Changing behavioral patterns to promote physical activity with motivational signs

Nudging Interventions on Stair Use: A Scoping Review

Stair use is a physical activity that can be incorporated into the daily lifestyle of a majority of the population, resulting in several health benefits. Nudges are increasingly used in public health interventions to encourage healthy behaviours such as physical activity in a cost-effective manner. This scoping review aimed to investigate the effect and the characteristics of nudges used on interventions to promote stair use. We reviewed the relevant literature published in PubMed, Cochrane Library, Mendeley and Google Scholar, from January 2009 to May 2022. Eligibility criteria included original studies of any type of design, written in English, targeting healthy adults, reporting nudging interventions, using elevator or escalator as comparators and defining a baseline for comparisons. Initially, 118 publications were identified, and after applying exclusion criteria, 27 articles were included in the analysis. Results showed that most of the nudging interventions had significant positive effect on stair use in several settings. The evidence from this review suggests that incorporating nudges into public health interventions can effectively promote physical activity through increased stair usage. Emphasizing prevention measures in public health interventions may contribute to better health outcomes.

Communicating Extremity: Fitness Efficacy and Standards Relate to Using Extreme Imagery and Messaging to Create Fitness-Related Media

Health-related social media increasingly competes with other forms of health communication for public attention. To advance understanding of the genesis of health-related social media communicating extreme fitness standards, we investigated women's creation of fitspiration, social-media content combining fitness images with effortful messages. In a pre-registered study, we hypothesized that creating extreme fitspiration content would relate positively to fitness fantasizing and to exercise self-efficacy, fitness perfectionism, physical activity, thin- and muscular-ideal internalizations, and self-objectification. Undergraduate women (N = 277) created their own fitspiration content by selecting from fitness images and messages that varied in extremity. Fitness fantasizing related positively to creating more extreme fitspiration. When controlling statistically for all other individual-difference variables, exercise self-efficacy and perfectionistic strivings emerged as key variables associated with creating extreme fitspiration content. Results suggest that women who are confident and strive toward challenging goals may create fitspiration content that communicates extreme standards. This work has implications for understanding a potential disconnect between fitspiration creators and consumers, which may illuminate ways to promote healthy fitness communications online.

Point of Decision Design to Address Adolescent Overweight and Obesity

OBJECTIVES

This study aims to utilize the point of decision design framework to understand how, where, and why adolescents and families make decisions about diet and physical activity and to explore how modifications to the environment can help to promote healthier choices and reduce obesity.

BACKGROUND

Child and adolescent obesity is a critical public health problem. As environmental factors are a primary contributor, understanding the role of design in our surrounding environment highlights an important area of interdisciplinary study. Design strategies have been used successfully to increase stair use and reduce sedentary behavior and can be used to further promote healthier diet and activity choices among adolescents and families.

METHODS

We leveraged the human-centered design-thinking process through (1) qualitative interviews and survey instruments, (2) persona and prompt development, and (3) a design workshop with multidisciplinary stakeholders.

RESULTS

Five personas were developed from the qualitative data and used in a design-thinking workshop. During the workshop, participants generated 12 influential factors and nine points of decision which were used to generate 33 solutions spanning the design continuum (from information and policy design to the design of urban, architectural, and interior environments) aimed at improving nutrition and physical activity among adolescents. Additionally, a tool kit was prototyped, which includes interview guides, a persona framework, and a workshop facilitation guide.

CONCLUSIONS

Our novel process led to the generation of design solutions that can be implemented to expand and improve upon existing interventions for childhood obesity and create environments that encourage positive health outcomes.

Promoting Stair Use is Possible by Displaying Signs, Even for Stairs of 80 or 105 Steps

