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, sex, 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 off ce 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 benef ts, health promotion, and weight control, and signs (in Spanish and English) used individual and family perspectives to specif cally 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 specif ed 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.

Effectiveness Review

Analytic Framework

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Effectiveness Review

Summary Evidence Table

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Effectiveness Review

Adams J, White M. A systematic approach to the development and evaluation of an intervention promoting stair use. Health Education Journal 2002;61(3):272-86.

Andersen RE, Franckowiak SC, Snyder J, Bartlett SJ, Fontaine KR. Can inexpensive signs encourage the use of stairs? Results from a community intervention. Ann Intern Med 1998;129(5):363-9.

Andersen RE, Franckowiak SC, Zuzak KB, Cummings ES, Crespo CJ. Community intervention to encourage stair use among African American commuters. Med Sci Sports Exerc 2000;32:38.

Blamey A, Mutrie N, Aitchison T. Health promotion by encouraged use of stairs. BMJ 1995;311(7000):289-90.

Boutelle KN, Jeffery RW, Murray DM, Schmitz MK. Using signs, artwork, and music to promote stair use in a public building. Am J Public Health 2001;91(12):2004-6.

Brownell KD, Stunkard AJ, Albaum JM. Evaluation and modification of exercise patterns in the natural environment. Am J Psychiatry 1980;137(12):1540-5.

Coleman KJ, Gonzalez EC. Promoting stair use in a U.S.-Mexico border community. Am J Public Health 2001;91(12):2007-9.

Kerr J, Eves F, Carroll D. Getting more people on the stairs: the impact of a new message format. J Health Psychol 2001;6(5):495-500.

Kerr J, Eves F, Carroll D. Six-month observational study of prompted stair climbing. Prev Med 2001;33(5):422-7.

Marshall AL, Bauman AE, Patch C, Wilson J, Chen J. Can motivational signs prompt increases in incidental physical activity in an Australian health-care facility? Health Educ Res 2002;17(6):743-9.

Russell WD, Dzewaltowski DA, Ryan GJ. The effectiveness of a point-of-decision prompt in deterring sedentary behavior. Am J Health Promot 1999;13(5):257-9.

Russell WD, Hutchinson J. Comparison of health promotion and deterrent prompts in increasing use of stairs over escalators. Percept Mot Skills 2000;91(1):55-61.

Point-of-decision Prompts When Used with Stair or Stairwell Enhancements

Boutelle KN, Jeffery RW, Murray DM, Schmitz MK. Using signs, artwork, and music to promote stair use in a public building. Am J Public Health 2001;91(12):2004-6.

Kerr NA, Yore MM, Ham SA, Dietz WH. Increasing stair use in a worksite through environmental changes. Am J Health Promot 2004;18(4):312 5.

The articles considered for this review were obtained from systematic searches of multiple databases, reviews of bibliographic reference lists, and consultations with experts in the field. Our updated search for evidence encompassed the period from 2000 to April 2005, which overlapped with the search conducted for the original Community Guide review of these interventions (search period 1980 2000).

The original review utilized the following seven databases: Enviroline, MEDLINE, PsychInfo, Social SciSearch, Sociological Abstracts, Sportdiscus, and Transportation Research Information Services (TRIS). For our updated search, the following 15 databases were examined: ArticleFirst, CINAHL, EMBASE, Enviroline, Health Promotion and Education Database, MEDLINE, Ovid, PsycINFO, PubMed, Social SciSearch, Social Science Citation Index , Sociological Abstracts, SPORTDiscus, Transportation Research Information Services (TRIS), and WorldCat.

This list includes some databases not available at the time of the original review. The search strategies for a selection of these databases is included below.

