Influencing policy and practice for stair climbing to increase Lifestyle Physical Activity
Submitting InstitutionUniversity of Birmingham
Unit of AssessmentSport and Exercise Sciences, Leisure and Tourism
Summary Impact TypeSocietal
Research Subject Area(s)
Medical and Health Sciences: Public Health and Health Services
Summary of the impact
Insufficient levels of physical activity are a major public health
challenge. In the 1990s, approaches to meeting the challenge of increasing
physical activity (PA) shifted to a focus on the accumulation of activity
during daily living and interest in the potential effects of the built
environment on lifestyle physical activity. Researchers from the
University of Birmingham tested methods to encourage the increased use of
stairs, rather than escalators and lifts, with the aim of increasing
calorific expenditure during daily life. This research made a major
contribution to the evidence base for NICE (UK), as well as CDC (USA),
leading to recommendations to use signage as a public health message to
increase stair use. Campaigns prepared for the Department of Health
(Cataluyna, Spain) were rolled out nationally, with advice currently being
extended to worksite campaigns. At a regional level, councils throughout
the Midlands have employed the stair use campaigns, as have the police and
commercial firms, with Unilever requesting them for use nationally and
internationally and an improved campaign rolled out by National Car Parks
It is widely agreed that populations throughout the western world are
insufficiently active for optimal health, and that low levels of PA are
one factor in escalating rates of obesity. During the 1990s, there was a
change in strategy to address this problem of low levels of PA.
Recommendations for formal sessions of vigorous exercise were replaced by
guidelines targeting the accumulation of moderate intensity PA as part of
daily living (American College of Sports Medicine Position Statement,
1995). Additionally, the focus shifted to the influence of the built
environment on lifestyle activity (e.g. Sallis et al., 2004).
Concurrently, researchers from the University of Birmingham were testing
methods to encourage the increased use of stairs as part of daily life.
Stair climbing expends more energy per minute than jogging, is readily
available to most of the population, and the activity can be accumulated
throughout the day as part of work, leisure and home life. The
University's research indicates that stair climbing interventions produce
a 6.4% increase in usage of public access stairs, with a 12.3% increase
recently reported in one workplace. An `overweight' man for example, who
climbs stairs in his home an extra ten times each day, expends energy
equivalent to 3lbs of fat over a year. Stair climbing interventions can,
therefore, contribute to obesity reduction efforts at a population level,
and it has been estimated they are six times more cost-effective, i.e.
value for money, than their nearest competitor.
Dr Eve's first publication on stair climbing (2000) was only the fifth in
the field, followed by a further 34 peer-reviewed papers. All but two
papers were first authored by Dr Eves or one of his PhD students [J. Kerr
(1998-2001), O. Webb (2003-2007), E. Olander (2007-2010), A. Lewis
(2007-2011)]. The selected papers below illustrate some of the
translational issues for successful interventions to increase stair
climbing addressed in this programme of research.
Output R1 explored effects of poster size, message content and context
for public access interventions. It was the first report of a) differences
in stair climbing frequency for different demographic groups and b)
different intervention effects depending on context (shopping vs. travel).
Output R2 introduced a new intervention approach. Messages affixed to
stair risers had twice the beneficial effect of posters. A companion paper
demonstrated maintenance of effects three months after intervention
removal. Subsequent research revealed that stair riser banners: a) are
more effective because of enhanced visibility (2005), and b) are
unsuitable for busy sites (2008, 2009). Follow-up research in Barcelona
led directly to work for the Department of Health in Catalunya, Spain
Output R3 was the first to emphasise that consistent success with public
access interventions did not generalize to workplaces where the choice was
between using stairs and a lift; a cautionary finding that was repeated in
2008 and 2010. Uncontrolled effects of building occupancy,
minute-by-minute pedestrian traffic and time of day that influence lift
availability are the likely explanations for this problem (2011).
Output R4 on a workplace intervention reported for the first time: a) the
use of stair riser banners, b) a sustained, successful stair climbing
intervention, and c) a demonstration of greater responsiveness in
overweight individuals than those of healthy weight. This was a unique
finding for population approaches to public health.
The letter to the editor (R5) corrected an error made by reviewers from
the community interventions task force at CDC that assumed that choice
between stairs and escalators was equivalent to choice between stairs and
a lift at work. Reviewers for NICE made the same error.
Output R6 generalised the multi-component approach to workplace
intervention developed in R4 to a public access setting (tram station).
Uniquely in public health interventions, the effects of this new calorific
expenditure campaign were only observed in overweight pedestrians.
References to the research
The evidence base for this impact case is located primarily in
international, peer reviewed public health journals.
R1) Kerr, J., Eves, F., & Carroll, D. (2001a). The influence of
poster prompts on stair use: The effects of setting, poster size and
content. British Journal of Health Psychology, 6, 397-405.