Installing signs is known to be effective in encouraging people to use stairs instead of escalators. However, it has been reported that the effectiveness of such signs is diminished as the number of stairs increases, and no effect was reported at 44 steps. Thus, this study examined whether stair use could be promoted even with 80 or 105 steps by presenting specific numerical values for the health benefits of using stairs. At two universities with parallel escalators and stairs (105 and 80 steps, respectively), we installed signs stating, "Going up one flight of stairs increases your life span by 4 seconds." A one-week baseline period was followed by a one-week intervention using signs displayed to passersby. Follow-up data were also collected for one week immediately after removing the signs. Measurements were collected Monday through Friday from 7:30 to 9:15 a.m. The number of passersby was recorded by categorizing them into four attributes: male and female students, and male and female faculty/staff. A total of 25,065 observations (963 stair users vs. 24,102 escalator users) at University A and 25,677 observations (1020 stair users vs. 24,657 escalator users) at University B were recorded. Sign installation promoted stair use at University A (odds ratio [OR], 1.513; 95% confidence interval [CI], 1.307-1.752) and University B (OR, 1.221; 95% CI, 1.046-1.425). However, there was no effect of the sign installation on the population with attributes that had a high percentage of stair use prior to this study, implying that there is a ceiling effect on the effectiveness of such signs. The implication of the findings is that it is effective to provide detailed information to passersby on the health benefits of stair use for stairs with 80 or 105 steps.

A longitudinal controlled signage intervention to increase stair use at university buildings: Process and impact evaluation using RE-AIM framework

Introduction

Stair climbing intervention could be suggested to address low occupational physical activity amongst university students and employees. Strong evidence showed the effectiveness of signage intervention in increasing stair use in public areas. However, evidence in worksite settings, including university settings, was inconclusive. This study aimed to evaluate the process and impact of a signage intervention to increase stair use at a university building using the RE-AIM framework.

Method

We conducted a non-randomised controlled pretest-posttest study to examine the effect of signage intervention placed in university buildings in Yogyakarta (Indonesia) between September 2019 and March 2020. The process of designing the signage involved the employees in the intervention building. The main outcome was the change in the proportion of stair use to elevator use measured by manual observations of video recordings from closed-circuit television. A linear mixed model examined the intervention effect by controlling the total visitor count as a confounder. RE-AIM framework was used in the process and impact evaluation.

Results

The change in the proportion of stair climbing from baseline to the 6th-month phase at the intervention building (+0.067 (95% CI = 0.014-0.120)) was significantly higher than that of the control building. However, the signs did not change the proportion of the stair descending at the intervention building. The signs were potentially viewed 15,077-18,868 times/week by visitors.

Conclusion

Signage intervention using portable posters could easily be adopted, implemented, and maintained in similar settings. A co-produced low-cost signage intervention was found to have a good reach, effectiveness, adoption, implementation, and maintenance dimension.

Indigenous Māori perspectives of smokefree parks

OBJECTIVE

This study aims to understand the context of place associated with smoking in urban Hamilton parks from a Te Ao Māori perspective (the worldview of Māori, the Indigenous people of Aotearoa New Zealand).

METHODS

Our study approached smokefree environments in Hamilton through a Māori lens, undertaking interviews with family groups and people from organisations involved in the local Smokefree environments policy.

RESULTS

The majority of the 26 adult participants identified as Māori, with 30% being current smokers. Parks had a place in the sporting memories of participants. Smoking was merged with these memories. Important features of places that influenced smoking behaviours were raised, with signage a key talking point.

CONCLUSIONS

The colonial construct of parks do not make visible Māori values and historical associations with the land, nor do they set a framework that would promote Māori ways of being and doing, including enacting smokefree spaces and places.

IMPLICATIONS FOR PUBLIC HEALTH

This study provides the incentive to address change in parks and reserve management that would support Māori aspirations for their health and wellbeing associated with ancestral land, and give meaning to smokefree environments.

A theoretical framework to improve adherence among older adults to recommendations received at a falls prevention clinic: A narrative review

BACKGROUND

Falls impose a prominent public health problem among older adults. Falls are preventable through multi-factorial interventions offered by a Falls Prevention Clinic. Yet, adherence to recommendations is often average or low, particularly for lifestyle recommendations. To achieve full health benefits from such a multifactorial intervention, improving adherence is critical.

PURPOSE

Our primary objective was to conduct a narrative review to develop a theoretical framework, categorized by intrinsic and extrinsic factors that impact adherence to falls prevention interventions, considering a Falls Prevention Clinic setting.

MATERIALS AND METHODS

We conducted a comprehensive literature review of all peer-reviewed manuscripts published between 1998 through August 2020 among older adults (i.e., aged 60 years and older) who fall. We used the following search engines: Pubmed, CINAHL, Embase, MedLine, Cochrane and Google Scholar.

