Background
Physical inactivity is a risk factor for global mortality with major implications for the prevalence of non-communicable diseases such as coronary heart disease, type-2 diabetes, some cancers and depression [
1,
2]. Research has shown that 150 minutes or more of moderate intensity physical activity per week reduces the risk and this has been incorporated into public health physical activity guidelines [
3]. Walking is a familiar, convenient and free form of physical activity that most people can incorporate into everyday life and evidence suggests that successful interventions can increase walking among targeted participants by up to 30–60 minutes a week on average [
4].
In the UK around 30 million people are classified as being in work [
5], which comprises nearly half the population. The most common mode of commuting to work is by car or van (66%), with public transport (17%) and walking (11%) also playing a role [
6]. Employing organisations are increasingly encouraged to reduce private car use amongst their employees and increase active commuting (walking and cycling) through Travel Plans, not only for health reasons but also the potential benefits for wider society resulting from a reduction in traffic congestion and improvements to air quality [
7]. There are also potential financial benefits for the individual because of reduced commuting costs, and for organisations through a reduction in the need for car parking facilities.
In the UK, public health guidance recommends that employers encourage employees to walk, cycle or use another mode of transport involving physical activity [
8]. This guidance also recommends further research on the effectiveness of interventions in different size and types of workplaces and the characteristics of employees (for example age, ethnicity, gender, socioeconomic status or disability).
Schemes to encourage active travel can be considered within a socio-ecological model examining influences at the policy, community, organisational, interpersonal and intrapersonal levels [
9] (see Table
1). Behaviour change techniques (BCTs) are the active ingredients within an intervention designed to change behaviour and are observable, replicable and irreducible components that can be used alone or in combination [
10]. BCTs to encourage active travel can be considered to be enacted at the intrapersonal and interpersonal levels, whilst being encouraged by employing organisations, supported by social norms and values in the community, and promoted through public policy. In a longitudinal study exploring patterns and predictors of changes in active commuting in Cambridge, UK it was found that the provision of more supportive physical environments for walking, improving public transport and limiting availability of workplace car parking may promote uptake and maintenance of active commuting [
11].
Table 1
The socio-ecological model and the Walk to Work intervention
Intrapersonal
| Individual knowledge, skills, attitudes, behaviour | Increase employees’ knowledge of the benefits of walking to work |
Identify and address perceived personal barriers |
Personal goal setting |
Change in travel to work routines |
Increase employers’ knowledge of the benefits of walk to work schemes |
Increase employers’ support for employee walk to work schemes |
Interpersonal
| Influence family, friends, work colleagues | Identify and address specific barriers e.g. school run |
Colleagues and friends encourage each other to walk to work |
Increase ‘culture’ of walking to work |
Institutional
| Workplace policies, procedures and facilities | Enhance employer/workplace support for walking to work |
Community
| Built, natural and social environment and local resources | Identify safe, feasible walking routes |
Identify local groups and organisations to support and enhance walking to work |
Public policies
| National and local initiatives, policies and plans | Increase employee and employer understanding of national and local policy context, walking initiatives and websites |
Until recently interventions to change individual behaviour have been difficult to replicate as techniques were often not readily identifiable or were poorly defined. A taxonomy of 26 BCT’s was identified in 2008 [
12] with subsequent work undertaken to improve labels and definitions and to reach a wider consensus of agreed distinct BCTs [
10,
13]. The 2008 taxonomy has been successfully used to categorise the BCTs used in healthy eating and physical activity interventions [
14] with ‘self-monitoring’ combined with at least one other technique the most effective. Bird et al. [
15] identified 46 walking and cycling controlled interventions targeted at adults and coded the BCTs using the 26 item taxonomy [
12]. They reported a statistically significant effect on walking and cycling outcomes with the mean number of BCTs used being 6.43 (SD = 3.92) and the most commonly used techniques ‘self-monitoring’ and ‘intention formation’ [
15]. The UK’s National Institute for Health and Care Excellence (NICE) has recently issued recommendations advising that interventions should use BCTs based on goals and planning, feedback and monitoring, and social support [
16].
Encouraging walking to work in a workplace environment, where most of the target population will not be classified as ‘ill’ , may be considered the responsibility of workplaces rather than external health promotion specialists. Workplace Travel Plans often incorporate measures to reduce private car use [
17]. In addition, peer delivered health promotion has been used [
18] to provide colleagues with information, social support and general encouragement.
