Intervention level factors.

Different factors played a fundamental role at this level and served as facilitators of the sports initiative, including relative advantage, adaptability, and intervention source. According to the literature, when the interested parties consider that the innovation’s implementation has an unquestionable benefit and advantage in effectiveness, its application will be more likely to be successful [20]. Moreover, this knowledge about advantages contributes to positive attitudes towards initiatives that influence the effort to demonstrate the initiative’s benefits, which will also help its implementation [36]. Therefore, relative advantage is an indispensable premise for an innovation to be accepted and implemented [37]. In line with the literature, our study participants showed a perceived relative advantage from the project as they manifested that offering sports initiatives for PwD within their clubs gave them a higher positioning than other sports clubs by offering more courses and inclusive programs. Additionally, participants stated that the project was very beneficial for PwD, as sports opportunities for this population are scarce but necessary due to their positive impact on physical, mental and social health. This perception of the projects’ advantages impacted practice because participants made a great effort to compromise with the project and demonstrate its efficacy. The practical application of these results might be translated into future sports initiatives involving educational strategies among PA providers and their settings that promote knowledge about benefits and advantages of PA in PwD. This may raise dementia awareness and future efforts to make sporting opportunities available to this population.

Adaptability was also an important implementation facilitator factor. A project that can easily be adjusted to address specific community needs has a higher chance of successful implementation [33, 38]. Results of this study support the previous statement as participants recognized that the project was easily modified to meet specific local need. For example, participants indicated that the project was adapted to the needs expressed by the association trainers, who stated that memory problems were becoming more and more evident in the long-term members. However, they needed more knowledge and tools to work with these members. Thus, their initiative within the project offered training courses for STs on dementia and sports to address lack of information manifested by STs. Moreover, they recognized that training sessions were a significant step forward and might have influenced the success of the project implementation as STs felt more self-confident and empowered to work with the target population. In this way, adaptability should be considered in practice when developing and applying PA initiatives. Those responsible for developing proposals should know their context’s needs and define core components (elements that cannot be changed) to ensure the implementation is relevant to their target population and adaptable periphery components (elements that can be changed of the innovation) to allow flexibility and adaptation for a variety of contexts [39].

Intervention source also stood out as a facilitating factor for the interviewees. In line with previous literature, a positive perception, whether the project is externally or internally developed, play an essential role in influencing effective implementation [33, 40]. Our results prove that study participants positively perceived that the project originated from external organizations (e.g. DOSB, DAlzG). They saw them as reputable, credible and trustable organizations which encouraged participation among actors to make decision and supported implementation providing from the beginning expertise, solutions, and previous efforts that served as a solid base for the subsequent execution of the project within the sports associations. In such a manner, involved actors from future PA strategies must perceive that change is not imposed on them by intervention sources; on the contrary, actors should feel included in the decision-making process when building change [40]. Those agents who impose change with low participation of those concerned are more likely to be ineffective in implementation [41]. Therefore, the success of the implementation will depend on the trust generated based on the participation between the source of the intervention and the participants.

In contrast, the complexity of the initiative was perceived as a relevant barrier influencing the initiative’s success. Complexity is defined by multiple interacting elements that often bring out low participation rates, variability in context, content, mode of application and uncertainty of the impact [42]. According to the CFIR framework, the perceived complexity of implementation at the interventional level also influences the effective execution of the project [32]. Our results show that participants expressed high complexity in developing sports initiatives aimed at PwD. These difficulties interfered with project implementation, affecting, in most cases, the number of PwD involved. Mainly, the complexity of the intervention, affecting low participation rates, resulted from three components: 1) Behavioral components and actions on behalf of the target population. For instance, PwD evidenced fearful behaviors when revealing their diagnosis to others. Especially people in the early stages of dementia were afraid to admit their diagnosis when participating in the sports initiative designed for PwD. Consequently, they preferred not to take part in these kinds of initiatives. Moreover, low motivation levels were also noticed among PwD as they manifested beliefs such as “working out requires more effort than the benefits it brings; I am too old to start exercising”. These results are consistent with findings from previous studies, showing that loss of motivation in PA is present in at least 70% of PwD [43, 44]. Likewise, low willingness was noticed from caregivers to bring and accompany persons with dementia in the sports sessions; 2) Community components, where sports associations manifested that dementia in their sports clubs was a fearful topic as STs and members lacked awareness and had a negative attitude against the disease; And 3) Contextual component, characterized by the COVID-19 pandemic, which interfered with the PA project implementation and participation of PwD as STs were forced to change their initial implementation ideas, adapt and restructure their plans according to the new restrictions and provide activities and spaces where it was safe to practice sports. Thus, those insights into the intervention’s complexity may be helpful for the successful implementation of future initiatives. The ability to illustrate and reproduce intervention’s complexity matters, given their extensive application across health and social support services and the increased concern for improving our understanding of their efficacy and outcomes [45]. Eventually, to illustrate project’s complexity, might lead to an in-depth comprehension of their action processes and impacts, i.e., how and why they operate in a particular setting [46]. In this particular project, the perceived complexity at the intervention level demonstrates that there is still a great need to sensitize and educate sports clubs and communities about the disease. Also, it is necessary to target motivational levels, including intra- and interpersonal aspects, when developing sports initiatives for PwD, such as preferred and enjoyable PA offers, promoting positive experiences and attitudes towards PA, and providing social support [13, 47]. Finally, the pandemic highlighted the importance of having PLs and STs responsible for PA initiatives with the resources and time to adjust plans and develop new ideas according to the inconveniences that might arise during implementation.

