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International Journal of
Environmental Research
and Public Health
Article
Outdoor Fitness Equipment Usage Behaviors in
Natural Settings
Hsueh-wen Chow * and Dai-Rong Wu
Graduate Institute of Physical Education, Health & Leisure Studies, National Cheng Kung University,
Tainan 70101, Taiwan; 40105901e@gmail.com
*Correspondence: hwchow@mail.ncku.edu.tw; Tel.: +886-62757575 (ext. 81806)
Received: 8 November 2018; Accepted: 25 January 2019; Published: 30 January 2019
Abstract:
Outdoor fitness equipment (OFE) areas have become a popular form of built environment
infrastructure in public open spaces as a means to improve public health through increased physical
activity. However, the benefits of using OFE are not consistent, and several OFE accidents have
been reported. In this study, we videotaped how OFE users operate OFE in parks and selected
four types of popular OFE (the waist twister, air walker, ski machine, and waist/back massager) for
video content analysis. Furthermore, we established coding schemes and compared results with
the instructions provided by OFE manufacturers. The results revealed various usage behaviors
for the same OFE types. In addition, we observed that a significant portion of user behaviors did
not follow manufacturers’ instructions, which might pose potential risks or actually cause injuries.
Children are especially prone to act improperly. This study provides empirical evidence indicating the
existence of potential safety risks due to inappropriate usage behaviors that might lead to accidents
and injuries while using OFE. This study provides crucial information that can be used to evaluate
the effectiveness of OFE and to develop future park or open space initiatives.
Keywords: fitness zone; outdoor gym; sports injury; park; built environment
1. Introduction
Although the benefits of physical activity have been well documented in many scientific studies
and public health campaigns [
1
], several surveys conducted by governments worldwide indicated that
their citizens do not meet desired physical activity levels [
2
]. To solve this problem, governments have
built physical exercise environments for public use. The effect of public physical exercise environments
on citizens’ actual daily physical activity has received considerable attention [3,4].
Among all physical activity–related built environments, parks play a crucial role in addressing the
issue of insufficient physical activity because most parks offer open spaces accessible to all, and entry
to these parks is free or inexpensive. Parks usually provide easy access within their geographical
proximity and are often equipped with exercise facilities, such as swimming pools and ball courts [
5
].
Recently, many parks worldwide have installed outdoor fitness equipment (OFE) to attract more
citizens to visit them and to engage in physical activities [
6
–
12
]. For example, Cohen reported that
parks in Los Angeles installed with OFE attracted new visitors and stimulated increased physical
activity [
6
]. In Sydney, the installation of OFE also increased park visits [
7
]; furthermore, the Health
Promotion Service in Sydney partnered with local health districts to promote increased physical
activity through the use of OFE [8].
The growing installation of OFE recently can be attributed to the fact that OFE areas have small
carbon footprints and are easy to build, practical, and enjoyable [
13
]. In addition, there is a strong public
demand for the provision of active environments that are easily accessible and inexpensive [
14
–
16
].
The installation of OFE in parks or open spaces has offered many benefits, including attracting new
Int. J. Environ. Res. Public Health 2019,16, 391; doi:10.3390/ijerph16030391 www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2019,16, 391 2 of 18
visitors and increasing the overall number of park visits [
6
–
8
], increasing engagement in physical
activities [
12
,
15
], improving perceptions of security [
12
], adding pleasant contributions to cities’
landscapes [12,17,18], and encouraging social interaction [7,15].
Only in the past decade have studies related to OFE directly addressed the benefits of using
OFE to individuals. These benefits include physical benefits, such as improved cardiorespiratory
fitness, muscle strength, balance, and flexibility [
8
,
19
,
20
]. However, to date, these studies have
reported limited and mixed results. For example, Nguyen and Raney found that after engaging in OFE
training, participants’ weight, body fat percentage, and waist circumference decreased significantly
and muscular endurance repetitions increased significantly. However, they did not observe an increase
in the index of cardiovascular ability (VO
2
max). This finding might be attributed to the fact that
unlike machines in indoor gyms, the resistance levels of most OFE cannot be adjusted to increase the
training effect [
11
]. Chow studied the effect of the intervention of OFE on older adults and reported
significant improvements in chair standing and 8-foot up-and-go tests when baseline (pretest) findings
were compared with post-test findings; however, these improvements decreased significantly from
the post-test to the retention test. No significant changes were detected for arm curl, 2-min walk,
chair sit-and-reach, and back scratch tests [21].
The benefits of OFE have not yet been fully explored, and adequate scientific results are not
available to support the idea that OFE can provide benefits such as increased aerobic and muscular
strength or balance and flexibility. The reason for this might be due to the presence of insufficient
specific instructions for using OFE, because a study that inspected all OFE facilities in Taipei and
Tainan parks found inadequate instructional labels for the proper use of equipment and recommended
durations or repetitions [
22
]. Moreover, an observational study indicated that many users use OFE
only for very short periods of time, which are insufficient to produce substantial health benefits [23].
Several studies have indicated that OFE poses many safety problems because of a lack of
surveillance and inadequate usage instructions. For example, a study reported that 79% of OFE
users developed health problems after using OFE and that 54% complained of muscle pain [
24
].
In addition, several studies have reported that many OFE accidents or sports injuries occurred because
users operated equipment incorrectly [
25
,
26
]. Xie found that 66.5% of OFE users in China reported
being injured after using OFE. Major factors attributing to injuries were the malfunction of equipment
(58.3%) and improper usage behavior (31.4%) [
25
]. While examining accidents or injuries related to
parks, many studies conducted between 1970 and 1990 have considered only playgrounds for children.
Many severe accidents, resulting in fractures, concussions, head injuries, use of ambulance services,
and extended hospital stays, have been reported. Studies have identified factors related to playground
injuries, including the playground environment, behaviors, and usage frequency, and such studies
have reported that after guidelines were established for playground safety (i.e., playground surface
and height), injuries associated with playgrounds decreased considerably [27–30].