The effectiveness of interventions to promote active travel tends to be measured using self-report surveys. The Walk to Work feasibility study used objective measures to show walking to work was associated with both higher levels of overall physical activity and moderate to vigorous physical activity (MVPA), compared with those travelling by car [
19]. The study also incorporated a process evaluation to examine the context and implementation of the intervention, and participants’ responses to it. Few studies have looked qualitatively at participants’ views and experiences of the BCTs used in interventions. The aim of this paper is to describe the BCTs used during the Walk to Work intervention, delivered by workplace Walk to Work promoters, and examine participants’ and promoters’ views and experiences of the different techniques.
Results
Participants
The flow of workplaces and participants through the study is shown in Figure
1. Following the distribution of information about the study, 187 participants consented to take part, of which 100 were in the intervention arm. Eight Walk to Work promoters were recruited from six of the workplaces. Of 16 participants approached for interview, 14 of them agreed, however two female participants from large workplaces E and F declined due to time commitments. The eight Walk to Work promoters were also interviewed. Details of the interviewees are shown in Table
3. Their ages ranged from 22 to 65 years, with a spread of household incomes, and 45% were female. All were in sedentary occupations, with most being city centre based. Each interviewee was given an alpha numeric ID to ensure participant confidentiality and anonymity: For example, interviewee F7 refers to workplace F and interviewee 7. The responses of participants are considered below in relation to each of the BCTs.
Table 3
Characteristics of participants and Walk to Work promoters interviewed (all sedentary occupations)
A1 | female | 50 | Participant/Promoter | small | Professional, scientific & technical | City centre | 30-40 |
B1 | female | 26 | Participant | small | Professional, scientific & technical | City centre | 20-30 |
B2 | female | 33 | Participant | small | Professional, scientific & technical | City centre | 20-30 |
B3 | male | 22 | Participant/Promoter | small | Professional, scientific & technical | City centre | >50 |
C1 | male | 29 | Participant/Promoter | small | Professional, scientific & technical | Suburban | >50 |
C2 | male | 25 | Participant | small | Professional, scientific & technical | Suburban | 20-30 |
C3 | male | 65 | Participant | small | Professional, scientific & technical | Suburban | Not given |
C4 | female | 52 | Participant | small | Professional, scientific & technical | Suburban | 40-50 |
D1 | male | 60 | Participant | medium | Professional, scientific & technical | City centre | >50 |
D2 | male | 38 | Promoter | medium | Professional, scientific & technical | City centre | 20-30 |
D3 | male | 37 | Participant | medium | Professional, scientific & technical | City centre | >50 |
D4 | female | 52 | Participant | medium | Professional, scientific & technical | City centre | Not given |
E1 | male | 30 | Promoter | large | Public administration | City centre | 20-30 |
E2 | male | 52 | Participant | large | Public administration | City centre | >50 |
E3 | female | 55 | Participant | large | Public administration | City centre | 30-40 |
F1 | male | 23 | Participant | large | Financial & insurance activities | City centre | 20-30 |
F2 | female | 58 | Promoter | large | Financial & insurance activities | City centre | 20-30 |
F3 | female | 46 | Promoter | large | Financial & insurance activities | City centre | 20-30 |
F4 | male | 46 | Participant | large | Financial & insurance activities | City centre | 30-40 |
F5 | female | 45 | Participant/Promoter | large | Financial & insurance activities | City centre | >50 |
F6 | female | 31 | Participant | large | Financial & insurance activities | City centre | 30-40 |
F7 | male | 45 | Participant | large | Financial & insurance activities | City centre | 40-50 |
When asked about intention formation, the participants focussed on their general targets for walking to work. For some this was the whole journey to and from work every day; others selected specific days of the week, either the journey to work or the journey home, or walking part of the journey and using the car or public transport for the remainder. Some justified these intentions for the health benefits such as ‘getting fit and losing weight’ (participant A1, female, 50). In two cases a doctor had recommended walking to alleviate medical conditions (high blood pressure and repetitive strain injury) and the study provided the opportunity to put this into practice: ‘My doctors said before that I need to, to walk more … I mean it’s the kind of thing that you sort of – you kind of know anyway really within yourself that you know you’re not doing enough of any kind of exercise. This [study invitation] is what gave me the stimulus if you like to actually get on and do something about it … and even the doctor didn’t even manage to persuade me of that’ (participant C4, female, 52). However, one promoter (F3, female, 46) observed that some people did not want to commit to a 10-week programme and, although people had good intentions, there was concern about dependency on use of cars ‘I think people [study participants] have the intentions of walking … but, because their character is, just they don’t know how to live without the car’.
