Technical Assistance for Systemic Change: Lessons Learned From a National Technical Assistance Center.

Despite the millions of dollars awarded annually by the United States Department of Education to build implementation capacity through technical assistance (TA), data on TA effectiveness are severely lacking. Foundational to the operationalization and consistent research on TA effectiveness is the development and use of standardized TA core competencies, practices, and structures. Despite advances toward a consistent definition of TA, a gap still exists in understanding how these competencies are used within an operationalized set of TA practices to produce targeted outcomes at both individual and organizational levels to facilitate implementation of evidence-based practices. The current article describes key insights derived from the evaluation of an operationalized set of TA practices used by a nationally funded TA center, the State Implementation & Scaling Up of Evidence Based Practices (SISEP) Center. The TA provided by the Center supports the uptake of evidence-based practices in K-12 education for students with disabilities. Lessons learned include: (1) the need to understand the complexities and dependencies of operationalizing TA both longitudinally and at multiple levels of the system (state, regional, local); (2) the relative importance of building general and innovation-specific capacity for implementation success; (3) the value of using a co-design and participatory approach for effective TA delivery; (4) the need to develop TA providers' educational and implementation fluency across areas and levels of the system receiving TA; and (5) the need to ensure coordination and alignment of TA providers from different centers. Gaining an understanding into optimal TA practices will not only provide clarity of definition fundamental to TA research, but it will also inform the conceptual framing and practice of TA.

Strengthening the Science and Practice of Implementation Support: Evaluating the Effectiveness of Training and Technical Assistance Centers.

Hundreds of millions of dollars are spent each year by U.S. federal agencies for training and technical assistance (TTA) to be delivered by training and technical assistance centers (TTACs) to "delivery system organizations" (e.g., federally qualified health centers, state departments of health, substance abuse treatment centers, schools, and healthcare organizations). TTACs are often requested to help delivery system organizations implement evidence-based interventions. Yet, counterintuitively, TTACs are rarely required to use evidence-based approaches when supporting delivery systems (in the use of evidence-based programs). In fact, evaluations of TTAC activities tend to be minimal; evaluation of technical assistance (if conducted at all) often emphasizes outputs (number of encounters), satisfaction, and self-reports of knowledge gained-more substantive outcomes are not evaluated. The gap between (a) the volume of TTA services being funded and provided and (b) the evaluation of those services is immense and has the potential to be costly. The basic question to be answered is: how effective are TTA services? This article introduces the special issue on Strengthening the Science and Practice of Implementation Support: Evaluating the Effectiveness of Training and Technical Assistance Centers. The special issue promotes 1) knowledge of the state of the art of evaluation of TTACs and 2) advances in what to evaluate in TTA. A major goal of the issue is to improve the science and practice of implementation support, particularly in the areas of TTA.

COVID-19: resuming International Travel in the Caribbean

This webinar, hosted by the PAHO/WHO Office for Barbados and the Eastern Caribbean Countries was for the health, tourism, immigration, and other relevant sectors to share experiences and provide technical guidance. The expected outcome was to build a common understanding on decision-making process for resuming non-essential travel during COVID-19.

Comparative Effectiveness of Coalitions Versus Technical Assistance for Depression Quality Improvement in Persons with Multiple Chronic Conditions.

Significance: Prior research suggests that Community Engagement and Planning (CEP) for coalition support compared with Resources for Services (RS) for program technical assistance to implement depression quality improvement programs improves 6- and 12-month client mental-health related quality of life (MHRQL); however, effects for clients with multiple chronic medical conditions (MCC) are unknown. Objective: To explore effectiveness of CEP vs RS in MCC and non-MCC subgroups. Design: Secondary analyses of a cluster-randomized trial. Setting: 93 health care and community-based programs in two neighborhoods. Participants: Of 4,440 clients screened, 1,322 depressed (Patient Health Questionnaire, PHQ8) provided contact information, 1,246 enrolled and 1,018 (548 with ≥3 MCC) completed baseline, 6- or 12-month surveys. Intervention: CEP or RS for implementing depression quality improvement programs. Outcomes and Analyses: Primary: depression (PHQ9 <10), poor MHRQL (Short Form Health Survey, SF-12<40); Secondary: mental wellness, good physical health, behavioral health hospitalization, chronic homelessness risk, work/workloss days, services use at 6 and 12 months. End-point regressions were used to estimate intervention effects on outcomes for subgroups with ≥3 MCC, non-MCC, and intervention-by-MCC interactions (exploratory). Results: Among MCC clients at 6 months, CEP vs RS lowered likelihoods of depression and poor MHRQL; increased likelihood of mental wellness; reduced work-loss days among employed and likelihoods of ≥4 behavioral-health hospitalization nights and chronic homelessness risk, while increasing faith-based and park community center depression services; and at 12 months, likelihood of good physical health and park community center depression services use (each P<.05). There were no significant interactions or primary outcome effects for non-MCC. Conclusions: CEP was more effective than RS in improving 6-month primary outcomes among depressed MCC clients, without significant interactions.

