Mechanisms of change in external implementation support: A conceptual model and case examples to guide research and practice

Abstract

Background External implementation support (EIS) is a well-recognized feature of implementation science and practice, often under related terms such as technical assistance and implementation facilitation. Existing models of EIS have gaps related to addressing practice outcomes at both individual and organizational levels, connecting practice activities to intended outcomes, or grounding in well-established theories of behavior and organization change. Moreover, there have been calls to clarify the mechanisms of change through which EIS influences related outcomes. Method In this article, we theorize about mechanisms of change within EIS. Our theorizing process aligns with the approach advocated by Kislov et al. We aim to consolidate prior EIS literature, combining related constructs from previous empirical and conceptual work while drawing on our extensive EIS experience to develop a higher-order, midrange theory of change. Results Our theory of change is empirically and practically informed, conceptually situated within an established grand theory of change, and guided by eight practice principles and social cognitive theory. The theory of change proposes 10 core practice components as mechanisms of change within EIS. When used according to underlying theory and principles, they are believed to contribute to favorable practice outcomes at individual, team, organizational, and system levels. The model offers flexibility by recognizing the need for sequential support processes and the demand to practice in dynamic and responsive ways. Case examples are presented to illustrate major themes and patterns of the model in action. Conclusions The proposed model is intended to support prospective EIS studies by conceptualizing discernable practice components with hypothesized relationships to proximal and distal practice outcomes. The model can be behaviorally operationalized to compliment and extend competency-based approaches to implementation support practitioner (ISP) training and coaching. Over time, the model should be refined based on new empirical findings and contributions from ISPs across the field.

Trajectory of external implementation support activities across two states in the United States: A descriptive study

“…The dosage of individual CPCs across the more than 5-year period provides helpful information to characterize key features of the support process, including when certain support activities may be more likely to take place. For example, in this study, EIS generally began with a high dose of support largely related to “foundational” and “co-design” CPCs (Aldridge et al, 2023). This may suggest key features and timelines for early phases of co-created support processes (Yazejian et al, 2019).…”

“…Activities related to the two foundational CPCs described by Aldridge et al, (2023), Build Collaborative Relationships and Reinforce Leaders’ and Teams’ Self-Regulation of Effective Implementation Performance , might be expected in most support interactions. For example, even in a support interaction well into the engagement, attention to building or maintaining a collaborative relationship with support participants using one or more related practice activities may be wise, if not necessary.…”

“…In their effort to better identify and organize strategies that may be central to EIS, Aldridge et al, (2023) proposed 10 core practice components (CPCs), conceptualized as mechanisms of change in EIS, as well as a theory of change for how these practice components may influence immediate-, short-, and long-term EIS outcomes such as implementation capacity and performance (see Figure 1). The model is empirically informed, guided by practice principles, conceptually situated within a grand theory of change for implementation and scale-up (see NASEM, 2019), and grounded in social cognitive theory, which has been widely applied to behavioral change in individuals, groups, organizations, and social systems (e.g., Bandura, 1986Bandura, , 1988Bandura, , 1991Bandura, , 2000Wood & Bandura, 1989).…”

“…The model is empirically informed, guided by practice principles, conceptually situated within a grand theory of change for implementation and scale-up (see NASEM, 2019), and grounded in social cognitive theory, which has been widely applied to behavioral change in individuals, groups, organizations, and social systems (e.g., Bandura, 1986Bandura, , 1988Bandura, , 1991Bandura, , 2000Wood & Bandura, 1989). For more information about this model, including its relation to other EIS concepts and literature, see Aldridge et al, (2023). Early in their development, these CPCs were adopted within The Impact Center at FPG's Implementation Capacity for Triple P (ICTP; https://ictp.fpg.unc.edu) projects.…”

“…These include training to build general capacity, technical assistance and facilitation for implementation processes, tools to support implementation processes, quality improvement strategies, infrastructure development, and benchmarking. In this paper, we refer to such strategies and related activities as external implementation support (EIS; Aldridge et al, 2023). We refer to providers of EIS as implementation support practitioners (ISPs; Albers et al, 2020; Metz et al, 2021).…”