Barrier identification
Interviewees discussed perceived barriers to walking, rather than the process of identifying barriers. The main barriers raised were the weather and motorised traffic: ‘The days when it’s raining isn’t quite so much fun but, apart from that, I mean crossing the roads is a bit of a nightmare sometimes especially if it’s raining and … you got to turn round and see if there’s a car and you’ve got to double check, wearing the glasses as well you know … you wouldn’t think there was a learning curve to crossing the road at my age but there is’ (participant C4, female, 52). Participant D1 (male, 52) raised the issue of the impracticality of wearing business suits in bad weather: ‘… turn up wet in the morning given the climate … you’re less inclined I think, if you walk, to wear any special clothing to walk in to work … normally people wouldn’t carry suits in their backpacks’. Participant F6 (female, 31) was also reluctant to walk in the rain: ‘I did walk sometimes in the rain though, it wasn’t actually too bad once you’re in it, it’s just the thought of going out’. Solutions proposed by participants tended to focus on being prepared for bad weather by having waterproofs and umbrellas: ‘I mean the weather this morning was horrendous but I’ve got some waterproof trousers, an overcoat and an umbrella and I came to work as dry as I would have been if it had been dry’ (participant D3, male, 37).
Having car parking at work was considered a barrier, and lack of car parking an enabler, to walking: ‘We haven’t really got limitations to car parking because we’ve got a free car park out the back so it is easier for us to drive because we know that we can park when we get here. If we didn’t have that then it would probably force us to walk a bit more – if you were in the centre or something like that I’d probably would have to walk or get public transport but because we’ve got free car park we can just come and go when we please in the car’ (participant/promoter C1, male, 29). Another barrier was a lack of facilities such as showers, changing facilities and lockers at work to support walkers: ‘If there were facilities or if you had that sort of stuff available to you I think I would be more inclined to walk or cycle, because I don’t – I don’t like feeling unclean, I like to be clean’ (participant C2, male, 25). This participant proposed a solution: ‘You’d have to like have a shirt ready in work so you’d have to make sure you prepare everything’.
Participant C4 (female, 52) also identified a solution to the barrier she felt of arriving at work flustered and not being able to work straight away: ‘I’ve settled on walking home partly because that’s logistically how it’s mostly worked out anyway … I did walk in a couple of times and one time you know it looked like it was going to rain and I’m hurrying along hoping it’s not coming and I arrive in work and actually I didn’t feel as good when I arrived in work as I thought it would. I felt flustered and I felt as though I was behind myself and I didn’t feel as calm and you know. Whereas I drive, I park in the car park, I sit down at my desk and I’m straight into it’.
The convenience and high fixed cost of cars were seen as barriers: ‘I’m paying so much for the petrol, the tax, the insurance I just think it’s there and it’s just convenient for me to use it so I think it’s just too easy to, to walk out the house, get in the car and just put my foot down and drive for 10 minutes up the road. Whereas if I walked I probably have to leave – maybe give it an hour just to make sure I was in time’ (participant C2, male, 25). The cost, time and unreliability of the public transport were important reasons why participants who lived further from the workplace chose to use their car, and ‘park and walk’ , rather than use the public transport system: ‘Public transport for me to try and get here is horrid. I tried it within the study, it was expensive, it will take me an hour and a half to get in here whereas by driving and walking I can do it in 35 minutes’ (participant F4, male, 46).
Caring responsibilities and time were highlighted as a barrier: ‘They’ve got to pick up children from schools or clubs or some people have elderly relatives that they look after… some people will be rushing home to go off to yoga, pilates, dance so it depends if it’s going to take a lot longer’ (promoter F2, female, 58). Other barriers included having to carry heavy items, needing the car for work appointments, walking in dark or unpleasant surroundings, pollution, shift work and the nature of the terrain: ‘I come down a very steep, two very steep hills … so walking in is not an issue, walking home is a bit more of an issue … it takes longer, it’s more tiring’ (participant E2, male, 52).
