Getting more people on the stairs: the impact of a new message format

How do different interventions impact stair climbing? A systematic review and meta-analysis

OBJECTIVES

This study aimed to analyze the effect of interventions to increase stair use.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

An online search was conducted in January 2021 in five databases (Web of Science, SPORTDiscus, MedLine/PubMed, PsycINFO, and CINAHL). Experimental studies (randomized and non-randomized) conducted in adults, which provided stair use measures with pre- and post-intervention periods were included. A random-effect meta-analysis, as well as subgroup analyses were conducted to evaluate the quantitative effect of interventions on stair use.

RESULTS

Overall, 34 studies were included in qualitative analyses, and 15 in the meta-analysis. Most of the studies were conducted in Europe and private settings (e.g., office buildings). Overall, interventions increased stair use in adults (odds ratio (OR) 1.48; 95% confidence intervals (CI) 1.38-1.58; I2 = 99.6%). Subgroup analyses showed that interventions increased stair use regardless of the continent and observer type (manual or electronic). However, different settings (shopping malls and office buildings), as well as studies (time of intervention) and intervention characteristics (sign size and location, message characters) were associated with increased stair use.

CONCLUSIONS

Different interventions can increase stair use in several continents and settings. Sign and message characteristics should be considered when designing interventions or policies to promote physical activity by increasing stair use.

Prompts to increase physical activity at points-of-choice between stairs and escalators: what about escalator climbers?

Since 1980, many studies have evaluated whether stair-use prompts increased physical activity by quantifying changes in stair use. To more completely evaluate changes in physical activity, this study addressed the often-overlooked assessment of climbing up escalators by evaluating the degree to which stair-use sign prompts increased active ascent-defined as stair use or escalator climbing. Over 5 months, at an airport stairs/escalator point of choice, we video-recorded passersby (N = 13,544) who ascended either stairs or escalators, on 10 days with signs and 10 days without signs. Ascenders using the stairs, standing on the escalator, and climbing the escalator were compared on days with versus without signs using multivariable logistic regression. The percentage of ascenders on days with versus without signs were as follows: stair use, 6.9 versus 3.6 percent; escalator standing, 75.2 versus 76.0 percent; and escalator climbing, 18.5 versus 20.4 percent. Signs more than doubled the odds of stair use (vs. escalator use; OR = 2.25; 95% CI = 1.90-2.68; p < .001). Signs decreased the odds of escalator climbing (vs. escalator standing or stair use); OR = 0.90; 95% CI = 0.82-0.99; p = .028). Signs increased the odds of active ascent versus escalator standing by 15 percent (OR = 1.15; 95% CI = 1.05-1.25; p = .002). Although stair-use prompts increased stair use more than twofold (125%), they increased active ascent by only 15 percent, partly because escalator climbing-a behavior not targeted by the intervention-decreased. Although our results corroborated the established consensus that point-of-choice prompts increase stair use, future studies should test interventions designed to increase active ascent.

When weight is an encumbrance; avoidance of stairs by different demographic groups

BACKGROUND

Locomotion is an energy costly behaviour, particularly when it entails raising weight against gravity. Minimization of locomotor costs appears a universal default. Avoidance of stair climbing helps humans minimise their energetic costs. In public access settings, demographic subgroups that raise more 'dead' weight than their comparison groups when climbing are more likely to avoid stairs by choosing the escalator. Individuals who minimise stair costs at work, however, can accumulate a deficit in energy expenditure in daily life with potential implications for weight gain. This paper tests the generality of avoidance of stairs in pedestrians encumbered by additional weight in three studies.

METHODS

Pedestrian choices for stairs or the alternative were audited by trained observers who coded weight status, presence of large bags and sex for each pedestrian. Sex-specific silhouettes for BMIs of 25 facilitated coding of weight status. Choices between stairs and a lift to ascend and descend were coded in seven buildings (n = 26,981) and at an outdoor city centre site with the same alternatives (n = 7,433). A further study audited choices to ascend when the alternative to stairs was a sloped ramp in two locations (n = 16,297). Analyses employed bootstrapped logistic regression (1000 samples).

RESULTS

At work and the city centre site, the overweight, those carrying a large bag and females avoided both stair climbing and descent more frequently than their comparison groups. The final study revealed greater avoidance of stairs in these demographic subgroups when the alternative means of ascent was a sloped ramp.

DISCUSSION

Minimization of the physiological costs of transport-related walking biases behaviour towards avoidance of stair usage when an alternative is available. Weight carried is an encumbrance that can deter stair usage during daily life. This minimization of physical activity costs runs counter to public health initiatives to increase activity to improve population health.

Nudging to move: a scoping review of the use of choice architecture interventions to promote physical activity in the general population

Background

Nudges are used to alter lifestyles and thus curb the rise of non-communicable diseases. Physical activity is a core prevention strategy to reduce the burden of non-communicable diseases. This paper aims to (1) give an overview of the scope of interventions using choice architecture techniques to promote physical activity at the population levels and (2) identify research gaps by analysing the different approaches in terms of class and type of intervention used.

