1 General introduction | 13 Second, in response to these challenges and evolving needs, changes are often made after the implementation of fall prevention interventions (60). For example, when implementing the In Balance intervention, the focus shifted from frail people living in nursing homes to both non-frail and pre-frail independently living older adults (55). Additionally, the intervention duration has been shortened from twenty to fourteen weeks, due to indications that the largest physical improvements are seen in this initial period (55). Cost-effectiveness analyses aim to inform healthcare allocation decisions by considering both costs and consequences of two or more decision alternatives (61), yet studies on the cost-effectiveness of fall prevention interventions are scarce according to a recent systematic review (62). Decision makers require comprehensive data on both the effectiveness and cost-effectiveness of healthcare interventions to allocate (63). Cost-effectiveness analyses are essential (64, 65). These studies provide a quantitative basis for comparing the value of different interventions (64). Despite its widespread implementation in the Netherlands, no previous cost-effectiveness study has been conducted before on the In Balance intervention. Process evaluation The translation of complex fall prevention interventions into clinical practice often lacks comprehensive insight into the factors influencing successful implementation (59). A thorough understanding of these factors is crucial as it provides contextual understanding of research findings and identifies barriers and facilitators for (further) implementation (59). Process evaluations in which the experiences and perceptions of stakeholders, participants, and providers are captured, provide valuable insights to enhance fall prevention interventions, guide effective dissemination, and develop successful implementation strategies (66). By addressing practical aspects of implementation, these evaluations ensure that interventions like In Balance achieve their intended outcomes in real-world settings. Objectives and outline of the thesis The primary aim of my thesis was to assess the (cost-)effectiveness of the widely implemented In Balance intervention, as well as to evaluate the process of its implementation. Moreover, we first investigated associations between falls and fall-related injuries on the one hand and physical activity and functional status on the other hand. Below follows a short overview of each chapter of this thesis addressing these aims. In Chapter 2, we first investigate the associations between physical activity and both falls and fractures, and we examine whether frailty status modifies these associations using data from the Longitudinal Aging Study Amsterdam (LASA study).
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