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Effects of “10,000 Steps Ghent”
A Whole-Community Intervention
Katrien A. De Cocker, MSc, Ilse M. De Bourdeaudhuij, PhD, Wendy J. Brown, PhD, Greet M. Cardon, PhD
Background: Currently there is a great deal of interest in multistrategy community-based approaches to
changing physical activity or health behaviors. The aim of this article is to describe the
effectiveness of the physical activity promotion project “10,000 Steps Ghent” after 1 year of
intervention.
Methods: A multistrategy community-based intervention was implemented in 2005 with follow-up
measurements in 2006 to promote physical activity to adults. A local media campaign,
environmental approaches, the sale and loan of pedometers, and several local physical
activity projects were concurrently implemented. In 2005, 872 randomly selected subjects
(aged 25 to 75), from the intervention community Ghent and 810 from a comparison
community, participated in the baseline measurements. Of these, 660 intervention subjects
and 634 comparison subjects completed the follow-up measurements in 2006. Statistical
analyses were performed in 2006.
Results: After one year there was an increase of 8% in the number of people reaching the “10,000
steps” standard in Ghent, compared with no increase in the comparison community.
Average daily steps increased by 896 (95% CI⫽599–1192) in the intervention community,
but there was no increase in the comparison community (mean change ⫺135 [95% CI⫽
⫺432 to 162]) (F time ⫻community⫽22.8, p⬍0.001). Results are supported by self-
reported International Physical Activity Questionnaire (IPAQ) data.
Conclusions: The “10,000 steps/day” message reached the Ghent population and the project succeeded
in increasing pedometer-determined physical activity levels in Ghent, after 1 year of
intervention.
(Am J Prev Med 2007;33(6):455–463) © 2007 American Journal of Preventive Medicine
Introduction
Regular physical activity is essential for maintaining
health and reducing the risk of many causes of
morbidity and mortality.
1
However, most adults
in Europe (43%–87%),
2
the United States (60%),
1
and
Australia (43%)
3
lead a sedentary lifestyle. Interna-
tional guidelines recommend the accumulation of a
minimum of 30 minutes of at least moderate intensity
physical activity on most, if not all, days of the week.
1
An
alternative guideline recommends the accumulation of
10,000 steps/day,
4
and both recommendations are be-
ing used in lifestyle physical activity interventions in
different populations and in controlled settings.
5
The “10,000 Steps Ghent” project was built on the
approach used in the Australian “10,000 Steps Rock-
hampton” project
6
and served as a pilot intervention
for Europe. In Rockhampton, which has high levels of
overweight and obesity,
6
physical activity was promoted
through a media campaign, health professionals, envi-
ronmental support, and community initiatives. The
present intervention also used multiple concurrent
community-based strategies to promote physical activity
to less at-risk adults. Guided by the social ecologic
model,
7
this whole community intervention was de-
signed to intervene at the individual (e.g., pedometer
sale), social (e.g., workplace projects), and environ-
mental (e.g., walking circuits) level.
8
Previous multi-
strategy community interventions (combining media
advertising; community-based face-to-face instructions;
walking groups; school, worksite, church and environ-
mental initiatives), have reported no or only small
physical activity changes,
9–13
and none have used ob-
jective pedometer assessment of physical activity as
their main outcome measure.
10
The primary aim of this paper was to report changes
in both pedometer-determined and self-reported phys-
ical activity levels in Ghent after 1 year of intervention,
compared with those in a comparison community.
Since the project involved a pedometer step-count
intervention, an influence on walking behavior was
expected; this was assessed using pedometers and
From the Department of Movement and Sports Sciences (De Cocker,
De Bourdeaudhuij, Cardon), Ghent University, Ghent, Belgium;
School of Human Movement Studies (Brown), University of Queens-
land, Brisbane, Australia
Address correspondence and reprint requests to: Katrien De
Cocker, Watersportlaan 2, B-9000 Ghent, Belgium. E-mail: Katrien.
DeCocker@UGent.be.
455Am J Prev Med 2007;33(6) 0749-3797/07/$–see front matter
© 2007 American Journal of Preventive Medicine •Published by Elsevier Inc. doi:10.1016/j.amepre.2007.07.037
through the “walking” item of the International Physi-
cal Activity Questionnaire (IPAQ). A secondary aim was
to evaluate whether the intervention was effective with
insufficiently active people. Respondents who did not
reach the 10,000 steps target at baseline were identi-
fied, and changes in their physical activity were com-
pared in the intervention and comparison community.
The final aim was to describe awareness of the project
and the most common sources of project information
in the intervention community.
Methods
Design
The study utilized a controlled pre–post design, with baseline
data collected in March–May 2005 and follow-up data 12
months later. The intervention community was Ghent (capi-
tal of the East Flanders province of Belgium; population,
228,000), and the comparison community was the smaller city
of Aalst (located 35 km to the southeast of Ghent; population,
77,000). Both communities were selected because of their
demographic and geographic comparability.
