5 The effectiveness of a nation-wide implemented fall prevention intervention in the Netherlands | 73 BACKGROUND About 30% of the adults of 65 years or older experience at least one fall per year (225). Of them, 20% causes potentially life-threatening injuries (226) and about 50% suffers from fear of falling (227). Specifically in the Netherlands, 33% of the adults of 65 years or older fall at least once per year, of which 10% require treatment at an emergency department. The direct medical costs after a fall were estimated at 1,4 billion euros in 2023 (2). The consequences of falls are associated with decreased quality of life and high healthcare and societal costs (24). The number of falls, fall-related injuries and associated healthcare costs are expected to rise further due to the ageing population (2). The alarming repercussions of falls underscore the essential need for preventing falls and fall-related injuries (135, 136). Fall prevention interventions have been proven to reduce the number of falls and injuries in older adults (46). However, the practical implementation of these interventions often encounters barriers that may negatively affect effectiveness (59). As a result, programs are adjusted when implemented in practice, for example by adapting the frequency and duration of sessions, a more diverse target population, and inconsistent aftercare, which have been associated with reduced effectiveness (228-230). Furthermore, challenges such as lack of resources, insufficient training for therapists, and resistance from participants can hinder the successful implementation of these interventions (228, 230, 231). These practical barriers may impact the effectiveness of fall prevention interventions, highlighting the importance of re-evaluating the effectiveness of implemented fall prevention interventions. An example of such an implemented fall prevention intervention is the ‘In Balance’ intervention, which is based on the core elements of fall prevention, including balance and strength training, education on fall risk, home environment modifications, and promoting continuity of exercise (47-49). In 2006, Faber and colleagues showed that the 20-week precursor to the current In Balance intervention, conducted in a residential care setting, led to a 61% reduction in fall risk among pre-frail older adults in a residential care setting (55). However, since its initial evaluation, several modifications have been made to the program including a shift in target population from frail to primarily community-dwelling non- and pre-frail older adults, as well as a reduction in program duration from twenty to fourteen weeks. While prior research has demonstrated the effectiveness of the original program, it remains unclear whether these adaptations have influenced its impact in real-world settings. A re-evaluation of the effectiveness of the In Balance program can provide insights into whether and how to further implement and utilise such a fall prevention program as effectively as possible. In another study, we conducted a process evaluation to assess its implementation in real-world practice. This evaluation, based on both qualitative and quantitative data,
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