Step on up! A multi-component health promotion intervention to promote stair climbing

Abstract

Objectives:

To study the influence of a multi-component poster-based intervention to promote stair climbing in a library on a Canadian university campus.

Participants:

Adults who ascended to upper levels via staircase/elevator.

Methods:

Individuals who used the staircase/elevators were counted by observers for 28 days, while either in the absence/presence of a poster-based intervention. Chi-square tests were used to compare staircase versus elevator use before, during and after the poster-based intervention. Data from weekdays and weekends were analysed separately.

Results:

A total of 7,663 stair climbers and elevator users were observed. Compared to the baseline period, the frequency of staircase use on weekdays was significantly higher during the intervention and follow-up periods. This effect was not found at weekends.

Conclusion:

This study provides evidence that a multi-component poster-based intervention can result in increased staircase use. The increase observed in this study is similar to that in previous research using point-of-choice prompts only.

Keywords

Adults health promotion physical activity signage stair climbing

With the recent release of the second edition of the Physical Activity Guidelines for Americans (Powell et al., 2018), a spotlight has once again been cast upon physical activity and its health benefits. At about the same time that these guidelines were released, the World Health Organization (WHO, 2018) published a Global Physical Activity Action Plan that focused on reducing rates of adult physical inactivity internationally, by 10% by 2025 (and 15% by 2030). WHO researchers also published a comprehensive analysis of physical inactivity and concluded that population-based policies need to be mandatory in order to meet the goal of reducing insufficient physical activity levels worldwide (Guthold et al., 2018). One population-based approach that could evolve into such a policy – and which was mentioned by the 2018 Physical Activity Guidelines Advisory Committee – is point-of-choice prompts (e.g. posters/signage that promote the use of staircases instead of elevators; Powell et al., 2018). Due to their potential positive influence on behaviours, point-of-choice prompts may offer a cost-effective and impactful public health approach for promoting higher activity levels (Bellicha et al., 2015; Reynolds et al., 2014).

Point-of-choice prompts, as a type of population-based physical activity intervention, may be particularly impactful if implemented among populations with higher physical inactivity rates. Objectively measured activity levels using accelerometers (among adults aged 20 years and older) have indicated rates of compliance to physical activity guidelines as low as ~15% in Canada (Colley et al., 2011). When considering early adulthood in particular, these formative years often include transitions (e.g. change of personal habits and/or residence) that can both disrupt current lifestyle behaviours and help to establish longer-term ones (Moreno- Gómez et al., 2012; Sevil et al., 2018). In fact, during this time of early adulthood, there is a noticeable decline (⩾5 minutes/day) in moderate- to vigorous-intensity physical activity (MVPA; Caspersen et al., 2000; Corder et al., 2019). This concerning trend of insufficient physical activity remains true when focusing specifically on Canadian post-secondary students (Irwin, 2007).

Physical activity has numerous health benefits such as, but not limited to, improving cognitive function and brain health, reducing the risk of excessive weight gain and lowering the risk of some diseases (e.g. diabetes and certain types of cancers; Ainsworth et al., 2011; Powell et al., 2018). In addition, post-secondary students who regularly engage in physical activity are known to have lower levels of anxiety and depression, and better mental health than students who are less active (Tyson et al., 2010). Of note, stair climbing is a physical activity that is available to many which could help individuals accrue health benefits such as improving cardiovascular function and fitness (Cho et al., 2018; Meyer et al., 2010). In terms of the amount of energy stair climbing necessitates, the updated compendium of physical activities described stair climbing (i.e. going up a flight of stairs) as a vigorous form of physical activity that requires 8 METs (moderate-intensity physical activity) – this makes it a more vigorous activity than ‘general’ jogging (7 METs; Ainsworth et al., 2011). In comparison, descending a flight of stairs requires only 3.5 METs (Ainsworth et al., 2011). Therefore, the promotion of stair climbing through a population-based intervention (e.g. point-of-choice prompts) could concomitantly facilitate the acquisition of physical activity–related health benefits and help to combat high rates of inactivity.

