88 | Chapter 5 per-protocol analysis. However, given the large number of non-significant findings, these results should be interpreted with caution. Nonetheless, all differences were in favor of the intervention group. Analyses stratified for frailty and per-protocol analyses showed similar results. There are various possible explanations for these findings. First, although the core elements of effective fall prevention programs were maintained in the In Balance intervention, the shortened duration (14 weeks) with unaltered frequency (two times per week) of the program might be insufficient to achieve the desired health effects within this time frame (136). Reviews suggest that fall prevention interventions should comprise at least 26 weeks to obtain significant effects (136). Extending the intervention is currently not feasible within the Dutch health care system, but there is a pathway for transition into regular follow-up exercise programs (243). Therefore, the In Balance intervention can serve as a stepping-stone toward long-term effects on physical activity and fall prevention, provided that exercises are continued. The process evaluation of the In Balance intervention showed that some municipalities offered follow-up exercise programs, but most did not yet (232). Second, low adherence to the In Balance intervention may have also contributed to the lack of significant results, with an average of 15.5 out of 24 sessions (65%) attended. However, the per-protocol analysis also showed no significant effect of the In Balance intervention. The 65% adherence we found in this study is in line with a meta-analysis that found an average adherence of 66% in fall prevention programs, while 80% adherence is recommended for fall prevention programs including exercise (229, 244). Comparing our study with the effectiveness study of the precursor of the program by Faber and colleagues, both showed that the In Balance fall prevention program can affect fall rates and functional performance, yet with differing outcomes (55). Faber and colleagues observed higher fall risk among frail participants and improvements in pre-frail individuals. Their study was conducted in an institutional setting, and additionally, the target group was later extended to non- and pre-frail older adults. Based on the results of Faber and colleagues, we expected that the non-frail population would benefit even more from the In Balance intervention. In contrast, our study showed no significant reduction in falls or fall-related injuries compared to usual care, nor significant differences in secondary outcomes like balance and mobility and between non- and pre-frail older adults. This discrepancies between the study of Faber and colleagues and our study could be attributed to differences in target group, setting, and program duration. For example, the institutional setting in Faber’s study might have offered a more controlled environment for delivering the program, which could lead to better adherence and more consistent implementation, potentially enhancing the intervention’s effectiveness. In the Netherlands, fall risk is assessed based on several factors, including
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