Because the installation of OFE is a new feature in parks or open spaces in many regions
worldwide, a limited number of studies have investigated the risks of these types of equipment
based on operating methods and patterns. Observing how people use OFE in real settings can assist
in identifying problems that cause OFE accidents and injuries. Therefore, the present study was
conducted to understand OFE usage behaviors. The specific aims of this study were (1) to observe OFE
usage behaviors in real settings and to classify these behaviors, (2) to determine differences between
OFE usage behaviors and instructional behaviors, (3) to investigate whether differences in gender and
age groups can lead to different behaviors when using OFE, and (4) to assess the potential risks of each
OFE usage behavior.
2. Materials and Methods
In this study, we performed video content analysis, where video recordings of OFE users’
behaviors were examined and classified into different movement patterns.
Int. J. Environ. Res. Public Health 2019,16, 391 3 of 18
2.1. Video Content Analysis
To determine OFE usage behaviors in a natural environment, we used a video recording method
to track users’ explicit behaviors. These subjects had come to use the OFE on their own volition.
These videos allowed us to review actual OFE use and to conduct a scientific analysis of events
of interest [
31
]. Video data analyzed in this study were obtained from an earlier study, in which
park visitors in two parks in Tainan City, Taiwan, were videotaped while using OFE [
22
]. In brief,
these videos were filmed in Xihu Park in the summer of 2012 and in Dongning Park in the summer of
2015. Data were collected during 2-h peak periods in the morning and afternoon to observe more users.
Videos were recorded on both weekdays and weekends to include a wide range of user backgrounds
because more children and youths visited parks during the weekend. Additional details were described
elsewhere [23]. A total of 28 h of video footage was analyzed in this study.
These videos were valuable in identifying the patterns of OFE use because these recordings
recorded individuals’ real behaviors in a field environment instead of in a controlled laboratory setting.
Recordings used in this study were approved by the Internal Review Board of National Cheng Kung
University (IRB_ER-99-375) [
23
], and the analysis of materials was approved by the Human Ethics
Committee of National Cheng Kung University (REC_105-065). The Mangold INTERACT software
program (Interact; Mangold International GmbH, Arnstorf, Germany), a professional behavioral
analysis tool, was used in this study because of its three advantages: (1) objectivity (the analysis
is objective); (2) repeatability (replicable results can be obtained from the same conditions); and (3)
comprehensibility (findings are easily understandable). This software is a multifunctional platform
that can implement behavioral event coding, behavioral data graphing, and analysis [31].
2.2. OFE Equipment for Analysis
In this study, a waist twister (Colisy; Community Lifestyle Co. Ltd., Taipei, Taiwan), air walker
(HUNGJWU Co., Ltd., Tainan, Taiwan), ski machine (Colisy; Community Lifestyle Co. Ltd., Taipei,
Taiwan), and waist/back massager (Timix; Community Lifestyle Co. Ltd., Taipei, Taiwan) were
selected as our targets for analysis, because these four types of equipment were popular among
users [
22
,
23
]. Each OFE user who performed movements on these four equipment types was coded.
Each individual was identified by gender (male/female), age group (children/youth/adults/seniors),
and usage behaviors and durations. In addition, because individuals might change their OFE usage
behaviors for the same equipment, the total behavior counts were recorded.
2.3. Coding Methods
To classify usage behaviors, we first checked the labels or operation instructions provided by
manufacturers for each OFE. If the behavior followed the instructions, users were coded as having
followed the indicated behavior. For example, the designed motion of the triple waist twister is to
“turn the waist,” so the indicated behavior of the triple waist twister is “standing in front of equipment
to turn the waist” and was coded as code WT-1. Behaviors that were nonindicative were coded based
on how individuals used each piece of OFE. A description for each behavior code was created to
illustrate each behavior (see Tables A1–A4).
To ensure the reliability of categorizing usage behaviors among different researchers, an inter-rater
reliability test was performed between independent raters to assess the consistency with which they
rated users’ gender, age, and behaviors while using OFE. All raters had received professional training
in the use of the Mangold INTERACT software program (Mangold International GmbH, Arnstorf,
Germany). In this study, the main rater first reviewed all videos, created coding schemes, and shared
the schemes with the second rater. Then, an hour-long video recording for each type of equipment was
randomly selected to examine inter-rater reliability. The resulting Cohen’s kappa value acquired within
the software averaged 0.83, 0.75, and 0.84 for gender, age, and behavior, respectively. These results
were considered to have acceptable reliability.
Int. J. Environ. Res. Public Health 2019,16, 391 4 of 18
2.4. Data Analysis
Statistical analysis was performed using SPSS (IBM statistics v.22.0, Armonk, NY: IBM Corp.)
for descriptive statistics and crosstab Pearson’s chi-square test to compare proportions of the
(non)indicative OFE behaviors of different gender and age groups. Significance levels were set at 0.05.
The Bonferroni method was used in post-hoc tests, with correction for alpha inflation, for comparing
distributions among four age groups. Furthermore, R software was adopted to conduct Fisher’s exact
test when the expected frequency was less than five in any group.
2.5. Expert Panel Interview
An interdisciplinary panel of experts from the backgrounds of physical therapy, sports science,
fitness training, and mechanical engineering was invited to critically evaluate potential sports injuries
or accidental risks and benefits of each usage behavior. The videos of each OFE behavior coded in the
early phase of this study were presented to the experts during the interview session, and discussions
were tape-recorded and transcribed for data analysis. General themes for overall OFE use and for each
identified behavior that emerged from the discussion were recognized. To ensure the accuracy of data
and analysis, all transcribed data and a summary of expert panel interviews were returned to each
expert for confirmation.
