

Data for Study 2 initially included a sample of 310 unique EBI implementations. The implementations reflected 10 different EBIs delivered by 168 human service organizations in Pennsylvania.

Measures

TA Strategy

Technical assistance strategy was the outcome measure and was operationalized along four dimensions—consultation, coordination logistics, monitoring, and resource delivery. Consultation denoted encounters through which providers gave advice, information, and expert opinions regarding applying services or program activities. Coordination Logistics described TA encounters through which providers supported organizing and tracking different elements of program activities, staff training, and sustainability planning and networking with community partners. Monitoring involved TA encounters during which TA providers offer oversight to program implementers, including observing and checking the progress or quality of implementation, data reporting, grantee compliance, and program activities. Finally, Resource Delivery describes TA encounters during which TA providers distribute materials and tools to help build skills, knowledge, and competencies and aid in best practices for implementation. The four TA strategies showed good inter-coder reliability (average κ = .88).

Prior EBI Funding

Prior EBI funding was operationalized as how often a human service organization received funding to deliver a particular EBI. It was a continuous variable reflecting the number of times the organization received funding, ranging from 1 to 11.

EBI Quality Characteristics

The EBI Quality Characteristics were assessed based on EBI developer support and evidence rating. EBI Developer Support was assessed using an 18-item Program Infrastructure Checklist developed by the first and second authors in consultation with EPIS implementation specialists. Initially, a list of 28 criteria was identified; the list was then refined to 18 indicators, combining constructs with overlapping meaning based on feedback from the implementation specialists. Focused questions were used to assess the presence or absence of each criterion. Responses were coded as Yes = 1 or No = 0. For each EBI, the checklist was completed by the first author and a program implementation specialist at EPIS. The checklist items were summed, resulting in a scale ranging from 0 to 18, with good internal consistency (α = 0.86). A full description of the checklist development, focused questions, and scoring rubric is available in the supplementary materials.

EBI Evidence Rating was assessed using a modified rating system based on Blueprints for Healthy Youth Development clearinghouse ratings (https://www.blueprintsprograms.org/). Evidence categories included Model Plus programs (very high confidence, experimentally proven, and ready for scale), Model programs (high confidence, experimentally intervention proven, and ready for scale), and Promising programs (moderate confidence, some experimental evidence). The rating was recorded if the EBI was listed on Blueprints and had an evidence rating. Additional clearinghouses were reviewed if the EBI was not listed or rated on Blueprints: CrimeSolutions (https://crimesolutions.ojp.gov), What Works Clearinghouse (https://ies.ed.gov/ncee/wwc/), and Results First (https://evidence2impact.psu.edu/what-we-do/research-translation-platform/results-first-resources/clearing-house-database/). The evidence ratings were crosswalked and aligned with the categories in the Blueprints model. Initially, four levels were assigned: Model Plus (0), Model (1), Promising (2), or Effective (3). These were then collapsed into two categories where 0 equaled Promising, and 1 equaled Exemplar. Programs rated Model Plus or Model by Blueprints and Effective by CrimeSolutions were coded as Exemplar. Programs rated Promising by both Blueprints and CrimeSolutions were coded as Promising. More details on the evidence ratings can be found in the supplementary materials.

EBI Design Characteristics

Evidence-based preventive intervention design characteristics were operationalized across four domains: prevention continuum, school-based delivery, family-focused delivery, and group-based delivery. The Prevention Continuum was identified using the Institute of Medicine’s model, which includes health promotion, prevention, treatment, and recovery. Programs were assigned to one of these categories based on program information and grantee data. The Program Continuum variable had four levels: Universal = 0, Selective = 1, Indicated = 2, and Treatment = 3. School-based delivery refers to programs targeting students or teachers in a school setting versus other settings. Family-focused programs delivered content focusing on the family unit versus others (i.e., teachers, parents, youth). Group-based delivery refers to programs offered to a group of respondents versus a single individual. A table of EBI classifications across quality and design characteristics is available via the online supplementary materials.