Methods

A systematic electronic database search was combined with snowball citation sampling of a starter set of publications to search for studies published through October 2018 reporting interventions to promote physical activity at the population level using choice architecture techniques. The methodology of the Joanna Briggs Institute for Scoping Reviews was applied.

Results

In all, 35 publications were included. Most of the interventions used point-of-choice prompts tested at railway stations, shopping malls and airports (N = 27). Eight studies were online studies. While all studies were aimed at the general population, details, if reported at all, were vague and basic. All studies focused on individual-level lifestyle behaviour. None of the studies attempted to alter population-based lifestyle behaviour. Online and “real-world” approaches were rarely combined. Neither, interventions targeting meso- and macro-level structures nor combinations of individual-level and specific meso- or macro-level interventions were found.

Conclusion

Nudging is in principle an effective approach to promote physical activity within the general population. However, there are large gaps in research. Available opportunities have not yet been exhausted. Further research is needed that is explicitly based on behavioural insights and covering the full range of nudging approaches, particularly focussing on theoretical developments, practical feasibility tests and scale-up activities.

Electronic supplementary material

The online version of this article (10.1186/s12966-019-0844-z) contains supplementary material, which is available to authorized users.

Nudging physical activity in offices

Purpose

This paper aims to investigate whether and why nudging interventions in an office environment are effective to stimulate stair use of employees.

Design/methodology/approach

This paper is based on a pre-test/post-test case study design at the headquarters of a Dutch online retailer. Observations were conducted to test the impact of two nudge interventions, being footprints and posters, on employees’ stair use in two consecutive pre-test/post-test weeks. An online survey questionnaire was used to assess employees’ overall experience with the nudging interventions after the fifth and again neutral week.

Findings

A total of 14,357 observations were recorded during five weeks. This research shows that footprints as nudging intervention significantly increase stair use of employees, and after removal, significantly decrease stair use again. Moreover, footprints were more effective than posters, of which the latter did not impact stair use significantly. Results from the survey questionnaire, completed by 46.2 per cent of the employees, showed that, in terms of degree of perception, footprints (91.4 per cent) were more noticeable than posters (46.3 per cent).

Originality/value

This paper contributes to the non-conclusive research regarding the effectiveness of nudging interventions on stair use in office environments. It clearly shows that perceptibility in combination with a positive attitude towards the nudge leads to a higher degree of initial behavioural change, yet not to a change of mind.

Designing effective point-of-choice prompts to promote active transportation and staircase use at a Canadian University

OBJECTIVE

The purpose of this study was to determine the most suitable health messages and designs to create point-of-choice prompts for promoting active transportation and staircase use that would appeal to undergraduate students.

PARTICIPANTS

Undergraduate students (N = 21; 71% women) were recruited during Fall (2016) and Winter (2017) semesters.

METHODS

Focus groups (50-80 minutes each) were organized to obtain students' feedback on the kind of messages and poster designs they found motivational. Inductive content analysis was performed on verbatim transcripts. Descriptive statistics were calculated to summarize demographic characteristics of participants.

RESULTS

The major themes revealed that participants: preferred simple designs with tailored messages; had diverse lifestyle-based values associated with physical activity; and participation in activities were affected by uncontrollable factors (eg, time, built environment, and weather).

CONCLUSIONS

This study provides insights for designing suitable point-of-choice prompts that are tailored for university students in terms of future interventions that aim to improve their activity levels.

Effectiveness of physical activity intervention among government employees with metabolic syndrome

BACKGROUND/OBJECTIVE

Our study aimed to assess the effects of physical activity interventions via standing banners (point-of-decision prompt) and aerobics classes to promote physical activity among individuals with metabolic syndrome.

METHODS

We conducted a cluster randomized controlled intervention trial (16-week intervention and 8-week follow-up). Malaysian government employees in Putrajaya, Malaysia, with metabolic syndrome were randomly assigned by cluster to a point-of-decision prompt group (n = 44), an aerobics group (n = 42) or a control group (n = 103) based on sample size calculation formula. Step counts were evaluated by Lifecorder e-STEP accelerometers for all participants. Metabolic syndrome was defined according to the 'harmonizing' definition, in which individuals who have at least three of the five metabolic risk factors (waist circumference, high-density lipoprotein cholesterol, triglycerides, fasting glucose levels, systolic and diastolic blood pressure) will be classified as having metabolic syndrome. A total of 80% of the enrolled government employees with metabolic syndrome completed the programme. Data were analyzed using SPSS for Windows (version 20, SPSS, Chicago, IL).

RESULTS

There were significantly higher step counts on average in the aerobics group compared to the control group over assessments. Assessments at baseline, post-intervention and follow-up showed a significant difference in step counts between the intervention and control groups. The greatest reductions in the proportions of individuals with metabolic syndrome were observed in the aerobics group with a reduction of 79.4% in the post-intervention assessment compared to the assessment at baseline.

CONCLUSION

The findings of this study suggest that physical activity intervention via aerobics classes is an effective strategy for improving step counts and reducing the prevalence of metabolic syndrome.

Promoting workplace stair climbing: sometimes, not interfering is the best

BACKGROUND

Stair climbing is a vigorous activity and can lead to several health benefits. Studies seeking to increase stair climbing in various public locations have shown positive effects, while results from similar studies conducted in the workplace are inconclusive. This study examined stair climbing in the workplace, and monitored effects from a single- and a combined intervention. Interventions were inspired by nudging, the libertarian method of influencing behavior.

