Scope and Limitations

Participants in this study volunteered predominantly from the Western/Northern suburbs of Melbourne representing a variety of independent living conditions. While the data obtained from this study enabled us to evaluate the feasibility and effectiveness of the outdoor senior exercise parks as well as older adults’ acceptability and perceptions towards this initiative, caution must be taken in generalising these findings to a wider Australian population or other older adults’ population across the globe. Conducting a similar trial across multiple sites across Australia or the globe would potentially make it possible to evaluate its effectiveness for individuals from different socioeconomic backgrounds and in different climatic regions.

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This study had a relatively modest sample size. Additionally, due to budget limitations, this study was not blinded and the principal researcher was conducting the assessments, the randomization and the exercise intervention. Also, a disparity in gender where more females volunteered to be part of this study was observed although there are indeed more older women than men living in Australia[308]. Similarly, there was an unequal number of fallers/non fallers recruited in the study. Therefore, further research is needed with a more homogeneous sample of older adults.

It has been reported that some participants who do not receive their preferred treatment may experience “resentful demoralisation” [151], may not comply with the program structure proposed, may not report accurate responses on the follow-up appointments and may even drop out from the trial [197]. This might have introduced some bias which may have possibly affected the internal validity of the trial. The project tried to control for this by asking participants their preference before randomization. Preference was then taken into account when analysing and interpreting the results. However, it is likely that some of the limitations of randomized controlled trial designs influenced findings.

Moreover, when participants of a research intervention are not allocated to their preferred option in the research project (i.e. the exercise intervention group) and end up allocated to a control group, they tend to engage more in other activities (e.g., attend gym sessions, join exercise groups or do more home exercises) [272]. One of the possible reasons for that could be that they do not want to be left behind while others are supposedly going to benefit from an intervention. Most participants who volunteer to a research intervention have potentially made a decision about the possibility of becoming more active and taking up more physical activities/exercise into their life (i.e., moved into the action stage as proposed in the Transtheoretical Model of Behavior

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Change) [273]. In the action stage of this model, making a change in habits is typically overt and observable [273].

As most randomized controlled trials, this project did not control for the potential external engagement on other physical activities or reduction on physical activities levels among participants in the CG. Some of these participants in the CG may have sought alternative treatment or become less active as a response to their disappointment for being randomized to the control group[309]. This, in turn, could potentially show a much bigger effect to the exercise intervention proposed. However, the information regarding changes on their levels of physical activity of participants in both groups was partly evaluated and accounted for in the analyses via the Incidental and Planned Exercise Questionnaire. An alternative would be to measure objectively physical activity behaviour prior to trial commencement using accelerometer and do this again towards the end. Although this is not without limitations and would enhance trial cost significantly.

In addition, some of the participants’ improvements reported in this thesis (e.g., muscle strength, balance, physical function and physical self-worth) may have been a consequence of the placebo effect [310]. Literature has shown the effect of encouragement and education on the improvement of outcome measures post- participation in randomized control trials and real clinical settings[311]. For example, participants during the exercise intervention may have received some encouragement and education about the benefits of the exercises they were performing and this may have contributed to the improvements reported. Also, the principal researcher conducting the assessments was also the one conducting the exercise intervention. As a result, some form of relationship between the researcher and the participants might have been developed. Thus, during the re-assessments, participants may have put extra

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efforts during tests to achieve better results and please the researcher. Although randomized controlled trials are still considered the gold standard in examining the efficacy of interventions there is a realisation that in behavioural change studies (e.g., exercise/physical activity or nutrition) these abovementioned factors may be problematic to the validity of these trials [312].

The BOOMER test battery was chosen as the primary outcome but appeared not adequately sensitive to the population group studied. Previous research on the BOOMER has only used older adults in geriatric and rehabilitation units [157]. Participants in the present study were mostly healthy and independent community dwelling older adults. Hence, the lack of improvement could be a reflection of a ceiling effect or the intervention proposed was not long or intense enough to demonstrate significant improvements in this measure.

It is believed that the involvement, adherence and attendance to this project could have been higher if the senior exercise park had been installed in a location more easily accessible by public transport and in a more central suburb of Melbourne. The exercise park used in this study was installed on a private property (i.e., at the St Bernadette’s Community Respite House, Catholic Homes) and moderately away from public transport. This, in turn, limited participation to those older adults who could drive to the site of the exercise park or organize their attendance by other means (e.g., taxi or family member dropping them off). Furthermore, the location of the exercise park also affected the recruitment of participants whereas installation of the exercise park in more central locations of Melbourne would allow seniors who live in less central suburbs to also volunteer and benefit from this initiative.

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The implementation of the senior exercise park project required some financial investments to prepare the land for the installation of the exercise park and to pay for qualified exercise supervisors to ensure safety of participants during exercise sessions. Specifically in this project, this preparation included the application of a soft fall and rubber surfacing to prevent slippages and also promote some cushioning in case of falls. Additionally, it was necessary to pay for a partial coverage of the exercise park area with a non-water proof shade sail to protect participants from direct sunlight in hot days. All of these mentioned points incur initial investment costs. Future studies, therefore, should also consider an economic evaluation of such initiative to examine whether it is a cost-effective way to prevent falls and or reduce health cost associated with falls in older individuals in the community.

Despite these limitations, the results of this study provide new insight on how older adults respond to this novel and unique outdoor exercise program as well the feasibility and effectiveness in reducing fall risks. Furthermore, this study was able to report the possible health benefits and well-being improvements for older people when using the senior exercise park.