Walking for Wellbeing in the West (WWW)

Physical activity is a critical component of energy balance, the term researchers use to describe how weight, diet, and physical activity influence health, including cancer risk. There is strong evidence that physical activity is associated with reduced risk of colon and breast cancers, and there appear to be links between physical activity and reduced risk of endometrial (lining of the uterus), lung, and prostate cancers. Regular physical activity improves health by controlling weight; maintaining healthy bones, muscles, and joints; promoting psychological well-being; and reducing the risk of high blood pressure, diabetes, and death from heart disease. The Centers for Disease Control and Prevention recommend that adults engage in 150 minutes of moderate-intensity physical activity per week (one way to approach this is to do 30 minutes of exercise at least 5 days a week), or engage in 75 minutes of vigorous-intensity physical activity per week.

The Walking for Wellbeing in the West (WWW) program is a 12-week, graduated, pedometer-based walking intervention delivered with two physical activity consultations. Originally developed in Scotland, the program targets adults who do not meet minimum physical activity recommendations (30 minutes of at least moderate intensity physical activity on at least 5 days weekly). The WWW program is designed to increase baseline walking activity by an additional 3,000 steps daily (approximately 30 minutes of walking per day, based on the average adult pace of 100 steps per minute) on at least 5 days per week.

Before starting the program, participants wear a pedometer for 7 days to determine their baseline physical activity level. The pedometer is sealed with tape to prevent self-monitoring of accumulated daily step counts and is worn at all times, except when showering, sleeping, or taking part in structured sport or exercise. Participants are asked not to alter their daily routine during this baseline week. At least 5 days of step counts must be recorded, including at least 1 weekend day, to move forward with the program.

Participants then receive a 30-minute, one-on-one, semi-structured physical activity consultation. The consultation is based on the Transtheoretical Model of behavior change and focuses on (1) enhancing motivation to increase walking behavior by identifying and overcoming barriers and (2) developing an individually tailored walking plan for the next 12 weeks, which is built upon each participant's baseline pedometer step counts. The consultation also includes a discussion of the participant's self-efficacy or confidence in their ability to increase walking, decisional balance (pros and cons) of increasing walking behavior, and strategies and techniques used to change (for example, social support)-- the three mediators of behavior change in the Transtheoretical Model. Toward the end of this consultation, participants receive instructions for their 12-week walking program. The goal of the walking program is to increase daily pedometer step counts by 3,000 steps above each participant's baseline value on at least 5 days per week by week 7 of the program, and then maintain that level of activity through week 12. Specific goals are given for each week, as follows:

- Weeks 1 and 2: Walk an additional 1,500 steps daily above baseline step count on at least 3 days of the week
- Weeks 3 and 4: Walk an additional 1,500 steps daily above baseline step count on at least 5 days of the week
- Weeks 5 and 6: Walk an additional 3,000 steps daily above baseline step count on at least 3 days of the week
- Weeks 7 and 8: Walk an additional 3,000 steps daily above baseline step count on at least 5 days of the week
- Weeks 9-12: Maintain walking levels using the week 7-8 goal

Participants are instructed on how to use their pedometers to monitor their daily step counts to achieve weekly walking target goals and are asked to keep the pedometers open through the end of their walking program. They are familiarized with the Borg 6-20 Rating of Perceived Exertion Category Scale and advised that their additional walking should be of a brisk nature that leaves them slightly breathless and hot but still able to talk (between 12 and 14 on the Borg scale). Episodes of at least 10 minutes per day of brisk walking (above baseline levels of activity) are advised to meet the weekly goals, although the accumulation of walking during everyday tasks wherever possible is also recommended.

Following the 12-week walking program, participants receive a second, individualized physical activity consultation focused on preventing relapse and encouraging the maintenance of walking activity.

WWW practitioners come from a variety of educational backgrounds, including sports and exercise science, psychology, nursing, and health education. An advanced degree in one of these fields, as well as specific knowledge of physical activity for better health, is helpful but not required.

- 10 minutes to calibrate each pedometer within 5% of actual steps walked in a 100-step test

- 5-7 days of pedometer-recorded walking activity to establish baseline step counts; must include at least 1 weekend day from each participant

- 10-15 minutes to download pedometer data from each participant at baseline and at the conclusion of the 12-week walking program

- Two 30-minute, one-on-one physical consultation sessions, one before and one after the 12-week walking program

- 12 weeks of gradually increasing pedometer-recorded walking activity

The WWW program targets adults 18-65 years old who can walk independently for 5-10 minutes and are not involved in regular physical activity, defined as 30 minutes of at least moderate intensity activity on at least 5 days of the week.

