A Multicomponent Intervention to Encourage Stair Use in Municipal Buildings

Abstract

Purpose:

Evaluate the incremental impact of environmental stairwell enhancements on stair usage in addition to prompts.

Design:

Phased, nonrandomized, quasi-experimental intervention.

Setting:

Two 6-story and one 8-story municipal government office buildings—each with 2 stairwells.

Participants:

Approximately 2800 municipal employees and 1000 daily visitors.

Intervention:

All stairwells received door wraps and point-of-decision and wayfinding prompts. Environmental enhancements were installed in 1 stairwell in each of the 2 buildings: wall paint, upgraded stair treads and handrails, artwork, light-emitting diode (LED) lighting, fire-rated glass doors, and removal of security locks on at least the ground floor.

Measures:

Staff surveys and focus groups, electronic and direct measures of stair and elevator use occurred at baseline and over 3 years of phased implementation and follow-up.

Analysis:

Change in the proportion of vertical movement by stairs using χ² analysis.

Results:

The prompts were associated with a significant increase in stair use (odds ratio [OR] = 1.36; 95% confidence interval [CI]: 1.31-1.41), with an average absolute increase of 3.2%. Environmental enhancements were associated with an additional significant increase in stair use (OR = 1.31; 95% CI: 1.25-1.37) beyond prompts alone with an average absolute increase of a further 3.5% that was sustained for 1 year. The initial increases in stair use with prompts alone were not sustained.

Conclusion:

Implementing environmental stairwell enhancements in office buildings increased stair usage in a sustained manner beyond that achieved by prompts alone.

Keywords

physical activity point-of-decision prompts stair-use interventions worksites facility design and construction

Purpose

Workplaces are an ideal setting to create supportive environments for health due to the number of hours of daily life spent there and the potential for workplace policies to influence employees’ health.¹ Stair use can be easily incorporated into everyday routines,² and previously inactive individuals who have increased their daily stair use have shown improved fitness, body composition, blood pressure, and lipid profiles.³ On a longer term basis, climbing 4 or more floors per day is associated with reduction in all-cause mortality and cardiovascular diseases.^4,5

Existing evidence-based recommendations support the use of point-of-decision prompts (PODPs) to encourage stair use.^6,7 A recent systematic review reported that in office buildings where stairs compete with elevators, the use of PODPs resulted in a median absolute increase in approximately 4% with a wide range in rates of baseline stair use.⁸ Although small, this reflects a shift in stair use across the population of office workers. The review also indicated that the impact of PODPs appears to be increased by the additional use of directional signage (ie, wayfinding).⁸ Nevertheless, there is uncertainty regarding the sustainability of PODP’s impact since most studies have been of 16 weeks duration or less.⁸

Environmental enhancements “change the structure of physical and organizational environments to provide safe, attractive and convenient places for physical activity.”⁹ To promote the use of stairwells, enhancements might include painted walls, artwork, and music. In 2010, The Community Guide concluded that there was insufficient evidence to recommend such interventions due to an inadequate number of studies.⁹ Although several studies have since been published assessing the impact of environmental enhancements, they have one or more limitations including not distinguishing effects of environmental enhancements from prompts,^10

-13 not distinguishing direction of stair travel,^10,12,13 not considering elevator use,^10,12 follow-up of less than 6 months,^11,13,14 or including a predominantly health profession–related population.^10,11,13,14

An opportunity to evaluate the incremental impact of environmental enhancements beyond PODPs alone occurred in the municipal administrative buildings of the Region of Peel (see box 1). This municipality of 1.4 million people is located west of Toronto, Ontario. Peel Public Health is a department of the Region of Peel, and the Region’s Council is not only the governance body for the Region but is also the Board of Health.