A recent systematic review of all signage-based staircase interventions since the 1980s reported that point-of-choice prompts could increase the likelihood of staircase usage by 52% (Bauman et al., 2017). Although point-of-choice prompts have been recommended as an efficacious way to promote this behaviour, there were relatively few studies that used a multi-component approach utilising different types of health posters simultaneously to promote staircase use (Bauman et al., 2017). A variety of health posters could be used to promote staircase use. For example, point-of-choice signs could be posted to encourage intentions into actions (e.g. a poster displayed at a location where someone has to choose between using the stairs or elevator; Eves et al., 2012; Lewis and Eves, 2012a; Ly and Irwin, 2019). In addition, motivational posters could be displayed to enhance attitudes towards an action (e.g. a poster with information about the benefits of stair climbing displayed inside of an elevator; Eves et al., 2012; Lewis and Eves, 2012a; Ly and Irwin, 2019). Beyond this, trivia-based posters in a stairwell (e.g. one question on the main floor with the answer and a new question on the next floor up) might encourage some adults to participate in stair climbing by making the activity more engaging and fun (Ly and Irwin, 2019). Finally, posting directional signs (i.e. arrows indicating staircase locations) can help people find hidden staircases (Grimstvedt et al., 2010). It is imperative however that the messages presented on each poster are suitable for a particular location because different types of information (e.g. a simple message vs a complex message) can impact whether people choose to engage in the activity (Lewis and Eves, 2012b).

Even though some researchers have found no significant change in staircase use among adults exposed to point-of-choice prompts (Cohen, 2013; Marshall et al., 2002), those who have studied the impact specifically on post-secondary campuses in the USA and UK have found it to be an effective strategy to increase staircase use (Ford and Torok, 2008; Grimstvedt et al., 2010; Lewis and Eves, 2012a). However, it is unknown whether the simultaneous use of multiple types of health posters (i.e. displaying point-of-choice prompts, directional posters, motivational posters and stairwell posters) as part of a health promotion intervention will substantially enhance rates of stair climbing among adults on a Canadian university campus – a place of study and worksite for thousands of young and other adults. As such, this study examined a multi-component health promotion poster-based intervention, tailored specifically for a busy library, to increase rates of stair climbing among adults on a Canadian post-secondary university campus.

Methods

Study setting and research context

At the time of the investigation, the post-secondary institution in which this study was conducted had 24,587 full-time undergraduate students (71.5%), 5,935 full-time graduate students (17.3%), 1,405 full-time members of faculty (4.1%), and 2,455 full-time administrative and support staff (7.1%) (Western University, 2018). The study site – a campus library – has five floors that also include a mezzanine and ground floor. It received 164,767 visitors in March 2018 (an average of 5,315 visitors per day). Prior to commencing the current study, a formative evaluation using focus groups was conducted. The resultant article (Ly and Irwin, 2019) reported details for content and aesthetics to create an effective and appealing multi-component poster-based intervention promoting stair climbing among adults at the campus library.

Study materials

The study included four different types of posters: a point-of-choice prompt, directional posters, motivational posters and stairwell posters (see details below). Based on participants’ suggestions from previous research focusing on what students find most suitable and appealing in point-of-choice prompts (Ly and Irwin, 2019), the poster designs were specifically tailored and professionally created by a graphic designer. Most were printed on ledger size paper (~ poster printing size A3, 42 cm × 30 cm) and laminated, but one directional poster for locating the staircase was printed on letter size paper (~ poster printing size A4, 30 cm × 21 cm) so it could fit in a frame that was placed underneath the elevator buttons (Table 1).

Table 1.

Locations of where health posters to promote stair climbing were displayed.

Study materials	Examples
A point-of-choice prompt poster displayed before two elevators.
A directional poster displayed below the elevator buttons.
A motivational poster displayed in an elevator.
Stairwell posters displayed at the bottom and top of a flight of stairs.