RESULTS

The theoretical framework categorizes two dominate factors (comprised of specific domains) that affect adherence among older adults who fall. Intrinsic factors comprised of three domains included: demographics (age, gender, ethnicity), individual factors (participation, control, behavioural habits) and health factors (physical health, mental state, perceived severity). Extrinsic factors comprised of four domains included: caregiver factors (family dynamics, miscarried helping) medication factors (availability, accessibility, drug handling, reliability), health system (costs, communication, relationship with doctors, attention) and environmental factors (public health policy interventions). Intrinsic factors such as high socioeconomic status, high health literacy, being married and extrinsic factors such as low healthcare cost, better communication and useful policy interventions were associated with greater adherence.

CONCLUSION

This theoretical model elucidates priority factors to target for promoting adherence to reduce falls, decrease mortality and, lower fall-related healthcare costs.

Motivational signage increases stair usage on a Hispanic serving institution

Objective: Stair climbing is considered a good physical activity. Motivational signage has been successful in promoting stair usage in various settings. This study was to investigate the effects of motivational signage on stair usage in a Hispanic serving institution. Participants: A total of 31,067 pedestrians were observed from February to March 2013. Methods: Stair usage was monitored for 9 h per day each week at phase 1 (baseline), 2 (intervention), and 3 (post-intervention). Results: Overall, participants' stair usage was higher during phase 2 (49.0%) and phase 3 (48.0%), compared with phase 1 (39.7%). The participants during phase 2 and 3 were more likely to use the stairs compared to participants during phase 1, regardless of floor level (3-story or 4-story building), status (student or staff/faculty), and time of day (7:30-10:29, 10:30-13:29, or 13:30-16:30) (p < .001). Conclusion: Motivational signage can effectively encourage more stair usage, and hence promote healthy behavior in a predominantly Hispanic-serving institution.

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.

Promoting Stair Climbing as an Exercise Routine among Healthy Older Adults Attending a Community-Based Physical Activity Program

Stair climbing provides a feasible opportunity for increasing physical activity (PA) in daily living. The purpose of this study was to examine the daily walking and stair-climbing steps among healthy older adults (age: 74.0 ± 4.9 years; Body Mass Index (BMI): 22.3 ± 2.5 kg/m²). Participants (34 females and 15 males) attended a weekly 6-month community-based PA program. During the entire program period, daily walking and stair-climbing steps were recorded using a pedometer (Omron, HJA-403C, Kyoto, Japan). Before and after the 6-month program, height, body weight and leg muscle strength were assessed. After the 6-month program, the mean walking and stair-climbing steps in both women and men increased significantly (p ≤ 0.01). Daily stair-climbing steps increased about 36 steps in women and 47 steps in men. At the end of 6 months, only male participants had significant correlation between the number of stair steps and leg muscle strength (r = 0.428, p = 0.037). This study reported that healthy older adults attending the community-based PA program had regular stair-climbing steps during daily living. Promoting stair climbing as an exercise routine was feasible to increase their walking and stair-climbing steps.

Smoke-free signage in public parks: impacts on smoking behaviour

Objective

Behavioural interventions, such as smoke-free signage, are used to support air quality in public outdoor spaces that are not protected by a smoke-free policy, such as states with preemptive clause legislation. However, there is little evidence of the effectiveness of these interventions. This paper is an evaluation of whether smoke-free signage posted in public parks altered smoking behaviours of park patrons.

Methods

A time-series quasi-experimental design was used. Cigarette butts were collected at the same day and time every week in ten amenities within four parks in 2011. Each park completed a baseline period until a stable trend emerged at six weeks, then received smoke-free signage for the six week intervention period. There were 1684 cigarette butts collected during baseline and 1008 collected during the intervention phase.

Findings

Wilcoxon signed-rank test demonstrated that smoking at seven out of ten amenities decreased and the overall decrease was significant at p=0.028. Individual parks and amenities grouped by type did not experience a statistically significant change. A neighbourhood median income trend was visually discovered, revealing that as income increased, there was a greater decrease in cigarette butts.

Conclusions

This study provides evidence on the impact of smoke-free signage not supported by local ordinance in public parks using a reproducible measure. States, especially those with a preemptive clause legislation, may benefit from incorporating smoke-free signage in public areas to protect community members from exposure to tobacco smoke, reduce littering, and denormalise smoking.

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.

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.