Project Context Timeline

Peel Health Status Report highlighting obesity and diabetes trends (2008)

Peel Public Health Strategic Plan - supportive environments for healthy weights strategic priority (2009)

Term of Council Priority - Supportive Environments for Healthy Weights (2011)

Council Resolution - Model employer to promote activity and reduce sedentary behaviour (2012)

Changing Course (Strategy) - Creating Supportive Environments for Healthy Living - workplaces as one of four priority settings (2012)

Healthy Peel by Design Symposium (2012)

Multi-Departmental Actively Designed Building Workgroup established (2012)

Active Stairs Pilot (2013–2016)

Peel Public Health had previously informed the council on trends in obesity and diabetes rates¹⁵ and the need to focus on creating supportive environments to make the healthy choice the easy choice and thereby addressing the underlying causes of unhealthy eating and physical inactivity.¹⁶ Following a review of evidence-based recommendations for addressing the obesity epidemic, a comprehensive strategy was developed that emphasize the importance of policy-based approaches.¹⁶ The strategy highlighted that recognizing the many contributing causes of obesity trends, multiple interventions will be required with no single intervention likely to produce a very high impact.¹⁷ Although taking action on the best available evidence, the strategy stressed that “there is an obligation to accumulate appropriate evidence not only to justify a course of action but to assess whether it has made a difference.”¹⁸

Workplaces were identified as 1 of 4 priority settings for public health’s efforts and with over 130 000 businesses in Peel,¹⁹ the initial focus was for the Region of Peel to become a model employer for healthy living by considering design, facilities, and service improvements to Regional buildings. This would not only benefit employees of, and visitors to, the Region’s workplaces but would also provide the opportunity to demonstrate the benefits of creating supportive environments for healthy workplaces in order to encourage adoption by other employers.

Following a Healthy Peel by Design Symposium in 2012 involving municipal staff, school boards, community agencies, and invited experts from New York City,²⁰ an actively designed buildings workgroup was established. The workgroup oversaw 3 pilots addressing active stairs, active outdoor space, and active workstations. This provided a mechanism for Peel Public Health to work with multiple departments across the Region to plan and implement the pilots. The workgroup’s terms of reference were signed off by each department’s senior leader with personal commitments on how they would champion active workday practices. A separate workgroup focused on implementing a healthy foods policy for the buildings’ cafeterias, vending machines, and catering.

The focus of this report describes the evaluation of the active stairs initiative that was a phased, multiyear pilot of PODPs and wayfinding signage, as well as environmental enhancements, to increase stair use at a regional municipality’s main administrative buildings.

Methods

Design

A longitudinal, nonrandomized, controlled, quasi-experimental study was conducted to ascertain the change in stairwell use associated with environmental staircase improvements above and beyond PODPs. The study consisted of the implementation of PODPs and wayfinding signage (phase 1) for the 2 staircases in each of the 3 office buildings. This was followed by the implementation of environmental enhancements a year later in 2 phases (2 and 3) in 1 of 2 staircases in 2 buildings. No environmental enhancements were made in the 2 staircases of a third building. Measures of stair use occurred at baseline, following phases 1 and 3, and a year after the enhancements were completed. Figure 1 shows the project’s timelines and phases.

Figure 1.

Pilot Implementation and Evaluation Timelines.

Sample

The Region of Peel has 3 administrative office buildings on 2 sites. Table 1 summarizes their characteristics. Two buildings, suites A and B, are located at 10 Peel Centre Dr (10 PCD), which is located in Brampton, Ontario. A third building is located at 7120 Hurontario St (7120 Hurontario) in Mississauga, Ontario. Collectively, the buildings have over 2800 staff and over a thousand visitors daily. Public health comprises the majority of staff at 7120 Hurontario, whereas staff at 10 PCD work in multiple other municipal departments.

Table 1.

Summary of Building Characteristics.

Characteristics	Building Site
	10 PCD		7120 Hurontario
	Suite A	Suite B	7120 Hurontario
# of floors	6	6	8
# of main stairwells	2	2	2
# of elevators	3	3^a	4
Main elevators serve underground parking garage	Yes	No. Separate elevators serve garage to ground floor	Not applicable–No underground garage
# employees^b	1643		1146
Departments (proportion of staff in building)	Human Services (31%) Corporate Services (27%) Public Works (20%) Service Innovation and Technology (19%) Executive Office and other services (2.1%)		Public Health and other health services (70%) Human Services (25%) Service Innovation and Technology (3%) Corporate Services (2%)
# of daily visitors	500-800		400-500

Abbreviation: PCD, Peel Centre Dr.

^a A fourth elevator is always on service.

^b As of June 2014.

