162 | Chapter 8 Fall prevention As described above, physical activity and functional status are related to fall risk, which are both essential aspects within the In Balance intervention (Chapter 3). In Balance seeks to foster physical capacity and performance, a more active lifestyle, and hence to decrease older individuals’ fall risk. The (cost-)effectiveness and implementation challenges of the In Balance fall prevention intervention In Chapter 5, 6 and 7, the effectiveness and cost-effectiveness of the In Balance intervention were studied and additionally we conducted a process evaluation in a naturalistic randomized controlled trial that was highly representative of the actual conditions encountered in daily practice (59). Differences in falls, injuries, physical outcomes, Quality-Adjusted Life-Years (QALYs) and costs between groups were in favour of the In Balance group, although these differences were not statistically significant. This consistency in outcomes suggests potential benefits of the In Balance intervention, as well as room for improvement to increase effectiveness. Below, potential explanations for our findings in the (cost-)effectiveness study are outlined, along with suggestions for improving the In Balance program. Impact of adherence Attendance, a relevant part of adherence, to the In Balance program was relatively low, with participants attending an average only 15.5 out of 24 sessions (65%). Attendance was influenced by factors such as holidays, personal appointments, and health issues, as seen in another study (304). A previous study suggested that attendance levels of 80% or higher are associated with greater reductions in fall risk among community-dwelling older adults (229). However, in our per-protocol analyses, we only included all participants who attended 75% or more of the sessions, and found that effects were not larger compared to the main analysis that included all participants. This suggests that in our trial, higher attendance does not lead to better outcomes in reducing falls and injuries. This raises the possibility that even full participation in the program may not be sufficient to significantly reduce falls and injuries, which could be explained by the 14-week duration of In Balance being too short, as further elaborated below (305, 306). In the process evaluation (Chapter 7), we found that perceiving some degree of training effects is a motivating factor for attendance. Moreover, the group component of the intervention is also helpful for attendance. A last factor that potentially increases attendance is that the participants pay a small own contribution to increase motivation and commitment to keep participating in the program. While emphasizing the importance of attendance during recruitment and program initiation is vital, this alone has proven insufficient, as this was already done during the In Balance intervention. Additional strategies, such as offering flexible session times, integrating online or remote options, or organizing smaller groups to enhance community and commitment, could help overcome
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