Intervention Development and Implementation
The intervention was based on and performed in cooperation
with researchers from the 10,000 Steps Rockhampton project.
6
The present project was developed by the Department of
Movement and Sports Sciences of Ghent University, in col-
laboration with local city and provincial governments, three
health insurance companies, and the local health promotion
service. Physical activity was promoted to all adults in the
defined Ghent community, using a central theme of 10,000
steps/day, with a secondary tagline of “Every step counts.”
The accumulation of at least 30 minutes of moderate-intensity
physical activity on most, preferably all, days of the week,
14,15
and participation in more-vigorous activity or sport for a
minimum of 20 minutes 3 days each week,
14
were also pro-
moted. The implementation included several strategies at the
different levels of the social ecologic model
16
(see Table 1).
Local media project. Press conferences were organized at the
start of the intervention and again on six occasions during the
year, with subsequent publicity about the project in local
newspapers. A full-page advertisement was also published in
the town magazine, a periodical delivered to every household.
The project was mentioned about six times in local newscasts,
and billboards were placed at 20 different locations.
Website. Information about the project, physical activity
and health, tips on how to increase daily activity, frequently
asked questions, contacts, and reports on planned or com-
pleted activities (e.g., a culinary walk in the city center) were
placed on the project website (www.10000stappen.be).
Environmental approaches. Street signs were placed strategi-
cally throughout the city to raise awareness of walkable
distances and to encourage walking. For example, from every
public parking place, signs showed the number of steps to get
to the city center. In addition, walking circuits were laid out in
two local town parks, with signs along these to show distances
traveled and the number of steps likely to be accumulated.
Sale and loan of pedometers. A booklet with “how-to” infor-
mation and a step-count log were designed to be sold with
pedometers that were used as both individual self-monitoring
and motivational tools. The pedometer package (pedometer
and booklet) was sold for €20 (about $26) by the local
government information store, by the Ghent sport services
department, by pharmacies, and by local divisions of the
health insurance companies. The local sport services also
coordinated a pedometer loan system of 15 kits through
which schools, companies, and community groups could
borrow a kit with flyers, posters, and 30 pedometers.
Workplace projects. A plan of action with specific informa-
tion on how to promote physical activity in the workplace was
given to the health/personnel departments of all companies
with at least 100 employees (n⫽23). Kits were made available
but no other (financial) support was given to the worksites.
Projects for groups of older people. In order to reach the
large population of older, mostly inactive
1
people, all clubs
(n⫽26) and services (n⫽8) for older people were given
promotional materials and instructed on how to promote
physical activity. All members of the clubs and services were
also invited to a walk-event in the local town park.
Dissemination of information. Flyers, posters, and informa-
tion about the pedometer loan system were sent to all schools
(n⫽169), general practitioners (n⫽592), dieticians (n⫽26),
and physical therapists (n⫽308), as well as to all associations
and societies.
Evaluation
Recruitment and response rates. Twenty-five hundred citi-
zens (25–75 years) were randomly selected from the popula-
tion registers of each city (500 for each age group: 25–35,
36–45, 46–55, 56– 65, 66 –75). For those with a telephone
number (1765 in Ghent, 1919 in Aalst), a minimum of four
calls were made before recording the person as “not con-
tactable” (419 in Ghent, 516 in Aalst). The response rate for
this telephone recruitment was 54% (729 of 1346) in Ghent
Table 1. The social–ecologic approach of the 10,000 Steps
Ghent intervention
Ecologic level Intervention strategy
Intrapersonal Local media campaign
Website use
Sale and loan of pedometers
Interpersonal Dissemination of information
through all associations
Organizational/
institutional
Workplace projects
Projects for older people
Dissemination of information
through health professionals
Dissemination of information
through all schools
Community Local media campaign
Environmental approaches
Social structure, policy,
and systems
Local media campaign
Sale and loan of pedometers
through the local town shop
Sale and loan of pedometers
through Ghent sport
services department
456 American Journal of Preventive Medicine, Volume 33, Number 6 www.ajpm-online.net
and 50% (695 of 1403) in Aalst. All those without a telephone
number were sent a written invitation to participate in the
study (735 in Ghent; 581 in Aalst). The response rate for this
mailed recruitment was 20% in both communities, making
the overall response rate 42% (n⫽872) in Ghent and 41%
(n⫽810) in Aalst. More than three quarters of the initial
respondents (Ghent: 76%, n⫽660; Aalst: 78%, n⫽634) com-
pleted the follow-up protocol. (see Figure 1).
Procedures for data collection. Participants were asked to
complete the telephone-administered long version of the
IPAQ and to monitor their pedometer steps daily for 7
consecutive days. Based on previous methods,
17
a package was
mailed to all participants who completed the IPAQ and
agreed to monitor their steps. The package included a
pedometer, a protocol describing how and when to use it, an
activity log for noting daily steps and keeping daily activity
records, a written informed consent form, and a stamped
addressed envelope for return mailing. All participants were
instructed to wear the pedometer on their waistband or belt
during waking hours. They were requested to reset their
pedometer to zero at the beginning of each day, to continue
with their usual activities, and to remove the pedometer only
while showering, bathing, or swimming. They were asked to
complete the activity log at the end of each day.