Methodological approach and tools for systems thinking in health systems research: technical assistants' support of health administration reform in the Democratic Republic of Congo as an application.

In the field of development cooperation, interest in systems thinking and complex systems theories as a methodological approach is increasingly recognised. And so it is in health systems research, which informs health development aid interventions. However, practical applications remain scarce to date. The objective of this article is to contribute to the body of knowledge by presenting the tools inspired by systems thinking and complexity theories and methodological lessons learned from their application. These tools were used in a case study. Detailed results of this study are in process for publication in additional articles. Applying a complexity 'lens', the subject of the case study is the role of long-term international technical assistance in supporting health administration reform at the provincial level in the Democratic Republic of Congo. The Methods section presents the guiding principles of systems thinking and complex systems, their relevance and implication for the subject under study, and the existing tools associated with those theories which inspired us in the design of the data collection and analysis process. The tools and their application processes are presented in the results section, and followed in the discussion section by the critical analysis of their innovative potential and emergent challenges. The overall methodology provides a coherent whole, each tool bringing a different and complementary perspective on the system.

Projeto de apoio e monitoramento de um serviço de referência às unidades de saúde da Atenção Básica na descentralização do atendimento da tuberculose / Project of support and monitoring of a reference service to health care units Primary Care in the decentralization of tuberculosis care

Relatar a experiência do Centro de Referência Estadual para TB do Hospital Sanatório Partenon no desenvolvimento de intervenções de apoio às equipes de saúde da AB que iniciaram suas ações de controle da TB a partir de capacitação teórico-prática para descentralização do atendimento desse agravo. (AU)

[Change management: An analysis of actors; perceptions about technical assistance in the Democratic Republic of Congo]. / Accompagnement du changement : une analyse de représentations d’acteurs sur l’assistance technique en République Démocratique du Congo.

INTRODUCTION: Technical assistance (TA) is a common component of health system strengthening interventions. This type of intervention is too often designed and evaluated according to a logic that fails to take into account social complexity. Actors' perceptions are one element of this complexity. This article presents a study conducted in the Democratic Republic of Congo designed to identify perceptions concerning two types of technical support providers for health system strengthening: long-term technical assistants (agents of development agencies) and provincial technical advisors (agents of the Ministry of Health). METHODS: Interviews were conducted with an innovative tool inspired by the principles of systems thinking. Interviewees were actors involved in a TA intervention in the province of Bandundu. Their expectations regarding TA providers were identified in terms of personal characteristics (knowledge, know-how and interpersonal skills), roles, and styles of interaction for capacity building ("interventionist/ prescriptive axes"). RESULTS AND DISCUSSION: Interviewees emphasized the importance of mutual learning and the quality of interactions, which depends on TA provider's interpersonal skills and mutual willingness. Perceptions of TA provider's characteristics tend to be similar, but several differences were observed concerning the expectations about the roles of TAs, and the style that should be adopted for capacity building. Ignoring these differences in expectations may be a threat to the effectiveness of TA.

Using data to improve fidelity when implementing evidence-based programs.