Specific goal setting
The participants commended the Walk to Work booklets for providing ‘structure’ (participant E2, male, 52) and being ‘helpful’ (participant/promoter A1, female, 50) in encouraging them to think about short-, intermediate- and long-term goals. The goals reported by participants varied in their degree of specificity and detail. One enthusiastic participant (participant E3, female, 55) articulated clearly: ‘Short term to walk to [supermarket] which is specific place at a gentle pace in week one … second week was to do the same but at a faster pace and week three was to walk halfway once a week at a faster pace, a brisker pace … intermediate walk halfway to work twice a week … and then long term walk halfway to work every day which is about 25 minutes’. Participant F6 (female, 31) was less precise: I parked like close … then gradually sort of kept parking further back’.
Pedometers assisted goal setting for seven participants: ‘I just said to myself for the first two weeks I will just park my car where I normally park it and walk to work, do my stuff, go home and over the two weeks was just to see how many steps I was taking, and then I just said to myself over the next two/three weeks put it up another 1,000 steps and then kept increasing it, over the 10 weeks’ (participant F4, male, 46).
The role of the Walk to Work promoter was to work closely with participants to help them set their goals. Promoters varied in their degree of engagement with this goal setting and listening to the specific needs of the participant. Participant E3 (female, 55) reported that the promoter was too forceful: ‘The barrier I had with him was, was that I kept saying my goal isn’t to walk to work … I knew that at the end of a working day I often don’t finish until 6.30-7.00 the last thing I want to do then is walk for nearly an hour … I was never wanting to do more than walk halfway to work … that was my ultimate, and that for me would be success and he [promoter] kept giving me routes and to get here and I kept saying but I’m not doing that am I because that isn’t my goal and you need to support me with my goal rather than yours … if I set my goal on what he wanted, I wouldn’t have achieved it and then I would’ve failed so I wanted to be able to succeed in what I wanted to do’. Promoter F3 (female, 46) had a more relaxed view and allowed participants to change goals depending on their weekly activities: ‘… don’t you worry about it, you don’t have to do the same amount every week. We all have busy lives so as long as you are walking every day if you can, that’s absolutely fine’.
Provide instruction
The promoter’s booklet outlined the role of the promoter and the BCTs for each of the four contacts. Overall the promoters found their booklet ‘was well set out’ (D2, male, 38) and helped them approach participants: ‘It was informative and useful and helped me set out what I needed to do, promote walking to work to the colleagues, and how to approach them and stuff, I thought it was quite good’ (participant/promoter B3, male, 22). This was reiterated by promoter E1 (male, 30): ‘It’s not too intimidating, it’s quite accessible, it’s got a, sort of a structure you can work through, when the walk to work promoter meets with the employees to discuss and set goals and review them’. However, promoter D2 (male, 38) commented: ‘I think it was well set out and bit disappointed with myself getting out of sync and not following it properly because it guides you well but I lost sight of which week I was on and what I was supposed to be achieving’. Participant/promoter C1 (male, 29) suggested that it would be useful to support and motivate the promoters themselves by having a ‘little newsletter each week like email a newsletter just to remind you about the entire thing and kind of give you more information to convince you to keep on doing it’.
The participants’ booklets were praised by both participants and promoters for their structure and the information provided, particularly details of websites and route planning information: ‘I thought it was very helpful, I mean the websites at the back were very good, one of them in particular … the Walkit one, walking to work was brilliant’ (participant F4, male, 46). The exception (participant D4, female, 52) compared the booklet unfavourably with a previous walking intervention she had been involved in: ‘I didn’t find it very helpful really no, it was very, sort of repetitive and I better admit before I go any further that I’ve done the most brilliant scheme in the past. They had like online articles so that you could earn so many points educating yourself round health benefits’.