3. Results
3.1. User Characteristics
Among the four types of OFE analyzed in this study from video recordings, the air walker
(
n = 195
) had the highest user count, followed by the triple waist twister (n = 142), ski machine (n = 96),
and waist/back massager (n = 60). More female OFE users (63%) than male OFE users were observed.
In terms of age group, seniors represented the highest proportion of users (47%). The distribution of
gender and age in terms of the four types of OFE is shown in Figure 1.
Int. J. Environ. Res. Public Health 2019, 16, x 5 of 21
Figure 1. Observed outdoor fitness equipment (OFE) user counts in terms of age and gender for each
piece of equipment.
3.2. User Behaviors of OFE
From the field setting, we observed that OFE users used the same equipment in different
manners. For example, for the air walker, most users strode in the reverse direction, standing in
front of the equipment (AW-1), whereas other users used two legs to stride in the same direction
simultaneously (AW-2), and others exercised with their back turned to the equipment (AW-3). We
categorized seven types of user behaviors for the triple waist twister, air walker, and ski machine,
and six types of user behaviors for the waist/back massager (see Appendix for detailed descriptions
of movement patterns for each coding scheme). The observed frequencies for each type of behavior
are presented in Figure 2. In addition, individuals might change their behavior for the same
equipment. For example, one might use the air walker in AW-1 behavior and later change to AW-2
behavior; this was recorded as once for the user count (same individual) but twice for the behavior
count (1 in AW-1 and 1 in AW-2). The same person using multiple types of equipment was coded
for one user count but was coded for multiple behavior counts for behaviors identified for each
observed OFE. Therefore, we also summarized behavior counts for each piece of equipment (please
see Figure 2 & Table 1). All behavior counts were higher than user counts, indicating that many
users changed their behaviors for a single type of equipment. The average durations of most
behaviors were very short.
3.3. Percentage of Indicative OFE User Behaviors
We further classified behaviors as “indicative behaviors” if they were in line with instructions
provided by equipment manufacturers, whereas all other behaviors were classified as
“nonindicative behaviors.” User behaviors for the triple waist twister (WT-1), air walker (AW-1),
and ski machine (S-1) that complied with manufacturers’ instructions were coded as 1, and user
behaviors for the waist/back massager (WM-1 and WM-2) that complied with manufacturer’s
instructions were coded as 1 or 2. Nonindicative behaviors accounted for 30% of our observations
18
8
38
78
18
8
38
78
22
9
31 34
13
2
19
26
0
10
20
30
40
50
60
70
80
90
Children
Teen
Adult
Senior
Children
Teen
Adult
Senior
Children
Teen
Adult
Senior
Children
Teen
Adult
Senior
Triple Waist Twister Air-Walker Ski Machine Waist and Back Massager
Female Male Total
Figure 1. Observed outdoor fitness equipment (OFE) user counts in terms of age and gender for each
piece of equipment.
3.2. User Behaviors of OFE
From the field setting, we observed that OFE users used the same equipment in different manners.
For example, for the air walker, most users strode in the reverse direction, standing in front of the
equipment (AW-1), whereas other users used two legs to stride in the same direction simultaneously
Int. J. Environ. Res. Public Health 2019,16, 391 5 of 18
(AW-2), and others exercised with their back turned to the equipment (AW-3). We categorized seven
types of user behaviors for the triple waist twister, air walker, and ski machine, and six types of
user behaviors for the waist/back massager (see Appendix Afor detailed descriptions of movement
patterns for each coding scheme). The observed frequencies for each type of behavior are presented in
Figure 2. In addition, individuals might change their behavior for the same equipment. For example,
one might use the air walker in AW-1 behavior and later change to AW-2 behavior; this was recorded
as once for the user count (same individual) but twice for the behavior count (1 in AW-1 and 1 in
AW-2). The same person using multiple types of equipment was coded for one user count but was
coded for multiple behavior counts for behaviors identified for each observed OFE. Therefore, we also
summarized behavior counts for each piece of equipment (please see Figure 2& Table 1). All behavior
counts were higher than user counts, indicating that many users changed their behaviors for a single
type of equipment. The average durations of most behaviors were very short.
Int. J. Environ. Res. Public Health 2019, 16, x 6 of 21
for the triple waist twister, 45% for the air walker, 45% for the ski machine, and 36% for the
waist/back massager (Figure 2).
Figure 2. Coding schemes and observed counts, percentages, and duration for four OFE.
Figure 2. Coding schemes and observed counts, percentages, and duration for four OFE.
Int. J. Environ. Res. Public Health 2019,16, 391 6 of 18
3.3. Percentage of Indicative OFE User Behaviors
We further classified behaviors as “indicative behaviors” if they were in line with instructions
provided by equipment manufacturers, whereas all other behaviors were classified as “nonindicative
behaviors.” User behaviors for the triple waist twister (WT-1), air walker (AW-1), and ski machine (S-1)
that complied with manufacturers’ instructions were coded as 1, and user behaviors for the waist/back
massager (WM-1 and WM-2) that complied with manufacturer’s instructions were coded as 1 or 2.
Nonindicative behaviors accounted for 30% of our observations for the triple waist twister, 45% for the
air walker, 45% for the ski machine, and 36% for the waist/back massager (Figure 2).
3.4. Differences in OFE Usage Behaviors among Different Genders and Age Groups
The results of the chi-square test showed no relationship between gender and the frequency of
nonindicative behaviors (X
2triple waist twister
= 1.506, p= .22; X
2air walker
= 0.113, p= .736; X
2ski machine
=
2.4, p= .121; X2waist and back massager = 0.016, p= .9). For age groups, significant differences were found
only for the air walker and ski machine (Table 1). For both the air walker and ski machine, a higher
percentage of nonindicative behaviors was observed in children and seniors than in those in other age
groups (Figures 3and 4).
Int. J. Environ. Res. Public Health 2019, 16, x 1 of 21
Figure 3. Post-hoc test results of user groups and indicative behaviors for the air walker.
Figure 4. Post-hoc test results of user groups and indicative behaviors for the ski machine.