Analytic Strategy

Data reduction was executed following a set of criteria established by the investigative team. The sample was reduced to only those implementations that received current or prior funding from the state agency. This resulted in a reduced number of TA encounters (n = 9063), service organizations (n = 138), and EBIs (n = 241) included in the sample for Study 2. Next, hierarchical regression analysis was conducted using the SPSS statistical software version 26 (IBM Corp., 2019) for each TA strategy. Independent variables were added in sequential order using the forward inclusion method, with variables entered based on the magnitude of their zero-order correlations with the outcome (individually predicting the four TA strategies). Prior EBI funding was added first (Model 1), followed by EBI quality characteristics variables (Model 2), and finally, EBI design characteristics variables (Model 3).

Results

Table 3 contains descriptive statistical information for all variables included in the models. The average amount of TA delivered to a given EBI ranged from a low of 6.68 (Monitoring) to a high of 10.76 (Resource Delivery). On average, human service organizations had had at least two prior experiences implementing an EBI. Concerning EBI Quality, the average number of developer-provided support events was 13.67, and more EBIs were rated as Promising (57%) than any other category. In terms of EBI Design, the majority of EBIs were for Universal programs (41%), delivered in school-based settings (78%), not family-focused (74%), and group-based (61%).

Table 3.

Descriptive Statistics for Implementation Support Activities, Program Providers’ Previous EBI Funding, and Characteristics of EBI Quality and Design

Study variables	Descriptive statistics
Study variables	M	SD	n	%
No. of Unique EBI Implementations^a			241	77.7
No. of TA Encounters^b			9063	82.9
No. of service Organizations^c			114	67.9
Implementation support Practice
Consultation	10.29	9.22	2481	27.38
Coordination-logistics	9.87	7.71	2379	26.25
Monitoring	6.68	6.91	1611	17.78
Resource delivery	10.76	12.72	2592	28.60
Predictor variables
Service Organization EBI Experience
No. of grants received	2.09	1.17
EBI Quality Characteristics
EBI developer supports	13.67	1.63
EBI evidence rating
Promising			138	57.26
Exemplar			103	42.74
EBI Design Characteristics
Prevention continuum
Universal			99	41.08
Selected			72	29.88
Indicated			29	12.03
Treatment			41	17.01
School-based^d
Not school-based			189	78.42
School-based			50	20.75
Family-focused
Not family-focused			179	74.27
Family-focused			62	25.73
Group-based
Not delivered to group			92	38.17
Delivered to group			149	61.83

Note. No. = Number, TA = Technical Assistance, EBI = Evidence-based preventive intervention.

^aTotal number of unique EBI implementations, reflects the sample n for regression models. Percentage is calculated out of the total count of implementation, N = 310. The denominator for calculating percentages for the EBI characteristics.

^bTotal number of coded contacts across EBI implementations. Percentage is calculated out of the total count of coded contacts, N = 10931.

^cTotal number of service organizations delivering EBIs. Percentage is calculated out of the count of organization initially coded, N = 168.

^dTwo implementations could not be coded to indicate if they were School-based.

Relating TA Frequency to EBI Characteristics

Consultation

For Consultation, the hierarchical regression model explained 17% of the variation in the amount of TA delivered, R² = .17, F (9, 229) = 5.24, p < .001. Table 4 shows the model results for the hierarchical regression analysis. Variation in TA encounters was coded as Consultation. Prevention Continuum, Family-Focus, and Group-Based. All were significantly associated with the amount of consultation delivered. The results showed a positive association between the Prevention Continuum and Consultation, indicating that, on average, EBIs for Treatment interventions received more Consultation TA than Universal EBIs. There was also a positive association between Family-Focused EBIs and Consultation. Results showed that Family-Focused EBIs received more Consultation TA than EBIs that were only parent- or youth-focused. Last, a positive association was found between Group-Based and Consultation. Results indicated that, on average, EBIs delivered in group settings received more Consultation TA than those offered to the individual.

Table 4.