METHODS

By quasi-experimental design, stair- and elevator traffic in two office buildings was monitored preceding-, during- and following interventions with stair leading footprints alone, and combined with stair-riser banners. Chi square tests were applied to determine differences between baseline and the subsequent periods. Web-based questionnaires were distributed after follow-up period.

RESULTS

Elevators and stairs were used 45 237 times, of which 89.6% was stair use. Intervention site stair climbing at baseline (79.0%) was significantly reduced with footprints (-5.1%, p < 0.001), and footprints with stair-riser banners (-5.7%, p < 0.001) while baseline stair climbing at the control site (94.2%) remained stable (p > 0.027).

CONCLUSIONS

Stair climbing was significantly reduced during the intervention periods. Use of stair leading footprints alone, or combined with stair-riser banners in an attempt to influence stair climbing may be ineffective, or cause a negative reaction, when applied in a workplace with a pre-existing high amount of stair climbing.

A Systematic Review of Interventions to Increase Stair Use

CONTEXT

Stair climbing is an accessible activity that can be incorporated into one's daily lifestyle to increase physical activity levels and provide health benefits. This review summarizes the effectiveness of stair interventions and explores key differences that may influence intervention effectiveness.

EVIDENCE ACQUISITION

Interventions to increase stair use published from January 1990 to July 2015 were identified in PubMed, Sport Discus, Web of Science, Environment Complete, CINAHL, Trial Register of Promoting Health Interventions, Embase, Scopus, and PsycINFO. Eligibility criteria included original studies, published in peer-reviewed journals, targeting adult samples, and clearly describing intervention design and results. Studies were also required to measure the use of stairs compared with an elevator, escalator, or moving stairway at baseline and during at least one timepoint when the intervention was in effect. Studies were required to provide data to determine if the intervention resulted in significant changes in stair use/climbing.

EVIDENCE SYNTHESIS

The search results yielded 2,136 articles in total; 54 articles met the criteria, which resulted in a final sample of 67 studies included in the analyses. Interventions settings included public sites (75%), worksites (21%), or a combination of both (4%). For Phase 1 results, 72% of studies reported significant improvements in stair use (n=10 of 14) and stair climbing (n=38 of 53).

CONCLUSIONS

Evidence from the review demonstrates support for the effectiveness of interventions to increase stair use and stair climbing. Although evidence supports the effectiveness of stair interventions in public settings, less support is provided for worksites.

Effects of Environmental Changes in a Stair Climbing Intervention: Generalization to Stair Descent

Purpose.

Visual improvements have been shown to encourage stair use in worksites independently of written prompts. This study examined whether visual modifications alone can influence behavior in a shopping mall. Climbing one flight of stairs, however, will not confer health benefits. Therefore, this study also assessed whether exposure to the intervention encouraged subsequent stair use.

Design.

Interrupted time-series design.

Settings.

Escalators flanked by a staircase on either side.

Subjects.

Ascending and descending pedestrians (N = 81,948).

Interventions.

Following baseline monitoring, a colorful design was introduced on the stair risers of one staircase (the target staircase). A health promotion message was superimposed later on top. The intervention was visible only to ascending pedestrians. Thus, any rise in descending stair use would indicate increased intention to use stairs, which endured after initial exposure to the intervention.

Measures.

Observers inconspicuously coded pedestrians' means of ascent/descent and demographic characteristics.

Results.

The design alone had no meaningful impact. Addition of the message, however, increased stair climbing at the target and nontarget staircases by 190% and 52%, respectively. The message also produced a modest increase in stair descent at the target (25%) and nontarget (9%) staircases.

Conclusions.

In public venues, a message component is critical to the success of interventions. In addition, it appears that exposure to an intervention can encourage pedestrians to use stairs on a subsequent occasion.

Promoting Stair Climbing: Intervention Effects Generalize to a Subsequent Stair Ascent

Purpose.

Studies report a significant increase in stair use when message prompts are introduced at the “point of choice” between stairs and escalators. Climbing one set of stairs, however, will not confer meaningful health dividends. Therefore, this study examined whether exposure to point of choice prompts also encouraged individuals to climb the next set of stairs that they encountered.

Design.

Interrupted time-series design.

Settings.

Two separate stair/escalator pairings within a U.K. shopping mall (the “intervention” site and the “generalization” site), separated by a 25-m long atrium.

Subjects.

Ascending pedestrians (intervention site n = 29,713; generalization site n = 47,553).

Interventions.

Two weeks of baseline monitoring were followed by a 13-week intervention in which banners carrying health promotion messages were introduced at the intervention site only.

Measures.

At both sites observers inconspicuously recorded pedestrians' methods of ascent, along with their gender, age, ethnicity, and baggage.

Results.

Banners increased stair climbing at the intervention site by 161%. Results also suggested a simultaneous increase of up to 143% at the generalization site, where no prompt was in place. At both sites stair use remained significantly elevated 5 weeks after the banners were removed.

Conclusions.