In fall 2011, the South Carolina Campaign to Prevent Teen Pregnancy (SC Campaign), with funding from Office of Adolescent Health, began replicating an evidence-based curriculum, It's Your Game, Keep It Real in 12 middle schools across South Carolina. Fidelity of the curriculum was monitored by the use of lesson fidelity logs completed by curriculum facilitators and lesson observation logs submitted by independent classroom observers. These data were monitored weekly to identify possible threats to fidelity. The innovative model Fidelity Through Informed Technical Assistance and Training was developed by SC Campaign to react to possible fidelity threats in real time, through a variety of technical assistance modalities. Fidelity Through Informed Technical Assistance and Training guided the 55 hours of technical assistance delivered by the SC Campaign during the first year of It's Your Game, Keep It Real implementation to 18 facilitators across 12 SC middle schools, and achieved 98.4% curriculum adherence and a high quality of implementation scores.

Strengthening government management capacity to scale up HIV prevention programs through the use of Technical Support Units: lessons from Karnataka state, India.

Scaling up HIV prevention programming among key populations (female sex workers and men who have sex with men) has been a central strategy of the Government of India. However, state governments have lacked the technical and managerial capacity to oversee and scale up interventions or to absorb donor-funded programs. In response, the national government contracted Technical Support Units (TSUs), teams with expertise from the private and nongovernmental sectors, to collaborate with and assist state governments. In 2008, a TSU was established in Karnataka, one of 6 Indian states with the highest HIV prevalence in the country and where monitoring showed that its prevention programs were reaching only 5% of key populations. The TSU provided support to the state in 5 key areas: assisting in strategic planning, rolling out a comprehensive monitoring and evaluation system, providing supportive supervision to intervention units, facilitating training, and assisting with information, education, and communication activities. This collaborative management model helped to increase capacity of the state, enabling it to take over funding and oversight of HIV prevention programs previously funded through donors. With the combined efforts of the TSU and the state government, the number of intervention units statewide increased from 40 to 126 between 2009 and 2013. Monthly contacts with female sex workers increased from 5% in 2008 to 88% in 2012, and with men who have sex with men, from 36% in 2009 to 81% in 2012. There were also increases in the proportion of both populations who visited HIV testing and counseling centers (from 3% to 47% among female sex workers and from 6% to 33% among men who have sex with men) and sexually transmitted infection clinics (from 4% to 75% among female sex workers and from 7% to 67% among men who have sex with men). Changes in sexual behaviors among key populations were also documented. For example, between 2008 and 2010, the proportion of surveyed female sex workers in 9 districts reporting that they used a condom at last intercourse rose from 60% to 68%; in 6 districts, the proportion of surveyed men who have sex with men reporting that they used a condom at last anal sex increased from 89% to 97%. The Karnataka experience suggests that TSUs can help governments enhance managerial and technical resources and leverage funds more effectively. With careful management of the working and reporting relationships between the TSU and the state government, this additional capacity can pave the way for the government to improve and scale up programs and to absorb previously donor-funded programs.

Promoting cross-sector partnerships in child welfare: qualitative results from a five-state strategic planning process.

Little is known about effective strategic planning for public and private child welfare agencies working together to serve families. During a professionally facilitated, strategic planning event, public and private child welfare administrators from five states explored partnership challenges and strengths with a goal of improving collaborative interactions in order to improve outcomes for children and families. Summarizing thematic results of session notes from the planning event, this article describes effective strategies for facilitation of such processes as well as factors that challenge or promote group processes. Implications for conducting strategic planning in jurisdictions seeking to improve public/private partnerships are discussed.

State "technical assistance programs" for nursing home quality improvement: variations and potential implications.

To improve nursing home quality, many states have developed "technical assistance programs" that provide on-site consultation and training for nursing facility staff. We conducted a national survey on these state programs to collect data on program design, operations, financing, and perceived effectiveness. As of 2010, 17 states had developed such programs. Compared to existing state nursing home quality regulations, these programs represent a collaborative, rather than enforcement-oriented, approach to quality. However, existing programs vary substantially in key structural features such as staffing patterns, funding levels, and relationship with state survey and certification agencies. Perceived effectiveness by program officials on quality was high, although few states have performed formal evaluations. Perceived barriers to program effectiveness included lack of appropriate staff and funding, among others. In conclusion, state technical assistance programs for nursing homes vary in program design and perceived effectiveness. Future comparative evaluations are needed to inform evidence-based quality initiatives.