Parameter Estimates for Final Regression Models for Consultation, Coordination-Logistics, Monitoring, and Resource Delivery Regressed on Organization EBI Experience, EBI Supports

Variables	Consultation							Coordination logistics
						95% CI							95% CI
	B	SE B	β	t	p	LL	UL	B	SE B	β	t	p	LL	UL
Model 1
# PCCD grants^a	−0.62	0.51	−.08	−1.21	.229	−1.63	0.39	0.54	0.40	.08	1.34	.182	−0.25	1.32
Model 2
EBI Supports^b	2.36	1.48	.42	1.59	.112	−0.56	5.29	2.83	1.15	.60	2.45	.015	0.56	5.11
EBI Rating^c	−1.12	2.87	−.06	−0.39	.698	−6.77	4.54	−7.98	2.23	−.51	−3.58	.000	−12.38	−3.59
Model 3
Continuum^d
Selected	4.86	2.77	.24	1.75	.081	−0.60	10.33	4.15	2.16	.25	1.92	.056	−0.10	8.40
Indicated	3.40	3.46	.12	0.98	.326	−3.41	10.22	4.46	2.69	.19	1.66	.099	−0.84	9.76
Treatment	12.71	5.25	.52	2.42	.016	2.37	23.05	23.41	4.08	1.15	5.74	.000	15.37	31.45
School-Based^e	1.44	3.20	.06	0.45	.652	−4.86	7.75	−4.19	2.49	−.22	−1.68	.093	−9.09	0.71
Family-Focus^f	5.33	2.56	.25	2.08	.038	0.29	10.37	−7.54	1.99	−.43	−3.79	.000	−11.46	−3.62
Group-Based^g	15.43	7.10	.82	2.17	.031	1.44	29.43	26.37	5.53	1.67	4.77	.000	15.49	37.26

	Monitoring							Resource delivery
						95% CI							95% CI
	B	SE B	β	t	p	LL	UL	B	SE B	β	t	p	LL	UL
Model 1
# PCCD grants^a	−0.67	0.34	−.11	−1.98	.048	−1.33	0.00	−1.92	0.59	−.18	−3.25	.001	−3.08	−0.76
Model 2
EBI Supports^b	−0.34	0.97	−.08	−0.35	.724	−2.25	1.57	1.30	1.70	.17	0.76	.447	−2.06	4.65
EBI Rating^c	−2.09	1.87	−.15	−1.11	.267	−5.78	1.61	−11.38	3.29	−.44	−3.46	.001	−17.87	−4.90
Model 3
Continuum^d
Selected	1.90	1.81	.13	1.05	.296	−1.67	5.47	−3.41	3.18	−0.12	−1.07	.285	−9.68	2.86
Indicated	0.00	2.26	.00	0.00	.999	−4.46	4.45	−3.77	3.97	−0.10	−0.95	.343	−11.60	4.05
Treatment	0.96	3.43	.05	0.28	.780	−5.80	7.72	18.04	6.02	0.53	3.00	.003	6.18	29.91
School-Based^e	0.95	2.09	.06	0.45	.650	−3.17	5.07	2.12	3.67	0.07	0.58	.564	−5.11	9.36
Family-Focus^f	7.81	1.67	.50	4.67	.000	4.52	11.11	5.50	2.94	0.19	1.87	.062	−0.29	11.29
Group-Based^g	3.20	4.64	.23	0.69	.491	−5.95	12.35	15.97	8.15	0.61	1.96	.051	−0.10	32.03

Note. ***p < 0.001, **p < 0.01, *p < 0.05, +p < 0.10.

^aNumber of grants received, 1 = 1 grant received, 2 = 2 grants received, 3 = 3 grants received, 4 = 4 or more grants received.

^bEBI Developer Supports Score is a continuous variable ranging from 0 to 18, however for all programs included in analysis range = 11 – 16.

^cEBI Evidence Rating, 0 = Promising EBI Evidence Rating, 1 = Exemplar EBI Evidence Rating.

^dReference group = Universal programs.

^eSchool-Based delivery setting, 0 = Not School-based; 1 = School-Based Program.

^fFamily-Focused delivery, Not Family-focused; 1 = Family-Focused Program.

^gGroup-Based, 0 – Single unit or individual; 1 = Program Delivered to Group.

Bolded value indicated to signify the significant parameters in the regression model for ease of visibility for the reader.