After 1 year of intervention, all participants who completed
baseline measurements were contacted again by telephone or
mail. They were asked to complete the IPAQ (baseline
procedures) and a questionnaire relating to awareness of the
10,000 Steps Ghent project. After completion of the question-
naires, a package was mailed to them to monitor their steps
for 7 consecutive days, if they had done this at baseline. All
participants gave written informed consent and the study
protocols were approved by the Ethical Committee of the
Ghent University.
Figure 1. Participant flow. IPAQ, completion of the International Physical Activity Questionnaire; PM, completion of the
pedometer records.
December 2007 Am J Prev Med 2007;33(6) 457
Seven interviewers (master degree, native speakers) were
given 2 hours of interview training, focusing on the potential
problem of overreporting, and were supervised throughout
data collection.
Instruments
Physical activity questionnaire. The long form of the IPAQ
was used to assess the different domains of physical activity in
a usual week, namely physical activity at work, transport-
related physical activity, domestic and gardening activities,
and physical activity during leisure time. The IPAQ has been
shown to be a valid and reliable instrument for assessing
physical activity at the population level in Europe
18
and in
Flanders, Belgium.
19
Total time for physical activity in the
four domains and total time for walking, moderate, and vigorous
physical activity, all expressed in minutes/week, were computed
(www.ipaq.ki.se). Questions were also asked about participants’
employment status (employed/unemployed), and about num-
ber of years of education and self-reported health (excellent/
very good/good/moderate/poor).
Pedometers. The Yamax Digiwalker SW-200 (Yamax, Tokyo,
Japan) was used in this study as it is known to be valid,
accurate, and reliable for counting steps in adults.
20
Activity log. Participants were requested to record the date,
steps taken at the end of the day, and the type and duration
of nonambulatory activities (i.e., biking and swimming) in an
activity log.
21
Following established guidelines,
22
researchers
added 150 steps to the daily total for every minute of reported
biking and/or swimming.
Questionnaire relating to awareness of the project at
follow-up. In 2006, additional items were used to assess
awareness of the project. Participants were asked to complete
the following questions: Have you heard or seen any messages
about physical activity? (yes/no); If you have heard informa-
tion about physical activity, where did you hear it? (open-
ended); Have you heard of the 10,000 Steps Ghent project?
(yes/no); Where did you hear about 10,000 Steps Ghent?
(radio, TV, print media, Internet, street signs, workplace,
health service, (para)medic, society, family, friends, or school);
Are you aware of any of the following activities which are
being supported by 10,000 Steps Ghent?: sale of pedometers,
loan of pedometer boxes, walk circuits in local town parks?
(yes/no); Have you used a pedometer in the last 10 months?
(yes/no), and Where did you get your pedometer? (bought
at 10,000 Steps point of sales/borrowed at 10,000 Steps/
elsewhere). A timeframe of 10 months was used to avoid
inclusion of baseline pedometer measurements.
Data Analysis
All data were analyzed in 2006 using SPSS 12.0 for Windows.
Demographic characteristics of intervention and comparison
respondents were compared, using independent-sample
t-tests and chi-square tests. Average daily steps were calculated
for the two periods of 7 days (baseline and follow-up). Values
over 20,000 steps/day were recorded as 20,000 to limit
unrealistically high average step counts and to ensure normal
distribution.
17
Repeated measures of analysis of covariance
(ANCOVAs) with time (baseline/follow-up) as the within-
subjects factor and community (Ghent/Aalst) as the between-
subjects factor, were conducted to evaluate the effects of the
project on pedometer-determined and self-reported physical
activity. These analyses were done for (1) the total sample and
(2) those who did not reach the 10,000 steps/day target at
baseline. Analyses were adjusted for age and number of years
of education. Time ⫻community interactions were used to
test for intervention effects. Effect sizes (Cohen’s d) were
computed by subtracting the change in Aalst from the change
in Ghent, and dividing this score by the pooled standard
deviation of change.
