How is tailored implementation undertaken using a self-guided toolkit? Qualitative study of the ItFits-toolkit in the ImpleMentAll project

Tracy L. Finch, Sebastian Potthoff, Carl R. May, Melissa Girling, Neil Perkins, Christiaan Vis, Leah Bührmann, Anne Etzelmueller, Claire Rosalie van Genugten, Josien Schuurmans, Jordi Piera-Jiménez, Tim Rapley, Adriaan Hoogendoorn, Ainslie O’Connor, Alexis Whitton, Alison Calear, Andia Meksi, Anna Sofie Rømer, Anne Etzelmüller, Antoine Yrondi, Arlinda Cerga-Pashoja, Besnik Loshaj, Bridianne O’Dea, Bruno Aouizerate, Camilla Stryhn, Carmen Ceinos, Caroline Oehler, Catherine Pope, Christine Marking, Claus Duedal Pedersen, Corinna Gumbmann, Dana Menist, David Daniel Ebert, Denise Hanssen, Elena Heber, Els Dozeman, Emilie Brysting, Emmanuel Haffen, Enrico Zanalda, Erida Nelaj, Erik Van der Eycken, Eva Fris, Fiona Shand, Gentiana Qirjako, Géraldine Visentin, Heleen Riper, Helen Christensen, Ingrid Titzler, Isabel Weber, Isabel Zbukvic, Jeroen Ruwaard, Jerome Holtzmann, Johanna Freund, Johannes H. Smit, Josep Penya, Josephine Kreutzer, Judith Rosmalen, Juliane Hug, Kim Mathiasen, Kristian Kidholm, Kristine Tarp, Linda Lisberg, Ludovic Samalin, Maite Arrillaga, Margot Fleuren, Maria Chovet, Marion Leboyer, Mette Atipei Craggs, Mette Maria Skjøth, Naim Fanaj, Nicole Cockayne, Philip J. Batterham, Pia Driessen, Pierre Michel Llorca, Rhonda Wilson, Ricardo Araya, Robin Kok, Sergi García Redondo, Sevim Mustafa, Søren Lange Nielsen, Ulrich Hegerl, Virginie Tsilibaris, Wissam Elhage, Ylenia Sacco,
Implementation Sci. 2024-07-11; 19(1):
DOI: 10.1186/s13012-024-01380-w


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Abstract
Background
The process of tailored implementation is ill-defined and under-explored. The ItFits-toolkit was developed and subsequently tested as a self-guided online platform to facilitate implementation of tailored strategies for internet-based cognitive behavioural therapy (iCBT) services. In ImpleMentAll, ItFits-toolkit had a small but positive effect on the primary outcome of iCBT normalisation. This paper investigates, from a qualitative perspective, how implementation teams developed and undertook tailored implementation using the toolkit within the trial.

Methods
Implementation teams in thirteen sites from nine countries (Europe and Australia) used the ItFits-toolkit for six months minimum, consistent with the trial protocol. A qualitative process evaluation was conducted. Descriptive data regarding goals, barriers, strategies, and implementation plans collected within the toolkit informed qualitative data collection in real time. Qualitative data included remote longitudinal interviews (n = 55) with implementation team members (n = 30) and observations of support calls (n = 19) with study sites. Qualitative data were analysed thematically, using a team-based approach.

Results
Implementation teams developed and executed tailored implementation projects across all steps in the toolkit process. Working in a structured way but with room for flexibility, decisions were shaped by team members’ ideas and goals, iterative stakeholder engagement, internal and external influences, and the context of the ImpleMentAll project. Although teams reported some positive impacts of their projects, ‘time’, both for undertaking the work, and for seeing project impacts, was described as a key factor in decisions about implementation strategies and assessments of success.

Conclusion
This study responds directly to McHugh et al.’s (2022) call for empirical description of what implementation tailoring looks like in action, in service settings. Self-guided facilitation of tailored implementation enables implementers in service settings to undertake tailoring within their organisations. Implementation tailoring takes considerable time and involves detailed work but can be supported through the provision of implementation science informed guidance and materials, iterative and ongoing stakeholder engagement, and working reflectively in response to external influencing factors. Directions for advancement of tailored implementation are suggested.

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