3.5. Results of Expert Panel’s Evaluations
From the discussion and evaluation of the expert panel, four major themes for proper OFE use
were identified. These include (1) design and safety, (2) correct posture and operation, (3) individual’s
ability, and (4) alternative behaviors. First, the experts found that many pieces of OFE in Taiwan are
equipped with unsteady pedals or platforms and do not have adjustable resistance functions.
Therefore, OFE users require careful control of their center of gravity to maintain balance and prevent
a fall. Users who use equipment with no resistance function tend to stretch over their limit or perform
movements rapidly without stopping. Thus, extra caution should be taken. Second, the expert panel
believed that although the design of OFE is not ideal, if users are mindful of operating the equipment
with correct postures and operation methods, they can achieve desired training goals. By contrast, if
users do not use the equipment correctly, for example, if users always stretch their joint too far,
exceeding their maximal degree of motion, it is likely to result in injuries in the long term. Third, the
expert panel emphasized that major differences exist in terms of fitness levels or skills among users.
Thus, individuals should adjust intensities or durations based on their abilities. Finally, after
Figure 3. Post-hoc test results of user groups and indicative behaviors for the air walker.
Int. J. Environ. Res. Public Health 2019, 16, x 1 of 21
Figure 3. Post-hoc test results of user groups and indicative behaviors for the air walker.
Figure 4. Post-hoc test results of user groups and indicative behaviors for the ski machine.
3.5. Results of Expert Panel’s Evaluations
From the discussion and evaluation of the expert panel, four major themes for proper OFE use
were identified. These include (1) design and safety, (2) correct posture and operation, (3) individual’s
ability, and (4) alternative behaviors. First, the experts found that many pieces of OFE in Taiwan are
equipped with unsteady pedals or platforms and do not have adjustable resistance functions.
Therefore, OFE users require careful control of their center of gravity to maintain balance and prevent
a fall. Users who use equipment with no resistance function tend to stretch over their limit or perform
movements rapidly without stopping. Thus, extra caution should be taken. Second, the expert panel
believed that although the design of OFE is not ideal, if users are mindful of operating the equipment
with correct postures and operation methods, they can achieve desired training goals. By contrast, if
users do not use the equipment correctly, for example, if users always stretch their joint too far,
exceeding their maximal degree of motion, it is likely to result in injuries in the long term. Third, the
expert panel emphasized that major differences exist in terms of fitness levels or skills among users.
Thus, individuals should adjust intensities or durations based on their abilities. Finally, after
Figure 4. Post-hoc test results of user groups and indicative behaviors for the ski machine.
Int. J. Environ. Res. Public Health 2019,16, 391 7 of 18
Table 1. Pearson’s chi-square test for the age group and non (indicative) behavior for each type of equipment.
OFE Triple Waist Twister Air Walker Ski Machine Waist/Back Massager
Users counts 142 195 96 60
Behaviors Indicative
behavior Count
(%)
Non- indicative
behavior Count
(%)
Indicative
behavior Count
(%)
Non- indicative
behavior Count
(%)
Indicative
behavior Count
(%)
Non- indicative
behavior Count
(%)
Indicative
behavior Count
(%)
Non- indicative
behavior Count
(%)
Age groups
Children 15 (7.8%) 7 (3.7%) 10 (3.2%) 36 (11.3%) 11 (8.0%) 25 (18.4%) 8 (8.3%) 9 (9.4%)
Teenager 7 (3.6%) 2 (1.0%) 6 (1.9%) 5 (1.5%) 7 (5.1%) 8 (5.9%) 2 (2.0%) 0 (0%)
Adult 38 (19.7%) 20 (10.3%) 65 (20.4%) 44 (13.8%) 26 (19.1%) 15 (11.0%) 23 (24.0%) 12 (12.5%)
Senior 75 (38.9%) 29 (15.0%) 93 (29.2%) 60 (18.8%) 31 (22.8%) 13 (9.6%) 29 (30.3%) 13 (13.5%)
Total
(=Behavior counts) 135 (70%) 58 (30%) 174 (54.7%) 145 (45.4%) 75 (55%) 61 (44.9%) 62 (64.6%) 34 (35.4%)
Chi-squared 1.07 23.51 *** 14.54 ** 3.76
p-value .8052 .0005 .002 .363
OFE—Outdoor fitness equipment, Note: ** p< .01, *** p< .001.
Int. J. Environ. Res. Public Health 2019,16, 391 8 of 18
3.5. Results of Expert Panel’s Evaluations
From the discussion and evaluation of the expert panel, four major themes for proper OFE use
were identified. These include (1) design and safety, (2) correct posture and operation, (3) individual’s
ability, and (4) alternative behaviors. First, the experts found that many pieces of OFE in Taiwan
are equipped with unsteady pedals or platforms and do not have adjustable resistance functions.
Therefore, OFE users require careful control of their center of gravity to maintain balance and prevent
a fall. Users who use equipment with no resistance function tend to stretch over their limit or perform
movements rapidly without stopping. Thus, extra caution should be taken. Second, the expert panel
believed that although the design of OFE is not ideal, if users are mindful of operating the equipment
with correct postures and operation methods, they can achieve desired training goals. By contrast,
if users do not use the equipment correctly, for example, if users always stretch their joint too far,
exceeding their maximal degree of motion, it is likely to result in injuries in the long term. Third,
the expert panel emphasized that major differences exist in terms of fitness levels or skills among users.
Thus, individuals should adjust intensities or durations based on their abilities. Finally, after reviewing
all coded behaviors, the experts agreed that not all nonindicative behaviors are risky. For example,
WM-6, wherein users performed upper body pushups on the waist and back massager, is considered
harmless and accepted by experts as the training goal is to increase upper body strength instead of
massage. The expert panel recommended that it is essential for users to first recognize the training
goals (i.e., endurance, muscular strength, flexibility, or balance) of each behavior, then select proper
equipment, and finally perform the behavior with correct postures and operation methods. Misuse of
OFE might eventually result in injuries that offset the good intention of increasing physical activity for
the benefit of public health. The expert panel also concluded that safety should be the first priority for
related authorities.
