Implementation evaluation of the EMBOLDEN program: perceived effectiveness and factors influencing implementation

Background: Mobility decline is associated with negative health outcomes and can reduce older adults’ quality of life. EMBOLDEN, a 3-month integrated care (primary care, public health, and municipal recreation) intervention, was co-designed with older adults and service providers to promote mobility and health in older adults through physical activity, healthy eating, socialization, and system navigation. The intervention was delivered through a group-based program and up to 3 individually-delivered system navigation sessions. We tested the new intervention plus usual care compared to usual care alone through a pragmatic randomized controlled trial. 

Approach: An implementation evaluation was conducted to understand 1) the perceived effectiveness of EMBOLDEN from the perspective of participants and interventionists, and 2) factors influencing implementation. EMBOLDEN was implemented in English (7 community sites) and Mandarin (1 site) in Hamilton, Ontario, Canada. Using maximal variability sampling, 4-6 intervention participants per site were invited to participate in individual semi-structured telephone interviews. Interventionists were invited to participate in virtual focus groups. Interviews were recorded and transcribed. Two independent coders performed thematic analysis; codes and themes were generated inductively and organized around the intervention components (physical activity, healthy eating, socialization, and system navigation) and the Consolidated Framework for Implementation Research 2.0. Weekly fidelity documentation and monthly research-intervention team meeting notes were also analyzed.

Adaptations for delivery in Mandarin included culturally appropriate recipes, educational topics, and exercise components (e.g., Tai Chi balance exercises). Program materials (e.g., nutrition, physical activity, and community resources) were translated into Simplified Chinese, and Mandarin-speaking Kinesiology students supported program delivery.

Results: A total of 45 participant interviews were completed. Age ranged from 57-91 years; the majority identified as women (64%) and lived alone (51%). Participant ethnicity was 76% White, 18% Chinese and 11% Black. A total of 10 interventionists were interviewed through three focus groups. Participants reported increased levels of physical activity (e.g., frequency of being active, walking more); increased motivation to be more physically active; increased mobility, energy, strength, balance, and flexibility; and increased knowledge about new exercises and equipment. Participants reported increased knowledge/awareness of healthy eating and cooking strategies and changes in eating habits (e.g., increased plant-based proteins and decreased processed foods). Participants also indicated improvements in mental health and mood. Participants felt less socially isolated and increased their peer learning, social connections, and awareness/ engagement with community programs and resources. The broad age-relevant themes of the program (e.g., mobility, social connection, nutrition) and engaging program facilitators were frequently reported when asked ‘what worked well’ about EMBOLDEN.

Implementation facilitators included organizational support for program delivery and adapting to context and strategies provided by research partners. Barriers included recruitment challenges in some communities, existing initiatives that targeted similar populations, and a lack of community resources for specific populations (e.g., Mandarin-speaking older adults).

Implications: Both English- and Mandarin-speaking participants reported positive experiences with the EMBOLDEN program, high levels of satisfaction, and positive impacts associated with multiple program components. The program was feasible, participants found it engaging and perceived that their health, mobility, and  well-being improved.