Coordination Logistics

For Coordination Logistics, the hierarchical regression model explained 28% of the variation in the amount of TA delivered, R² = .28, F (9, 229) = 9.96, p < .001. Table 4 shows the model results for the hierarchical regression analysis explaining variation in TA encounters coded as Coordination Logistics. EBI Developer Support, EBI Evidence Rating, Prevention Continuum, Family-Focus, and Group-Based were all significantly associated with the amount of Coordination TA provided. The results showed a positive relationship between EBI Developer Support and Coordination Logistics, such that increases in the number of developer-provided supports for an EBI were associated with increased amount of Coordination Logistics TA. There was also a negative association between EBI Evidence Rating and Coordination Logistics; results indicated that EBIs of programs rated as Exemplar received a smaller amount of Coordination Logistics TA when compared to programs rated as Promising.

Additionally, there was a positive association between the Prevention Continuum and Coordination Logistics. Results indicated that EBIs for Treatment interventions received more Coordination logistics TA when compared to Universal EBIs. A negative association was found between Family-Focused and Coordination Logistics; results indicated that, on average, Family-Focused EBIs received less Coordination Logisitics TA compared to EBIs that were only parent- or youth-. Last, there was a positive association between Group-Based and Coordination Logistics, indicating that, on average, EBIs delivered in group settings received lower amounts of Coordination Logistics TA compared to those offered to the individual.

Monitoring

For Monitoring, the hierarchical regression model explained 37% of the variation in the amount of TA delivery, R² = .37, F (9, 229) = 14.89, p < .001. Table 4 shows the model results for the hierarchical regression analysis explaining variation in TA encounters coded as Monitoring. Only Prior EBI Funding and family-focused were significantly associated with the amount of Monitoring TA provided. A negative relationship was found between human service organization experience and Monitoring; results indicated that increases in the number of times a human service organization previously implemented an EBI were associated with a decrease in the amount of Monitoring TA delivered. There was a positive association between Family-Focus and Monitoring; results showed that Family-Focused EBIs received more Consultation TA than EBIs that were only parent- or youth-focused.

Resource Delivery

The hierarchical regression model explained 43% of the variation in Resource Delivery, R² = .43, F (9, 229) = 19.12, p < .001. Table 4 shows the model results for the hierarchical regression analysis explaining variation in TA encounters coded as Resource Delivery. Prior EBI Funding, EBI Level of Evidence Rating, and Prevention Continuum were all significantly associated with the amount of Resource Delivery TA provided. A negative relationship was found between human service organization experience and Resource Delivery. Results indicated that increases in the number of times a human service organization previously implemented an EBI were associated with less Resource Delivery. There was also a negative association between EBI Evidence Rating and Resource Delivery; results indicated that EBIs of programs rated as Exemplar received less Resource Delivery than programs rated as Promising. Lastly, there was a positive association between the Prevention Continuum and Resource Delivery, with EBIs for Treatment interventions receiving more Resource Delivery than Universal EBIs.

Discussion

In Study 2, the findings generally supported our hypotheses regarding EBI quality and design characteristics and the amount of TA provided. Differential patterns within these associations emerged across the different TA strategies examined. For example, more EBI experience within human service organizations was associated with less TA for Monitoring and Resource Delivery but not for Consultation or Coordination Logistics. Prior research has demonstrated that experience implementing an EBI is associated with greater innovation-specific capacity (Bergling et al., 2022; Dogherty et al., 2013); however, given our findings, more work is warranted to understand the specific capacity needs of program implementers with previous experiences implementing EBIs. With respect to EBI Characteristics, the results support the notion that features of the EBI design and quality contribute to how much TA is delivered to support quality implementation (Damschroder et al., 2009, 2015). However, these associations varied along several dimensions. For instance, EBIs with higher evidence ratings received less TA, but this finding was only evident for Coordination Logistics and Resource Delivery. Associations between EBI design characteristics varied across types of TA strategy and the specific design features (e.g., Family-based, Group-Based, Prevention Continuum). Implementing programs in schools was the only feature that did not show significant associations with any of the TA strategy outcomes. These findings provide a first look into how EBI characteristics relate to the amount of TA provided for different TA strategies. More research is needed to unpack the complex relationships among EBI characteristics, TA dosage, and TA strategy in determining how much of what is needed to support high-quality implementation, given the different features of the intervention.

