160 | Chapter 8 unit of effect gained, the probability that the In Balance program was cost-effective compared to usual care was 98%. Based on the process evaluation study described in Chapter 7 (as described in the study protocol in Chapter 3), we concluded that the translation of complex intervention programs such as the In Balance fall prevention intervention from research settings into clinical practice is difficult. There is still a lack of insight into factors that influence successful implementation. Therefore, the aim of this study was to conduct a process evaluation among In Balance participants, therapists and stakeholders involved with In Balance. Overall, 93% of the 104 participants was satisfied with the In Balance program. Of the therapists, 86% (n=12) would recommend the In Balance intervention to older adults with balance or mobility difficulties, and thus an increased fall risk. Within the qualitative data we identified six themes that are important for further and sustainable implementation: (1) Recruiting and motivating older adults to participate, (2) Structure and content of the program, (3) Awareness, confidence and physical effects, (4) Training with peers, (5) Funding and costs, and (6) Long-term continuation. This process evaluation resulted in practical recommendations for optimizing and further implementing the In Balance fall prevention program and is also generalizable to other fall prevention programs. GENERAL DISCUSSION Understanding physical activity and functional status in relation to falls and fall-related injuries Physical activity We expected an association between physical activity, falls and fractures, yet we did not find such an association in Chapter 2, neither in frail, nor in non-frail older adults. Thus, we suggest that healthcare providers should emphasize the broad health benefits of physical activity, such as improved balance and mobility, while also considering specific individual risk factors for falling (26, 49). Although not addressed as such in the In Balance program, such an encouragement may cause a side effect of the intervention or is a starting point for physical activity in the future. In our trial (Chapter 5), physical activity levels, defined as the total duration in hours per day of classified activity episodes of walking, stair walking and cycling combined, remained stable over time among non- and pre-frail participants, with no significant differences between the intervention and control groups (Table 8.1). Apparently, participants of our study did not perceive the program as a stepping stone to further activity during and or after following the program (179, 300). Nor did the control group decline more in terms of physical activity levels
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