## 7 Conclusions: Lessons Learned and Future Directions  
The feasibility cluster-randomized control trial and its qualitative component produced several useful findings. Attitudes toward falls and the fear of falling are similar to that reported in the global literature but have not been reported in South African participants to date. Given the diverse linguistic and cultural groups, future work should explore falls and related constructs in different settings to establish the need and awareness of fall interventions. For instance, it is not known if falls are a taboo subject in certain ethnic groups. Moreover, the health and societal consequences of falls are likely to be no different in an ageing population in an emerging region. Whereas Afro-centric communities have a tradition of family responsibility and intergenerational care [80] similar to that of filial piety in Asia [81], scholars are questioning the erosion of such values, meaning that state resources will have to be provided to care for older adults [80]. Thus, efforts aimed at fall prevention should be prioritized. This feasibility study is a first step toward larger-scale studies and, eventually, programme implementation. Balancing adherence and attrition is important, and this study showed that while intervention participants availed themselves for follow-up assessments, allowing the collection of quantitative data to support preliminary evaluations of improvements in balance and possible reduction of fall risk, their exercise dose was sub-optimal. Low levels of adherence have been reported for both randomized control trials and fall prevention programmes. From a developing country perspective, sub-optimal participation is especially concerning where research funding is limited, and researchers have an ethical imperative to ensure their work is relevant to the population they serve rather than burdensome. Having older adults and their communities involved in every stage of the research design might alert researchers to potential issues which could impact the results of a fully powered study. Finally, maintaining the 'personal touch' could have underpinned the lack of attrition, but not supported adherence, so realizing older adults' appreciation of participant-centred contact is an important lesson for success in future trials. The WBB intervention was designed and implemented by physiotherapists, and participants articulated the benefit to balance (upheld by physical endpoints such as improvements in TUG scores, preferred walking speed and MiniBESTest). Whereas the SUS suggested that participants had mastered the technology of the WBB and found it user-friendly, the exergaming avatar produced irritation. Negative affective responses might have reduced enthusiasm to engage with the intervention, an impact which would appear to be contrary to one of the'selling points' of exergaming, that is, fun and immersion. Briefer warm-up periods and more explanation of the improvements and their meaning for falls could be built into future programmes. Although participants noted that the completion of a calendar on which exercise sessions, walks and falls were recorded was, at times, motivating, it also induced feelingsof guilt when participants did not do so regularly. Both the OEP and WBB interventions had monthly follow-up (either a phone call or personal visit by the physiotherapist). However, more regular follow-up could have enhanced motivation. A possible solution could be to consider an app-based reminder and feedback system. Most (\(\approx\)80%) South Africans have access to smartphones [82], although research suggests that older adults prefer to use the devices for calls or texts rather than accessing apps [83]. Moreover, owning a mobile phone does not necessarily imply competence with it [84], so the interface would have to be user-friendly and uncluttered. With the proliferation of telehealth partially spurred by the current pandemic, advances in tailoring programmes for older adults can be expected.