The purpose of this study was to address the problem of how national PA recommendations can be translated into practice involving change agents of PA promotion. Through a comprehensive consideration of their situation and context, we identified facilitators and obstacles that have to be considered in dissemination strategies. Recommendations for action are highlighted in italic letters. A summary of the recommended actions is provided in Additional file 1.
The first aim of this study was to investigate the change agents’ perceived relevance and knowledge concerning PA and PA promotion. Overall, PA and PA promotion were of high to very high perceived relevance to all change agents. None of the experts considered the topic to be unimportant. In addition to the aspect of health promotion, social interaction, physical and social development of children and adolescents, and de-escalation of violence were cited as reasons for the importance of PA and PA promotion. Although scientific studies show that the economic relevance of PA is considerable [6, 7], only one change agent mentioned this as a motive for engaging in PA promotion. To strengthen the importance of PA promotion, especially at the political level, it seems necessary to focus more on the financial consequences of a lack of PA and to communicate the results of relevant studies to decision-makers.
In their occupation and organization, about half of the change agents assigned high priority to PA and PA promotion. The topic was of low relevance to the sporting goods manufacturers and the department of urban planning. Due to their high level of popularity and their marketing budget, sporting goods manufacturers, in particular, have great potential for the dissemination of PA recommendations . Actors that are not directly involved in health and PA promotion often do not realize that they play a significant role in this context . It is therefore important to develop strategies on how to integrate such change agents from non-health sectors into networks of PA promotion. Concerning sporting goods manufacturers, a decisive step would be to give prominence to the economic advantages of an engagement in PA promotion, e.g., if they take up the topic in a marketing campaign. To persuade stakeholders in urban and transport planning, it is important to present the topic in a broader context, e.g., emphasizing quality of life instead of PA promotion, and to focus on the ecological relevance of PA promotion, such as sustainable mobility and climate protection .
Some change agents delegated responsibility for disseminating PA recommendations to other authorities emphasizing that the relevance of PA and PA promotion is not in their hands but depends heavily on political decisions and the focus and management of individual institutions. A lack of coordination, the absence of a strategic plan, and the failure to take responsibility are phenomena frequently observed also in other countries, hampering the dissemination of national PA recommendations [42, 43]. At this point, it is important to better involve change agents in dissemination strategies and to appeal to their personal responsibility for implementing PA recommendations.
Although the majority of change agents rated their knowledge in the field of PA effects and PA promotion as good or very good, about half had not yet heard of the NRPP. Strikingly, this concerned some change agents from the educational, social, and workplace environment who have direct contact with target groups. It seems that there is an intuitive rather than a systematic approach to NRPP implementation in Germany. One of the next steps should be to make the NRPP known across sectors with a special focus on change agents interacting directly with relevant target groups in order to bring more structure into the dissemination and implementation process.
The second aim of this study was to analyze the change agents’ needs with regard to the implementation of the NRPP in specific settings. To give NRPP dissemination a higher priority on the political agenda, the establishment of a national authority responsible for PA promotion is needed. Furthermore, there needs to be closer cooperation and networking of relevant change agents at the national, state, and community level. This is in line with the demands of previous research to form intersectoral networks to solve complex health problems, such as physical inactivity, by combining core competencies and resources, creating synergies, and working more effectively on solutions involving different perspectives [37, 44–46]. Drawing on findings from research on network governance , a central institution for PA could act as an administrative unit that initiates and manages networks of relevant actors at the national level.
Within the infrastructure environment, more public PA spaces are needed. Here, urban and landscape planning play an important role. Not only should the planning specifications be changed regarding the design of PA promoting environments but there must also be a change in awareness so that urban planners become aware of their responsibility concerning the implementation of the NRPP.
PA and PA promotion should become a larger part of the vocational training of educational and health care staff as these topics seem to be currently underrepresented. In particular, teaching staff needs to be adequately qualified with regard to high-quality and multi-faceted physical education, in which health skills are taught.
Overall, more financial incentives should be provided for the dissemination of the NRPP with regard to different target groups. In the health sector, a stronger focus on disease prevention is required . Physicians should be able to charge for the prescription of PA and health insurance companies should be rewarded for realizing sustainable NRPP implementation instead of one-off campaigns aiming at member recruitment. For individuals, more attractive reward systems and financial resources for high-quality PA programs are required. Financial incentives should also be used to encourage sports clubs to focus more on offers that explicitly aim at fulfilling PA recommendations. Finally, the suggestion was made to increase the tax allowance for companies that are committed to promoting PA among their employees. To ensure that more financial resources are available regarding PA promotion, again a national institute for PA that has the appropriate resources would be important.
To ensure that greater attention is paid to the topic of PA promotion, a change in social norms and awareness as well as health education are needed so that the importance of PA and sport is anchored in the consciousness throughout society but also becomes more present in certain settings and among certain target groups (e.g., employers, educational staff, departments of urban planning). This requires, among other things, a clearly elaborated communication concept that is disseminated through media campaigns, especially involving social media. However, it has to be taken into account that the effectiveness of stand-alone mass-media campaigns in PA promotion is still unclear. It seems more effective to embed such campaigns into broader multicomponent interventions . Also, care should be taken to comprehensively cover all relevant contents of PA recommendations and to develop different communication concepts for different target groups . In addition, there should be a comprehensible and compact online representation of national PA recommendations which is easily accessible to everyone.
