Implementation of the Ironbark falls prevention program: a mixed methods process evaluation with Aboriginal communities

BACKGROUND: Falls are a leading cause of injury and loss of independence among older Aboriginal people. The Ironbark program is a culturally co-designed, community-based fall prevention initiative, incorporating exercises and Yarning circles, a culturally grounded form of group discussion. This paper presents a process evaluation of the program, examining fidelity and key factors influencing implementation across settings. METHODS: Sixteen sites across two Australian states implemented the Ironbark Standing Strong and Tall program. Process data were collected from 15 sites through structured session observations and semi-structured interviews with exercise facilitators. Fidelity and dose were assessed quantitatively, with adherence scored using a summative checklist score. Qualitative data were thematically analysed and mapped onto the Consolidated Framework for Implementation Research (CFIR). RESULTS: The program was delivered with high fidelity to 117 participants with median adherence scores consistently above 80%. Sessions were implemented as planned, with strong participant engagement in both exercise and Yarning components. Key facilitators included Aboriginal leadership, trusted site managers, program flexibility and supportive service structures. Challenges included managing varying physical abilities, maintaining engagement over time and external disruptions (e.g. Coronavirus -19 pandemic, weather). Content repetition was noted as a barrier to sustained attendance by participants in later stages. Facilitators recommended additional training, mid-program assessments and access to site-collected data. Sustainability was linked to workforce capacity and securing ongoing funding, particularly to support Aboriginal staff and transport. CONCLUSION: This process evaluation indicated that a culturally-relevant fall prevention program for older Aboriginal people can be implemented with fidelity across community settings. Findings provide practical guidance for exercise facilitators and on sustaining and expanding the Ironbark program and inform broader efforts to embed culturally safe, community-led health programs in routine practice.