It appears that exposure to point of choice prompts can encourage pedestrians to climb stairs when they are encountered in a subsequent setting. Consequently stair-climbing interventions are likely to engage the public in more physical activity than previously realized.

Design Implications to Increase Utilization of Stairwells

Stairwell use is a cost-effective opportunity to increase physical activity. Although stairwell use can integrate moderate physical activity in daily work routines, little information is available to guide architects and engineers on how to design facilities that promote stairwell use. This study examined the reasons behind using stairwells versus elevators through a case study at a teaching hospital. A broad range of physical design recommendations were evaluated to understand how the design of stairwells can encourage hospital staff and students to use them. An online survey was used to collect data. Findings indicated travel distance and travel direction as primary reasons for preferring elevators. Design recommendations such as motivational signs and physical movement reinforcements (e.g., cardio indicators) are discussed.

Stair-use interventions in worksites and public settings - a systematic review of effectiveness and external validity

OBJECTIVE

We performed a literature review with the main aims to propose an updated overview of the effectiveness of stair-use interventions and to determine the most effective type of intervention.

METHODS

We systematically searched stair-use interventions performed in worksites or public settings, published up to mid 2013. We used a harvest plot approach to visualize the findings in addition to a quantitative synthesis. We also assessed external validity using the Reach, Efficacy, Adoption, Implementation, Maintenance (RE-AIM) framework.

RESULTS

Of 8571 articles identified, 50 were included. In worksites (25 studies) and public settings (35 studies), an increase in stair climbing was found during the intervention period in 64% and 76% of studies, respectively. Combining motivational and directional signs in worksites or conducting a second intervention phase in public settings increased stair climbing in 83% and 86% of studies, respectively. Elements of external validity were overall largely under-reported.

CONCLUSION

There is evidence that stair-use interventions are effective to increase stair climbing in public settings, but evidence of such effect is limited in worksites. Issues regarding the best sequencing of interventions or the potential importance of environmental interventions should be addressed in future studies. Process evaluation should be an integral part of interventions.

Systematic review of incidental physical activity community interventions

BACKGROUND

Increasing incidental physical activity (IPA) such as active transport has substantial public health potential.

OBJECTIVE

This systematic review describes community-based and community-wide IPA interventions and assesses their effectiveness.

METHOD

Data sources (Medline, Embase, PsycINFO and CINAHL) were searched along with the reference lists of identified systematic reviews and included articles. Eligibility criteria; 4+ weeks in duration; 20+ participants; community-based or community-wide; stated aim to increase IPA.

RESULTS

Forty three studies were identified from 42 original articles; more than half (60%) aimed to increase stair use compared to escalator and/or lift use; a quarter (23%) aimed to increase active transport; and, 16% to increase playground energy expenditure. More than two-thirds of studies reported a significant increase in IPA. Accurate comparisons between studies were not possible due to substantial heterogeneity in study design. Critical appraisal of studies revealed that the level of bias was moderate-high in most of the studies (77%).

CONCLUSION

Due to the heterogeneity and bias of included studies, only limited conclusions can be drawn about the effectiveness of IPA interventions. However, this systematic review provides a timely summary of current evidence that can be used to inform decision-makers in designing IPA interventions in the community.

Associations between building design, point-of-decision stair prompts, and stair use in urban worksites

OBJECTIVE

Incidental forms of physical activity such as stair use offer frequent opportunities for energy expenditure and may contribute to the prevention and control of chronic diseases. This study analyzes the associations between building characteristics, stair prompts, and stair use in large urban worksites.

METHODS

Bootstrapped generalized mixed models were used to analyze self-reported stair use, using data from 1348 surveys of city employees and fourteen building assessments conducted in New York City in 2012.

RESULTS

57% of respondents reported climbing ≥1 flights of stairs daily at the workplace. Model results show that stair prompts were associated with a 3.21 increased likelihood of stair use. Naturally lit stairwells and stairwell visibility were also positively associated. Higher floor residency and BMI were negatively related, as were gender, stairwell distance from lobby entrances, the total number of floors in each building, and building averages for BMI and gender. Residual heterogeneity measured by adjusted median odds ratios indicates that buildings can have a moderate effect on the likelihood of stair use beyond those of individual characteristics.

CONCLUSIONS

Specific building features and stair prompts may potentially be leveraged to positively influence rates of incidental physical activity and contribute to improvements in population health.

Population approaches to improve diet, physical activity, and smoking habits: a scientific statement from the American Heart Association

BACKGROUND

Poor lifestyle behaviors, including suboptimal diet, physical inactivity, and tobacco use, are leading causes of preventable diseases globally. Although even modest population shifts in risk substantially alter health outcomes, the optimal population-level approaches to improve lifestyle are not well established.