The point-of-choice prompt message was, ‘Stair climbing burns more calories per minute than jogging. Raise your level of fitness one step at a time’ (Eves et al., 2012) and it was posted on the wall of a corridor that provided access to the elevators and stairwell. The more complex message stating, ‘Stair climbing always burns calories; 10 flights a day for over a year burns over 3lb of fat!’ (Lewis and Eves, 2012a) was included on the motivational posters, and these were displayed inside two elevators. These messages were adapted from previously published studies of staircase use (Eves et al., 2012; Lewis and Eves, 2012a), and they were selected based on ratings from focus groups with undergraduate students as part of a needs assessment (Ly and Irwin, 2019).

Directional signs were also posted on the walls of a corridor and below the elevator buttons to help individuals locate the stairs. Finally, stairwell posters that contained a trivia question/answer (i.e. ‘How many steps would it take to walk to the next floor?’ and ‘It took ___ steps to get up to this floor’) were displayed at the bottom and top of each flight of stairs.

Inclusion and exclusion criteria

The inclusion criteria for this study were adults who ascended to upper levels of the building using the busiest staircase and elevators from the main floor of a campus library. Exclusion criteria were children using the staircase/elevators who were with an adult in the library. They were excluded because it could reasonably be assumed that they would comply with the decision made by the adult accompanying them. Individuals were also excluded if they were carrying noticeably heavy objects (e.g. a bin or a large instrument), pushing a cart or had noticeable physical limitations that might preclude stair climbing (e.g. people in wheelchairs or using a cane/walker).

Study design

Upon approval by the institutional review board (Western University Research Ethics Board approval # 113009), this pre–post intervention study was conducted for a total of 28 days in March 2019. Before data collection began, the research team observed the study site and used previously gathered data from electronic sensors at the entrance of the library to determine times of high levels of pedestrian traffic (data from March 2018 were used). Consequently, data collection occurred between 12:30 p.m. and 1:30 p.m. on weekdays and 1:30 p.m. and 2:30 p.m. at weekends during a 7-day baseline assessment period, a 14-day intervention period and a 7-day follow-up period.

On the first floor of the library, an investigator and a research assistant observed a set of two elevators and a stairwell with 14 flights of stairs (Figure 1). The behaviour of a convenience sample of adults who used the elevators and stairs to go to upper levels were recorded with a tally counter (Staples® Tally Counter – a mechanical device with a thumb push that can record and display a count between 0 and 9,999), while either in the absence/presence of a point-of-choice prompt, motivational posters, directional posters and stairwell posters.

Figure 1.

Floor plan for the first floor of the university library where data collection took place (the study setting).

At baseline, no prompts or posters were displayed and each adult who used the stairs or elevator was counted. During the intervention phase, the study materials were displayed and the research team recorded the number of individuals who used the stairs or elevators. At follow-up, the prompts and posters were removed and final observations were made. The lead investigator (H.L.) and research assistants met before each data collection period to confirm that the posters were properly displayed and then after each period to discuss any disruptions in data collection. To facilitate this process, an observation guide with a comment section was created to track any inconsistencies at the study site that might have disrupted data collection (e.g. the need to replace missing posters or fix those not properly displayed).

Data analysis

The information collected was entered into Microsoft Excel (version 16, 2016). Frequencies and percentages were calculated to summarise each phase of data collection. Chi-square tests were performed, using an alpha of .05, to evaluate whether the frequency of staircase use differed before and after the posters were presented. Data collected on weekdays (Mondays–Fridays) and at weekends (Saturdays and Sundays) were analysed separately given that substantially more people visited the library on weekdays than on weekends during data collection.

Results

In total, 7,663 adults used the staircase or elevator (6,344 on weekdays and 1,319 on weekends) during 28 days of data collection (see Table 2).

Table 2.

Total number of observations and percentages for each phase (N = 7,663).

	Weekdays		Weekends
	Elevators (%)	Stairs (%)	Elevators (%)	Stairs (%)
Baseline	1,405 (84.4)	260 (15.6)	379 (91.1)	37 (8.9)
Intervention	2,517 (80.7)	604 (19.4)	480 (89.2)	58 (10.8)
Follow-up	1,274 (81.8)	284 (18.2)	326 (89.2)	39 (10.7)
Total	5,196 (81.9)	1,148 (18.1)	1,185 (89.8)	134 (10.2)

Observations and percentages of adult users who met the inclusion criteria. Data collection included a 7-day baseline period, 14-day intervention period and 7-day follow-up period.