General Discussion

Research suggests that TA contributes positively to individuals’ and organizations' capacity to deliver and sustain EBIs effectively. What is lacking, however, are studies delineating which types and quantities of TA are most effective and for whom. The current study represents a first step in “unpacking” some of these specifics regarding TA. The study’s overall goal was to develop a method of classifying and empirically examining the amount of TA given as the effort was tailored to fit the needs of individuals, organizations, and programs.

Study Limitations and Future Considerations

Some limitations warrant consideration. First, TA contact notes were often brief or offered limited information about the encounter. In addition, notes provided by implementation specialists varied in their level of detail. Thus, coding TA strategies may not have captured the entire nature or quality of the TA encountered. This was especially true in the case of coaching. Second, this study did not include other essential dimensions along which TA can vary. For example, TA provision can vary extensively across dimensions such as dosage, frequency, modality (Feinberg et al., 2008; Le et al., 2016; Scott et al., 2022), content focus, and knowledge brokering (Baumgartner et al., 2018; Moreland-Russell et al., 2018; Williams et al., 2017). Indices of modality, dosage, and dissemination to groups versus individuals were not included in the current analyses. Still, these may be important considerations to clarify how much TA is delivered to whom and under what conditions.

Another limitation of the study is that we did not link TA strategies to actual implementation outcomes, such as program fidelity, quality of delivery, or provider capacity. A future step in understanding these relations would examine the effectiveness of TA strategies by delineating how such strategies improve the motivation and capacity of practitioners who are implementing EBIs (Wandersman & Scheier, 2024). Our findings do, however, add value to the discussion on facets of TA employed by support systems. Further research is also needed to unpack the mechanisms by which support is delivered and uptaken by programs. For example, the logic model provided by Wandersman and Scott (2022) may provide a means to identify the processes of TA delivery, TA recipient outcomes, and, ultimately, the impact of TA on organizational and community outcomes.

Although these limitations can potentially influence the interpretation of the study findings, the study has several strengths. First, direct links between TA and EBI characteristics have rarely been explored. To our knowledge, this study is the first to provide empirical data linking specific aspects of TA to the features of the EBIs, shedding some light on how those features play a role in determining how much TA to provide. Second, this study represents a mixed-method design reflecting the coding of over 10,000 archival TA encounters starting from 2011 and continuing through 2017. In addition, TA encounters reflect those across more than 200 program implementations for 10 different EBIs. The richness of the dataset presents an opportunity for future investigations to further unpack TA delivery along multiple dimensions across various facets that occur within the implementation context.

Implications for Science, Practice, and Policy

The results of this study indicate that a support system may employ multiple facets of implementation support to aid program providers in implementing EBIs. Previous research situates organizations operating as support systems as an opportune context for determining, examining, and building an evidence base for implementation support mechanisms (Franks, 2010; Franks & Bory, 2017). Our findings lead us to offer several recommendations for researchers and evaluators of TA, training and TA funders, and TA providers.

Implications for Researchers and Evaluators of Training and Technical Assistance

First, we recommend further investigation into the unique characteristics of EBIs and the specific types of TA strategies offered to individuals and organizations. Specifically, using the CFIR may help to illuminate how different intervention context factors and EBI implementation indices may be related to the TA needs of human service provider organizations. Additionally, challenging EBI implementations require exploring methods that improve access to a broad range of TA strategies and how TA provision occurs within support systems. In this respect, further investigations unpacking the EBSIS components are also warranted. We recommend further empirical validation and measurement of the specific types of TA strategies employed, with consideration of how different facets of TA are distinct from the different facets of training, tools, and QA/QI (Wandersman et al., 2012).

Furthermore, Wandersman and colleagues (2012) note that the cyclical process of implementation support is embedded within interpersonal relationships. Thus, ensuring open communication, collaboration, and trust among stakeholders, including funders, practitioners, TA providers, researchers, evaluators, and consumers, might be a key mechanism for the effective delivery and uptake of TA. Some studies have found that the relationship between TA providers and program implementers helps determine the effectiveness of the TA provided (Chilenski et al., 2016, 2018). Therefore, relationships are essential for the success of implementation support. It may be beneficial to examine the quality of the relationship between TA providers and program implementers as an additional facet of implementation support or even a mediating mechanism through which TA strategies are effectively delivered.