The findings show that there is disagreement as to whether structured training programs or fun-focused PA in everyday life are more effective in implementing the NRPP. Among other things, this highlights the need for concrete information, working aids, and methodological kits that can support change agents in implementing suitable, scientifically based measures of PA promotion. It is essential for this purpose that change agents are addressed in a transdisciplinary approach of science and practice to translate the scientific findings of the NRPP into political implementation strategies, medical treatment strategies, and specific PA promoting measures useful in practice tailored to the respective setting . Such an approach could also lead to change agents taking more responsibility for the implementation of jointly developed programs.
Besides the provision of more attractive PA programs for all age groups provided by sports clubs as well as the development of easily accessible public and digital PA programs, the implementation of PA recommendations should be structurally anchored in the settings where people live, learn and work. This includes the establishment of a PA-friendly organizational culture and flexible working hours by employers as well as PA breaks and programs that are firmly anchored in the daily routine of educational institutions supported by the respective management.
Schools, kindergartens, and organized sport are considered central settings for PA promotion . However, the respective change agents point out some problems that currently hamper the implementation of the NRPP, such as too rigid daily routines, a lack of staff qualifications, a lack of space (e.g., gymnasiums and swimming pools), the cancellation of physical education, the shortage of financial resources and a lack of awareness on the part of kindergarten, school, and sports club administrators. In addition, performance orientation in physical education and sports clubs would leave very little room for more general approaches to PA promotion. These findings are also supported by existing literature [52, 53]. In this context, it is even more important to appeal to the personal responsibility of sports clubs and educational institutions to critically question their performance orientation and to better fulfill their educational and social mission [52, 54–56].
To solve obstacles to the dissemination and implementation of PA recommendations in settings such as educational institutions, the workplace, or the health care setting, appropriate resources have to be provided. These can ensure that the personnel, time, and spatial capacities needed to carry out adequate PA promotion are covered.
Referring back to Diffusion of Innovations Theory , one could assign the change agents as well as their needs to the different phases of the innovation-decision process (Fig. 1). As individual actors alter their position towards an innovation according to external influences, this process underlies dynamic changes and therefore provides various starting points to the dissemination of PA recommendations. Change agents have different needs depending on the stage they are in and therefore they have to be addressed accordingly to successfully involve them in the dissemination and implementation of PA recommendations. Since some change agents had not yet heard of the NRPP or even had no connection to the topic of PA promotion, such as the representative of the urban planning department, we added a further phase to the model, the ignorance phase. Change agents in this phase need to be informed about PA recommendations and convinced that PA promotion is a relevant topic to them so that they move on to the knowledge and persuasion phase. One of the sporting goods manufacturers was convinced that the NRPP and PA promotion are something worth striving for but had not yet decided to engage in NRPP dissemination which is why he could be assigned to the persuasion phase. To move on to the decision phase, change agents must be made aware of the advantages of an engagement in the dissemination of PA recommendations, e.g., by focusing on the economic, societal, or ecological benefits. Change agents in the decision phase, such as the primary care physician, were willing to implement the NRPP but did not yet proceed systematically. At this stage, appropriate financial resources, working aids, and practicable information that support change agents in implementing PA recommendations are needed. Some change agents (e.g., from the fitness and health center or the health insurance company) could be assigned to the implementation phase since they used the NRPP in a structured way in their daily work. These change agents need to be supported through appropriate resources and political backing to keep their implementation decision valid.
The major strength of this study is the consideration of needs on the policy and behavior setting level going beyond individual sectors of society: The present study is one of the first to involve stakeholders from various sectors of society and administrative levels in the development of a national dissemination strategy of PA recommendations. Furthermore, extensive data material was collected and analyzed ensuring high credibility of the study findings. Transferability was guaranteed through a thick description of contextual conditions and participants surveyed. Finally, intercoder reliability and self-reflection of the researchers during the research process ensured dependability and confirmability of the study findings. However, some limitations have to be mentioned: The study findings cannot readily be generalized. The change agents’ statements are based on subjective opinions, depending on their individual situation and context. Thus, some of the needs cited might be linked to predominant conditions (organizational structure, relevance of PA promotion, financial, spatial, and personnel capacities) of specific settings. Moreover, the majority of respondents were male. A greater diversity of interviewees and a more balanced ratio of women and men may have led to additional or different needs related to NRPP dissemination. To verify, if these findings are representative and applicable to other organizations of the same type, in-depth needs analysis of individual settings are necessary. Finally, the aspect of social desirability based on the interview situation must be taken into account. When asking the respondents about their motives for an engagement in PA promotion, altruistic motives, such as health promotion, may have been given preference over, e.g., economic motives.