Database: Ovid MEDLINE(R)

[1999 to April Week 1 2005]

1. exercise/ or physical fitness/ (17239)
2. (physical activit$ or climb$ or walk$).mp. (21373)
3. 1 or 2 (33722)
4. health promotion/ and environment/ (32)
5. health promotion/ or environmental change$.mp. or environmental intervention$.mp. [mp=title, original title, abstract, name of substance word, subject heading word] (10840)
6. 4 or 5 (10840)
7. 3 or 6 (43437)
8. decision making/ or point of decision.mp. or prompt$.mp. or decision$.mp. [mp=title, original title, abstract, name of substance word, subject heading word] (62856)
9. 7 and 8 (891)
10. stair$.mp. (1071)
11. 9 and 10 (18)
12. limit 11 to (english language and yr=2000 – 2005) (13)
13. from 12 keep 2,6-9,12-13 (7)
14. from 13 keep 1-7 (7)

Database: EMBASE

[1996 to 2005 Week 15]

1. exercise/ or fitness/ (31388)
2. physical activity/ or climb$.mp. or walk$.mp. [mp=title, abstract, subject headings, drug trade name, original title, device manufacturer, drug manufacturer name] (34061)
3. 1 or 2 (59826)
4. health promotion/ and environment/ (56)
5. health promotion/ or environmental change$.mp. or environmental intervention$.mp. [mp=title, abstract, subject headings, drug trade name, original title, device manufacturer, drug manufacturer name] (13841)
6. 4 or 5 (13841)
7. 3 or 6 (72094)
8. decision making/ or point of decision.mp. or prompt$.mp. or decision$.mp. (73887)
9. 7 and 8 (1613)
10. stair$.mp. (1496)
11. 9 and 10 (22)
12. limit 11 to (english language and yr=2000 – 2005) (14)
13. from 12 keep 2-3,6-7,9-13 (9)
14. from 13 keep 1-9 (9)

Database: PsycINFO

[2000 to April Week 2 2005]

1. exercise/ or physical fitness/ (2496)
2. (physical activit$ or climb$ or walk$).mp. [mp=title, abstract, subject headings, table of contents, key concepts] (4335)
3. 1 or 2 (5719)
4. health promotion/ and environment/ (17)
5. health promotion/ or environmental change$.mp. or environmental intervention$.mp. [mp=title, abstract, subject headings, table of contents, key concepts] (2334)
6. 4 or 5 (2334)
7. 3 or 6 (7699)
8. decision making/ or point of decision.mp. or prompt$.mp. or decision$.mp. (20959)
9. 7 and 8 (323)
10. stair$.mp. (188)
11. 9 and 10 (5)
12. limit 11 to english language (5)
13. from 12 keep 1-5 (5)

Database: Chronic Disease Prevention File Health Promotion and Education Database

1. MJ= exercise or physical activity or physical fitness or physical fitness programs
2. tw= stair* and (prompt* or decision*)
3. 1 and 2
4. 3 and yr = 2000-2005

Database: SPORTDiscus_1962-2005/Sep (c) 2005 Sport Information Resource Centre

1. stair? and (health promotion or prompt? or decision?)

Total = 4

Database: Web of Science

(includes Science Citation Index and Social Science Citation Index)

1. Stair* and (prompt* or decision*)
2. 1 and yr = 2000-2005

Total: 11

The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion.

• 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.
• Stair use, and in turn, intervention effectiveness may vary according to the following:
  • Environmental characteristics (e.g., accessibility of stairs, number of flights to destination, or cleanliness of stairwell)
  • Personal factors (e.g., body composition, presence of children or heavy loads)
  • Settings (e.g., buildings with single or multiple flights of stairs, public locations and worksites)
  • Goal (e.g., leisure activity or work)
  • Type of dress (e.g., suit or work shoes) of people in certain types of locations

Evidence-Based Cancer Control Programs (EBCCP)

Find programs from the EBCCP website that align with this systematic review. (What is EBCCP?)

Healthy People 2030

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.

• Reduce the proportion of adults who do no physical activity in their free time — PA‑01
• Increase the proportion of adults who do enough aerobic physical activity for substantial health benefits — PA‑02
• Increase the proportion of adults who do enough aerobic physical activity for extensive health benefits — PA‑03
• Increase the proportion of adults who do enough aerobic and muscle-strengthening activity — PA‑05