Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Wednesday, December 12, 2007

Ten Thousand Steps a Day: An Overly-Simplistic Strategy to Increase Physical Activity – Sandy Askew

Step counting has become a popular means for increasing physical activity. Several studies have used pedometers and step counting as a central component in physical activity and weight control campaigns and interventions (1-6), including those which urge participants to take 10,000 steps a day (7-11). The interest in these types of interventions has grown because walking seems like a simple exercise and monitoring steps doesn’t require large or expensive equipment. In fact, some pedometers are so affordable to produce, McDonald’s restaurants and Kellogg’s cereal company were able to give thousands away in adult happy meals and cereal boxes during their own pedometer campaigns (12-14). Despite this seemingly simple solution, half of all American adults don’t meet current recommendation of 30 minutes or more of moderate physical activity 5 or more days per week for a healthy lifestyle (15, 16). Evidence from intervention studies suggests that most people who try one of these walking programs will be unlikely to maintain it long term (8, 17, 18). Despite their simplicity, or perhaps because of it, these campaigns are not achieving wide spread success. In creating these step count programs, many intervention designers have limited their thinking to individual-oriented approaches to behavioral change which will continue to have limited success. Physical activity interventions focused on a step count recommendation are overly simplistic because they rely heavily on an individual-oriented approach and assume that by changing a person’s attitudes and intentions toward walking, they will change behavior. These interventions seldom consider more complex consider social and behavioral factors like social norms, competing behaviors and perceived behavioral control, which may have a greater impact on physical activity adoption.

Background: 10,000 Steps
One popular pedometer intervention recommendation is to take 10,000 steps a day. Based more on an advertising campaign than scientific research, the popularity of the 10,000 steps figure grew from “Manpo-kei”: the advertising slogan of a 1960’s pedometer which literally means “10,000 steps meter” (19). As the recommendation was not created through research, there was no formal theoretical model used to develop it. Nonetheless, the recommendation is clearly an individual-oriented approach urging each person to walk 10,000 steps a day for better health and focusing on creating positive attitudes about walking and its effects. Like some traditional models, including the Health Belief Model and the Theory of Planned Behavior, the 10,000 steps approach assumes that behavior will follow intention: If people adopt a goal of 10,000 steps a day, they will walk more to reach that goal (20). Like the theoretical framework of the intervention, the step goal did not originate in scientific evidence leaving it open to scientific inquiry and criticism. While the idea of walking 10,000 steps for wellness has spread throughout Japan and to other parts of the world, researchers have been attempting to find evidence to support it.

Is 10,000 Steps an Achievable Goal?
A growing body of research supports the idea of increased walking for health, although no clear consensus has developed regarding the figure of 10,000 steps per day. The Centers for Disease Control and Prevention (CDC) and the American College of Sports Medicine (ACSM) recommend that adults engage in moderate-intensity physical activities, like brisk walking, for at least 30 minutes on 5 or more days of the week (15, 16). Walking as a form of moderate exercise may reduce a person’s risk for cardiovascular disease, diabetes, hypertension certain cancers and obesity (21, 22). Some researchers have found the 10,000 steps recommendation to approximately match the CDC’s and ACSM’s recommendation (19, 23, 24) and that it could lead to improvements in glucose tolerance and lipid profiles, lower body fat and blood pressure as well as other health benefits (25-28). Yet other studies have reported that a 10,000 steps goal may be difficult for some people to achieve and maintain, even with 30 minutes of activity a day (23, 28, 29) and some evidence suggests fewer steps may be needed to achieve some health benefits (26, 30, 31). This raises questions about the impact of the figure of 10,ooo steps on a person’s self-efficacy and if it is wise to promote such a high figure if it is unnecessary or unrealistic. While 10,000 steps a day may be considered an easy to remember, concrete goal (19), if it is too high people may quickly grow discouraged with it or not adopt it at all. Further, if interventions don’t address other influences on self-efficacy and barriers to walking, even a lesser figure may be unattainable.

Although 10,000 steps interventions attempt to improve physical activity self-efficacy by focusing on a simple exercise behavior, they fail to account for an individual’s perceived behavioral control. Even if an individual wants to walk more, he may feel there are barriers beyond his control which prevent him from doing so. Features of the physical environment may serve as barriers to physical activity, including an activity as simple as walking (32-38). Urban sprawl, poor neighborhood aesthetics, poor street connectivity, high traffic, no sidewalks or poorly maintained sidewalks and no streetlights have all been found to have a negative association with walking activity (38-45). Concerns about neighborhood safety may also inhibit people from walking (33, 34, 37). The Theory of Planned Behavior postulates that a person’s attitude toward a given behavior, as well as his perceived and actual behavioral control, will help determine his intention to engage in that behavior (20). However, step count interventions often don’t address environmental barriers which may make a person feel that walking is unpleasant, difficult or even unsafe. Instead, these interventions focus on the simplicity of walking more without realizing that for many people it is not at all simple. On the other hand, some aspects of the environment may encourage walking. For example, the presence of nearby shops, parks, beaches and walking paths is positively associated with walking (39, 41, 45-48). A concept taken from ecological psychology explains that there are “behavioral settings”: places or situations which promote or discourage certain behaviors (38). Living proximal to parks and shopping centers may encourage walking activity through design: They lessen the perceived barriers to walking more. Alternatively, living near one of these settings may also lessen perceived barriers through social mechanisms by providing both social models and social expectations, or norms, to walk because other people are walking there. Unfortunately, these kinds of social influences are also seldom addressed in physical activity interventions built on step counts like 10,000 steps.