4. Discussion
4.1. Various Types of OFE Usage Behavior
The provision of OFE has become a popular built environment infrastructure choice in public
open spaces as a means to improve public health through increased physical activity [
10
,
14
,
32
]. To our
knowledge, no study has investigated the actual use of OFE, even though this can provide crucial
information for evaluating the effectiveness of OFE and develop future park or open space initiatives.
The results of this study revealed that participants presented a variety of behaviors for the same OFE.
For example, for the air walker, seven different behaviors were identified based on our real field video
recordings and coding schemes, indicating that many users did not follow indicative behaviors labeled
by manufactures. A previous interview study indicated that many users merely mimic how others
use the equipment because no information session was conducted after installing the OFE and many
instructions were absent [
15
]. In addition, we found that some users may change their behaviors
while using the same OFE. This might be because users felt sore after using the same posture/pattern,
users wanted to increase the difficulty of using the OFE, or users wanted to explore different behaviors
for fun. The design of the equipment cannot restrict users to particular approaches to using OFE,
which can lead to potential injuries due to several risky nonindicative user behaviors. The results are
also in line with previous research indicating that users operated the OFE only for short periods of
duration [23].
4.2. Potential Risks of OFE Usage Behaviors
Among various OFE usage behaviors, although some nonindicative behaviors were found to
be harmless, many behaviors presented a potential safety risk. The results of this study revealed
that user behaviors for the triple waist twister, air walker, ski machine, and waist/back massager
respectively followed manufacturers’ instructions only 70%, 55%, 55%, and 64% of the time that they
were used. This finding indicates that approximately half of the user behavior counts for the air walker
Int. J. Environ. Res. Public Health 2019,16, 391 9 of 18
and ski machine did not follow suggested instructions for preventing risks or injuries. The expert
panel identified that many users could lose their balance because they stood on only one pedal (e.g.,
AW-6 and S-5) or they did not face the equipment (e.g., WT-2, AW-3, AW-5, AW-6, S-5, and S-6).
Some users strode too fast or the amplitude of their sway was too large (e.g., AW-2, AW-4, AW-5, S-2,
and S-4); these actions may strain or sprain the lower body or waist because the sudden stretching
of ligaments above users’ limits is likely to tear muscle fibers or tendons. Some users twisted their
waists too fast or exceeded the twisting angle appropriate for that individual (e.g., WT-5 and WT-6);
these actions may strain or sprain the waist because it is pulled too far out of its normal range.
Using OFE correctly is important to prevent injuries or other health problems. We did not observe
any confirmed injuries from our video data. However, several news reports have described OFE
accidents [
33
,
34
]. Attention should be focused on improper OFE usage behavior because it might not
result in acute sports injuries or severe accidents immediately, but it can more likely result in chronic
sports injuries or pain over time. Studies have indicated that many OFE sites do not have instructional
signage or users do not pay attention to instructions that are provided, which can lead to accidents
resulting from the misuse of OFE [
15
,
23
]. Because of misuse or inappropriate actions, the health
benefits associated with the installation of OFE may not be achieved. In addition, several chronic or
acute injuries resulting from misuse of OFE can limit or prevent physical activity participation, leading
to poor health.
4.3. OFE Usage Behaviors: Age Differences
In this study, most of the users were seniors (47%); this finding is in line with those of previous
studies [
8
,
20
,
23
]. In addition, a high proportion of seniors performed nonindicative behaviors.
This might be because many older adults lack the knowledge or confidence to use OFE correctly [15].
In addition, our results showed that many children were interested in using OFE, even though many
OFE sites or fitness zones are designed for adults. Compared with other age groups, children are
more likely to be attracted to play equipment and tend to be more physically active in the open
spaces of a public park [
35
,
36
]. The findings of this study revealed that children were more likely to
perform nonindicative behaviors than other age groups. Therefore, children are more prone to be
injured. Many pieces of OFE are not designed for children, and numerous fitness zones equipped
with OFE have set age restrictions. However, because many of these pieces of OFE are placed in
non-supervised open spaces, such as parks or open green spaces, it is difficult to prevent children from
using OFE even if it has clear instructions indicating the minimum age and height requirements for
users. Such equipment is usually not suitable for children and may jeopardize their safety.
OFE has been popular as a means for promoting public health by engaging the public in active
living. To our knowledge, this is the first study to provide empirical data regarding OFE usage
behaviors. This study has identified, in real settings, user behaviors in various forms while using four
popular types of OFE. The study results indicated that a significant number of behaviors in the field do
not follow instructions provided by manufacturers for operating their OFE. Although some alternative
behaviors are anodyne, most of the observed nonindicative behaviors were not safe, as indicated by
the experts. This study has raised crucial questions regarding the safety of using OFE, which have
significant implications for governmental policies and manufacturers. Because several OFE accidents
have been reported [
33
], it is important for the government and for manufacturers to carefully consider
these safety issues while installing this type of equipment in public places.
5. Conclusions
The installation of OFE in public spaces has become increasingly popular as a means to encourage
the public to become more physically active and socially connected. However, this study provides
empirical evidence indicating that there are potential safety risks in the manner in which many
people use OFE, which might lead to accidents and injuries that can result in issues of liability for
manufacturers or related authorities. The results of this study suggest that manufacturers should
Int. J. Environ. Res. Public Health 2019,16, 391 10 of 18
provide clear equipment operation guides (or demonstration videos) on the correct use of their
equipment and warning messages regarding risky behaviors. Manufacturers should also design OFE
with suitable ranges of swing angles or fixed operating positions. Governments or local authorities that
authorize or sponsor the installation of OFE might conduct instructional sessions in which professional
trainers can explain how to use OFE properly, safely, and effectively in order to meet each individual’s
capability and fitness level [
8
,
10
,
16
]. This is especially required for older adults who might lack
confidence when using the equipment [
9
,
37
]. Information sessions should also target parents with
children, emphasizing the risks posed to children in adult-only OFE areas. These instructional sessions
can also serve as marketing strategies to attract park visitors or to promote new OFE sites [8].