Each of the 3 Regional buildings has a pair of stairwells with industrial-type features consistent with an emergency exit function including basic metal handrails, harsh lighting, and bland paint colors (Figure 2). Although all 6 stairwells received PODPs and wayfinding signage, the 2 intervention stairwells receiving environmental enhancements were chosen because of their central location, closer proximity to the main entrance than the elevator banks, and fewer security concerns in removing the ground floor security swipe requirements for these stairwells. As such, the nonintervention stairwells in the same buildings are nonequivalent controls since baseline characteristics differ among pairs. No intervention stairwell was included at 10 PCD suite A because that building is scheduled for major future renovations at which time stairwell enhancements could be made informed by the results of this pilot.

Figure 2.

Baseline - Buildings’ Stairwells.

Measures

The pilot was implemented from April 2013 to May 2016. Several sources of data were included in the evaluation including baseline and follow-up staff surveys and focus groups, stair use measurement, and a postpilot partner key informant survey (Table 2). Figure 1 also shows the timing of data collection throughout the pilot.

Table 2.

Evaluation Data Sources.

Data Source	Timing	Provided Information On
All-staff surveys	Baseline Post-environmental enhancements (post-Phase 3)	Demographics (age, sex, building site) Enablers (eg, familiarity with location) and barriers (eg, carrying too much) of stair use Frequency of stairwell use Typical number of flights traveled Relative frequency of up and down travel
Focus groups–volunteers from survey respondents	Baseline Post-environmental enhancements (post-phase 3)	Enablers and barriers to use Suggestions for improvement
Direct observation of stair and elevator use	Baseline Post-phase 1 Post-phase 3 1-year follow-up	Counts of stair and elevator use in all buildings Direction of travel (at 3 follow-up times)
Electronic counts of stair use	Baseline Post-phase 1 Post-phase 3 1-year follow-up	Counts of stair use at ground floor entrances

An intraoffice e-mail invitation was sent to all staff of all 3 buildings inviting their participation in a baseline survey. Participation was voluntary and submissions anonymous. Information was collected to inform the 3 actively designed buildings’ pilots, as well as the healthy foods served and sold pilot. Relevant information collected for the active stairs pilot included staff demographics, perceived enablers, and barriers to stair use, as well as current stair use. Descriptive statistics were calculated from the results.

Survey respondents were offered an opportunity to volunteer for focus groups to collect information to inform all 4 pilots. Four focus groups including a total of 27 staff were led by a pair of Peel Public Health staff. A semistructured interview guide was used and included both sit-down and walking tours of their buildings’ stairs and cafeteria. Each of the staff members collected notes for each focus group, and the key themes from the 4 focus groups were identified. The staff survey and focus groups (32 staff) approaches were repeated following the completion of the environmental enhancements and similarly analyzed.

Direct observation of ground floor stairwell and elevator use (direct counts) occurred at baseline and following phase 1, phase 3, and 1 year following phase 3. Each observation period was comprised of 4 days of measurement from 8:30 am to 4:30 pm and was conducted by an external contractor. The direction of stairwell travel was captured in the last 3 measurement periods.

Additional infrared motion tracking (electronic counts) of stairwell use was captured on a 24-hour basis. Motion tracking of elevator use was not feasible, and the absence of these data made interpretation of stairwell use counts challenging in the presence of daily fluctuations in the volume of vertical travel in the buildings.

As an evaluation project, this pilot was excluded, by policy, from review by Peel Public Health’s Research Review Committee, which conducts reviews of primary research projects with a focus on methodological quality and research ethics.

Intervention

Based on existing evidence, feedback from staff baseline survey and focus group results, and recommendations from Active Design Guidelines,²¹ a series of phased improvements were planned (Table 3). In phase 1, door wraps, PODPs, and wayfinding were implemented for all 6 ground floor stairwells in the 3 buildings (Figure 3). To assess the impact of increasing stairwells’ access and environmental appeal, more intensive changes were made to an “intervention” stairwell at 10 PCD suite B and 7120 Hurontario during phases 2 and 3.

Table 3.

List of Phased Stairwell Improvements.