The development and successful implementation of the VINCat Program.

In 2006 the VINCat Program was established in order to develop and support a standardized surveillance system of hospital-acquired infections (HAI). All acute care hospitals included in the public health system network of Catalonia (Spain) were invited to participate. The aim was to provide risk-adjusted, procedure-specific rates for most relevant infections. Data are collected by the local multidisciplinary infection control teams and transmitted electronically to the Coordinating Centre, which acts as the core of a network of infection control committees and has the support of a Technical Advisory Committee. The program website provides updated information on program activities, training workshops, aggregated data on past infection rates and access to databases, manuals and protocols. During the period 2007-2011, 64 hospitals have joined the program: 9 tertiary, 16 district and 39 small hospitals, providing records on 4.044 episodes of catheter-related blood stream infections, 14.389 elective colorectal surgical interventions, 14.214 hip and 29.599 knee arthroplasties, among the most significant indicators. Nowadays, it appears that VINCat has been successfully implemented and is well established as the official HAI surveillance program in Catalonia. Determinants for success have been: the maintenance of a close contact between the hospitals and the coordinating center, the timely and regular data feedback to institutions, the program's contribution towards reducing HAIs, the ongoing efforts to improve performance and, a key factor, the perception among the infection control professionals of the value added by the program to their daily work in different ways. Adequate funding, commitment of infection control teams and the generous collaboration of experts from different specialties are essential for maintaining the success of the VINCat Program.

Defining and assessing evidence for the effectiveness of technical assistance in furthering global health.

In an era when health resources are increasingly constrained, international organisations are transitioning from directly managing health services to providing technical assistance (TA) to in-country owners of public health programmes. We define TA as: 'A dynamic, capacity-building process for designing or improving the quality, effectiveness, and efficiency of specific programmes, research, services, products, or systems'. TA can build sustainable capacities, strengthen health systems and support country ownership. However, our assessment of published evaluations found limited evidence for its effectiveness. We summarise socio-behavioural theories relevant to TA, review published evaluations and describe skills required for TA providers. We explore challenges to providing TA including cost effectiveness, knowledge management and sustaining TA systems. Lastly, we outline recommendations for structuring global TA systems. Considering its important role in global health, more rigorous evaluations of TA efforts should be given high priority.

How to deploy online guidance during a major incident.

The experience of users of the web resource developed by the Health Protection Agency, following the arrival of H1N1 influenza, can be used to formulate criteria for web communication of up-to-date guidance in any incident management. Users participated in an online questionnaire survey. Responses were analysed quantitatively and qualitatively. Seventy-four per cent (95 per cent CI 67-81) of respondents rated the online content as 'excellent' or 'good', with higher levels of satisfaction among healthcare professionals. Across all respondent categories there was demand for information more specific to their circumstances, alongside implementation of mechanisms such as text and e-mail to alert users to updates of web content. Based on the study findings, several recommendations were made on the use of similar web-based resources in future. With consideration of these recommendations, this strategy of web-based communication can be employed in other high profile incidents requiring a national response.

Training and technical assistance to enhance capacity building between prevention research centers and their partners.

INTRODUCTION: The Centers for Disease Control and Prevention has administered the Prevention Research Centers Program since 1986. We quantified the number and reach of training programs across all centers, determined whether the centers' outcomes varied by characteristics of the academic institution, and explored potential benefits of training and technical assistance for academic researchers and community partners. We characterized how these activities enhanced capacity building within Prevention Research Centers and the community. METHODS: The program office collected quantitative information on training across all 33 centers via its Internet-based system from April through December 2007. Qualitative data were collected from April through May 2007. We selected 9 centers each for 2 separate, semistructured, telephone interviews, 1 on training and 1 on technical assistance. RESULTS: Across 24 centers, 4,777 people were trained in 99 training programs in fiscal year 2007 (October 1, 2006-September 30, 2007). Nearly 30% of people trained were community members or agency representatives. Training and technical assistance activities provided opportunities to enhance community partners' capacity in areas such as conducting needs assessments and writing grants and to improve the centers' capacity for cultural competency. CONCLUSION: Both qualitative and quantitative data demonstrated that training and technical assistance activities can foster capacity building and provide a reciprocal venue to support researchers' and the community's research interests. Future evaluation could assess community and public health partners' perception of centers' training programs and technical assistance.