Two limitations of this study should be noted. First, because we used video recordings in real
settings instead of in a controlled laboratory, coding schemes could not objectively measure the details
of behaviors in terms of the twisting angle, the amplitude of sway, the range of motions of a joint,
or operating speed. Second, we analyzed only the manner in which people used the four popular OFE
types in Taiwan. Thus, our results may not be fully generalizable to other equipment types or regions.
Despite these limitations, the findings of this study have many crucial implications for future practice.
For example, governments can formulate clear policies and regulations concerning safety issues before
building fitness zones or installing OFE. Manufacturers can design and develop equipment that meets
certain principles of safety, ergonomics, and maintainability. Park authorities can conduct sessions to
provide user guidelines to the public in the community and implement effective promotional strategies.
For example, governments can attach a label to the equipment with a quick response (QR) code that
links to a video demonstrating how to use each OFE appropriately. Park managers can post warning
signs to restrict children from using OFE and routinely monitor and manage OFE areas.
This study has raised many questions that require further investigation. Future research should
explore other types of OFE and other user behaviors and determine whether different OFE designs
lead to different patterns of use. For instance, studies can determine whether an OFE with a swing
function (e.g., an air walker) can more likely result in nonindicative behaviors. Furthermore, future
research should broadly survey OFE users or those who quit using OFE in terms of their OFE-related
injury/accident experience and identify behaviors that are associated with these accidents. Another
study could invite participants to perform different OFE behaviors observed in this study and use
electromyography to detect the activation of corresponding muscles to clearly illustrate the effect
of different behaviors on the human body and identify potential risks or benefits and the physical
effectiveness inherent in each of these fitness training behaviors. This research has identified several
behaviors commonly used by the public while using OFE and has offered many opportunities for
future scientific inquiry. Ensuring the safety of OFE users should be a priority when promoting public
health through the encouragement of active lifestyles.
Author Contributions:
H.C. conceived the design, analyzed the literature, designed graph and wrote/edited
the manuscript. D.-R.W. analyzed the data and drafted the manuscript. All authors read and approved the
final manuscript.
Funding:
The research was funded by National Cheng Kung University. The funder had no involvement in data
analysis, data interpretation or writing of the paper.
Acknowledgments:
The authors would like to thank I-Yao Fang, Cheng-Fend Lin, Shih-Wen Lo and Dian-Siang
Huang, for their expertise and valuable comments on OFE usage behavior and potential benefits/risks.
Conflicts of Interest:
The authors declare that they have no conflict of interest. The funders had no role in the
design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the
decision to publish the results.
Int. J. Environ. Res. Public Health 2019,16, 391 11 of 18
Appendix A
Table A1. Depictions of user behaviors for the triple waist twister.
Coding Number Behavior Movement
WT-1 Turn the waist, standing
in front of equipment
Int. J. Environ. Res. Public Health 2018, 15, x FOR PEER REVIEW 5 of 21
Appendix S1. Depictions of user behaviors for the triple waist twister
Coding
number Behavior Movement
WT-1 Turn the waist, standing in
front of equipment
WT-2
Turn the waist, standing
with back turned to the
equipment
WT-3 Turn the waist, squatting in
front of the equipment
WT-2
Turn the waist, standing
with back turned to the
equipment
Int. J. Environ. Res. Public Health 2018, 15, x FOR PEER REVIEW 5 of 21
Appendix S1. Depictions of user behaviors for the triple waist twister
Coding
number Behavior Movement
WT-1 Turn the waist, standing in
front of equipment
WT-2
Turn the waist, standing
with back turned to the
equipment
WT-3 Turn the waist, squatting in
front of the equipment
WT-3 Turn the waist, squatting
in front of the equipment
Int. J. Environ. Res. Public Health 2018, 15, x FOR PEER REVIEW 5 of 21
Appendix S1. Depictions of user behaviors for the triple waist twister
Coding
number Behavior Movement
WT-1 Turn the waist, standing in
front of equipment
WT-2
Turn the waist, standing
with back turned to the
equipment
WT-3 Turn the waist, squatting in
front of the equipment
WT-4 Lower body exercise
Int. J. Environ. Res. Public Health 2018, 15, x FOR PEER REVIEW 6 of 21
Coding
number Behavior Movement
WT-4 Lower body exercise
WT-5 Rotation: 360 degrees
WT-6
Both hands sway while
rotating 360 degrees slowly
or rotating randomly in any
degree range
Int. J. Environ. Res. Public Health 2019,16, 391 12 of 18
Table A1. Cont.
Coding Number Behavior Movement
WT-5 Rotation: 360 degrees
Int. J. Environ. Res. Public Health 2018, 15, x FOR PEER REVIEW 6 of 21
Coding
number Behavior Movement
WT-4 Lower body exercise
WT-5 Rotation: 360 degrees
WT-6
Both hands sway while
rotating 360 degrees slowly
or rotating randomly in any
degree range
WT-6
Both hands sway while
rotating 360 degrees
slowly or rotating
randomly in any degree
range
Int. J. Environ. Res. Public Health 2018, 15, x FOR PEER REVIEW 6 of 21
Coding
number Behavior Movement
WT-4 Lower body exercise
WT-5 Rotation: 360 degrees
WT-6
Both hands sway while
rotating 360 degrees slowly
or rotating randomly in any
degree range
Table A2. Depictions of user behaviors for the air walker.