23
Effect sizes were interpreted as negli-
Table 2. Characteristics of participants who completed pedometer and IPAQ registrations
Demographics
Ghent
baseline
(nⴝ648)
a
Follow-up
(nⴝ440)
a
Aalst
baseline
(nⴝ592)
a
Follow-up
(nⴝ426)
a
Baseline
comparison
t/
2
(p)
Follow-up
comparison
t/
2
(p)
Age (years) 0.2 (ns) 0.2 (ns)
Years (mean ⫾SD) 48.7 ⫾14 49.8 ⫾13.3 48.5 ⫾13.3 50 ⫾12.9
25–35 (%) 21.6 16.1 18.9 14.8 2.2 (ns) 1 (ns)
36–45 (%) 20.5 22 23 21.1
46–55 (%) 22.8 25.2 23.5 26.8
56–65 (%) 19.8 22.5 20.3 21.6
66–75 (%) 15.3 14.1 14.4 15.7
Gender (%) 1.3 (ns) 2.2 (ns)
Men 47.2 47.5 50.5 52.6
Level of education (%) 2.9 (ns) 2.3 (ns)
College or university degree 60 58.9 55.2 53.8
Employment status (%) 0.1 (ns) 5.8 (pⱕ0.05)
Employed 68.1 62.4 67.3 54.4
Self-related state of health (%) 2.4 (ns) 8.5 (ns)
Excellent 9.6 11.2 8.3 7.8
Very good 2.9 30.5 29.3 29.6
Good 51.2 49 48.7 49.4
Poor 9.9 8.2 11.2 9.6
Weak 1.9 1.1 2 3.5
a
Numbers vary slightly due to missing data for some items.
IPAQ, International Physical Activity Questionnaire; ns, not significant (p⬎0.05).
458 American Journal of Preventive Medicine, Volume 33, Number 6 www.ajpm-online.net
Table 3. Mean physical activity at baseline and follow-up for respondents in each community
Respondents who completed IPAQ and pedometer records Respondents who only completed IPAQ
Baseline
(nⴝ440)
Follow-up
(nⴝ426) ⌬(95% CI) F(p)d
Baseline
(nⴝ220)
Follow-up
(nⴝ208) ⌬(95% CI) F(p)d
Pedometer-determined PA
(steps/day)
22.6 (***) 0.33
Ghent 9596 ⫾4256 10,491 ⫾4306 ⫹896 (599 to 1192)
Aalst 9669 ⫾4018 9534 ⫾3978 ⫺135 (⫺432 to 162)
Walking (min/week) 4.7 (***) 0.15 5.7 (*) 0.23
Ghent 288 ⫾357 305 ⫾382 ⫹17 (⫺47 to 14) 321 ⫾391 323 ⫾407 ⫹2(⫺53 to 49)
Aalst 301 ⫾387 271 ⫾353 ⫺30 (1 to 61) 308 ⫾423 219 ⫾335 ⫺89 (31 to 145)
Moderate PA (min/week) 7 (***) 0.17 1.1 (ns) 0.12
Ghent 480 ⫾385 468 ⫾372 ⫺12 (⫺28 to 52) 448 ⫾428 445 ⫾390 ⫺3(⫺55 to 59)
Aalst 554 ⫾432 470 ⫾401 ⫺84 (43 to 125) 513 ⫾427 461 ⫾385 ⫺52 (⫺7 to 111)
Vigorous PA (min/week) 1.4 (ns) 0.05 0.1 (ns) 0.01
Ghent 112 ⫾276 99 ⫾255 ⫺13 (⫺10 to 36) 120 ⫾284 106 ⫾271 ⫺14 (⫺16 to 45)
Aalst 106 ⫾258 80 ⫾200 ⫺26 (1 to 50) 103 ⫾258 93 ⫾231 ⫺10 (⫺25 to 46)
Work-related PA (min/week) 15.9 (***) 0.27 5.3 (*) 0.23
Ghent 286 ⫾561 355 ⫾625 ⫹68 (⫺111 to ⫺26) 333 ⫾619 355 ⫾642 ⫹22 (⫺98 to 54)
Aalst 350 ⫾642 300 ⫾591 ⫺50 (10 to 89) 410 ⫾675 306 ⫾576 ⫺104 (33 to 175)
Transport-related PA (min/week) 0.2 (ns) 0.03 0 (ns) 0.02
Ghent 140 ⫾189 134 ⫾168 ⫺6(⫺12 to 23) 144 ⫾205 126 ⫾193 ⫺18 (⫺11 to 48)
Aalst 110 ⫾170 99 ⫾131 ⫺11 (⫺6 to 26) 101 ⫾185 78 ⫾118 ⫺23 (1 to 45)
Household PA (min/week) 1.5 (ns) 0.08 2.5 (ns) 0.17
Ghent 347 ⫾375 308 ⫾304 ⫺39 (6 to 72) 299 ⫾361 300 ⫾318 ⫹1(⫺50 to 48)
Aalst 423 ⫾439 351 ⫾369 ⫺72 (31 to 113) 380 ⫾415 317 ⫾327 ⫺63 (7 to 120)
Leisure time PA (min/week) 4.4 (*) 0.15 0.1 (ns) 0.02
Ghent 140 ⫾185 125 ⫾178 ⫺15 (⫺3 to 34) 140 ⫾195 127 ⫾206 ⫺13 (13 to ⫺12)
Aalst 172 ⫾264 125 ⫾173 ⫺47 (26 to 68) 118 ⫾148 107 ⫾143 ⫺11 (⫺13 to 34)
*pⱕ0.05; **pⱕ0.01; ***pⱕ0.001.