General encouragement
Most participants valued the encouragement they received from promoters: somebody being ‘enthusiastic’ and ‘showing an interest’ (participant D4, female, 52) or being encouraged and offering to walk together ‘She’s been very good at encouraging me to try different things … congratulating me … we’ll walk together when I was going to [local landmark] because she walks past there’ (participant/ promoter F5, female, 45). Promoter F3 (female, 46) felt it was important to see participants trying their best and encouraging them even if they did not achieve their initial goals: ‘The people I am promoting they are doing their best even if they are not doing as much as they thought they were going to do. That is now in their mind and they will think twice … whether they really need the car or they can walk, and for me that is a fantastic achievement’.
However, there were challenges for the Walk to Work promoters in fulfilling their role: ‘I was quite busy during the middle and that was one of the reasons why the third contact slipped … I did tend to slightly put it off and say well I’ll do it start of next week and then on one of those starts of next week I was off sick and by the time I got back into work I forgotten that I’d been planning to do it that week, and time just gets away from you sometimes’ (Promoter E1, male, 30).
Several participants suggested external health promoters could provide additional encouragement: ‘Somebody coming in from outside, say doing half an hour at lunchtime just doing a presentation about it or, you know, longer and getting people there and talking about that and saying ‘and we have our in-house person who you know if you want to talk to him, d’you wanna get encouragement from him/her’ that would be great but I think somebody coming in from outside actually would be a good idea’ (participant D1, male, 60).
Participant C4 (female, 52) felt it was important for management to show encouragement by allowing people time to get used to their new routine: ‘They’re not going to get penalised if they are a little bit late in because they didn’t leave early enough while they’re getting the hang of walking’.
Self- monitoring
Self- monitoring was encouraged through the use of diaries and pedometers. The diary included space to record the method of travel, time taken and, if using a pedometer, the number of steps per day. Participants commented on the usefulness of a diary to provide structure, visual representation of progress and highlight inactivity: ‘It was just that structure of doing that every day and noticing that, no this week I haven’t actually walked as many times as I thought I might do, and so you know, tomorrow I’ll make sure I do’ (participant E2, male, 52). The diaries were also thought to be useful in assessing journey times: ‘… made me far more aware of what time I need to leave home to get here on time’ (participant D3, male, 37).
However, participant C4 (female, 52) preferred talking with colleagues: ‘… found myself you know doing the walking home without having written it down and you know having told several people – I mean telling people that that’s what you’re doing actually makes you hold to it even more than if you, if I’d written it down’. One participant found diary completion repetitive and time-consuming, while another found his initial enthusiasm tended to diminish with time ‘I used it a few times to start with but then sort of fade out’ (participant/promoter B3, male, 22). However, the diary could be helpful for promoters in monitoring how participants were progressing: ‘Every time I meet with them I just have a quick look [at the diary]’ (F3, female, 46).
Promoter C1 (male, 29) praised computer applications to aid self-monitoring: ‘I thought the apps and all the stuff that you do on the computer to be able to track and log everything and find the easier routes to walk and things like that was really, really good … I think they should be publicised a bit more because I definitely think that would help people and convince more people to walk’.
Although pedometers were offered free of charge, seven of the participants chose not to use them, seven participants used the pedometers within goal setting aiming to increase their steps per day and the remaining four commented on problems using them: ‘I’ve not been very good at using a pedometer because I’ve either forgotten to put it on in the morning and I find them quite uncomfortable’ (participant/promoter F5, female, 45). One promoter (E1, male, 30) expressed his concern at asking participants to wear a pedometer for the duration of the intervention: ‘Ten weeks is a long time to be wearing such a device’.
However, there was evidence that the step count could be motivating: ‘We were probably hitting on a day when we weren’t walking an average of about 3,000 … it’s just a bit of a shock … I used the pedometer which I found really interesting, just to see how little we actually did walk when using the cars and how much more you actually do just walking to and from work’ (participant/promoter C1, male, 29).
Social support
There were mixed feelings about the level of support offered by the Walk to Work promoters. Some participants felt the promoters were well placed to help them, particularly if the promoter had changed their own behaviour, had local knowledge, and was able to discuss barriers and support participants who needed reminding. Participant E3 (female, 55) expected her promoter to check progress more rigorously: ‘I expected we were going to go through this and he was going to go “Oh look you took a bit of a dip there [looking at diary]” … he just wrote to me and said “How you doing?”, and I wrote back and said “It’s going fine” and that was it really. Yeah I’m not sure what else he could have done I suppose but it did – it felt very light touch … I think I was expecting a bit more … kind of looking at this together and maybe another meeting’. Another participant reported little or no contact from the Walk to Work promoter after the initial session: ‘I must admit in the 10 weeks they didn’t … they initially set you up yeah but no one to sort of halfway through said have you increased’ (F4, male, 46).