R2) Kerr, J., Eves, F., & Carroll, D. (2001b). Encouraging stair use:
Banners are better than posters. American Journal of Public Health,
91, 1192-1193. [DOI:10.2105/AJPH.91.8.1192]
R3) Eves, F.F. & Webb, O.J. (2006). Worksite interventions to
increase stair climbing; Reasons for caution. Preventive Medicine,
43, 4-7. [DOI:10.1016/j.ypmed.2006.03.011]
R4) Eves, F.F., Webb, O.J. & Mutrie, N. (2006). A workplace
intervention to promote stair climbing: greater effects in the overweight.
Obesity 14, 2210-2216. [DOI:10.1038/oby.2006.259]
R5) Eves, F.F. (2010). Effects of point-of-decision prompts for
stair use depend on the alternative. American Journal of Preventive
Medicine, 38, 573-574. [DOI:10.1016/j.amepre.2010.02.004]
R6) Lewis, A. & Eves, F.F. (2011). Specific effects of a calorific
expenditure intervention in overweight pedestrians. Annals of
Behavioral Medicine, 42, 257-61. [DOI:10.1007/s12160-
R Masters, F Eves & A McManus. `Development and validation of
prompted stair climbing as an intervention to increase healthy lifestyle
activity in Hong Kong.' Health & Health Services Research Fund, Hong
Kong Government, 2004-2006. HK$ 460,333.
F Eves, & N Mutrie. `Incremental stair climbing at a worksite;
An assessment of the efficacy of a worksite intervention employing new
point-of choice prompts and multiple messages on stair risers.' NHS Health
Scotland, 2004-2005. £10,711
F Eves. `Prompted stair-climbing; Worksite campaigns targeting
heart health and obesity.' Heart of Birmingham Teaching PCT, 2005-2006.
A Puig-Ribera, F Eves. `Validation of messages to increase energy
expenditure and prevent obesity.' AGAUR, Catalunya, Spain, 2006. 04046430.
F Eves & A. Puig-Ribera. `Testing of Stair Climbing
Point-of-Choice Prompts in the Barcelona Metro.' Department of Health,
Catalunya Spain, 2006-2007. 04045335.
L Engbers, M Holewijn, F Eves, V Hildebrandt, PJ Mol, T
Paulussen, W van Mechelen & M van Poppel. `FoodSteps-2: Development of
an innovation strategy for and trial-implementation of an intervention on
stimulating physical activity and healthy eating by changing the work
environment.' ZonMw Programme Prevention, The Netherlands, 2009-2013.
F Eves, A Daley, D Carroll, S Greenfield & R Holder.
`Prompting Increases in Stair Climbing at Work to Promote Physical
Activity. NPRI-3, MRC, 2010-2013. £236,934
F Eves, A Puig-Ribera, S Greenfield, T Puig-Reixarch, C Torgerson,
A Tort-Bardolet et al. `CLIMBS at Work: Calorie Labelling at Intake and
Modified Behaviour for Stair choice.' Bupa Foundation Multi-Country
Competition Grant. 2012-2016. £359,359.
Details of the impact
Providing the Evidence Base for Policy Guidelines
a) Stair climbing interventions for Public Health
This pioneering research on environmental prompts for physical activity
contributed to the evidence base for policy guidelines on the use of
signage for stair climbing as a means of increasing lifestyle physical
activity at the population level. For example in the UK, NICE Public
Health Guidance 13, 2008 recommends: `putting up signs at strategic
points to encourage them (employees) to use the stairs rather than lifts
if they can'. Dr Eves' research contributed nine out of the twenty
three worldwide studies that formed the evidence base for this conclusion
. In the UK, these guidelines were the first to identify the effects of
the environment on lifestyle physical activity. In the USA, Dr Eves'
research contributed to both initial guidelines and the updated guidelines
in 2010 (Centres for Disease Control reviews, Kahn et al., 2002; Soler et
al., 2010: ). Dr Eves' interactions with Robin Soler (head of CDC
Community Intervention Task Force in 2010) identified an error in the
CDC's updated summary of effectiveness, and changed Soler's understanding
of how prompts work and subsequent planning for implementation of policy
guidelines in community interventions . Dr Eves' research also
contributed twenty three out of forty two effects to a systematic review
of effectiveness, twenty one of which were successful (Nocon et al., 2010;
), a prominence in the field which contributed to the NICE (2008) and
CDC (2010) guidelines for PA engagement in the general population. This
systematic review relied heavily on Dr Eves work for its conclusions (R3,
b) Nudge Interventions for Public Health
To change stair climbing, Dr Eves' research uses point-of-choice prompts
which are messages displayed in the environment where a healthy choice can
be made. These interventions, first used in 1980, are predecessors to the
recent interest in `nudge' approaches to health. They predate the global
prominence afforded to Nudge by Thaler
book, `Nudge: Improving Decisions about Health, Wealth, and Happiness'
published in 2008 and the Behavioural Insights Team, known as the `Nudge
Unit' set-up by the Cabinet Office in July, 2010. Dr Eves was recruited as
a consultant for the Behavioural Insight Team at the Cabinet Office
because they were proposing to use messages he developed as nudges (paper
R4 above; source ). His research contributed approx 7.2% of the total
evidence base for a review on `nudge' and 45.5% of the evidence base for
physical activity nudges submitted to the Department of Health (UK) by the
Behaviour Change Unit at Cambridge (2012). This provides further evidence
of the way in which the research has informed the evidence base for
decisions at government level. It is premature at this stage to calculate
the hard end outcomes from this input into government decision making .