IPAQ, International Physical Activity Questionnaire; ns, not significant (p⬎0.05); PA, physical activity.
December 2007 Am J Prev Med 2007;33(6) 459
gible (⬍0.15), small (0.15–0.40), medium (0.40–0.75) or
large (⬎0.75).
23
Descriptive statistics and chi-square tests
were used to analyze the responses to questions about aware-
ness of the project. A statistical significance level of 0.05 was
used in all analyses.
Results
Participant characteristics
Demographic characteristics of the respondents who
completed both the IPAQ survey and the pedometer/
activity logs are shown in Table 2. Both samples were
representative of the general population in each city,
with the exception that respondents in Ghent were
significantly older than the total community population
(Ghent: 48.7 vs 46.5, t⫽4.0, p⬍0.001; Aalst: 48.5 vs 48.6,
t⫽0.1, p⫽0.910). The proportion of men in both samples
(Ghent: 48%; Aalst: 53%) were comparable to those in
the total populations (Ghent: 50%, chi-square⫽22.1,
p⫽0.605; Aalst: 50%, chi-square⫽0.3, p⫽0.603). There
were no significant differences between Ghent and
Aalst at baseline but at follow-up the proportion of
employed participants was significantly higher in Ghent
than in Aalst (see Table 2).
For the total sample, comparisons were made be-
tween subjects who provided step-count data at baseline
and those who did not. Subjects who had a job were
more likely to complete the pedometer protocol than
unemployed subjects (odds ratio⫽1.58, p⫽0.002). Analy-
ses of gender, age, level of education, state of health,
and total amount of physical activity (based on IPAQ
reports) showed no significant differences between the
two groups.
Physical activity measures
Significant intervention effects were found for mean
steps/day with an average increase of 896 steps/day in
Ghent and a decrease of 135 in Aalst (see Table 3). In
Ghent, 48% of the respondents had a minimum in-
crease of 896 steps/day and average daily step counts
increased significantly in both men (F⫽10.5, p⫽0.001)
and women (F⫽12.8, p⬍0.001); and in young (25–45
years) (F⫽4.9, p⫽0.029), middle-aged (46–65 years)
(F⫽6.8, p⫽0.009), and older (66–75 years) (F⫽9.3,
p⫽0.002) adults.
Pedometer-based data revealed that the proportion
of participants reaching the 10,000 steps/day target
had increased from baseline (42%) to follow-up (50%)
in Ghent (t⫽3.2, p⫽0.001). Extrapolation of this in-
crease of 8% to the total population of Ghent indicates
that 18,500 citizens became more active. Correspond-
ing proportions in Aalst were 41% and 40% (t⫽1.3,
p⫽0.205).
There were significant intervention effects for re-
ported time spent in walking, moderate, work-related,
and leisure-time physical activity for participants complet-
ing the IPAQ and pedometer protocol (see Table 3).
Table 4. Mean physical activity at baseline and follow-up for respondents in each community who did not reach the 10,000
steps target at baseline
Baseline
(nⴝ250)
Follow-up
(nⴝ242) ⌬(95% CI) F(p)d
Pedometer-determined PA (steps/day)
Ghent 6660 ⫾2284 8247 ⫾3137 ⫹1586 (⫺1934 to ⫺1239) 12.2 (***) 0.31
Aalst 6961 ⫾2128 7710 ⫾3051 ⫹749 (⫺1070 to ⫺428)
Walking (minutes/week) 0.4 (ns) 0.03
Ghent 243 ⫾333 242 ⫾339 ⫺1(⫺32 to 35)
Aalst 224 ⫾329 210 ⫾308 ⫺14 (⫺16 to 43)
Moderate PA (minutes/week) 1.8 (ns) 0.09
Ghent 444 ⫾397 421 ⫾370 ⫺23 (⫺26 to 72)
Aalst 488 ⫾421 429 ⫾389 ⫺59 (10 to 108)
Vigorous PA (minutes/week) 4.4 (*) 0.15
Ghent 81 ⫾240 78 ⫾235 ⫺3(⫺22 to 26)
Aalst 81 ⫾233 44 ⫾131 ⫺37 (9 to 63)
Work-related PA (minutes/week) 9.6 (**) 0.26
Ghent 211 ⫾496 280 ⫾566 ⫹68 (⫺121 to ⫺16)
Aalst 248 ⫾556 206 ⫾503 ⫺42 (⫺4to87)
Transport-related PA (minutes/week) 0.4 (ns) 0.03
Ghent 113 ⫾179 100 ⫾145 ⫺13 (⫺7to31)
Aalst 97 ⫾153 80 ⫾108 ⫺17 (⫺1to34)
Household PA (minutes/week) 0.6 (ns) 0.05
Ghent 356 ⫾393 303 ⫾307 ⫺53 (9 to 97)
Aalst 414 ⫾454 341 ⫾372 ⫺73 (20 to 126)
Leisure time PA (minutes/week) 0 (ns) 0.02
Ghent 116 ⫾174 87 ⫾145 ⫺29 (8 to 49)
Aalst 124 ⫾208 100 ⫾141 ⫺24 (⫺1to49)
*pⱕ0.05; **pⱕ0.01; ***pⱕ0.001.
ns, not significant (p⬎0.05); PA, physical activity.