[Mesoamerican Public Health Institute: technical support and capacity strengthening arm of the Mesoamerican Public Health System]. / Instituto Mesoamericano de Salud Pública: órgano de apoyo técnico y fortalecimiento del Sistema Mesoamericano de Salud Pública.

OBJECTIVE: The Mesoamerican Public Health Institute (IMSP) was constituted in 2009 as the technical organ of the Mesoamerican Public Health System (SMSP) and the Virtual Network of Academic Institutions. Health system capacity strengthening needs and preliminary training results were assessed in the first phase. MATERIAL AND METHODS: The SMSP Master Plans were content-analyzed for each priority and members of the Malaria and Dengue Working Group were surveyed. RESULTS: The training needs required for each SMSP priority area were identified and knowledge management needs for malaria and dengue analyzed. Competencies were mapped across strategic, tactical and operative personnel that will be requiring them. IMSP trained in its first year 91 persons in eight countries. CONCLUSIONS: IMSP is responding to the Mesoamerican region's public health needs.

Instituto Mesoamericano de Salud Pública: órgano de apoyo técnico y fortalecimiento del Sistema Mesoamericano de Salud Pública / Mesoamerican Public Health Institute: Technical support and capacity strengthening arm of the Mesoamerican Public Health System

OBJETIVO: El Instituto Mesoamericano de Salud Pública (IMSP) se constituyó en 2009 como órgano técnico del Sistema Mesoamericano de Salud Pública (SMSP) y la Red Virtual de Instituciones Académicas. En la primera fase se identificaron las necesidades de fortalecimiento de sistemas de salud y se evaluaron los primeros resultados de capacitación. MATERIAL Y MÉTODOS: Se realizó un análisis de contenido de los Planes Maestros del SMSP para cada prioridad y se encuestó a los integrantes del Grupo de Trabajo en Malaria y Dengue. RESULTADOS: Se identificaron los temas de capacitación requeridos por áreas de prioridad del SMSP y las necesidades de gestión de conocimiento para control y eliminación de la malaria y dengue. Se elaboró un mapeo de competencias a desarrollar con el personal estratégico, táctico y operativo. El IMSP capacitó a 91 funcionarios de ocho países en su primer año. Estas actividades se desarrollaron de julio 2009 a junio 2010, en consulta a directivos de servicios de salud de países integrantes del Sistema Mesoamericano de Salud Pública, Colombia y México. CONCLUSIONES: El IMSP está respondiendo a las necesidades de salud pública en la región mesoamericana.

OBJECTIVE: The Mesoamerican Public Health Institute (IMSP) was constituted in 2009 as the technical organ of the Mesoamerican Public Health System (SMSP) and the Virtual Network of Academic Institutions. Health system capacity strengthening needs and preliminary training results were assessed in the first phase. MATERIAL AND METHODS: The SMSP Master Plans were content-analyzed for each priority and members of the Malaria and Dengue Working Group were surveyed. RESULTS: The training needs required for each SMSP priority area were identified and knowledge management needs for malaria and dengue analyzed. Competencies were mapped across strategic, tactical and operative personnel that will be requiring them. IMSP trained in its first year 91 persons in eight countries. CONCLUSIONS: IMSP is responding to the Mesoamerican region's public health needs.

Toward a statewide health information technology center (abbreviated version).

With the passage of The American Reinvestment and Recovery Act of 2009 that includes the Health Care Information Technology for Economic & Clinical Health Act, the opportunity for states to develop a Health Information Technology Center (THITC) has emerged. The Center provides the intellectual, financial, and technical leadership along with the governance and oversight for all health information technology-related activities in the state. This Center would be a free-standing, not-for-profit, public-private partnership that would be responsible for operating one or more (in large states) Regional Health Information Technology Extension Centers (Extension Centers) along with several Regional Health Information Exchanges (HIEs) and one or more Regional Health Information Data Centers (Data Centers). We believe that if these features and functions could be developed, deployed, and integrated statewide, the health and welfare of the citizens of the state could be improved while simultaneously reducing the costs associated with the provision of care.