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

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.