Phase 1(May 2013)		Phase 2Intervention Stairwells(January 2014)	Phase 3Intervention Stairwells(Early 2015)
All Stairwells	Intervention Stairwells	Phase 2Intervention Stairwells(January 2014)	Phase 3Intervention Stairwells(Early 2015)
Door wraps Point-of-decision prompts Wayfinding	Remove security swipe (in addition to the universal Phase 1 improvements)	Wall paint, improved stair treads, vinyl handrails, and permanent PODP and wayfinding signage	Artwork on noise canceling boards, LED lighting around the artwork, and fire-rated glass entry doors Improvements to stairwell corridor creating immediate access between cafeteria and at 10 PCD Suite B stairwell; corridor lined with photographs

Abbreviation: PODP, point-of-decision prompts.

Figure 3.

Use of door wraps (left), directional prompts (left and middle) to make ground floor stairwell entrances more visible. Elevator point of decision posters (right). Point-of-decision prompt (middle).

Figure 4 provides examples of the phase 2 improvements including the addition of vibrant-colored wall paint, improved stair treads, and vinyl handrails. Phase 3 included further improvements in artwork and LED lighting, as well as fire-rated glass entry doors, permanent signage, and access corridor improvements as shown in Figures 5 and 6, respectively.

Figure 4.

Vibrant wall paint, stair treads, and Vinyl handrails.

Figure 5.

Art work on noise cancelling boards with surrounding LED lighting.

Figure 6.

Fire-rated glass doors for greater visibility into the stairwells or access corridors (top left and right). As part of staff engagement, photo contest winners exhibited in corridor to stairs (top right). Permanent stairwell wall-mounted signage (top right). Improved access corridor between cafeteria and Suite B stairwell with corridor lined with historical photos of Region (bottom).

Periodic staff e-mails were distributed to announce the stairwell improvements and promote use of the stairs. Staff engagement and social marketing also occurred at phase-specific launch events, which included the active participation of senior management and elected officials and who also modeled stair use in their regular routines. A staff photo contest was also conducted with winning photos installed near the stairwells.

Analysis

Due to the daily variation in the magnitude of total vertical travel in buildings, the distributions of mode of travel among individual stairwells and the elevators were compared over time. Changes in the proportions of stairwell use were assessed using χ² analyses for 2 main time points: from baseline to final follow-up and from prior to the environmental improvements (post-phase 1) to final follow-up. Two sets of odds ratios (ORs) were calculated.

The impact of the door wraps, PODPs, and wayfinding was assessed comparing the changes in use of the 2 stairwells and the elevators for each building with an adjusted Mantel-Haenszel Odds Ration (MH-OR) calculated for the 3 buildings. The impact of the environmental improvements was assessed by comparing use of the intervention stairwells (prompts + environmental enhancements) versus the nonintervention stairwells (prompts alone) and elevators from after the phase 1 improvements until after the environmental improvements. An MH-OR was also calculated pooling the results of the 2 buildings. This is a conservative estimate of the impact of the environmental improvements since any spillover effect in stair use to the nonintervention stairwells would decrease the apparent effect of the environmental improvements.

Results

Survey and Focus Groups

The response rates of the baseline and follow-up staff surveys were 34% and 27%, respectively. The response rates were significantly higher at 7120 Hurontario (42%) than 10 PCD (28%) at baseline (P < .001), although the response rates at follow-up were comparable between the 2 buildings (29%; 26%; P = .14).

At baseline, stair use at 7120 Hurontario was less than at 10 PCD. Over half of staff (51%) at 7120 Hurontario reported using the stairs once or fewer times per day, although the comparable figure was only 35% of staff at 10 PCD. The most commonly identified barriers to using the stairs at both sites included carrying too much (41%), work attire (32%), and lack of time (24%). The most commonly identified actions to encourage use of the stairs more often were a more visually appealing atmosphere in the stairs (50%), music in the stairs (48%), and a colleague to take the stairs with (39%). Focus group participants described the stairs as visually unwelcoming (see Table 4) with recommendations for improving their appeal such as the use of paint colors, murals, and music.

Table 4.

Focus Group Descriptions of the Unimproved and Intervention Stairwells.

