Challenging Dogma - Fall 2009

Thursday, December 17, 2009

Failure To Account For The Effect Of Environment: A Critique of the “Take The Stairs – Every Step Counts!” Campaign – Mollie Wright

I. Introduction
Over the past two decades, obesity has risen significantly in the United States, developing into a major public health problem (1). A drop in physical activity and increased access to calorie dense, high fat foods has created an environment in which Americans are taking in more energy than they are burning (2). In 2006, The US Department of Health and Human Services introduced the “Small Steps” Campaign, promoting 100 small lifestyle changes to combat the obesity epidemic (3). Small Step #67, “Take the stairs instead of the escalator”, prompted the development of the “Take the Stairs – Every Step Counts!” Campaign by the Boston Public Health Commission. The intervention is designed to promote exercise in the work place because physical activity has been shown to enhance employee morale, reduce absenteeism, better retain healthy employees, and lower overall health care costs (4). Placing signs near escalators and elevators, at the point-of-decision, has been shown to be effective in increasing stair use (5). However, a review of eight studies evaluating sign interventions suggests that the effect may not be significant enough to reduce obesity prevalence on a population level (6). Public health campaigns require an understanding of human decision making. Specifically, taking into account irrational decision making, in the form of context, expectations, and framing, and the external environment may be beneficial (7). Modifying the way the signs are presented by understanding how people make decisions may enhance the overall effect of the intervention and prove to be a valuable recommendation in the national “Small Steps” campaign.
II. Critique of the “Take the Stairs – Every Step Counts!” Campaign
A. The Effect of Context Stair on Stair Usage
It is important to understand the effect of context when analyzing human behavior. A common mistake is to overestimate an individual’s character, and underestimate the effect of the environment on decision making. (7) Specific to the “Take the Stairs” Campaign, the intervention succeeds with the placement of the signs at the point-of-decision (5). The signs are placed next to elevators and escalators, encouraging individuals to use the stairs instead (4). While many interventions have shown increased stair use after the signs are placed, the overall effect is not currently strong enough to affect the prevalence of obesity (6).
The original intervention is based on an individual level theory of behavior, as opposed to an environmental level model. Individual behavior theories, such as the Health Belief Model, weigh perceived benefits and barriers of the decision before choosing the behavior. The problem with these theories is that they assume that human behavior is rational, planned, and static. There is no room for spontaneity and the effect of the environment is not taken into account. (8) In contrast, environmental level theories describe behavior as unplanned and dynamic, while considering the effect of the environment and structural factors (9).
Therefore, a possible failure of this intervention is the assumption that reading the sign will be enough to encourage an individual to take the stairs. By not taking into account the environment, the intervention isn’t considering that many buildings are not designed with central staircases and they can often be difficult to locate. If the signs fail to provide information about where to actually find the stairs, then individuals may perceive the staircases as being difficult to find and will most likely choose the escalator or elevator. (10) The context in which an individual is presented the decision will directly affect their behavior (7). In this case, the environment, specific to the building design, may inhibit the effectiveness of the intervention.
B. The Effect of Expectations on Stair Usage
Expectations are another aspect of irrational behavior that can be modified to affect individual decision making. Overall, people behave the way they are expected to behave. Stereotypes and priming have been shown to directly affect behavior, even when there is no rational reason. (11) In the United States, health disparities between ethnic groups have become an increasing problem. Blacks and Hispanics have a 51% and 21% higher prevalence of obesity, respectively, than Whites. Obesity and overweight are associated with comorbidities such as hypertension, cancer, and heart disease. (1) Studies evaluating the effectiveness of the “Take the Stairs” campaign found higher rates of increased stair use in White men and women than in Black and Hispanic men and women (6). In particular, one study found no significant change in stair use for Black men and women with the placement of the signs (12).
As explained before, the original intervention is based on an individual level behavior model. If the decision to take the stairs was based entirely on weighing the expected outcomes with the social acceptability of the behavior, as modeled in the Theory of Reasoned Action, then designing signs to promote this behavior would be simple and effective, because the behavior would be predictable (8). However, the failure of these signs in reaching Black and Hispanic populations reveals the complexity of human behavior. Expectations and social norms are different for different ethnic groups and need to be taken into account (13).
If overweight has become the social norm for Blacks and Hispanics, it may also not be the norm for these populations to choose the stairs over escalators and elevators. People are behaving the way they are expected to behave (7). Therefore, a possible failure of the “Take the Stairs” campaign is that the signs do not identify with specific ethnic groups. In order to enhance the effect of the intervention and lessen the health disparities between groups, it may be important to take into account expectations and social norms by personalizing the signs, rather than assuming that all populations will identify with standard messages.
C. The Effect of Framing on Stair Usage
Framing is another characteristic of irrational behavior that directly affects human behavior and decision making. How a decision is framed or presented can persuade an individual to make a certain decision, despite being irrational. (14) Framing is commonly used in public health as a way to encourage healthy behavior changes. It has been found that most people do not prioritize health when asked to list their core values. Freedom, control, love, and acceptance are typically thought of as important, but health is rarely considered (15). Based on this idea, public health campaigns that frame a behavior recommendation as a change for improving health are not as effective as those that promote core values (12).
Once again, the original intervention is based on an individual level model of behavior. As described with the Health Belief Model and the Theory of Reasoned Action, individual level models assume rational decision making, based on weighing the pros and cons of a behavior (8). However, if an individual does not prioritize their health, it is unlikely they will view taking the stairs as a beneficial decision. The perceived barrier of locating the stairs and the effort required to climb them may be too high if the message delivered is framed as a health based one, rather than one targeting core values.