In some workplaces, participants offered mutual support, particularly if they were sitting close to each other: ‘We would always be having a conversation, there would always been a time when he would say “Oh I walked to work today, what did you do?” (participant C2, male, 25). Such support included shared experiences of bad weather: ‘It was quite nice that there was other people that get drenched when you get drenched’ (B1, female, 26). In contrast, participant E2 (male, 52) had the support of his promoter but was not aware of anyone else taking part in the study: ‘It might’ve made a difference if I actually knew somebody else who was doing it’.
The promoters reported it was not always easy to support walkers particularly if there was work pressure or a more junior member of staff was supporting a manager: ‘One of the walkers is a manager … he’s way above my pay grade … I felt like I was demanding his precious time to meet with him to do the study, although of course he volunteered for it but … it was slightly strange relationship for me to be the sort of the mentor to someone whose on a sort of higher grade, managerial role’ (E1, male, 30).
Review of behavioural goals
Participants appeared willing to reconsider their initial goals, particularly if they had been easily achievable, and to increase the amount and frequency of walking: ‘I reviewed myself and found that I can actually walk to work a lot more than I thought I could so I just upped the amount of times that I actually walked’ (participant/promoter C1, male, 29). A change in seasons had the potential to affect behaviour: ‘I did a little bit [review goals] when it first started getting really dark like in the mornings and evenings, and then when the clocks went back it kind of evened it out a bit better so I could sort of go back to finishing at six and feel OK about walking back’ (participant F6, female, 31). Promoter D2 (male, 38) highlighted the experience of one participant who reviewed his goals as he was concerned about the safety of the area he walked through. However, as there was no alternative, he continued with that route: ‘He thought, because he’s near the [local landmark], he’s got to walk through [local area], probably not safe, but there’s no other route you know, but he risked it anyway’.
Relapse prevention
One promoter suggested the term ‘relapse prevention’ was probably not appropriate for an intervention that increased walking to work: ‘Relapse prevention sounds like a stop smoking campaign. It’s a bit drastic for someone who has stopped walking’ (participant/promoter C1, male, 29). However, he acknowledged the need to give people tools to help them maintain their new behaviour: ‘It’s almost like having an internet site that you could go to for advice and stuff … like a little push just to say look you can still keep doing this if you do this, this and this’.
Participant C2 (male, 25) suggested it was difficult to continue walking after a holiday but he was able to build up gradually after his break: ‘I went on holiday for two weeks so when I came back I was a little less inclined to be walking, but eventually I got myself back on track’. He was also anxious that he was having a knee operation and this would cause him to resort back to using the car: ‘I’ve got my operation next week I’m off for six weeks then so I’m going to be on my bum a lot (laugh) so I can see me getting lazy over the winter period’.
Suggestions for change
There were some suggestions for introducing further BCTs not used in the intervention which participants felt would help them change their behaviour. Two promoters and five participants felt that the intervention would benefit from incentives: ‘Offering a cash incentive for people to walk rather than drive’ (participant F7, male, 45). Other incentives discussed included training shoes, vouchers or a free breakfast to encourage them to walk to work. ‘I think more of an incentive that, you know, if we got people to walk to work they got a free breakfast when they came to work or they you know if they started out earlier to walk to work well then there’d be some sort of just a little something, you know, people might think oh actually if I leave half an hour earlier and I walk into work, alright it’s two miles there might be a, you know, something or a voucher for a coffee place or something, breakfast bap or something’ (participant /promoter F5, female, 31).
Participants also talked about introducing competition between different workplaces taking part in the scheme: ‘An element of competition may help … if the progress was recorded and shared between all the people on the scheme, it could possibly have a positive effect … for people being able to walk the most or the greatest number of times’ (participant C3, male, 65). Participant B2 (female, 33) talked about competition within the workplace: ‘I sit predominantly around a load of lads they are very competitive so maybe some kind of competition maybe something with the pedometers where you can measure how far everybody walks each day’.