METHODS AND RESULTS

For this American Heart Association scientific statement, the writing group systematically reviewed and graded the current scientific evidence for effective population approaches to improve dietary habits, increase physical activity, and reduce tobacco use. Strategies were considered in 6 broad domains: (1) Media and educational campaigns; (2) labeling and consumer information; (3) taxation, subsidies, and other economic incentives; (4) school and workplace approaches; (5) local environmental changes; and (6) direct restrictions and mandates. The writing group also reviewed the potential contributions of healthcare systems and surveillance systems to behavior change efforts. Several specific population interventions that achieved a Class I or IIa recommendation with grade A or B evidence were identified, providing a set of specific evidence-based strategies that deserve close attention and prioritization for wider implementation. Effective interventions included specific approaches in all 6 domains evaluated for improving diet, increasing activity, and reducing tobacco use. The writing group also identified several specific interventions in each of these domains for which current evidence was less robust, as well as other inconsistencies and evidence gaps, informing the need for further rigorous and interdisciplinary approaches to evaluate population programs and policies.

CONCLUSIONS

This systematic review identified and graded the evidence for a range of population-based strategies to promote lifestyle change. The findings provide a framework for policy makers, advocacy groups, researchers, clinicians, communities, and other stakeholders to understand and implement the most effective approaches. New strategic initiatives and partnerships are needed to translate this evidence into action.

A multi-component stair climbing promotional campaign targeting calorific expenditure for worksites; a quasi-experimental study testing effects on behaviour, attitude and intention

Background

Accumulation of lifestyle physical activity is a current aim of health promotion, with increased stair climbing one public health target. While the workplace provides an opportunity for regular stair climbing, evidence for effectiveness of point-of-choice interventions is equivocal. This paper reports a new approach to worksite interventions, aimed at changing attitudes and, hence, behaviour.

Methods

Pre-testing of calorific expenditure messages used structured interviews with members of the public (n = 300). Effects of multi-component campaigns on stair climbing were tested with quasi-experimental, interrupted time-series designs. In one worksite, a main campaign poster outlining the amount of calorific expenditure obtainable from stair climbing and a conventional point-of-choice prompt were used (Poster alone site). In a second worksite, additional messages in the stairwell about calorific expenditure reinforced the main campaign (Poster + Stairwell messages site). The outcome variables were automated observations of stair and lift ascent (28,854) and descent (29,352) at baseline and for three weeks after the intervention was installed. Post-intervention questionnaires for employees at the worksites assessed responses to the campaign (n = 253). Analyses employed Analysis of Variance with follow-up Bonferroni t-tests (message pre-testing), logistic regression of stair ascent and descent (campaign testing), and Bonferroni t-tests and multiple regression (follow-up questionnaire).

Results

Pre-testing of messages based on calorific expenditure suggested they could motivate stair climbing if believed. The new campaign increased stair climbing, with greater effects at the Poster + Stairwell messages site (OR = 1.52, 95% CI = 1.40-1.66) than Posters alone (OR = 1.24, 95% CI = 1.15-1.34). Follow-up revealed higher agreement with two statements about calorific outcomes of stair climbing in the site where they were installed in the stairwell, suggesting more positive attitudes resulted from the intervention. Future intentions for stair use were predicted by motivation by the campaign and beliefs that stair climbing would help weight control.

Conclusions

Multi-component campaigns that target attitudes and intentions may substantially increase stair climbing at work.

Step it UP: A Multicomponent Intervention to Increase Stair Use in a University Residence Building

Purpose.

Examine the effects of a multicomponent intervention on stair usage.

Design.

Nonrandomized controlled intervention.

Setting.

Two multistory university dormitories.

Subjects.

Total of 5711 direct observations of university dormitory residents.

Intervention.

The 2-week “Step It UP” intervention used poster prompts and fun/competitive challenges with incentives to encourage residents to take the stairs instead of the elevators.

Measures.

Ascending stair and elevator use was directly observed and coded for gender at high traffic times in intervention and control dormitories for 14 nonconsecutive hours over 1 week each at baseline, midintervention, and 1 week postintervention.

Analysis.

The proportions of ascending stair and elevator users were compared using χ2 analyses.

Results.

Baseline stair use was equal between intervention and control dormitories (24.9% and 27.8%, respectively; χ2[1, N = 1849] = .08; p = .77). Stair use significantly increased from baseline in the intervention dormitory to 33.24% (χ2[1, N = 2192] = 18.44; p < .001) compared with no change in the control. Stair use returned to baseline in the intervention dormitory at postintervention (25.4%; χ2[1, N = 2297] = .08; p = .78). There were no significant differences between genders.

Conclusion.

This multicomponent, short-duration intervention significantly increased stair usage in a university dormitory relative to the control but was unable to sustain the increase when prompts were removed. Campaigns to sustain stair use are needed. Formative assessment is required to determine what combinations of components may yield the most cost-effective approach for future interventions.

Investigating behavioural mimicry in the context of stair/escalator choice

OBJECTIVES

We investigated whether individuals mimic the stair/escalator choices of preceding pedestrians. Our methodology sought to separate cases where the 'model' and 'follower' were acquaintances or strangers.

DESIGN

Natural experiment.

METHODS

Infrared monitors provided a second-by-second log of when pedestrians ascended adjacent stairs/escalators in a mall. Manual timings established that stair climbers spent ≥ 7 s on ascent, during which time they could act as models to following pedestrians. Thus, individuals who mounted the stairs/escalator ≤ 7 s after the previous stair climber were assigned to a 'stair model' condition. A 'no stair model' condition comprised individuals with a gap to the previous stair climber of ≥ 60 s. The stair model condition was subdivided, depending if the gap between model and follower was 1-2 s or 3-7 s. It was hypothesized that the former cohort may know the model.