The Importance of Social Norms
Ten thousand steps interventions focus largely on the individual and fail to address social norms which may inhibit adoption of physical activity recommendations. According to the Theory of Planned Behavior an individual is more likely to adopt a behavior if it is supported by the norms of their social networks (20). “Nobody walks in L.A.” is an expression popularized by a song in the 1980’s (49), but more than that, it may be an expression of the social or cultural norms of a city and other places like it. A person who lives in a place where walking is not the norm, or is even seen as distasteful, will be less likely to walk. The social acceptability, or unacceptability, of the behavior has a direct effect on a person’s intention because he may feel he will be stigmatized or socially sanctioned for engaging in that behavior. The literature on the impact of neighborhood norms on walking behavior is limited, but some authors have described the influence of these norms through a “contagion” perspective where people are influenced by the behaviors of those around them, copying behaviors, whether they are positive or negative, and thereby creating acceptable norms in the neighborhood (50, 51). This perspective includes ideas presented in Modeling theory where people emulate the behaviors they see in other people, gaining self-efficacy vicariously by observing successful behaviors (20). It also includes aspects of Diffusion of Innovations theory where, as with the spread of some diseases, a few people may initially perform a behavior, but it slowly begins to spread (20). When it reaches a tipping point, it will spread rapidly through a population, becoming normalized. If a physical activity campaign could manipulate these norms and use theories like Diffusion of Innovations to their advantage, physical inactivity could become an oddity. Unfortunately, 10,000 steps and other step count interventions fail to address these norms. While it is easy to recommend that someone take a walk at lunch or use the stairs instead of the elevator, many people may be very uncomfortable deviating from the norms of their peers. They may feel self-conscious walking through a neighborhood where walkers are observed as unusual or the subject of suspicion. Unless interventions find a way to help participants beyond those feelings or to normalize walking, they will continue to have limited success.

Behavioral Principles and 10,000 steps
Step counting interventions fail to consider that although an individual may intend to walk more, competing behaviors may be given higher priority if they seem more equally or more rewarding. Perhaps essential to altering norms or changing individual behaviors is to understand and use basic behavioral learning principles to affect behavior. At the core of the Behavioral paradigm in psychology are the concepts of reinforcement and punishment. Reinforcement is anything which leads to an increase in the performance of a behavior and punishment is anything which leads to a decrease in the performance of a behavior (52). At any given time, a person has a nearly limitless repertoire of behaviors he can perform; however according to Behavioral principles, the behavior he perform s will likely be the one he perceives, consciously or not, to be most rewarding (53, 54). Step count interventions try to lower the costs of increasing physical activity by focusing on an exercise that, for most people, is physically easy to perform and to promote the rewards of better health. Unfortunately, while doing so they usually fail to address behaviors which may more attractive because they are supported by an individual’s attitudes, culture or social norms and perceived as more rewarding. For example in a qualitative study conducted by Airhihenbuwa et al., the cultural beliefs of African Americans about health were explored through a focus group (55). The study observed that the African Americans in the focus group seemed to value rest over exercise, believing it to be as important or more important to health (55). If one’s values conflict with the performance of a behavior central to an intervention, it is unlikely that behavior will be successfully adopted. If two behaviors are believed to serve a similar function, like promoting health or relieving stress, but one perceives one behavior, like rest, as somehow more beneficial or reinforcing, than the other behavior, like walking, it is likely he will chose to rest rather than to walk.

A major difficulty public health interventions have is that health behaviors don’t typically have strong or immediate reinforcers or punishers, so the psychological link between health and the health behavior is relatively weak. This means that other behaviors which are produce faster or stronger feedback are likely to win when they compete with health behaviors. To many people, playing video game, for example is more enjoyable than going out for a walk. Feeling sweaty or tired may seem more important to avoid right now than the possible risk of heart disease a long time from now (56). A person may fully intend to walk and increase their step count in order to lower their health risks, as some theoretical models like the Health Belief Model would predict (20), but that behavior may continually be prioritized under more instantaneously gratifying activities. To be successful, step count interventions would do better to try to pair other types of reinforcement with physical activity along with potential health benefits. Reframing exercise as social or exciting by combining it with other activities or encouraging group activity is one way to do this. The more potential a behavior has to be rewarding, the more likely it is to be adopted and continued.

Step count interventions have some undeniable strengths. They are simple and affordable and therefore can be implemented on a large scale. A 10,000 step goal is concrete and easy to remember and might match CDC and ACSM recommendations for physical activity for many people. For long-term or wide-spread adoption, however, these interventions, as usually presented, are too simplistic to have maximum success. To build on the strengths of these kinds of interventions, intervention and campaign designers need to address a wider range of behavioral determinants, including environmental, social and cultural determinants. They also need to draw on the knowledge of other disciplines like behavioral psychology to understand what motivates behavior and to push beyond creating intention into generating behavior change. By addressing social as well as individual components, step count intervention like 10,000 steps can take a multilevel approach to improving physical fitness and reach far greater levels of success than it will by depending on the simplicity of their goal setting alone.

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  • At December 13, 2007 at 7:25 AM , Anonymous Meg Gavaghan said...

    Sandy - Great paper! I especially agree with your arguments regarding the environment in which one lives as having an influence on accomplishing this health behavior. Thorough support, as well!

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