5 The effectiveness of a nation-wide implemented fall prevention intervention in the Netherlands | 89 whether a person has fallen in the past 12 months, concerns about falling, difficulties with movement, walking, or balance, and the 4-meter walk test as an objective measure of fall risk (40, 41, 235). With this broad approach, In Balance is not only aimed at those with a high risk of falling but also at individuals with an increased risk, for whom preventive measures can help reduce the likelihood of future falls. This raises the question what the most appropriate target population of the In Balance intervention is. According to recommendations from a review of Sherrington and colleagues, fall prevention interventions should be targeted at older adults in the general community as well as community-dwelling older adults with an increased risk of falls (179). Our study findings align with these recommendations. Specifically, we observed that the risk of falls was non-significantly lower with approximately 20% among non-frail individuals who participated in the intervention compared to those who did not, in contrast with a 12% lower risk of falls among pre-frail participants. These results highlight the benefits of also targeting non-frail older adults with the In Balance program. There was a 15% difference in the mean number of falls between the intervention and control group, whereas earlier studies showed a reduction of 17% to 39% in the number of falls after exercise interventions, depending on the type of exercise (balance, functional, and resistance exercises) and the delivery method (effect is higher if there is more than 3 hours of exercise per week for at least 26 weeks) (136). Approximately 62% of the intervention group and 66% of the control group, consisting of older adults with increased fall risk, experienced at least one fall during the one-year follow-up, which is considerably higher than the 33% reported in the literature for the general population of older adults, and also higher than the 19% found in a study within the Canadian Longitudinal Study on Aging of 2022 (245). This could possibly be explained because this study monitored falls by asking the question whether a participant fell in the past 12 months instead of prospective monitoring of falls. The intensive follow-up with fall diaries and monthly telephone calls likely resulted in more accurate reporting, which could explain the higher percentages compared to other studies. Moreover, depending on the population, between 20% and 60% of older people suffer from fall-related injuries (246, 247). In our study we found that a relatively high number of 43% of the In Balance group suffered from an injury and this was 50% in the control group. A strength of this study is that the In Balance intervention was already implemented in practice, allowing us to evaluate its effectiveness in a real-world setting. This pragmatic design enhances the external validity of our findings, as it reflects the actual conditions under which the intervention is delivered. Additionally, using robust methods to reduce bias, such as blinded outcome assessment and intention-to-treat analysis, strengthens the credibility of
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