460 American Journal of Preventive Medicine, Volume 33, Number 6 www.ajpm-online.net
Separate within-group changes were significant in
Ghent for vigorous physical activity (F⫽1.6, p⫽0.029)
and there was a trend of significance for moderate
physical activity (F⫽1.4, p⫽0.058). In Aalst, transport-
related physical activity decreased significantly (F⫽6.3,
p⫽0.012). In the group that only completed the IPAQ,
intervention effects were significant for walking and
work-related physical activity (see Table 3). Within-
group changes revealed that work-related physical ac-
tivity increased significantly in Ghent (F⫽6.8, p⫽0.010)
and decreased significantly in Aalst (F⫽11.5, p⫽0.001).
In participants, who did not reach the 10,000 steps/
day target at baseline (at-risk group), there was an in-
crease of 1586 steps/day in Ghent (⫹23%), compared
with 749 steps/day (⫹11%) in Aalst (F time ⫻commu-
nity ⫻group (at risk/not at risk)⫽1.1, p⫽0.285).
Intervention effects were also significant for reported
vigorous physical activity and work-related physical ac-
tivity (see Table 4).
Awareness of the 10,000 Steps Project
In 2006, 54% of the Ghent sample and 41% of the Aalst
sample reported hearing or seeing information about
physical activity promotion (Table 5). In Ghent, about
12% voluntarily indicated 10,000 Steps Ghent as the
source of their information, while in Aalst only one
person answered 10,000 Steps Ghent. Almost two thirds
(63%) of the Ghent respondents confirmed having
heard of the project, compared with 10% in Aalst. The
most commonly cited sources of information about the
project were the print media, local TV, and street signs.
In Ghent, more than 32% of respondents were aware of
the sale of pedometers and about 12% of the loan
system, but only 7% were aware of the walking circuits.
About 14% of the Ghent sample reported using a
pedometer in the last 10 months, compared with 10%
in Aalst. In Ghent, 2% purchased a pedometer through
one of the project’s points of sale, and 1% borrowed
one from the loan system. In the Ghent sample, signif-
icantly more women than men answered positively to
most of the awareness questions (see Table 5).
Discussion
These findings demonstrate that the 10,000 Steps
Ghent project was successful in increasing physical
activity levels and reaching the population in the
intervention community. Evidence of this positive
impact was the significant increase in both pedometer-
determined physical activity and self-reported physical
Table 5. Project awareness
Ghent
(nⴝ660)
(%)
Aalst
(nⴝ634)
(%)
2
Ghent gender
comparison
2
Have you heard or seen any messages about PA?
Yes (total group) 54 41.3 20.9 (***)
Yes (men/women) 44.7/62.8 39.4/43.3 21.7 (***)
If you had information about PA, where did you get it from? 86.6 (***)
10,000 Steps Ghent 12.1 0.2
Men/women 11.9/12.3 0.3/0 4.4 (ns)
Media 30.3 32.8
Men/women 25.4/34.9 32.7/32.9 5.1 (*)
Health services 11.2 8.4
Men/women 6.9/15.2 6.0/10.7 10.2 (***)
Have you heard of the project “10,000 Steps Ghent”?
Yes (total group) 63.2 10.4 384.9 (***)
Yes (men/ women) 55.2/70.7 10.2/10.7 17 (***)
Are you aware of any of the following activities which are
being supported by 10,000 Steps Ghent?
Sale of pedometers (yes) 32.9 0.5 240.6 (***)
Men/women 25.1/40.2 0/0.9 17 (***)
Loan of pedometer boxes (yes) 12.4 0.2 81.1 (***)
Men/women 9.4/15.2 0.3/0 5.2 (*)
Walk circuits in local town-parks (yes) 6.5 0 42.7 (***)
Men/women 4.1/8.8 0/0 6 (*)
Have you used a pedometer in the last 10 months?
Yes (total group) 13.9 9.5 6.2 (ⴱ)
Yes (men/women) 10/17.6 8.0/11.0 7.9 (**)
If you used a pedometer, where did you get it? 11.1 (ns)
Bought at 10,000 Steps point of sales 2.0 0.3
Borrowed at 10,000 Steps 1.2 0.3
Elsewhere 10.7 8.9
*pⱕ0.05; **pⱕ0.01; ***pⱕ0.001.
ns, not significant (p⬎0.05); PA, physical activity.