Baseline/Unimproved Stairwells	Follow-up (Intervention Stairwells)
– Like climbing a mountain	– A burst of energy
– A workout	– Electric
– Industrial – Like a tunnel, confining, cramped	– A moment for yourself, a break
– Old/dusty	– Brightens your day
– Suffocating, concrete jungle

Although the top 3 barriers to using the stairs remained the same at follow-up, focus group participants indicated that the environmental enhancements in the intervention stairwells had made the stairwell experience more enjoyable. Stairs were viewed as more welcoming, inviting, and interesting (Table 4).

According to the self-reported survey results, the frequency of self-reported stair use significantly increased at 7120 Hurontario, with an increase in those using the stairs 3 or more times per day (25%, 33%; P = .02) and a decrease in those reporting zero uses per day (28%, 21%; P = .04). The survey results from 10 PCD did not detect a change, but the results combine staff from suites A and B and only the latter had an intervention stairwell.

The number of floors traveled per stair trip did not significantly change at either building between baseline and follow-up surveys, although the average number of floors per trip was higher at the tallest of the buildings, 7120 Hurontario (4.7), than at 10 PCD (3.6). Just over a third (37%) of stair travel was reported in the upward direction in both sites in both surveys.

Stair Usage

Table 5 summarizes the baseline, post-phase 1 and final results by building and stairwell. In addition to the number of trips observed, the proportion of vertical travel by stairwell or elevator (ie, mode share) is provided to adjust for differences in the amount of vertical travel.

Table 5.

Summary of Direct Observations by Staircase, Building and Phase.

Building	Staircase	Baseline	Prompts Alone						Prompts + Environmental Enhancements			No. New Daily Trips (%)
		Baseline	Post-Phase 1			Final			Final
		# Trips (Mode Share %)	# Trips (Mode Share)	Absolute Change	Relative Change	# Trips(Mode Share)	Absolute Change	Relative Change	# Trips (Mode Share)	Absolute Change	Relative Change
7120 Hurontario	Intervention	1011 (9.8%)	1731 (12.8%)	3.0%	30.6%				2623 (16.1%)	6.4%	65.3%	259 (31.9%)
	Non-Intervention	772 (7.5%)	923 (6.8%)	−0.7%	−9.3%	1707 (10.5%)	3.1%	41.3%				124 (15.3%)
	Elevator	8578 (82.8%)	10852 (80.3%)	−2.5%	−3.0%	11921 (73.4%)	−9.4%	−11.4%	11921 (73.4%)	−9.4%	−11.4%
10 PCD—Suite A	Nonintervention	1665 (16.5%)	2136 (20.0%)	3.5%	21.2%	2120 (19.0%)	2.5%	15.2%				35 (net) (4.3%)
	Nonintervention	2746 (27.2%)	2941 (27.5%)	0.3%	1.1%	2895 (25.9%)	−1.3%	−4.8%				35 (net) (4.3%)
	Elevator	5696 (56.4%)	5619 (52.5%)	−3.9%	−6.9%	6159 (55.1%)	−1.3%	−2.3%
10 PCD —Suite B	Intervention	1667 (10.2%)	2351 (15.1%)	4.9%	48.0%				2586 (19.1%)	8.9%	87.3%	300 (37.0%)
	Nonintervention	789 (4.8%)	1365 (8.8%)	4.0%	83.3%	1030 (7.6%)	2.8%	58.3%				93 (11.5%)
	Elevator	13828 (84.9%)	11810 (76.1%)	−8.8%	−10.4%	9931 (73.3%)	−11.6%	−13.7%	9931 (73.3%)	−11.6%	−13.7%

Among the 6 stairwells, after correction for changes in the volume of vertical travel over time, there was an average daily increase of 811 stair trips from a baseline of 2163 trips, a 37% relative increase. However, the extent of change markedly differed among individual stairwells.

Figure 7 shows the proportion of vertical building travel by travel mode, building, and observation period. Baseline stair use was highest at 10 PCD suite A and showed little net change by the final follow-up measurement. However, at 10 PCD suite B and 7120 Hurontario, stair use increased with most of this occurring in the intervention stairwells.

Figure 7.

Proportion of Vertical Building Travel by Mode, Direct Observation. Nonintervention (prompts only). Intervention: prompts + environmental enhancements).

