132 | Chapter 7 balance and strength. In Balance is provided by certified therapists, with a background in exercise- and physiotherapy. In 2006, In Balance was shown to be effective in reducing the amount of fallers in pre-frail older adults living in care centres (55) and has since then been implemented on a wide scale in the Netherlands. However, during the years the target group shifted to independently living older adults. Besides, the program duration has been shortened from twenty to fourteen weeks, because the largest physical improvements were seen in this initial period (55). To evaluate this widely implemented, yet adjusted program, we are currently conducting a randomized controlled trial with the aim to determine the (cost-)effectiveness of the In Balance program (198). However, the implementation in practice of such complex interventions often is difficult and results in adaptation of the program. Therefore, insight into the implementation process provides context to research findings and may identify barriers and facilitators for further implementation of the FPP and similar programs. Identifying experiences and perceptions of those involved is crucial to gain insight into how FPPs can be optimized, and provides insights to aid dissemination and implementation (66). Additionally, results of this study can provide new insights for the implementation of other FPPs in a real life setting (279). Therefore, the aim of this study was to conduct a process evaluation among FPP participants, therapists and other stakeholders to identify how the In Balance FPP can be optimized and further implemented. METHODS Study design, recruitment, and participants This process evaluation is part of a project in which we investigate the (cost-)effectiveness of the In Balance program (280). Recruitment of the FPP participants and therapists was done by mail, email, and telephone. For the stakeholder group, we invited people working at the municipal health services, municipality, elderly associations, Royal Dutch Society for Physical Therapy, Association of Cesar and Mensendieck Exercise Therapists, Consumer Safety Institute, and health care insurance companies. For the current study, we used a convergent parallel mixed methods design. This design includes that the quantitative and qualitative parts of the study are performed independently, and their results are interpreted together (281). For the quantitative part, FPP participants and certified therapists who provided the program were asked to participate in this study and to fill out a questionnaire about their experiences with the program. The qualitative part
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