December 2007 Am J Prev Med 2007;33(6) 461
activity from the IPAQ, as well as high project awareness
in the intervention sample. The average increase of
896 steps/day was commensurate with a 9% increase
from baseline steps/day in Ghent. This finding, to-
gether with the increase of 8% in the number of
individuals who reached the 10,000 steps standard, is
noteworthy on a population level. Even though effect
sizes were relatively small (0.15–0.33), they are consid-
erable for a whole-community intervention. Importantly,
effect sizes for the pedometer data did not differ be-
tween the total study sample and the at-risk group,
indicating that the intervention reached many who
were deemed at risk at baseline. Surprisingly, the
intervention was effective for total physical activity and
not only for walking, as hypothesized.
Few other studies have examined the effect of mul-
tistrategy population-level interventions on physical ac-
tivity behaviors.
11–13,24,25
In general, increases in phys-
ical activity have been reported among motivated
subgroups of volunteers who register for intervention
studies, but few of these have reported increases in
physical activity on a community level. In contrast, in
this study, there were significant increases in physical
activity in randomly recruited community residents, as
well as in those who were not initially meeting guide-
lines for physical activity. Self-reports revealed that the
at-risk group increased their physical activity mostly at
work, which suggests that the workplace might be an
appropriate setting to reach this group.
The Australian 10,000 Steps Rockhampton project
was the first whole-community multistrategy interven-
tion to promote the 10,000 steps/day concept. Based
on self-reported physical activity data from interview
surveys, the main outcome of the Rockhampton project
was that the downward trend in the percentage of
citizens categorized as active (⫺6%) in the comparison
community for the current study was not evident in
Rockhampton (⫹1%). In contrast, in Ghent, there was
a much greater increase (8%) in physical activity, as
measured by objective pedometer data, and a much
smaller decline in the comparison community of Aalst
(⫺2%).
However, in Rockhampton (population 60,000), which
is considerately smaller than Ghent (population 228,000),
almost 95% of all respondents had heard of the project,
compared with 63% in Ghent. This probably reflects
the greater emphasis on social marketing in the Rock-
hampton project.
6
Interestingly, in both countries,
women showed a greater awareness of the project
strategies than men, and in Rockhampton there were
significant increases in physical activity in women but
not in men. This gender difference was not apparent in
Ghent.
In Australia, 34% of the comparison community had
heard of the project, compared with only 10% in the
present study. Once again, this may reflect the greater
emphasis on social marketing in the Australian project,
with TV reports being picked up in both the compari-
son and intervention Australian communities. Appar-
ently, the Aalst residents were less likely to have been
exposed to the social and environmental intervention
strategies, despite the close distance between present
communities.
Even though Aalst (population 77,000) is the second
largest city in East Flanders after Ghent, there is a
reasonable difference in the size of these two commu-
nities. In terms of demographic variables however,
respondents from each community were comparable,
except that the proportion of employed participants
was higher in Ghent at follow-up. Although this may
have influenced pedometer-determined physical activity,
the evidence is somewhat ambiguous.
22,26
Baseline step-
count levels in both communities were also compara-
ble, and relatively high compared with American sam-
ples (6000–6800 steps/day),
22
but lower than those
reported in the UK (11,300 steps/day).
27
The present
sample included more highly educated people than the
total Belgian population (43%) (www.iph.fgov.be); this
can be a potential source of bias. Furthermore, the
intervention sample was slightly but significantly older
than the general Ghent population. This is important
because pedometer-determined physical activity is neg-
atively associated with increasing age.
17,28
The strengths of this study include the random
recruitment of participants, intervention in a real-life
setting, use of objective step data, and relatively small
loss to follow-up. The main limitation of the study is
that only short-term effects are described. Additionally,
it is important to note that awareness may have been
influenced by study participation; this would however
have been true for both the Ghent and Aalst samples.
Moreover, the awareness questionnaire reported only
on descriptive items, so that further theoretic implica-
tions of the effect of the specific ecologic components
on behavior could not be made.
Conclusion
The preliminary results of this pilot study for Europe
are promising. The 10,000 Steps Ghent project is the
first pedometer-based intervention to show an in-
crease in physical activity levels at the whole-commu-
nity level, supporting, the implementation of multistrat-
egy intervention programs in whole communities.
Consequently, the intervention will be continued in
Ghent and will now be implemented in other parts of
Flanders, Belgium, and possibly in other European
cities.
No financial disclosures were reported by the authors of this
paper.
462 American Journal of Preventive Medicine, Volume 33, Number 6 www.ajpm-online.net
References
1. U.S. Department of Health and Human Services (USDHHS). Physical
activity and health: a report of the Surgeon General. JAMA 1996;276:522.
2. Varo JJ, Martínez-González MA, de Irala-Estévez J, Kearney J, Gibney M,
Martínez JA. Distribution and determinants of sedentary lifestyles in the
European Union. Int J Epidemiol 2003;32:138–46.