The “Take the Stairs” campaign offers a mixture of template signs, most of which emphasize taking the stairs for health reasons. Two of the signs offered made reference to the stairs as a replacement gym, such as “Do some reps, take the steps!” and “The cheapest gym anywhere…” However, the rest of the signs simply asked “Have you thought about the stairs?” (4) Therefore, a possible failure of the “Take the Stairs” campaign is the emphasis on health and lack of emphasis on the values that people tend to prioritize.
III. Proposed Changes to Enhance the effect of the “Take the Stairs – Every Step Counts!” Campaign
A. The Effect of Modifying Context and Building Design
The concept of herding behavior is a group level theory describing the mob effect, or the alignment of thoughts and behavior of individuals in a group without centralized coordination (16). The idea that groups tend to move as a unit, choosing the same behavior, can be applied in the promotion of stair use. The building design and environment may be inhibiting people from choosing to take the stairs over the elevator or escalator. A study looking at the effects of neighborhood and street design on physical activity in children found that the presence of sidewalks and the attractiveness of a neighborhood have a positive effect on walking behavior (17). This same idea can be applied to building design and stairwells, such that if a pathway is provided in a visually pleasing setting, it is more likely to encourage pedestrian use.
Buildings are usually designed for function and many institutions closely constrain where people are allowed to walk within a building. Therefore, site design should involve pedestrian elements to encourage walking around within and between buildings. Features, such as a central staircase, can promote physical activity in the work place. (10) Taking the stairs would become the primary choice because pedestrian traffic is directed in that direction, taking advantage of herding theory and modifying the context of stair use.
For older buildings, the effect of space, light, and bright paint colors make stairwells more inviting and encourage more use (10). Also, the addition to the sign of an arrow or map, directing individuals to the stairwells, can encourage stair use. The visual of showing where to locate the stairs will lower the perceived barriers of using the stairs and may change the context in which the sign is presented to increase use. Therefore, the presence of other users and the visual setting plays a key role in pedestrian choices and behavior (10).
B. The Effect of Modifying Expectations and Designing Signs Specific to Ethnic Groups
Social Expectations Theory is a group level model used in public health to determine what human behaviors are social norms. As the social norms change, measured behavior changes along a diffusion curve. (18) This theory can be applied when considering the norms of physical activity in certain populations. A study looking at activity levels found that individuals in neighborhoods with low sidewalk connectivity were associated with a higher body fat percentage (19). If the neighborhood environment prevents regular physical activity, the inhabitants of that area are less likely to make exercise a part of their lifestyle. This habit may extend beyond the home and affect the activity level of the individual in other neighborhoods and in the workplace.
If the social norm is for certain ethnic groups to choose the escalator or elevator over choosing the stairs, then the goal of the “Take the Stairs” Campaign should be to create signage specific to individuals from these groups. When implemented, studies evaluating the effect of the signs found that stair use was higher in White men and women than in Black and Hispanic men and women (6). Therefore, it is important to target signs to Black and Hispanic populations.
A community intervention in Baltimore created culturally sensitive signs to promote stair use by Black men and women in the subway. They found that Black men and women increased their stair use from 10.3% to 16.4%, with the greatest increase in Black women. Additionally, White commuters increased their stair use from 23.1% to 28.3%. Therefore, the study confirmed that signs encouraging stair use can be effective in targeting specific ethnic groups without alienating others. (20) Modifying and targeting signs to Black and Hispanic individuals has the potential to change the social norms and expectations for these groups. If choosing the stairs over the escalator and elevator becomes the social norm, this increase in physical activity could extend beyond the workplace and potentially lessen the health disparities for these groups.
C. The Effect of Modifying Framing and Promoting Core Values
Advertising Theory is another group level model that can be applied to public health interventions. According to the theory, effective advertising contains a primary promise and supporting facts that focus on core values. (21) A study looking at the use of signs to promote stair use for heart health found that signs promoting health were less effective than those promoting weight control (12). As described before, very few people will list health when asked to list their values and priorities (15). Therefore, it is important to design interventions that promote values other than health with a specific behavior change.
In the case of stair use, this form of physical activity has a number of health benefits. Specifically, the added exercise to an individual’s schedule can help with weight maintenance. Therefore, personalizing and catering signs that promote weight loss could identify with individuals who prioritize looking attractive. For example, one study looking at physical activity and obesity in adolescents found that most of the participants interviewed were more interested in being thin than being healthy in order to be accepted by their peers. In this case, weight loss was prioritized for social acceptance, rather than health. (22) Also, signs that indicate the lack of time wasted waiting for an elevator could target people who prioritize freedom and control. Personalizing and framing the recommendation of taking the stairs as something that will benefit each person in a way that they find important could make the “Take the Stairs” campaign more effective.
IV. Conclusion
The “Take the Stairs” campaign has the potential to be an effective way of modifying behavior and promoting a healthy lifestyle change. Studies have shown that signs posted at the point-of-decision can be effective in promoting stair use (5). However, the campaign is currently not effective enough to affect obesity on a population level (6). Also, studies have shown that the behavior change is not sustained after the signs are removed, with the number of people using the stairs reverting to baseline levels by three months (12). Therefore, the building environment and the type of signs used may need to be modified to increase use. The intervention design needs to move away from individual level behavior models and take into account the environment, spontaneity, and irrational decision making behavior. Specifically, the characteristics of context, expectations, and framing that describe irrational human behavior could be used to direct decision making and promote stair use. Taking the stairs is just one of many USDA recommendations toward a healthier lifestyle. It is important to promote this change and show the general population that this is an easy modification that could benefit their lives. With obesity and comorbid conditions on the rise in the United States, the “Take the Stairs” campaign has the potential to be very effective in changing behaviors.

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