Physical Activity: Point-of-Decision Prompts to Encourage Use of Stairs

The CPSTF finding is based on evidence from a systematic review of 11 studies (search period 1980 - 2005).

The review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to increasing physical activity. This review updates and replaces the previous CPSTF finding on point-of-decision prompts to increase physical activity.

Eleven studies qualified for the review of point-of-decision prompts when used alone.

• In 10 of the 11 studies reviewed more people used the stairs when point-of-decision prompts were posted.
• Stair use during the intervention period in these study arms ranged from 4.0% to 41.9% of potential users.
• Stair use increased by a median 2.4 percentage points, a relative increase of 50% (interquartile interval: 0.83 to 6.7 percentage points; 21 study arms).
• Findings from several of the studies suggest that tailoring the prompts to describe specific benefits or to appeal to specific populations may increase the intervention’s effectiveness.

Only two studies qualified for the review of use of point-of-decision prompts when used with stair or stairwell enhancements, and both were conducted in office buildings.

• In one study, all interventions (paint, carpet, art, signs, and music) together led to a relative increase in stair use of 8.8% (baseline use 2.14 mean trips per day per occupant).
• In the other study, use of point-of-decision prompts with artwork and music resulted in a 39.6% relative increase in stair use (percent of people using stairs at baseline: 11.1%).

An economic review of this intervention did not find any relevant studies.

This type of intervention is likely to be effective across diverse settings and population groups, provided that the appropriate care is taken to adapt the messages for each setting or population.

CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

• What effect does varying the message or format of the prompt have on providing a “booster” to stair use among the targeted population?
• What type of prompt is most effective? What effect does format or size have, if any?
• Is there a "critical distance" from the elevator or escalator to the stairs, in which the effect of signage on stair use is reduced?
• Are there a minimum or maximum number of flights one must expect stair users to ascend in order for the prompt to be effective?
• How many individuals read the point-of-decision prompt and react (i.e., increase their use of the stairs) as a result, as opposed to reacting to other knowledge that the intervention is occurring?
• What strategies can be used to maintain the intervention effect after the intervention ends? Are periodic “boosters” necessary or helpful?

General Research Issues

The following outlines evidence gaps for reviews of these interventions to increase physical activity: Individually-Adapted Health Behavior Change Programs; Social Support Interventions in Community Settings; Family-Based Social Support; Enhanced School-Based Physical Education (archived); College-Based Physical Education and Health Education; Classroom-Based Health Education to Reduce TV Viewing and Video Game Playing; Community-Wide Campaigns; Mass Media Campaigns (archived); Classroom-Based Health Education Focused on Providing Information; Creation of or Enhanced Access to Places for Physical Activity Combined with Informational Outreach Activities.

Effectiveness

Several crosscutting research issues about the effectiveness of all of the reviewed interventions remain.

• What behavioral changes that do not involve physical activity can be shown to be associated with changes in physical activity?
  
  • For example, does a decrease in time spent watching television mean an increase in physical activity or will another sedentary activity be substituted?
  • Does an increase in the use of public transportation mean an increase in physical activity or will users drive to the transit stop?
• Physical activity is difficult to measure consistently across studies and populations. Although several good measures have been developed, several issues remain to be addressed.
  
  • Reliable and valid measures are needed for the spectrum of physical activity. Rationale: Current measures are better for vigorous activity than for moderate or light activity.
  • Sedentary people are more likely to begin activity at a light level; this activity is often not captured by current measurement techniques.
  • Increased consensus about “best measures” for physical activity would help to increase comparability between studies and would facilitate assessment of effectiveness.
• Note: This is not intended to preclude researchers’ latitude in choosing what aspects of physical activity to measure and to decide which measures are most appropriate for a particular study population. Perhaps a useful middle ground position would be the establishment of selected core measures that most researchers should use which could then be supplemented by additional measures. The duration of an intervention’s effect was often difficult to determine.

Applicability

Each recommended and strongly recommended intervention should be applicable in most relevant target populations and settings, assuming that appropriate attention is paid to tailoring. However, possible differences in the effectiveness of each intervention for specific subgroups of the population often could not be determined. Several questions about the applicability of these interventions in settings and populations other than those studied remain.

• Are there significant differences in the effectiveness of these interventions, based on the level or scale of an intervention?
• What are the effects of each intervention in various sociodemographic subgroups, such as age, gender, race, or ethnicity?

Other Positive or Negative Effects

The studies included in this review did not report on other positive and negative effects of these interventions. Research on the following questions would be useful:

• Do informational approaches to increasing physical activity help to increase health knowledge? Is it necessary to increase knowledge or improve attitudes toward physical activity to increase physical activity levels?
• Do these approaches to increasing physical activity increase awareness of opportunities for and benefits of physical activity?
• What are the most effective ways to maintain physical activity levels after the initial behavior change has occurred?
• Are there other benefits from an intervention that might enhance its acceptability? For example, does increasing social support for physical activity carry over into an overall greater sense of community?
• Are there any key harms?
• Is anything known about whether or how approaches to physical activity could reduce potential harms (e.g., injuries or other problems associated with doing too much too fast)?

Economic Evidence

The available economic data were limited. Therefore, considerable research is warranted on the following questions:

• What is the cost-effectiveness of each of these interventions?
• How can effectiveness in terms of health outcomes or quality-adjusted health outcomes be better measured, estimated, or modeled?
• How can the cost benefit of these programs be estimated?
• How do specific characteristics of each of these approaches contribute to economic efficiency?
• What combinations of components in multicomponent interventions are most cost-effective?

Barriers

Research questions generated in this review include the following:

• What are the physical or structural (environmental) barriers to implementing these interventions?
• What resource (time and money) constraints prevent or hinder the implementation of these interventions?

• Point-of-decision prompts were evaluated in a range of settings including shopping malls, train and bus stations, airports, an offıce building, a bank, a healthcare facility, a medical school, a university, and a university library.
• Studies were conducted in the U.S. (7 studies), the United Kingdom (2 studies), Scotland specifically (1 study), and Australia (1 study).
• Signs and banners of varying designs were used as the point-of-decision prompts.
• Messages addressed health benefıts, health promotion, and weight control, and signs (in Spanish and English) used individual and family perspectives to specifıcally target the Hispanic community.
• Program duration varied, with a maximum observation period of 12 weeks.
• All of the included studies used time–series designs and measured stair use in adult populations.
• While only four studies specifıed that workers were included among those observed, it is likely that workers were present in all places included in this review.
• Six studies (13 study arms) measured effectiveness separately among men and women and found that point-of-decision prompts had similar effects for both groups.
• Four studies (8 eight study arms) measured effectiveness for whites and African Americans and found no difference between racial groups.