Table 6 shows the absolute and relative changes from baseline to final measure for each stairwell. The 2 intervention stairwells at 10 PCD suite B and 7120 Hurontario had the highest absolute change (8.9% and 6.4%, respectively) and relative change (87% and 65%, respectively). These results reflect the cumulative effect of prompts plus the environmental enhancements. Lesser increases were observed for all nonintervention stairwells ranging from absolute changes of −1.3% to 3.1% reflecting the results of prompts alone. All but one of the changes were highly statistically significant. If the results of the 2 nonintervention stairwells at 10 PCD suite A are combined, then the net result of prompts for these stairwells over the course of the pilot is a slight absolute increase use of 1.2% that is not distinguishable from chance alone (P = .07).

Table 6.

Absolute and Relative Change in Stairwell Use from Baseline to Final Follow-up, by Stairwell, Direct Observation.^a

Building	Stairwell	Stairwell Usage		Absolute Change (%)	Relative Change (%)
Building	Stairwell	Baseline	Final Follow-Up	Absolute Change (%)	Relative Change (%)
7120 Hurontario	Intervention	9.8%	16.1%	6.4^b	65.3
7120 Hurontario	Nonintervention	7.5%	10.5%	3.1^b	41.3
10 PCD-suite A	Nonintervention	16.5%	19.0%	2.5^b	15.2
10 PCD-suite A	Nonintervention	27.2%	25.9%	−1.3^c	−4.8
10 PCD-suite B	Intervention	10.2%	19.1%	8.9^b	87.3
10 PCD-suite B	Nonintervention	4.8%	7.6%	2.8^b	58.3

Abbreviation: PCD, Peel Centre Dr.

^a Some differences due to rounding. Intervention: prompts + environmental enhancements. Nonintervention: prompts alone.

^bP < .001.

^cP = .039.

As suggested visually in Figure 7, the intervention stairwells are responsible for the majority of the observed increase in stairwell substitution for elevators. Of the 9.4% absolute increase in stair use at 7120 Hurontario, 68% of this (6.4% absolute change) was attributable to the intervention stairwell. At 10 PCD suite B, the intervention stairwell was responsible for 76% (8.9% absolute change) of the 11.6% absolute increase in stairwell use.

Figure 8 shows the trends in changes in stairwell use over the course of the pilot. For the intervention stairwells at 7120 Hurontario and 10 PCD suite B, improvements were seen following the phase 1 changes in door wraps, PODP, wayfinding, and security swipe removal of absolute changes in 3.0% and 4.9%, respectively. Stairwell enhancements made during phases 2 and 3 resulted in additional incremental improvements in stairwell usage, with further absolute increases of 2.5% and 4.5%. These increases in stair use were maintained a year later with a further absolute increase of 0.8% at 1 building and a small absolute reduction in 0.5% in another.

Figure 8.

Trends in Absolute Changes in Stairwell Use. A indicates Suite A; B, Suite B; NI, nonintervention (prompts only); I: Intervention (prompts + environmental enhancements). 10PCD-A-NI combined results of the 2 nonintervention stairwells in that suite.

Table 7 shows the OR results for the increases in stair use with prompts and with environmental enhancements beyond prompts alone. The prompts installed in all 6 stairwells were associated with a significant increase in stair use (MH OR = 1.36; 95% CI: 1.31-1.41) with an average absolute increase of 3.2%. Environmental enhancements were associated with an incremental significant increase in stair use (MH OR = 1.31; 95% CI: 1.25-1.37) beyond prompts alone with an average absolute increase of 3.5% that was sustained for 1 year.

Table 7.

Odds of Increased Stair Use.

Building	Time		Intervention	Comparison	OR (95% CI)	MH-OR (95% CI)
Building	Pre	Post	Intervention	Comparison	OR (95% CI)	MH-OR (95% CI)
7120 Hurontario	Baseline	Post-phase 1	All stairs (PODPs, wraps, wayfinding)	Elevators	1.18 (1.10-1.26)	1.36 (1.31-1.41)
10 PCD suite A					1.17 (1.10-1.23)
10 PCD Suite B					1.77 (1.67-1.23)
7120 Hurontario	Post-phase 1	Post-phase 3	Intervention stairs (prompts + environmental enhancements)	Nonintervention stairs (prompts alone) and elevators	1.23 (1.15-1.32)	1.31 (1.25-1.37)
10 PCD suite B	Post-phase 1	Post-phase 3	Intervention stairs (prompts + environmental enhancements)	Nonintervention stairs (prompts alone) and elevators	1.36 (1.29-1.45)	1.31 (1.25-1.37)

Abbreviations: CI, confidence interval; PODP, point-of-decision prompts; PCD, Peel Centre Dr; OR, odds ratio; MH-OR, Mantel-Haenszel odds ratio.