Influencing Physical Activity Strategies
Examples that predate the current REF period illustrate that Dr Eves was
one of the first researchers worldwide to investigate the promotion of
stair climbing and offer insights into the genesis of the impacts
reported. Dr Eves' research provided the evidence for nine out of ten
successful stair interventions in the UK at the time of the NICE review
and is the primary source of evidence that applies this field to a UK
population. In Catalunya (Spain), the Department of Health was developing
a lifestyle physical activity strategy and they sought advice from Dr Eves
who was working on a stair climbing intervention there with Dr Puig-Ribera
(2005). This resulted in commissioned research, the outcomes of which
directly influenced the content and method of intervention for the
Catalunya Department of Health's PA campaigns that were launched in 2010
. Dr Eves is currently advising these policy makers on a new approach
to worksite campaigns (2013-2015) to be made available throughout
Catalunya, Spain, in which stair climbing prompts are combined with
food-related prompts in canteens.
Changing practice at a regional level
Dr Eves designed and installed stair climbing interventions that changed
employers' practice in local authorities in Birmingham (2008, 2011),
Coventry (2011), Walsall (2012), Dudley (2012), Nottingham (2013) and
Worcester (2013), as well as Severn Trent (2008), the West Midlands police
(2009), Pilkingtons (2011) and the Birmingham Chamber of Commerce (2011).
A combined workforce of 6,650 was exposed to stair climbing campaigns over
this period, as well as a significant number of uncounted visitors to the
targeted buildings. A published research paper on these workplace
interventions reported a 12.3% increase in stair climbing, demonstrating
that such campaigns can change employees' behaviour towards a
health-enhancing alternative. This paper also prompted Unilever to request
use of Dr Eves' campaigns for their workforce nationally and
internationally. In Nottingham, the public health department was alerted
to Dr Eves' research by academics in the national PA field. In addition,
he was recruited by John Lloyd, the regional manager for Heart Research
UK, to offer expert comment on a planned stair climbing intervention for
use by National Car Parks Ltd (2010). The modified campaign that was
rolled out was `very well received' by end users of the car parks in
Birmingham, Walsall, Stratford-upon-Avon and Manchester. Use of this
campaign is currently being extended within the UK .
More broadly, this research has been picked up by individuals who are not
directly involved in public health and the implementation of physical
activity strategies, thus leading to the potential for even wider impacts.
For example, Rob Koelewijn from KLM Health services requested a paper on
the effects of stair climbing as a means of `designing the working
environment to prevent health risks' (2008) for summary in the Dutch
Egonomics Journal (Tijdschrift voor Ergonomie); a US school requested
permission to use our stair climbing campaign (iv) in their school (2011);
Chris Hammer from a `green' architect's collective in the US used our
research (ii) to illustrate the potential for reduced carbon footprints
for lifts (2010); and a website, InformeDesign, that translates research
for use by architects and housing specialists amongst others, disseminated
a paper on potential effects of station design on stair usage.
Additionally, Dr Eves informs public debate about the benefits of stair
climbing. He is on the British Psychological Society expert panel and is
regularly requested to comment on research in this area. He provides
information for journalists preparing articles on stair climbing/physical
activity/weight loss (e.g., Self, 2008; Country Walking,
2008; Men's Health Magazine, 2009; Slimming World, 2012)
and has given radio interviews in the UK, Australia and the US on the
Sources to corroborate the impact
 Factual statement provided by Evaluation Team Leader, Division of
Adult and Community Health National Center for Chronic Disease Prevention
and Health Promotion.
 Nocon, M., Müller-Riemenschneider F., Nitzschke, K., & Willich,
S.N. (2010) Increasing physical activity with point-of-choice prompts — a
systematic review. Scandinavian Journal of Public Health, 38,
 Factual statement provided by Public Health Specialty Registrar,
Department of Health.
 Factual statement provided by Behaviour and Health Research Unit,
Insitute of Public Health.
 Factual statement provided by Deputy Director of Health Promotion,
 Factual statement provided by Heart Research, UK.