Rates of staircase and elevator use on weekdays

The overall percentage increase in staircase use was 3.7% between the baseline and intervention periods, and 2.6% between the baseline and follow-up periods. A chi-square test of the association between stair use (vs elevator use) and observation period (baseline, intervention, follow-up) was statistically significant, χ²(2) = 10.26, p < .01, indicating that, overall, staircase use differed between the three observation periods.

This overall effect was followed-up by performing three post hoc comparisons using a Bonferroni-adjusted alpha (i.e. .05 divided by 3). It was found that staircase use during the intervention period (19.4%) was significantly higher, χ²(1) = 10.25, p < .01, than during the baseline period (15.6%). In addition, staircase use during the follow-up period (18.2%) was significantly higher, χ²(1) = 6.72, p < .01, than during the baseline period. Finally, it was found that staircase use did not differ significantly between the intervention and follow-up periods, χ²(1) = 3.60, p = .06.

Rates of staircase and elevator use on weekends

A chi-square test of the association between stair use and observation period was not statistically significant, χ²(1) = 1.07, p > .05, indicating that at weekends, staircase use did not differ between the three observation periods. It is also interesting to note that the overall percentage of adults who took the stairs at weekends (10.2% stairs vs 89.8% elevator) was significantly lower, χ²(1) = 49.4, p < .001, than the overall percentage of adults who took the stairs on weekdays (18.1% stairs vs 81.9% elevator).

Discussion

This study demonstrated that health posters can be part of a health promotion intervention to help change behaviour patterns in a library on a Canadian university campus. As such, the study adds to previous research reporting point-of-choice prompt interventions having positive results in other settings such as offices, hospitals, shopping centres and transportation hubs (Eves et al., 2012; Kerr et al., 2001; Meyer et al., 2010). That said, findings similar to this multi-component study have previously been observed in other poster-based interventions that only utilised point-of-choice prompts (Bauman et al., 2017). The differences between weekday and weekend library users found in the current study indicate that more research is needed to fill this gap in the literature.

Health posters appear to be a cost-effective and simple approach to help promote the sentiment that an active lifestyle is important and there are ways to achieve incidental accumulations of physical activity. Based on the current and previous studies, health posters may be one way of helping ‘. . . make the healthier choice the easier choice . . .’ (Ottawa Charter for Health Promotion, WHO, 1986).

Limitations and future directions

A limitation to the internal validity of the current study’s findings is social desirability bias. That is, some of the participants being observed throughout this study may have noticed the research team taking counts, which could have influenced their decision to take the stairs versus the elevator. In addition, only the busiest staircase and elevators from the main floor at the campus library were observed, with other staircases and elevators not included in data collection; it is difficult to know if our findings are generalisable to other entrances and other libraries across campus or if different findings would have occurred at these other locations. Also, it was not feasible for the research team to conduct data collection during all hours that the library was open. To try to reduce the impact of this reality, periods of highest traffic were chosen, but these might not reliably reflect other times of use. However, the busyness of a building can also be considered a limitation because it could increase staircase use independent of any intervention (Puig-Ribera et al., 2019). In addition to the limitations noted above, the inherent limitations of an observational study design include many confounding variables that may have been at play; no inference of causality can be suggested between the intervention and findings. To help combat this limitation, future studies that employ similar interventions could be conducted in multiple buildings while utilising one location as a control group. Furthermore, discretely placed video cameras or electronic sensors could be used as objective measurements instead of human observers at the study site(s) in order to reduce the potential effects of social desirability bias.

Conclusion

This study investigated the use of several different types of health posters to increase rates of stair climbing at a busy library on a Canadian university campus. The results of the study suggest that a multi-component health promotion poster-based intervention was associated with increased rates of stair climbing among adults during weekdays but not on weekends. Findings parallel those from previous research relying only on point-of-choice prompts to promote staircase use.

Footnotes

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

ORCID iD

Hieu Ly

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