Effects of Point-of-Choice Prompts on Stair Usage in a Psychiatric Setting

To the Editor: Psychiatric settings and services have been described as potentially obesogenic because they provide opportunities for increased calorie intake and reduced energy expenditure (1). To supplement traditional weight-loss interventions that mainly target individual behavioral change and to address the higher prevalence of obesity among psychiatric inpatients, ecologically framed interventions are required. For example, in one uncontrolled study, changing how meals were served in a psychiatric ward led to significant weight loss (2).

In terms of physical activity, persons with serious mental illness constitute a large population of adults who are not active enough to experience health benefits (3). A potential strategy to increase overall physical activity among sedentary individuals is to modify the physical and sociocultural environments to facilitate engagement in more incidental physical activity (4). Stair use is an environmental modification that has been studied for its impact on increasing physical activity and improving health. Stair use interventions mainly rely on point-of-choice signs, such as posters, to promote stair use over escalator or elevator use. A recent review of studies of point-of-choice prompts found that most led to a significant increase in stair climbing (5).

We decided to assess the effectiveness of point-of-choice prompts in increasing stair use between two floors of a five-floor building at the Centre for Addiction and Mental Health in Toronto, Canada. The purpose of this “proof-of-principle” study was to examine whether environmental modifications to increase incidental physical activity are feasible in a psychiatric setting.

Our six-week study, conducted in the summer of 2010, used a quasi-experimental, interrupted time-series research design. Individuals who lived and worked on the unit were participants. Stair use was measured by an infrared motion sensor and by systematic behavioral observations during three study phases—before, during, and after the installation of point-of-choice prompts. Elevator use was measured only by observation. No significant change in the overall number of stair users was noted over the three phases. Logistic regression analysis of observational data did not find an effect of sex or hospital status (whether participants lived or worked at the hospital) on stair or elevator use. Although patients did not change their stair use behavior, male employees and male volunteers significantly increased stair use over the study period (N=133, χ²=13.4, df=2, p=.001).

Overall, this study showed that a simple environmental intervention is feasible in a psychiatric setting and that it can have an effect on certain demographic groups. Individuals with schizophrenia face many physical and mental health challenges; inclusive and accessible strategies must be created to encourage them to become active. As this study found, such efforts may have a secondary effect of increasing activity levels of staff. In addition to stair use, other environmental strategies should focus on increasing low-intensity or incidental physical activity, because individuals with schizophrenia are largely inactive and any increase in the level of physical activity would be beneficial (3).

Although more research is necessary, environmental interventions can play a role in increasing levels of physical activity and help address the obesogenic environment that faces individuals living in psychiatric settings.