Coding Number Behavior Movement
AW-1
Stride in reverse
direction, standing in
front of equipment
Int. J. Environ. Res. Public Health 2018, 15, x FOR PEER REVIEW 7 of 21
Appendix S2 Depictions of user behaviors for the air walker.
Coding
number Behavior Movement
AW-1
Stride in reverse direction,
standing in front of
equipment
AW-2 Two legs stride in the same
direction
AW-3
Stride in reverse direction
with back turned to the
equipment
AW-2 Two legs stride in the
same direction
Int. J. Environ. Res. Public Health 2018, 15, x FOR PEER REVIEW 7 of 21
Appendix S2 Depictions of user behaviors for the air walker.
Coding
number Behavior Movement
AW-1
Stride in reverse direction,
standing in front of
equipment
AW-2 Two legs stride in the same
direction
AW-3
Stride in reverse direction
with back turned to the
equipment
Int. J. Environ. Res. Public Health 2019,16, 391 13 of 18
Table A2. Cont.
Coding Number Behavior Movement
AW-3
Stride in reverse
direction with back
turned to the equipment
Int. J. Environ. Res. Public Health 2018, 15, x FOR PEER REVIEW 7 of 21
Appendix S2 Depictions of user behaviors for the air walker.
Coding
number Behavior Movement
AW-1
Stride in reverse direction,
standing in front of
equipment
AW-2 Two legs stride in the same
direction
AW-3
Stride in reverse direction
with back turned to the
equipment
AW-4
Stride with one leg,
standing in front of the
equipment
Int. J. Environ. Res. Public Health 2018, 15, x FOR PEER REVIEW 8 of 21
Coding
number Behavior Movement
AW-4
Stride with one leg,
standing in front of the
equipment
AW-5
Stride with one leg with
back turned to the
equipment, another leg
standing on the land
AW-6 Stand on the same pedal
with side lateral to stride
AW-5
Stride with one leg with
back turned to the
equipment, another leg
standing on the land
Int. J. Environ. Res. Public Health 2018, 15, x FOR PEER REVIEW 8 of 21
Coding
number Behavior Movement
AW-4
Stride with one leg,
standing in front of the
equipment
AW-5
Stride with one leg with
back turned to the
equipment, another leg
standing on the land
AW-6 Stand on the same pedal
with side lateral to stride
AW-6 Stand on the same pedal
with side lateral to stride
Int. J. Environ. Res. Public Health 2018, 15, x FOR PEER REVIEW 8 of 21
Coding
number Behavior Movement
AW-4
Stride with one leg,
standing in front of the
equipment
AW-5
Stride with one leg with
back turned to the
equipment, another leg
standing on the land
AW-6 Stand on the same pedal
with side lateral to stride
Int. J. Environ. Res. Public Health 2019,16, 391 14 of 18
Table A3. Depictions of user behaviors for the ski machine.
Coding Number Behavior Movement
S-1 Stride side-to-side with
using hands and legs
Int. J. Environ. Res. Public Health 2018, 15, x FOR PEER REVIEW 9 of 21
Appendix S3 Depictions of user behaviors for the ski machine.
Coding
number Behavior Movement
S-1 Stride side-to-side with
using hands and legs
S-2 Stride with hands and legs
using the same side
S-3
Stride with legs side-to-
side, hands are doing other
things or not holding the
grips
S-4 Stride with one hand and
one leg side-to-side
S-5
Stand on the same pedal
with lateral side to stride
movement
S-2 Stride with hands and
legs using the same side
Int. J. Environ. Res. Public Health 2018, 15, x FOR PEER REVIEW 9 of 21
Appendix S3 Depictions of user behaviors for the ski machine.
Coding
number Behavior Movement
S-1 Stride side-to-side with
using hands and legs
S-2 Stride with hands and legs
using the same side
S-3
Stride with legs side-to-
side, hands are doing other
things or not holding the
grips
S-4 Stride with one hand and
one leg side-to-side
S-5
Stand on the same pedal
with lateral side to stride
movement
S-3
Stride with legs
side-to-side, hands are
doing other things or not
holding the grips
Int. J. Environ. Res. Public Health 2018, 15, x FOR PEER REVIEW 9 of 21
Appendix S3 Depictions of user behaviors for the ski machine.
Coding
number Behavior Movement
S-1 Stride side-to-side with
using hands and legs
S-2 Stride with hands and legs
using the same side
S-3
Stride with legs side-to-
side, hands are doing other
things or not holding the
grips
S-4 Stride with one hand and
one leg side-to-side
S-5
Stand on the same pedal
with lateral side to stride
movement
S-4
Stride with one hand and
one leg side-to-side
Int. J. Environ. Res. Public Health 2018, 15, x FOR PEER REVIEW 9 of 21
Appendix S3 Depictions of user behaviors for the ski machine.
Coding
number Behavior Movement
S-1 Stride side-to-side with
using hands and legs
S-2 Stride with hands and legs
using the same side
S-3
Stride with legs side-to-
side, hands are doing other
things or not holding the
grips
S-4 Stride with one hand and
one leg side-to-side
S-5
Stand on the same pedal
with lateral side to stride
movement
S-5
Stand on the same pedal
with lateral side to stride
movement
Int. J. Environ. Res. Public Health 2018, 15, x FOR PEER REVIEW 9 of 21
Appendix S3 Depictions of user behaviors for the ski machine.
Coding
number Behavior Movement
S-1 Stride side-to-side with
using hands and legs
S-2 Stride with hands and legs
using the same side
S-3
Stride with legs side-to-
side, hands are doing other
things or not holding the
grips
S-4 Stride with one hand and
one leg side-to-side
S-5
Stand on the same pedal
with lateral side to stride
movement
Int. J. Environ. Res. Public Health 2019,16, 391 15 of 18
Table A3. Cont.
Coding Number Behavior Movement
S-6
Stride with side-to-side
movement with hands
and legs and back turned
to the equipment
Int. J. Environ. Res. Public Health 2018, 15, x FOR PEER REVIEW 10 of 21
Coding
number Behavior Movement
S-6
Stride with side-to-side
movement with hands and
legs and back turned to the
equipment
Table A4. Depictions of user behaviors for the waist/back massager.