Individual level factors.

At the individual level, three main facilitators were found for successful sports initiative implementation: motivation, knowledge and beliefs about the intervention and self-efficacy. According to the CFIR framework, the individual level emphasizes the significance of people’s roles and features in the innovation’s execution and delivery, mainly since individuals’ actions and behaviors drive the project’s implementation and personal attributes also mediate the effective delivery of the project [32]. This study supports this statement as highly motivated and self-confident PLs and STs implemented the project despite the various challenges that such an initiative entails. Thus, care practice and future PA initiatives for PwD should capture and incorporate strategies to enhance PA provider’s motivation, knowledge and beliefs about the intervention and self-efficacy as determinants for successful implementation, as mentioned in the literature [48]. Motivation understood as the willingness of individuals to undertake an action because they are intellectually and emotionally connected to it [49]. Accordingly, when individuals are motivated, such enthusiasm can translate into the effective use of innovations as positive subjective opinions, personal experiences, perceptions, and attitudes towards a new behavior precede engagement and change [50, 51]. In addition, self-efficacy, individuals’ belief in their ability to carry out roles and make a change [52], is a relevant factor for the successful implementation of the initiatives because those who feel confident in their skills tend to be more motivated and committed to participating and implementing the proposals despite obstacles [20]. One helpful way to understand and improve the willingness and readiness of people involved in implementing initiatives is the Stages of Change Model (Transtheoretical Model), as it outlines the way an individual builds up new behaviors through different stages (pre-contemplation, contemplation, preparation, and action and maintenance) [53]. Different strategies can support individuals to move forward into the next phase and thus gradually move toward skillful, enthusiastic, confident and motivated PA providers who are needed to implement successful innovations [20].

Process level factors.

At the process levels, different determinants also played a fundamental role for successful implementation, including planning, formally appointed internal implementation leaders, engaging and execution. Different theories from the perspective of quality management and integrated care provide a set of principles that illustrate how implementations should be conducted to be successful, thus, most approaches agree on four activities: planning, engagement, implementation and evaluation [33]. Consistent with the literature, this study supports these theories as planning, engagement and implementation were used to implement the initiatives successfully. Nevertheless, it was not possible to implement an evaluation because evaluation processes exceeded the possibilities of non-profit associations in terms of staffing and lack of funding, which underlines that in future, such projects should focus on ensuring that there are enough resources to support projects at every stage. In this way, future programs could consider such implementation activities (planning, doing, evaluating) so that their projects have structures and processes to ensure sustained effort and change.

Inner setting level factors.

At the inner setting level, implementation climate, compatibility, learning climate, and available resources were facilitator factors for implementation. The CFIR framework states that the degree to which an intervention’s application is valued, supported, and expected within an organization impacts its success [32]. This is reflected in our results since the sports associations showed compatibility (with current work practices), had a positive implementation climate (receptiveness towards the initiative), provided a positive learning climate, and provided resources facilitating the project implementation. In particular, most participants indicated that it was essential for implementation that the project provided associations with resources, including financial support for covering costs associated with the payment of STs, the provision of materials, and the availability of educational opportunities. On the contrary, relative priority and communication were factors considered by participants as barriers for implementation. In this way, the inner setting should also be addressed within the practice as a factor that has an active role in interacting with the implementation. As such, future initiatives could include an objective description of their settings, i.e., specialization, size, maturity, and age, as these may be positively or negatively associated with implementation [54].

Outer setting level factors.

Finally, at the outer setting level, cosmopolitanism and external policy and incentives were influencing implementation factors. According to the literature, organizations that are supported and encouraged by external agents are more likely to implement new practices readily and sustain them over time [32]. This was reflected in the results of our assessment, as the participants stated that having a solid network, the support of DOSB and DAlzG, and active national policies allowed them access to the necessary resources to carry out the project. However, the participants remained concerned about the need for a more robust networks with other associations and relevant actors in this field (policymakers, PLs, STs, PwD, general practitioners, neurological clinics) for sustainable proposals as networking encourages active participation, exchange of knowledge, and funding opportunities [33]. Thus, for further sports initiatives to be implemented, should take into account macro-level factors, as connections and changes in the outer setting can positively or negatively impact the implementation.

Strengths and limitations.

Planning and delivering sports projects for PwD is challenging, as different interpersonal, organizational, and community factors influence the success of these initiatives. Therefore, this study corroborates the potential of the CFIR as a conceptual guide for the successful implementation of sports projects in PwD, mainly since it permits the identification of multilevel factors that will affect large-scale project application. Moreover, in this study, we have focused our attention on sport association and their sport clubs, contexts that play a crucial role in persons PA engagement in Germany because of the ongoing sport opportunities they provide to a large sector of the population. Therefore, we believe that having qualitative data from this precise context, provides important insights about factors and barriers that might support the development of future strategies to increase PA participation among PwD, optimize the benefits of PA and prolong the sustainability of such initiatives. When interpreting the results of the present study, account should be taken on the following limitation. While we sought to collect data on factors affecting the implementation of sports initiatives at different levels, we interviewed PLs and STs from the sports associations. Therefore, the interview responses and our findings represent the individual perspectives shared by PLs and STs, rather than the perspectives of PwD and their caregivers.