Implications for Training and Technical Assistance Funders

With increasing demand for EBI support and limited resources to support TA operations, it is essential to identify effective and efficient TA approaches that best fit the organizational and implementation contexts of EBIs. The implications are multifaceted and significant for funders of technical assistance and prevention programs. First, we recommend explicit investment in training and technical assistance to support EBI implementation. Investing in TA centers demonstrates a commitment to proactive measures rather than reactive solutions, highlighting a strategic approach to addressing implementation challenges. This investment supports the development and implementation of innovative solutions and fosters a culture of prevention, potentially reducing long-term costs associated with addressing the aftermath of issues the arise with implementation fidelity and poor context fit. Furthermore, funders play a critical role in shaping the landscape of program implementation, influencing priorities, and encouraging collaboration among stakeholders. Effective funding strategies can enhance program efficiency, ensure the sustainability of initiatives, and maximize impact. However, it also requires funders to undertake rigorous due diligence, maintain flexibility to adapt to emerging challenges and commit to ongoing evaluation to measure the impact of TA in supporting EBIs’ success.

Investing in technical assistance has far-reaching implications beyond the immediate beneficiaries. Resourcing TA can help create a more comprehensive and coordinated approach to addressing complex multi-leveled implementations that address various levels of systems (e.g., families, schools, and communities). Funding initiatives can also facilitate cross-sectoral cooperation and promote systemic change by promoting collaboration among stakeholders within the ISF. Additionally, funders can leverage their investments to attract other key players, such as private sector partners or government agencies, further amplifying the impact of their funding.

Implications for Training and Technical Assistance Providers

Coordinated TA is necessary for program implementers. This includes training sessions and ongoing support to help them effectively utilize the technology and understand its features. It also involves addressing any issues that may arise during program implementation. Moreover, technical assistance plays a crucial role in promoting program scalability and adaptability. With continuous guidance and support, prevention programs can be easily scaled up to reach a larger audience and adapted to meet the unique needs of different communities or populations. In addition, a technical assistance infrastructure can facilitate more adequate data collection and evaluation efforts. We recommend that TA providers proactively develop accurate and timely data collection procedures and facilitate data analysis and reporting. These processes should be incorporated into daily operations for TA support systems. This not only helps in measuring the impact of TA but also allows for continuous improvement and refinement.

Furthermore, analyzing TA activity can aid in addressing potential barriers or challenges that may hinder successful program implementation. By working closely with implementers and users, developers can identify any roadblocks or issues and provide solutions or alternative approaches. This promotes a collaborative and problem-solving approach, ensuring that prevention programs are effective and sustainable.

Conclusion

In conclusion, our findings support the notion that TA delivery is multifaceted and responsive to the implementing context. Ultimately, TA should be regarded as an ongoing process that adapts to changing provider needs, implementation contexts, and program characteristics. We conclude that different EBI characteristics contribute to the amount of TA delivered to human service organizations to support implementation capacity. Unsurprisingly, our data indicate that those EBIs that are more complex and challenging to do require additional technical support and resources. Policymakers and prevention support systems can leverage this research to aid decision-making regarding methods for efficient allocation of resources to promote EBI adoption, dissemination, and sustainability. Further, our findings could be used to inform future research initiatives focused on refining the measurement and operationalization of implementation support, and specifically TA strategies, as they are executed within and across prevention support systems. We hope this research will contribute to a better understanding of TA metrics and conceptualizations and their potential to support the quality implementation of EBIs.

Supplemental Material

Supplemental Material - Unpacking Technical Assistance (TA) Strategies Within a State-Level Prevention Support System: A Mixed-Method Study in Determining Types and Amount of TA

Supplemental Material for Unpacking Technical Assistance (TA) Strategies Within a State-Level Prevention Support System: A Mixed-Method Study in Determining Types and Amount of TA by Jochebed G. Gayles, Sarah M. Chilenski, Nataly Barragán, Brittany Rhoades Cooper, Janet A. Welsh, and Megan Galinsky in Evaluation & the Health Professions.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: We gratefully acknowledge funding from the Social Science Research Institute at The Pennsylvania State University Social Science Research Institute (Welsh, Chilenski, Gayles).

ORCID iD

Jochebed G. Gayles

Supplemental Material

Supplemental material for this article is available online.

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