Coding Number Behavior Movement
WM-1 Massage back or waist in
the vertical direction
Int. J. Environ. Res. Public Health 2018, 15, x FOR PEER REVIEW 11 of 21
Appendix S4 Depictions of user behaviors for the waist/back massager.
Coding
number Behavior Movement
WM-1 Massage back or waist in
the vertical direction
WM-2 Massage back or waist in
the horizontal direction
WM-3
Massage waist with upper
body leaning forward and
laying back
WM-4 Massaging hands
WM-2 Massage back or waist in
the horizontal direction
Int. J. Environ. Res. Public Health 2018, 15, x FOR PEER REVIEW 11 of 21
Appendix S4 Depictions of user behaviors for the waist/back massager.
Coding
number Behavior Movement
WM-1 Massage back or waist in
the vertical direction
WM-2 Massage back or waist in
the horizontal direction
WM-3
Massage waist with upper
body leaning forward and
laying back
WM-4 Massaging hands
WM-3
Massage waist with
upper body leaning
forward and laying back
Int. J. Environ. Res. Public Health 2018, 15, x FOR PEER REVIEW 11 of 21
Appendix S4 Depictions of user behaviors for the waist/back massager.
Coding
number Behavior Movement
WM-1 Massage back or waist in
the vertical direction
WM-2 Massage back or waist in
the horizontal direction
WM-3
Massage waist with upper
body leaning forward and
laying back
WM-4 Massaging hands
Int. J. Environ. Res. Public Health 2019,16, 391 16 of 18
Table A4. Cont.
Coding Number Behavior Movement
WM-4 Massaging hands
Int. J. Environ. Res. Public Health 2018, 15, x FOR PEER REVIEW 11 of 21
Appendix S4 Depictions of user behaviors for the waist/back massager.
Coding
number Behavior Movement
WM-1 Massage back or waist in
the vertical direction
WM-2 Massage back or waist in
the horizontal direction
WM-3
Massage waist with upper
body leaning forward and
laying back
WM-4 Massaging hands
WM-5 Massaging abdomen
Int. J. Environ. Res. Public Health 2018, 15, x FOR PEER REVIEW 12 of 21
Coding
number Behavior Movement
WM-5 Massaging abdomen
WM-6
Others (Upper body
stretching exercise; Upper
body exercise; Chatting or
taking a break in any
posture)
(Upper body exercise)
References
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R.C.; Lancet Physical Activity Series Working Group. Evidence-based intervention in physical activity:
Lessons from around the world. Lancet 2012, 380, 272–281.
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collaborative project. Health Promot. J. Aust. 2014, 25, 212–214.
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WM-6
Others (Upper body
stretching exercise;
Upper body exercise;
Chatting or taking a
break in any posture)
Int. J. Environ. Res. Public Health 2018, 15, x FOR PEER REVIEW 12 of 21
Coding
number Behavior Movement
WM-5 Massaging abdomen
WM-6
Others (Upper body
stretching exercise; Upper
body exercise; Chatting or
taking a break in any
posture)
(Upper body exercise)
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R.C.; Lancet Physical Activity Series Working Group. Evidence-based intervention in physical activity:
Lessons from around the world. Lancet 2012, 380, 272–281.
2. Hallal, P.C.; Andersen, L.B.; Bull, F.C.; Guthold, R.; Haskell, W.; Ekelund, U.; Group, L.P.A.S.W. Global
physical activity levels: Surveillance progress, pitfalls, and prospects. Lancet 2012, 380, 247–257.
3. Sallis, J.F.; Floyd, M.F.; Rodríguez, D.A.; Saelens, B.E. Role of built environments in physical activity,
obesity, and cardiovascular disease. Circulation 2012, 125, 729–737.
4. Ferdinand, A.O.; Sen, B.; Rahurkar, S.; Engler, S.; Menachemi, N. The relationship between built
environments and physical activity: A systematic review. Am. J. Public Health 2012, 102, e7–e13.
5. Han, B.; Cohen, D.; McKenzie, T.L. Quantifying the contribution of neighborhood parks to physical activity.
Prev. Med. 2013, 57, 483–487.
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fitness zones: A natural experiment in urban public parks. Health Place 2012, 18, 39–45.
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in parks. Health Promot. J. Aust. 2014, 25, 211.
8. Scott, A.; Stride, V.; Neville, L.; Hua, M. Design and promotion of an outdoor gym for older adults: A
collaborative project. Health Promot. J. Aust. 2014, 25, 212–214.
9. Stride, V.; Cranney, L.; Scott, A.; Hua, M. Outdoor gyms and older adults–acceptability, enablers and
barriers: A survey of park users. Health Promot. J. Aust. 2017, 28, 243–246.
10. Sibson, R.; Scherrer, P.; Ryan, M.M. ‘I think it adds value, but i don’t use it’: Use, perceptions and attitudes
of outdoor exercise equipment in an urban public park. Ann. Leisure Res. 2018, 21, 58–73.
11. Nguyen, C.H.; Raney, M.A. Exercise training with fitness zone equipment in sedentary hispanic women:
A pilot study. Californian J. Health Promot. 2014, 12, 83–87.
12. Mora, R.; Weisstaub, G.; Greene, M.; Herrmann, G. Outdoor gyms in santiago: Urban distribution and
effects on physical activity. Motriz: Revista de Educação Física 2017, 23, doi:10.1590/s1980-6574201700030005.
13. Qing, F.B. The condition of path leading to national bodybuilding progrm activity and its social effect
research. J. Harbin Phys. Educ. Inst. 2006, 24, 29–30.
14. Madren, C. Hit the outdoor gym. Parks Recreat. 2013, 48, 40–46.
(Upper body exercise)
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