Several studies showed that office workers and university students were at health risk due to the high occupational sitting time and low occupational physical activity (PA) (1–4). Stair climbing, which was categorised as vigorous PA, has been associated with health benefits amongst both healthy individuals and also individuals with health conditions, including improvements in aerobic capacity, blood pressure, lipid profiles, body composition, mood states, cognitive performance, and reduced risk of several non-communicable diseases and mortality (5–13). Thus, an intervention that motivates stair climbing in university settings could be suggested to increase occupational PA to improve office workers’ and students’ health.

Several systematic reviews reported that motivational signage posted near stairs and elevators could increase stair use in public areas (14–16). However, the effectiveness of stair use intervention in worksite buildings was not consistent, particularly in university-based settings (14, 17–20). In addition, contemporary phenomena could interfere with the effect since there was no control group in previous university building studies (19, 20). Most of the available studies on the effectiveness of signage also had weak internal validity and lacked external validity reporting (14–20).

Our study aimed to examine the effectiveness of motivational signage using a specific message on stair use and to report its process evaluation using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) Framework to improve its external validity and to inform future trials (21). We examined the outcome in an identical building as a control to minimise the bias from contemporaneous phenomenons. Objective measurement using video recording by two independent observers blinded to the intervention status was employed to reduce measurement bias and Hawthorne effects.

A longitudinal non-randomised controlled quasi-experimental study was conducted to assess the change in stair use for stair climbing or descending as an effect of point-of-decision motivational signage (Figure 1). The study was retrospectively registered at thaiclinicaltrials.org (TCTR20220804005) and was ethically approved by the Medical and Health Research Ethics Committee Faculty of Medicine, Public Health, and Nursing Universitas Gadjah Mada (Ref No: KE/FK/0973/EC). This pragmatic trial was reported in line with the Consolidated Standards of Reporting Trials (CONSORT) statements for pragmatic, pilot, and feasibility trials (22, 23). This study consisted of 1-week pre-intervention data collection to measure the baseline stair use and elevator use, followed by 6 months period of intervention monitoring (October 2019–March 2020). The second monitoring phase was conducted in the last week of the 3rd month, and the third phase was conducted in the last week of the 6th month.

We described the process of designing the stair-use intervention and evaluating the intervention using the RE-AIM framework (21). A low-cost motivational prompt significantly increased the stair climbing rate at the intervention site by 6.7% during the 6th-month intervention phase. Still, it did not affect the stair use in the 3rd month and the stair descending rate during the whole study period. In contrast, the stair rate at the control site remained similar to the baseline.

The 6.7% increase in stair climbing in our study was higher than a previous systematic review reported, which showed a median increase of 0.8% with a motivational sign only (15). Our results (6.7% increase in stair climbing) almost reached the increase in stair climbing in intervention involving a combination of motivational and directional signs, which were reported to increase stair climbing by 8.1% within a worksite setting (15). Our study is also in line with a previous study that reported that the changes in stair climbing could only be observed in the second phase (25). However, the decrease in stair climbing proportion in the first phase of our study might be caused by the decrease in total visitors during this period since people were more likely to choose the elevator in the less busy period (27–29). In comparison, previous studies required additional interventions in the second phase, such as improving the aesthetic of the stair or installing music (18, 30, 31). Our study’s increase in stair climbing could be observed without additional intervention. Therefore, we could identify that the positive influence on the stair climbing rate resulted from the repetition of prompts, which might be necessary to create sustainable habits in choosing the stair rather than the elevators. The stronger influence of motivational signs in our study could be attributed to the specific type of message, poster size, and the effect of co-production in designing the specific messages in the motivational sign (20, 32–34). Therefore, co-designing the intervention by involving the occupants of the buildings in designing large-size posters with specific messages since the early phase of intervention development could be suggested to improve the effectiveness as an alternative to using multiple intervention components.

Our study also found that employees easily adopted portable stair posters. This sign might solve overcoming adoption barriers reported by a previous study (25). Portable signage could still be located in the visible section of the building without interfering with the needs of corporate communications (25). Therefore, the placement of the stair posters could also be overtime during the study period.

Our study had several strengths. It employed a controlled design with two identical buildings and objective monitoring with less burden of observers, less observer bias, and less contamination bias. In addition, we also controlled total visitors as a confounder (20, 30, 32, 35, 36). However, there were several limitations of this study. Using double speed and reduced video recording resolution, our observers could not identify visitors’ characteristics, including gender, age, and whether visitors were students or employees. Previous studies found that gender, age, and status of visitors (students or employees) could influence the signage effect (29, 31, 36, 37). Therefore, future studies should consider controlling these confoundings. The difference in the number of floors, lift capacity, and the stair landing between the two buildings might also influence the visitors’ decision in choosing the stair for their journey, which could be examined in future studies. Whilst the number of flights was associated with health outcomes (10), the nature of the CCTV monitoring also did not allow for monitoring the number of flights the visitor took. We also examined the implementation process based on informal interviews and opinions, which could produce more naturalistic data but could be prone to bias and unreliable data (38). More rigorous mixed-method studies with a more representative sample involved in the development process of the intervention should also be considered in future process and impact evaluation studies. In addition, the effects of the intervention on individual or population health outcomes were also important to be examined in future studies.

Our study strengthens previous works on the usefulness of low-cost stair-use interventions at worksites using signage. Based on process evaluation using the RE-AIM framework, co-producing the intervention with employees was associated with the intervention’s effectiveness, adoption, and implementation. Effects of intervention on stair use amongst various genders, ages, and statuses of visitors, as well as effects on health outcomes, need to be elucidated in future studies.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by Medical and Health Research Ethics Committee Faculty of Medicine, Public Health, and Nursing Universitas Gadjah Mada. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.

ZM: conceptualization, funding acquisition, and supervision. WW: conceptualization, funding acquisition, methodology, and writing–review and editing. MS: methodology, investigation, project administration, funding acquisition, and writing–review and editing. RW: conceptualization, methodology, investigation, formal analysis, writing–original draft, and writing–review and editing. DA: conceptualization, writing–review and editing, and supervision. All authors contributed to the article and approved the submitted version.

This work was supported by the Community Empowerment Grant, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada. This funding source had no role in the design of this study and will not have any role during its execution, analyses, interpretation of the data, or decision to submit results.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.