Table 4.

Barriers to implementation.

CFIRa domain and subdomainsb			Quotes
Innovation
	Adaptability (virtual delivery of CSTc)	“I was running face-to-face sessions before they started [vCST]. Face-to-face CST was great...my group ran with eight members, six to eight, consistently. So, I had a huge group coming every Friday. It was amazing, they could form more connections, and turn taking is a little bit easier...It’s a little harder like you with the Zoom.” [Group leader 2, India
	Innovation design (need for marketing)	“It doesn’t have much publicity. If it wasn’t for chance, if this person hadn’t put us in, I wouldn’t have made it. So, I think in terms of dissemination it could be broader.” [Caregiver 4, Brazil]
Outer setting
	Critical incidents (COVID-19 pandemic)	“It was COVID and people are falling sick...even the facilitators are sick, at some point.” [Group leader 1, India]
	Local attitudes (dementia awareness)	“In Brazil, I think it’s a cultural thing to think that dementia symptoms it’s part of a natural aging...So, when older people, and people living with dementia...come to a doctor to be evaluated they sometimes don’t have mild symptoms anymore.” [Group leader 2, Brazil]
	Local attitudes (traditional focus on medical model)	“People weren’t aware of psychosocial interventions for dementia prior to this. They had very different model for working with people with dementia.” [Decision maker 1, India]
	Local conditions (access to technology)	“Most of the people that we had in the groups were from the south eastern region. And that’s kind of a more developed region financially...I think today most people in Brazil have access to internet. Maybe not their computer, but maybe cell phones and something like that.” [Group leader 3, Brazil]
Inner setting
	Structural characteristics—work infrastructure (staff availability)	“When we think of scaling it up, we might have to do it first of all in institutions where there is enough manpower of mental health professionals to deliver the CST...dementia care in India is still mental health care and we’re still very under-resourced as far as manpower is concerned.” [Decision maker 2, India]
Individuals
	High-level leaders—capability (lack of dementia awareness)	“Some of the policymakers, who we interviewed at the beginning [in previous stakeholder engagement] weren’t even aware of the issues relating to dementia.” [Decision maker 1, India]
	Intervention deliverers—capability (basics in clinical skills needed)	“I think we if we didn’t have the training, it would be very hard to just come to the groups...I didn’t have any contact [with people with dementia] before.” [Group leader 3, Brazil]
	Intervention recipients—capability (sensory impairment and computer literacy)	“So, one challenge was delivering it virtually. My mother was not able to hear very well. Now she has a hearing aid, she has the headphones but still that was a part of a problem of communication.” [Caregiver 5, India] “I don’t know how to use the computer (laughs).” [Person with dementia 10, Brazil]
Implementation process
	Assessing needs—innovation recipients (severity of dementia)	“If you have some difference in severity of dementia, because the activities demand something, and maybe it can be boring for who is not so severe.” [Group leader 4, Brazil]
	Assessing needs—innovation recipients (baseline assessments)	“The first is, I think, the baseline evaluations were very long, and that was kind of hard on the, not on the people with dementia, but on their family members, the caregivers.” [Group leader 3, Brazil]
	Reflecting and evaluating—implementation (lack of long-term follow-up)	“One question that most people with dementia their caregivers made was, if it was possible to have more than 14 sessions. So maybe adapting the maintenance CST for the virtual program. I think it would be a suggestion for the future.” [Group leader 1, Brazil]

^aCFIR: Consolidated Framework for Implementation Research.

^bContext-specific descriptions are given in parentheses.

^cCST: cognitive stimulation therapy.