The incremental increase in stair use observed in the intervention stairwells following the phase 3 environmental enhancements reflects the combined effects of phases 2 and 3 since observations were not scheduled between these phases. The electronic tracking data were assessed and found not to be helpful in distinguishing the relative impacts of phases 2 and 3.

Among the nonintervention stairwells, only 2 of the 4 stairwells, at 10 PCD suite B and 1 of the stairwells at 10 PCD suite A, showed an increase in use following the phase 1 changes. Although the nonintervention stairwells at 7120 Hurontario and 10 PCD suite B reached peaks in absolute increases of about 4%, these peaks were observed following the phase 3 improvements in those buildings’ intervention stairwells. Both of these nonintervention stairwells then declined in use by 25% by the final observation period.

The 2 nonintervention stairwells at 10 PCD suite A showed quite different patterns of use. One peaked following phase 1 showing a decrease in use by the post-phase 3 measurements and then had recovered for a net 2.5% absolute change. The other nonintervention stairwell showed little change over the course of the pilot and showed a negative change by the final measurement. If these 2 stairwells are combined, they show a peak in use following phase 1, which then declines over the subsequent 2 measurement periods.

Implementation Issues

In planning the pilot, an administrative concern emerged that increased stair use would increase the risk of staff injury. This was resolved by the Medical Officer of Health indicating in writing that the status quo of inadequate physical activity and wide scale sedentariness is a significant and greater health risk and that injury risks could be mitigated. Environmental health staff ensured stairwell air quality was safe in response to staff concerns regarding fumes resulting from the installation process.

Removing security swipe access requirements on at least the ground floor intervention stairwells was negotiated at project baseline. A data information breach in October 2013 unrelated to the stairwells resulted in the temporary reinstatement of the stairwell security swipes. However, they were permanently reinstated in October 2014 to restrict public access to the stairwells following major security incidents in other Canadian cities. This also created an additional step for staff to use the stairs compared to the elevators.

Following completion of phase 3, key informants from other Regional departments identified that the mandate provided from Council and strong support from senior leadership were critical to establishing the work as a priority and enabling time and resource commitments. Implementing the project in phases helped to build partner buy-in and secure funds. Having the right players involved at the right times was also identified, although staff turnover was a challenge considering the multiyear duration of the pilot.

Discussion

This pilot project showed that the use of PODPs, wayfinding, and door wraps can increase stairwell use in most but not all existing stairwells. Overall, the 6 stairwells had a mean absolute increase in use of 3.2% following these changes, which is somewhat less than the 4.3% average reported in a recent review of the worksite literature.⁸

In contrast to most previous studies that have only been conducted for up to 16 weeks, this pilot continued measurements for a period of 3 years. Overall, use of the nonintervention (prompts only) stairwells had diminished 1 to 2 years following implementation, which suggests the need to periodically refresh the PODPs. A recent review reported that a second intervention phase of messaging was associated with an increase in stair use in 36% of studies.⁸ The peak use of the nonintervention stairwells at 7120 Hurontario and 10 PCD suite B occurred after the phases 2 and 3 environmental enhancements of the intervention stairwells in those buildings, suggesting that a spillover effect may have occurred from the intervention to the nonintervention stairwells.

There have been a limited number of studies addressing improving the access and appeal of existing stairwells. Multiple types of environmental enhancements were implemented in this pilot and were associated with a 31% increase in use of the stairs with absolute increases in stair use of 2.5% to 4.5% beyond that achieved with prompts alone. Other studies typically implemented the environmental improvements simultaneously with the prompts, although 1 study reported an incremental absolute increase of 2.8%.¹⁴ The combination of prompts and environmental enhancements resulted in absolute increases in stair use of 6.4% and 8.9% in the 2 intervention stairwells. These increases were sustained, on average, at 1 year of follow-up.