RESULTS

Percentage stair climbing was significantly higher in the 'stair model' versus 'no stair model' condition (odds ratio [OR]= 2.08). Subgroup analyses showed greater effects in the '1-2 s' cohort (OR = 3.33) than the '3-7 s' cohort (OR = 1.39).

CONCLUSIONS

Individuals appear to mimic the stair/escalator choices of fellow pedestrians, with more modest effects between strangers. People exposed to message prompts at stair/escalator sites are known to take the stairs unprompted in subsequent situations. Our results suggest that these individuals could recruit a second generation of stair climbers via mimicry. Additionally, some of the immediate behavioural effects observed in interventions may be a product of mimicry, rather than a direct effect of the messages themselves.

An informational stair climbing intervention with greater effects in overweight pedestrians

Previous interventions have successfully increased levels of stair climbing in public-access settings (e.g. malls). This study used robust methods to establish the magnitude of intervention effects among a specific target group-the overweight. Ascending stair/escalator users (N = 20 807) were observed in a mall. A 2-week baseline was followed by a 5-week intervention in which message banners, promoting stair climbing, were attached to the stair risers. Standardized silhouettes were used to code individuals as normal/overweight. Logistic regression analyses were conducted with stair/escalator choice as the outcome variable and weight status entered as a moderator alongside condition, gender, ethnicity and 'pedestrian traffic volume'. Overall, the intervention significantly increased the rate of stair climbing [odds ratio (OR) = 1.28, 95% confidence intervals (CI) = 1.08-1.53], with the effects sustained over 5 weeks. There were differential effects between weight categories, with greater increases in overweight (OR = 1.95, CI = 1.34-2.83) versus normal weight individuals (OR = 1.29, CI = 1.09-1.53). In conclusion, message prompts produced larger effects among overweight individuals, who could benefit most from stair climbing. The public health value of these interventions may, therefore, be greater than realized. The heightened effects among the overweight were likely due to the salience of the current message, which linked stair climbing with the target of weight control.

Review Article: Increasing physical activity with point-of-choice prompts--a systematic review

AIMS

Stair climbing is an activity that can easily be integrated into everyday life and has positive health effects. Point-of-choice prompts are informational or motivational signs near stairs and elevators/escalators aimed at increased stair climbing. The aim of this review was to assess the effectiveness of point-of-choice prompts for the promotion of stair climbing.

METHODS

In a systematic search of the literature, studies that assessed the effectiveness of point-of-choice prompts to increase the rate of stair climbing in the general population were identified. No restrictions were made regarding the setting, the duration of the intervention, or the kind of message.

RESULTS

A total of 25 studies were identified. Point-of-choice prompts were predominantly posters or stair-riser banners in public traffic stations, shopping malls or office buildings. The 25 studies reported 42 results. Of 10 results for elevator settings, only three reported a significant increase in stair climbing, whereas 28 of 32 results for escalator settings reported a significant increase in stair climbing.

CONCLUSIONS

Overall, point-of-choice prompts are able to increase the rate of stair climbing, especially in escalator settings. In elevator settings, point-of-choice prompts seem less effective. The long-term efficacy and the most efficient message format have yet to be determined in methodologically rigorous studies.

Point-of-decision prompts to increase stair use. A systematic review update

In 2000, the Guide to Community Preventive Services (Community Guide) completed a systematic review of the effectiveness of various approaches to increasing physical activity including informational, behavioral and social, and environmental and policy approaches. Among these approaches was the use of signs placed by elevators and escalators to encourage stair use. This approach was found to be effective based on sufficient evidence. Over the past 5 years the body of evidence of this intervention has increased substantially, warranting an updated review. This update was conducted on 16 peer-reviewed studies (including the six studies in the previous systematic review), which met specified quality criteria and included evaluation outcomes of interest. These studies evaluated two interventions: point-of-decision prompts to increase stair use and enhancements to stairs or stairwells (e.g., painting walls, laying carpet, adding artwork, playing music) when combined with point-of-decision prompts to increase stair use. This latter intervention was not included in the original systematic review. According to the Community Guide rules of evidence, there is strong evidence that point-of-decision prompts are effective in increasing the use of stairs. There is insufficient evidence, due to an inadequate number of studies, to determine whether or not enhancements to stairs or stairwells are an effective addition to point-of-decision prompts. This article describes the rationale for these systematic reviews, along with information about the review process and the resulting conclusions. Additional information about applicability, other effects, and barriers to implementation is also provided.

Effects of episodic variations in web-based avian influenza education: influence of fear and humor on perception, comprehension, retention and behavior

In order to provide empirical evidence on the role of a web-based avian influenza (AI) education program for mass communication and also ultimately help young children learn and develop healthy behaviors against AI and all types of influenza, an education program with two episodic variations (i.e. fear and humor) has been developed and examined with 183 fifth-grade elementary students. A quasi-experimental design was employed to find potential differential effects on the context-specific risk perception, AI knowledge acquisition, retention and behavior. The study results reveal that the fear appealed AI web-based education program was much more effective than the humor-based program in improving risk perception and educating the students about healthy behaviors (i.e. against influenza infection). However, a significant behavior change or improvement of health practices was not apparent on the post-tests (i.e. 1 month after the treatment) in either episode of the program.

