Article
Point-of-Decision Prompts to Increase Stair Use: A Systematic Review Update

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Abstract

In 2000, the Guide to Community Preventive Services (Community Guide) completed a systematic review of the effectiveness of various approaches to increasing physical activity including informational, behavioral and social, and environmental and policy approaches. Among these approaches was the use of signs placed by elevators and escalators to encourage stair use. This approach was found to be effective based on sufficient evidence. Over the past 5 years the body of evidence of this intervention has increased substantially, warranting an updated review. This update was conducted on 16 peer-reviewed studies (including the six studies in the previous systematic review), which met specified quality criteria and included evaluation outcomes of interest. These studies evaluated two interventions: point-of-decision prompts to increase stair use and enhancements to stairs or stairwells (e.g., painting walls, laying carpet, adding artwork, playing music) when combined with point-of-decision prompts to increase stair use. This latter intervention was not included in the original systematic review.

According to the Community Guide rules of evidence, there is strong evidence that point-of-decision prompts are effective in increasing the use of stairs. There is insufficient evidence, due to an inadequate number of studies, to determine whether or not enhancements to stairs or stairwells are an effective addition to point-of-decision prompts. This article describes the rationale for these systematic reviews, along with information about the review process and the resulting conclusions. Additional information about applicability, other effects, and barriers to implementation is also provided.

Introduction

The prevalence of overweight and obesity in the U.S. has increased over the past several decades. In 2003–2004, 66.3% of adults in the U.S. were overweight or obese, and 32.2% were obese.1 Obesity increases the risk of many diseases and health conditions, including hypertension, type 2 diabetes, coronary heart disease, stroke, gallbladder disease, osteoarthritis, and some cancers.2 The primary cause of overweight and obesity in the U.S. is energy imbalance.2, 3 Energy imbalance occurs when the number of calories used is not equal to the number of calories consumed. Energy expenditure has been on the decline in the U.S. for decades, due in part to increasing automation of previously manual activities. In 1996, the U.S. Preventive Services Task Force (USPSTF) recommended that healthcare providers counsel all patients on the importance of incorporating physical activity into their daily routines.4 One way to increase energy expenditure, and improve energy balance, is to incorporate small bouts of physical activity into daily routines.3

Many intervention approaches are available to increase engagement in physical activity by adults.5 Each of these approaches has a set of advantages and disadvantages and can be applied, with differing degrees of success, to people with a variety of demographic characteristics and lifestyles in diverse locations. As noted in an earlier review by the Guide to Community Preventive Services (Community Guide), which evaluated interventions designed to increase physical activity, “the role of community-based interventions to promote physical activity has emerged as a critical piece of an overall strategy to increase physical activity behaviors among the people of the United States.”5 This 2002 review focused on community-based intervention approaches, including:

  • Informational approaches to change knowledge and attitudes about the benefits of and opportunities for physical activity within a community;

  • Behavioral and social approaches to teach people the behavioral management skills necessary both for successful adoption and maintenance of behavior change and for creating social environments that facilitate and enhance behavioral change; and

  • Environmental and policy approaches to change the structure of physical and organizational environments to provide safe, attractive, and convenient places for physical activity.

This article reports the findings from an update to the 2002 Point-of-Decision Prompts review, which is a behavior and social approach as described above. The updated systematic review examines literature regarding the effectiveness of prompts on increasing stair use either by increasing the number of actual stair users or increasing the frequency of stair use through prompts that relate to both of these foci, which can be implemented by communities to help increase levels of physical activity. Point-of-decision prompts can be used alone or with stairwell enhancements in an attempt to improve the effectiveness of the prompt (i.e., by making stairwells more attractive to potential users).

The systematic reviews in this report present the findings of the independent, nonfederal Task Force on Community Preventive Services (Task Force). The Task Force is developing the Community Guide with the support of the USDHHS in collaboration with public and private partners. The CDC provides staff support to the Task Force for development of the Community Guide. The book, The Guide to Community Preventive Services. What Works to Promote Health? (Oxford University Press, 2005; also available at www.thecommunityguide.org) presents the background and the methods used in developing the Community Guide. The physical activity review noted above was published in the American Journal of Preventive Medicine in 20025, 6 and describes the broader analytic framework used to evaluate the effectiveness of community-based physical activity interventions.

Section snippets

Methods

This updated review was conducted according to the methods developed for the Community Guide, which have been described in detail elsewhere.5, 7 As an update to an existing Community Guide review,5 some information and guidance was drawn from the previous review team and resulting documentation. Inclusion criteria for studies in this review were: (1) primary research published in a peer-reviewed journal; (2) published in English before April 20, 2005; (3) met the minimum research quality for

Part I: Interventions to Increase the Use of Stairs (Updated)

The team examined the evidence from qualifying studies for two related interventions: (1) point-of-decision prompts; and (2) stairwell enhancements when combined with point-of-decision prompts.

Review of Evidence: Point-of-Decision Prompts

Point-of-decision prompts are motivational signs placed on or near stairwells or at the base of elevators and escalators encouraging people to use stairs. These signs, such as the one shown in Figure 1, inform individuals about a health or weight-loss benefit from using stairs, about a nearby opportunity

Summary and Discussion: Effectiveness of Point-of-Decision Prompts

In general, the qualifying studies identified in this review reported a low level of observed baseline use of stairs, and small but significant increases in the use of stairs following the implementation of point-of-decision prompts. Although absolute changes were small, these differences represent modest relative improvements in the use of stairs. In general, the lower the level of baseline use, the greater the improvements in use. The duration of observation reported in the qualifying studies

Summary

In this article, the team reported results from an updated review of point-of-decision prompts that included an additional review of stair or stairwell enhancements when used with point-of-decision prompts. The inclusion of more recent studies provides strong evidence of effectiveness of the point-of-decision prompt intervention in increasing the use of stairs. On average these improvements represent a modest improvement in stair use. Point-of-decision prompts may represent a simple, lower-cost

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