Eves and Webb cautioned that increasing stair use in office buildings when competing against elevators is challenging.²² The observed absolute percentage changes are modest but reflect stairs being substituted for elevator trips over 800 times daily in these buildings. It is not known among how many people these trips are distributed, but the survey results indicate a decrease in those never or rarely using the stairs at baseline, as well as no decrease in the proportion of stair climbing trips. If 200 people added 4 daily stair trips, this is the level of intensity associated with physiologic health benefits.³

Over a period of decades, physical activity has been engineered out of people’s lives. Reinserting physical activity into daily life will require the cumulative impacts of small changes in the transportation, occupational, and recreational domains of daily activities. This pilot has shown that environmentally enhancing buildings’ stairwells is one of those potential interventions to increase the activity at a population level.

The hypothetical concern that stair studies with public health staff may find increased impacts compared to the general population²² was not observed in this pilot. Although the majority of staff at 7120 Hurontario work in public health, there was a greater absolute increase in stair use in the intervention stairwell at 10 PCD suite B. In addition, 10 PCD suite A had a much greater baseline use of the stairs than at either of the other buildings. This may reflect the unique features of that building including the stairwells’ central location, lack of locks, and being in competition against 3 elevators that also serve the underground parking lot. This suggests that it is the environmental context of the building that may be more important for influencing stair use than the profession of the building’s staff.

The active participation of multiple Regional departments was required to achieve the pilot’s implementation. A perspective of creating a supportive workplace environment for health had been built over a multiyear period within the Region. Being empowered by Council and actively supported by senior management were critical to the success of this pilot. Concerns regarding injury risks were addressed by public health senior leadership, and no increase in injuries was reported. However, security concerns regarding public access to stairwells were more challenging to placate. This was anticipated because New York City officials had reported at Peel’s symposium of difficulties removing locks on their buildings’ stairwells.²⁰ Although public health was able to negotiate the removal of locks from selected stairwells, underlying concerns remained as locks were temporarily and eventually permanently reinstated in association with external events. It is therefore unknown what additional benefit removing security swipe access requirements might have had on stairwell use.

Although there is a cost involved in having direct observation of stair and elevator use, it was critical for assessing changes. Surveys are susceptible to low response rates and bias, and electronic counts do not capture the direction of travel, which is relevant for both caloric expenditures and health benefits.²² It was also not feasible to use the infrared tracking of elevator use, which was needed to determine the extent that stairs are being substituted for elevators, which is the ultimate intent of the intervention.

This pilot’s findings have a number of implications. The phase 1-type changes including door wraps, PODP, and wayfinding are easier and less costly to implement than environmental enhancements. However, such changes did not work on all stairwells, were time limited, and of lesser magnitude than environmental enhancements. These considerations will need to be weighed when advising workplaces on options to promote stairwell use.

Further work is needed to assess the impact of different types of messages and the optimal frequency for them to be updated. In addition, distinguishing impacts of different types of environmental enhancements, such as those in phase 2 and phase 3 in this pilot, is needed to inform cost-effectiveness decisions. Moving forward, Peel Public Health intends to apply the learnings from this pilot to other Region of Peel sites, as well as in promoting supportive environments for healthy workplaces across Peel.

So What?

What is Already Known on this Topic?

Existing studies have shown that PODPs can increase stairwell use in office buildings, although it has been unclear the duration of that effect and whether environmental enhancements to stairwells would increase stair use beyond PODPs alone.

What does this Article Add?

This study showed that environmental enhancements of stairwells will approximately double the impact of PODPs alone and do so in a sustained manner for at least a year. In contrast, PODPs will increase stair use in some but not all stairwells and the impact wanes over time.

What are the Implications for Health Promotion Practice or Research?

Altering the environment of an office building’s stairwells will influence people’s use of the stairs. Therefore, modifying stairwells should be an option for improving the design of buildings particularly if a building is being renovated. There is a need to determine which aspects of stairwell environmental improvements are the most effective and least costly to implement, as well as to how best to sustain the impact of PODPs.

Footnotes

Authors’ Note

This manuscript’s content has not been published or submitted for publication elsewhere, except as a brief abstract in the proceedings of a scientific meeting.

All authors have contributed significantly to the preparation of this manuscript, and all authors are in agreement with the content of the manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

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

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