Charting Progress in the Science of Technical Assistance for Implementation of Evidence-Based Interventions

Improving Operationalization of TA Activities

Technical assistance as it is applied to implementation of interventions takes many different forms (cf. Wandersman & Scheier, 2024). Similar to the concepts of building a therapeutic alliance, or enhancing provider-client communication, there may still be a tendency to lump many different activities, orientations, and strategies under a broad “technical assistance” heading. As a result, studies of TA may be challenged to ensure consistency across different actors and settings, and our collective evidence base may lack specificity in how TA approaches directly generate desirable implementation outcomes. Studies that seek to better operationalize a range of TA approaches could help the field navigate toward optimal use of TA and provide improved quality metrics to guide TA practice. This could follow distinctions between what some have labeled “core components” and “adaptable periphery” (e.g., Damschroder et al., 2009) or the more recent discussion of “form” versus “function” (Perez Jolles et al., 2019). Fine-tuning our understanding of the components of effective TA could reap significant benefits for implementation science and practice, and support justification for provision of TA within a range of service systems.

Tailoring of Technical Assistance for Specific Needs and Times in the Process

Like many interventions and other implementation strategies, TA may be assumed to have a specific form that can be applied to multiple settings and interventions. And yet we know that many of our existing interventions need to be tailored to meet the needs of individuals and circumstances, or they may be deemed unusable. Similarly, TA will likely provide different benefits at different stages of the implementation process. For example, needs for TA while someone is exploring the use of an intervention, or in the initial stages of implementation will likely vary from the needs at a sustainment phase. Studying tailoring of TA across contexts and timepoints will help to equitably optimize its effectiveness and could improve the fit between TA and all who can benefit from it. This is consistent with other work contained in this special issue, particularly in the discussion of “client-centered and intentionally-designed” TA stemming from consensus-building efforts in education (Holdheide et al., 2024).

Building Evidence on Long-Term Sustainability/Adaptability of Technical Assistance Programs

In a similar vein, much of our personal experience with TA resides at the beginning of the implementation process, and yet we know that TA is likely beneficial for the long-term. As we assume the specific issues for which TA can be helpful will change over time, we expect that the provision of TA will also likely evolve over time. Like the consideration of intervention sustainability as a dynamic process (Chambers et al., 2013), studying how TA evolves would help systems to better plan for its long-term support and better measure its effectiveness in positively influencing practice.

Supporting Decision-Making Around External Versus Internal Provision of Technical Assistance

Our personal experience with studies that have included TA as an implementation strategy is that a key decision point governs whether it should be provided in-house or by an external entity. Indeed, Wandersman et al.’s (2008) Interactive Systems Framework is built on the recognition that an external implementation support system is needed to ensure that service settings have necessary guidance to integrate desired interventions. At the same time, an externally driven TA service may not be sustained as service systems may instead look to build capacity internally to create “local experts” to support the intervention over time. Additional studies that provide evidence for the relative impact of external versus internal provision of TA around a variety of implementation activities could guide these challenging decisions, as well as specify options for how effective TA can be provided and by whom. One key consideration for the provision of internal TA is the source of sustainable funding to provide staff to deliver this assistance. In healthcare organizations, funding for quality improvement activities can be used to provide assistance, but for a range of other organizations, this capacity may not be built in, and may require a piecemeal approach, where program grants from public and non-profit funders fill this gap. Research that quantifies the return on investment for building internal capacity and delivering TA could provide helpful evidence in this regard.

Improving Measurement of Technical Assistance Process and Outcomes

The field of quality improvement contributes greatly to our recognition that what we can measure provides the targets for what we can improve. Indeed, while in the context of TA, we have identified specific metrics for implementation success, in our experience we have seen fewer efforts to ensure our measures of TA process and outcomes are valid and reliable. While implementation science is continuing to expand measurement resources (Rabin et al., 2015), particularly where we can identify causal mechanisms to explain the impact of various implementation strategies, more work is needed. These measures must not be useful only for research studies; indeed, continued progress in TA practice will benefit from improved measurement that can be integrated within service systems. Measures that are developed collaboratively by researchers and service system representatives to report on process and outcomes of TA will make it much easier to pinpoint characteristics of optimal TA, and limit services that are ineffective or unnecessary in supporting implementation of effective interventions.

The Combination of Technical Assistance with Other Implementation Strategies

There seems little question that TA is an essential component of most implementation efforts, particularly where knowledge acquisition and skill-building is part of integrating a new intervention. And yet we also know that other strategies are likely required to address additional barriers (e.g., financing, IT system redesign, augmenting human resources). Improving our understanding of how TA combines with other strategies will be important, so that we can be more targeted as a field in understanding the reach and targets of our implementation strategies. In some cases, TA will amplify the effectiveness of another strategy (e.g., consultation on staff needs could directly affect the benefit of hiring new staff to provide an innovative intervention). In other cases, it will enable different barriers to implementation to be addressed. The better we understand complementarity of TA with other strategies, the more likely our implementation activities will be successful, and the easier it will be for funders of services to incorporate TA provision in budgeting. Building the knowledge base of how implementation strategies optimally improve adoption, implementation, and sustainment remains an important area within ongoing research funding opportunities (NIH, 2022).

Characterizing and Building the Technical Assistance Workforce

For TA to be maximally effective in supporting implementation activities across sectors, contexts, and interventions, the development, expansion, and support of the workforce is of paramount importance, particularly with a desired goal of equitable implementation (Acosta et al., 2024, this issue). As is described in the many papers collected in the two special issues on TTA, there are a range of different roles and organizations involved in the provision of TA, and yet we have not effectively assembled a full picture of who is currently performing these roles. In the cancer control environment that we work with, this may include clinicians, administrators, advocacy organizations, professional societies, investigators, and Federal, state and local agencies. To ensure that the workforce is sufficient and appropriately supported for the work they do, an effort to map both existing and desired capacities for the workforce would be quite valuable. Imagine having a dashboard that shows coverage of TA services in supporting implementation of specific programs across community and clinical settings; decisionmakers could more accurately gauge feasibility of integrating a new program, and prospective TA providers could work to fill gaps in coverage. We are also aware that technologies may extend capacity in a variety of ways; a landscape analysis (and subsequent mapping tools) could include identification of both human capital and other ways in which TA can be accessed.

Improving Understanding of Financing for Technical Assistance Strategies

In the context of research studies as well as program initiatives, TA may be provided with funds requested in an application, where it greatly facilitates the strategy to be used for the length of time that budgets have been appropriated. Unfortunately, if the specific costs of TA required within the project are not measured and reported, we may have little ability to determine whether TA is sustainable beyond the project’s funding period. Capturing information from experiences in financing TA as a discrete activity or ongoing learning collaborative (Bohnenkamp et al., 2024, this issue) could be quite beneficial to ensure that these tangible costs are factored into long-term planning for TA.

We are so gratified to see the tremendous advances in implementation science and practice since we started work in this field many years ago, and the refinement of our understanding of TA, a core implementation strategy, with specific attention to the many papers in these special issues, has been truly impressive. At the same time, our work is not done. Pursuing some of the areas we identify in this commentary could enhance the precision, quality, and impact of our TA efforts, and generate further support for sustained provision of TA within health and other service systems, with local, national, regional, and global benefits. We look forward to the next generation of efforts and are excited about what’s to come.