The WWW program can be implemented in any community setting where participants can walk and the physical activity consultations can be delivered. Appropriate settings for the consultations include the workplace, community centers, health organizations, medical practices, and more specialized outpatient clinics (for example, sports medicine, physical rehabilitation, and cardiac rehabilitation clinics).

Materials required for implementation include:

- WWW Physical Activity Consultation Booklet
- WWW Weekly Walking Programme
- Pedometers

For costs associated with this program, please contact: Graham Baker. (See products page on the EBCCP website for contact information).

A randomized controlled trial evaluated the effects of the intervention among 79 adults on daily step counts, self-reported physical activity, and positive affect. Study recruitment targeted low active adults within a 1.5-kilometer radius around the University of Strathclyde campus and included leaflets sent to households; advertisements in the local newspaper; and posters and leaflets placed within surgical offices, other health care facilities, shops, veterinary practices, pubs, community stands in the local library, the shopping center, and high-rise blocks of flats. Recruited, consented adults provided at least 5 days of step counts, recorded by pedometer, including at least 1 weekend day to determine their baseline physical activity levels. Participants were then randomly assigned to either the intervention or waitlist control (a delayed 12-week walking program). Randomization was stratified by gender and average daily baseline step counts (less than or equal to 7,999 steps daily, vs. greater than or equal to 8,000 steps daily). The value of 8,000 steps per day (equivalent to roughly 80 minutes of walking) was used as a stratification variable to account for individuals with a high baseline step count. Individuals walking less than this amount daily may be considered sedentary, and positive effects on conventional metabolic parameters such as blood pressure are more likely to be attained above this threshold of daily walking.

Participants in the intervention group received a physical activity consultation, were instructed to follow a 12-week, graduated, pedometer-based walking program, and then received one additional physical activity consultation. Participants randomized to the waitlist control group were asked not to change their baseline physical activity level. After 12 weeks, those in the waitlist control group received a short feedback session and brief advice and then were asked to follow the 12-week walking program using a provided pedometer. Although there were six study assessments-- baseline and 12, 24, 36, 48, and 60 weeks-- the results reported here are restricted to the baseline and the week 12 assessment.

Seventy-nine of 91 adults were randomized to either the intervention group or the waitlist control group. The mean age of the total sample was 49.2 years; most of the participants were female (79.8%) and White (95%), 2.5% were Black, and 2.5% were Asian. Overall, 70% of the participants had baseline activity levels below 8,000 steps.

Physical activity was measured as steps per day using the Omron HJ-109E Step-O-Meter (Omron Healthcare UK Ltd) and by 7-day recall on the long version of the International Physical Activity Questionnaire (IPAQ) at baseline and week 12. The IPAQ long version is a 31-item instrument that collects information about moderate and vigorous physical activity across four domains: work-related, transportation, housework/gardening, and leisure time physical activity. Walking time is also included for the work, transport, and leisure domains. Two additional questions from the IPAQ measure time spent sitting.  

Positive affect was measured using the Positive and Negative Affect Schedule (PANAS) at baseline and 12 weeks. The PANAS is a self-report measure consisting of 10 words relating to positive feelings and emotions, such as "interested" and "alert", and 10 words that relate to negative feelings, such as "distressed" and "upset". For each item, respondents rate the degree to which they felt that emotion or feeling in the previous few weeks using a Likert scale that ranges from 1 (very slightly or not at all) to 5 (extremely). Items are summed to give mean scores (0-50) for positive and negative affect.

There were no significant baseline differences between the intervention and waitlist control groups for any outcome measures.

• From baseline to week 12, intervention participants increased their daily step counts more than waitlist control participants (6,802 to 9,977 vs. 6,924 to 7,078, p<.001).

•  At week 12, a greater percentage of intervention than waitlist control participants achieved an increase of 15,000 steps per week (64.1% vs. 10.0%, p<.001).

•  Compared with waitlist control participants, intervention participants recalled larger increases in minutes walked for leisure (p=.008) and total minutes walked (p=.03) during the prior 7 days on the IPAQ at week 12.

• Compared with waitlist control participants, intervention participants recalled larger decreases in total minutes sitting (p=.022) during the prior 7 days on the IPAQ at week 12, due to fewer minutes spent sitting on weekends (p=.003).

•  From baseline to week 12, intervention participants reported an increase in positive affect compared to waitlist control participants, who reported a decrease on positive affect subscale scores from the PANAS (31.2 to 33.5 vs. 31.7 to 31.3, p=.042).