Modelling effects of stair width on rates of stair climbing in a train station

OBJECTIVES

Commuters leaving a station often choose the stair as a quicker exit than the escalator. This paper models the effects of speed leaving the station and stair width on choice of the stairs or escalator.

METHODS

Aggregated data from previous studies (n=82,347) revealed a plateau at about 45% stair use as the number leaving each train rose. Subsequently, the time taken by passengers on the stairs and escalator was measured in a station in Birmingham, UK in 2007 (n=5848). The resulting transport rates (passengers s(-1)) for stairs and escalators at the average commuting traffic were used to estimate the effects of increases in stair width on choice of the stairs.

RESULTS

Average transport rates were higher for the escalator (0.93+/-0.33 passengers s(-1)) than the stairs (0.58+/-0.24 passengers s(-1)). Modelling of the effects of transport rate with multiple regression suggested 40.1% of passengers would use the stairs, a figure close to the observed rate. Using similar calculations, a doubling of width of the stairs could result maximally in a 17.2% increase in stair use.

CONCLUSIONS

Changes to the width of stairs could produce a permanent increase in lifestyle physical activity immune to the effects of time on healthy intentions.

Promoting stair climbing: stair-riser banners are better than posters... sometimes

OBJECTIVE

Stair-riser banners are twice as effective as posters in encouraging stair climbing in shopping centres. This study tested the effectiveness of stair-riser banners in an English train station in 2006-2007.

METHOD

The train station had a 39-step staircase and an adjacent escalator. Baseline observations (3.5 weeks) were followed by 10.5 weeks of a banner intervention supplemented with 3 weeks of a poster intervention. Both poster and banner featured the message 'Stair climbing burns more calories per minute than jogging. Take the stairs'. Ascending escalator and stair users (N=36,239) were coded for gender.

RESULTS

Analyses, controlling for effects of gender and pedestrian traffic volume, revealed no significant change in stair climbing between baseline (40.6%) and the banner intervention (40.9%; p=0.98). Addition of the poster increased stair climbing (44.3%; OR=1.36, 95% CIs 1.16-1.60, p<0.001), with the effect reduced at higher pedestrian traffic volumes.

CONCLUSION

While stair-riser banners had no effect, the poster intervention increased stair climbing. The high pedestrian volumes as the wave of disembarking passengers seek to leave the station would have obscured the visibility of the banner for many commuters. Thus stair-riser banners appear unsuitable point-of-choice prompts in stations where pedestrian traffic volume is high.

A poster-based intervention to promote stair use in blue- and white-collar worksites

OBJECTIVE

Previous studies have generally shown the effectiveness of prompts to promote stair use in worksites that mainly consist of white-collar workers. The present study tested whether an intervention using prompts is effective in stimulating stair use in two types of worksites: one consisting mainly of white-collar workers and one mainly of blue-collar workers.

METHOD

In 2005, elevator and stair use (stair climbing and descent) was monitored in two types of worksites in the Netherlands, namely one office building (n=150 white-collar workers) and one paper factory (n=800 blue-collar workers). The study used a simple time-series design of collecting data in three waves: before, during and after implementation of posters containing prompts stimulating stair use.

RESULTS

A total of 6771 choices between stairs and elevator were observed. There was a significant difference between stair use at baseline and during the poster intervention in both types of worksites. There was no worksite-by-intervention interaction, implying that the prompts were equally effective in both types of worksites. After removal of the posters stair use decreased significantly to a level that was not significantly different from baseline.

CONCLUSION

Stair use can be positively influenced in both blue- and white-collar workers by a short-term low-cost intervention using prompts on posters.

Spatial measures associated with stair use

PURPOSE

Although stair use in workplaces can provide an accessible means of integrating physical activity into work routines, there is little information available on how building design influences stair use.

DESIGN

This cross-sectional study assessed the relationship between stair use and the design and location of stairs.

SETTING

Ten three- or four-story academic buildings on two university campuses.

SAMPLE

The buildings contained a total of 38 stairs and 12 elevators.

MEASURES

Stair use was measured using infrared monitors. Eighteen environmental variables that operationalized the appeal, convenience, comfort, legibility, and safety of stairs were measured.

RESULTS

Regression analysis identified eight spatial variables associated with stair use: travel distances from stair to nearest entrance and the elevator, effective area or occupant load of each stair, accessibility of each stair, area of stair isovist (a graphic representation of the horizontal extent of a person's visual field from a specific point of reference within a building floor plan), number of turns required for travel from the stair to closest entrance, and the most integrated path (MIP). Three variables (effective area, area of stair isovist, and number of turns for travel from the MIP), explained 53 % of stair use in the 10 buildings. Most variables operationalizing the appeal, comfort, and safety of stairs were not statistically influential.

CONCLUSIONS

This study suggests that the spatial qualities that optimize the convenience and legibility of stairs may have the most influence on stair use in buildings.