Is there any Proffitt in stair climbing? A headcount of studies testing for demographic differences in choice of stairs

The apparent slope of a hill, termed geographical slant perception, is overestimated in explicit awareness. Proffitt (2006) argued that overestimation allows individuals to manage their locomotor resources. Increasing age, fatigue, and wearing a heavy back pack will reduce the available resources and result in steeper reports for a particular hill. In contrast, Durgin and colleagues have proposed an alternative explanation for these effects based on experimental design—particularly, the potential effects of experimental demand. Proffitt’s resource-based model would predict that pedestrians with reduced resources should avoid climbing a hill that would further deplete their resources if the opportunity arose. Within the built environment, stairs are the man-made equivalent of relatively steep hills (20°–30°). In many public access settings, pedestrians can avoid climbing the stairs by opting for an adjacent escalator. Observations of pedestrian behavior in shopping malls reveal that 94.5 % do so. This article summarizes the effects of demographic grouping on avoidance of stairs in public health research. Observations in shopping malls (n = 355,069) and travel contexts (n = 711,867) provide data consistent with Proffitt’s resource model. Women, the old, and those carrying excess body weight or large bags avoid the stairs more than do their comparison groups. Discussion focuses on differences in physiology that may underlie avoidance of stair climbing in order to highlight the pedestrian behavior that psychology needs to explain.

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.

The use of point-of-decision prompts to increase stair climbing in Singapore

Physical inactivity is a significant contributor to worldwide mortality and morbidity associated with non-communicable diseases. An excellent avenue to incorporate lifestyle physical activity into regular routine is to encourage the use of stairs during daily commutes. We evaluated the effectiveness of point-of-decision prompts (PODPs) in promoting the use of stairs instead of the escalators in a Singapore Mass Rapid Transit (MRT) station. We measured the number of stair climbers before the PODPs were put up, during the 4 weeks that they were in use, and 2 weeks after they were removed. Measurements at a no intervention control site were additionally taken. The use of stair-riser banners was associated with an increase in the number of people using the stairs by a factor of 1.49 (95% CI 1.34–1.64). After the banners were removed, the number of stair climbers at the experimental station dropped to slightly below baseline levels. The Singapore MRT serves a diverse multi-ethnic population with an average daily ridership of over 2 million and 88 stations island-wide. An increase of physical activity among these MRT commuters would have a large impact at the population level. Our findings can be translated into part of the national strategy to encourage an active lifestyle in Singaporeans.

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.

Lifestyle changes and reduction of colon cancer incidence in Europe: A scenario study of physical activity promotion and weight reduction

BACKGROUND

Across Europe, there are over 300,000 new cases of colorectal cancer annually. Major risk factors include excess body weight (usually expressed by a high body mass index, BMI) and physical inactivity (PA). In this study we modelled the potential long-term effects on colon cancer incidence of changes in prevalence of excess body weight and physical inactivity in seven European countries across Europe with adequate data.

METHODS

We addressed the impact of interventions aimed at preventing weight gain and increasing physical activity on colon cancer incidence using the Prevent model as refined in the FP-6 Eurocadet project. Relative risk (RR) estimates were derived from meta-analyses; sex- and country-specific prevalences of BMI and PA were determined from survey data. Models were made for Czech Republic, Denmark, France, Latvia, the Netherlands, Spain and the United Kingdom.

RESULTS

In a hypothetical scenario in which a whole population had obtained an ideal weight distribution in the year 2009, up to 11 new cases per 100,000 person-years would be avoided by 2040. The population attributable fractions (PAF) for excess weight were much higher for males (between 13.5% and 18.2%) than for females (2.3-4.6%). In contrast, using the optimum scenario where everybody in Europe would adhere to the recommended guideline of at least 30 min of moderate PA 5d per week, the PAFs for PA in various countries were substantially greater in women (4.4-21.2%) than in men (3.2-11.6%). Sensitivity analyses were performed assuming underreporting of BMI by using self-reports (difference of 5 and 0.8 percent-points in males and females, respectively), using different risk estimates (between 5.8 and 11.5 percent-points difference for BMI for men and women, respectively, and up to 11.6 percent-points difference for PA for women).

INTERPRETATION

Changes in lifestyle can indeed result in large health benefits, including for colon cancer. Two interesting patterns emerged: for colon cancer, achieving optimum BMI levels in the population appears to offer the greatest health benefits in population attributable fractions in males, while increased physical activity might offer the greatest fraction of avoidable cancers in females. These observations suggest a sex-specific strategy to colon cancer prevention.

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.