3. Bauman A, Armstrong T, Davies J, et al. Trends in physical activity
participation and the impact of integrated campaigns among the Austra-
lian adults, 1997–99. AustNZJPublic Health 2003;27:76–9.
4. Tudor-Locke C, Bassett DR. How many steps/day are enough? Preliminary
pedometer indices for public health. Sports Med 2004;34:1–8.
5. Kahn EB, Ramsey LT, Brownson RC, et al. The effectiveness of interven-
tions to increase physical activity: a systematic review. Am J Prev Med
2002;22:73–107.
6. Brown WJ, Eakin E, Mummery K, Trost SG. 10,000 Steps Rockhampton:
establishing a multistrategy physical activity promotion project in a Queens-
land community. Health Promot J Aust 2003;14:95–100.
7. Stokols D. Translating social ecological theory into guidelines for commu-
nity health promotion. Am J Health Promot 1996;10:282–98.
8. McKinlay JB, Marceau LD. To boldly go . . . Am J Public Health 2000;
90:25–33.
9. Brown WJ, Mummery K, Eakin E, Schofield G. 10,000 Steps Rockhampton:
evaluation of a whole community approach to improving population levels
of physical activity. J Phys Activity Health 2006;3:1–14.
10. Dunn AL, Andersen RE, Jakicic JM. Lifestyle physical activity interventions:
history, short- and long-term effects, and recommendations. Am J Prev Med
1998;15:398–412.
11. Young DR, Haskell WL, Jatulis DE, Fortmann SP. Associations between
changes in physical activity and risk factors for coronary heart disease in a
community-based sample of men and women: the Stanford Five-City
Project. Am J Epidemiol 1993;138:205–16.
12. Luepker RV, Murray DM, Jacobs DC, et al. Community education for
cardiovascular disease prevention: risk factor changes in the Minnesota
Heart Health Program. Am J Public Health 1994;84:1383–93.
13. Reger B, Cooper L, Booth-Butterfield S, et al. Wheeling Walks: a commu-
nity campaing using paid media to encourage walking among sedentary
older adults. Prev Med 2002;35:285–92.
14. American College of Sports Medicine. The recommended quantity of
exercise for developing and maintaining fitness in healthy adults. Med Sci
Sports Exerc 1978;10:7–10.
15. American College of Sports Medicine. Guideline for exercise testing and
prescription, 6th edn. Philadelphia: Lippincott Williams & Wilkins, 2000.
16. Glanz K, Lewis ML, Rimer BK. Health behaviour and health education:
theory, research, and practice, 2d edn. San Francisco: Jossey-Bass, 1997.
17. Tudor-Locke C, Ham SA, Macera CA, et al. Descriptive epidemiology of
pedometer-determined physical activity. Med Sci Sports Exerc 2004;36:
1567–73.
18. Craig CL, Marshall AL, Sjöström M, et al. International Physical Activity
Questionnaire: 12-country reliability and validity. Med Sci Sports Exerc
2003;35:1381–95.
19. Vandelanotte C, De Bourdeaudhuij I, Sallis J, Philippaerts R, Sjostrom M.
Reliability and validity of a computerised and Dutch version of the
International Physical Activity Questionnaire (IPAQ). J Phys Activity Health
2005;2:63–75.
20. Crouter SE, Schneider PL, Karabulut M, Bassett DR. Validity of 10
electronic pedometers for measuring steps, distance and energy cost. Med
Sci Sports Exerc 2003;35:1455–60.
21. Tudor-Locke C, Lind KA, Reis JP, Ainsworth BE, Macera CA. A preliminary
evaluation of a pedometer-assessed physical activity self-monitoring survey.
Field Methods 2003;15:1–17.
22. De Cocker K, Cardon G, De Bourdeaudhuij I. Pedometer-determined
physical activity and its comparison with the International Physical Activity
Questionnaire in a sample of Belgian adults. Res Q Exerc Sport (in press).
23. Cohen J, ed. Statistical power for the behavioural sciences. Hillsdale NJ:
Erlbaum, 1988.
24. Cavill N, Bauman A. Changing the way people think about health-
enhancing physical activity: do mass media campaigns have a role? J Sports
Sci 2004;22:771–90.
25. Sorenson G, Emmons K, Hunt MK, Johnston D. Implications of the results
of community intervention trials. Annu Rev Public Health 1998;19:
379–416.
26. Chan CB, Spangler E, Valcour J, Tudor-Locke C. Cross-sectional relation-
ship of pedometer-determined ambulatory activity to indicators of health.
Obes Res 2003;11:1563–70.
27. Clemes SA, Griffiths PL, Hamilton SL. Four-week pedometer-determined
activity patterns in normal weight and overweight UK adults. Int J Obes
2007;31:261–6.
28. Wyatt HR, Peters JC, Reed GW, Barry M, Hill JO. A Colorado statewide
survey of walking and its relation to excessive weight. Med Sci Sports Exerc
2005;37:724–30.
December 2007 Am J Prev Med 2007;33(6) 463