A workplace intervention to promote stair climbing: greater effects in the overweight

OBJECTIVE

Stair climbing is a lifestyle physical activity that uses more calories per minute than jogging. This study tested an intervention designed to promote stair climbing in a workplace. Because previous studies provide only equivocal evidence of the effects of increased stair climbing in worksites, a formal comparison of the effects of the intervention on stair ascent and descent was made.

RESEARCH METHODS AND PROCEDURES

In a five-story public sector building, a 2-week baseline was followed by 6 weeks of an intervention involving a 23(1/2)- x 16(1/2)-inch poster in the lobby, the same poster and six messages affixed to the stair risers between floors, and an 11(3/4)- x 8(1/4)-inch point-of-choice prompt at the elevators. Stair and elevator choices (n = 26,806) were videotaped throughout and subsequently coded for direction of travel, traveler's sex, and traveler's load. Weight status was coded using silhouettes beside the computer monitor.

RESULTS

A significant effect of the intervention on stair climbing was greater in those coded as overweight (+5.4%; odds ratio = 1.33) than in individuals of normal weight (+2.5%; odds ratio = 1.12). Although stair descent was more common than ascent, the intervention had similar effects for both directions of travel.

DISCUSSION

Stair climbing at work has few barriers and seems to be a type of physical activity that is acceptable to overweight individuals. The relatively weak effect of workplace interventions compared with results for public access staircases may reflect uncontrolled effects such as the immediate availability of the elevator for the traveler.

Worksite interventions to increase stair climbing; reasons for caution

Point-of-choice prompts to use the stairs rather than the escalator consistently increase physical activity at public access staircases such as those in shopping malls. More recently, exercise promoters have targeted stair climbing in the worksite. A review of interventions in worksites reveals little hard evidence of successful increases in stair climbing, though the increases in stair usage are encouraging. The contrast between the worksites and public access staircases, however, is not simply one of location. In a worksite, the choice is between the stairs and an elevator rather than an escalator. We reason that the availability of the elevator or the stairwell may be the major immediate determinant of stair climbing in worksites and dilute any possible effects of an intervention.

Promoting stair use: single versus multiple stair-riser messages

Message banners attached to stair risers produced a significant increase in pedestrian stair use, exceeding effects previously reported for conventional posters. Multiple instances of the same message banner, however, were as effective as banners featuring different messages. Therefore, greater visibility, rather than message variety, appears to account for the superiority of the banner format. Our findings indicate the feasibility of simple stair-use promotion campaigns based around the repetition of a single message.

Changing the environment to promote health-enhancing physical activity

Supportive environments have been used to change and influence health behaviours like smoking. While psychological and ecological theories and models demonstrate the possible influences of the environment on health-enhancing physical activity (HEPA), little is known about the effectiveness of the environmental interventions. This paper presents the results of a systematic review of studies that used environmental interventions to increase health-enhancing physical activity. Two groups of studies were found, studies that changed the physical environment by creating new HEPA facilities, policies and supporting mechanisms, and studies that used the elements of the environment as an active or sedentary 'point of choice', via educational materials to promote stair use. Environmental change studies showed a small increase on HEPA behaviour, but the relative impact of environment changes was not evaluated. A number of before and after studies have observed a weak effect of a simple environmental change to stimulate stair climbing while travelling or shopping. Current national policy has embraced the environment as an option for promoting health-enhancing physical activity, especially active travel, in spite of the lack of effectiveness data. It is recommended that existing or planned public health environment and HEPA initiatives should use appropriate evaluation methods to assess their efficacy and effectiveness. Further developmental research into the nature of the relationship of the environment to particular HEPA behaviours is strongly recommended before developing new environmental interventions.

Hand hygiene posters: selling the message

This literature review was undertaken to determine the established theory and research that might be utilized to inform the construction of persuasive messages on hand hygiene posters. It discusses the principles of message framing and the use of fear appeals. Current theory suggests that the most effective messages for health promotion behaviours should be framed in terms of gains rather than losses for the individual. However, as clinical hand hygiene is largely for the benefit of others (i.e. patients), messages should also invoke a sense of personal responsibility and appeal to altruistic behaviour. The use of repeated minimal fear appeals have their place. Posters that simply convey training messages are not effective persuaders.

Six-month observational study of prompted stair climbing

BACKGROUND

Despite strong evidence that prompts at the point of choice between escalators and stairs encourage stair use, the long-term effects of stair prompts have not yet been investigated. Presented here are the results of a 6-month observational study of prompted stair climbing.

METHODS

Escalator and adjacent stair use were monitored in a shopping mall in the Midlands region of the United Kingdom. Participants were coded for gender, age, and ethnicity. A 2-week baseline period was followed by a 12-week intervention using motivating messages on the stair risers. Follow-up data were also collected for 2 weeks immediately after the removal of the banners and 6 weeks later.

RESULTS

A total of 45,361 escalator/stair-choice observations were made. Stair use increased significantly during the intervention period and, when the banners were removed, remained higher than at baseline. There were also significant interactions with time across the different population groups.

CONCLUSIONS

The full public health benefits of increasing physical activity levels can only be realized if the activity is sustained. These results demonstrate that stair-riser banners can elicit a sustained increase in stair use and, even when the banners were withdrawn, overall stair use remained higher than at baseline.