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“You don't have to …”: walking to a healthier nation
  1. Andrew Tannahill
  1. Chief Executive, Health Education Board for Scotland Woodburn House, Canaan Lane Edinburgh EH10 4SG, Scotland

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    One of the best pieces of public health news in recent years has been that you do not have to be a marathon runner, sports champion, or even regular jogger to derive substantial health benefits through exercise: regular moderate physical activity has cardioprotective and other health benefits.1 From this and our low levels of exercise as a population, it can reasonably be concluded that promoting regular moderate physical activity—active living—is not only the most feasible route for exercise promotion but also the one that will yield the largest population health gain.2

    HEBS (the Health Education Board for Scotland) has been something of a pioneer of the active living approach in the United Kingdom.2–4 We place a strong emphasis on walking because of its accessibility. Walking is easy for most people to contemplate and do, regardless of age or fitness level. It does not require special skills, expensive equipment, or facilities. It can be built into everyday life—for example, in commuting, shopping, and leisure. And the risk of injury is generally low.5 HEBS commissioned qualitative research conducted in 1995 supported this notion of accessibility, with preference being shown for walking over swimming or dancing. The same research, however, suggested that walking was not generally viewed as “real” exercise, there being a belief that to be beneficial exercise has to make people sweaty and out of breath. Also, there were negative “non-aspirational” perceptions of walking, including (older) age profile, low status as a form of transport, and a boring image. Further developmental research pointed to the value of giving people “surprising” information about the value of walking.

    A few years on, if you ask people what they think of when they hear of “HEBS”, their answer will probably include the name “Gavin”. They are referring to the TV advertising campaign that arose from the developmental research. Paradoxically using a sporting hero to promote regular moderate activity, the advertisement features Gavin Hastings comparing walking a mile with energy equivalent amounts of vigorous exercise. He points out that “you don't have to” take part in sweaty, frenetic, or very demanding forms of exercise to gain health and fitness benefits; in essence you can walk to good health. In the first phase of running the advert on TV, it was backed up by a special telephone helpline offering a pack containing the HEBS self help guide Hassle free exercise and information on local level physical activity facilities and contacts.

    Formal evaluation of the first phase of the campaign is reported in detail elsewhere.6 Campaign awareness and walking related knowledge and beliefs were monitored through adult population surveys. Self reported changes in physical activity levels were assessed through a panel study involving a sample (initially 700) drawn from the 4036 people who had called the helpline during its first six weeks. A composite measure of “stage of change” (precontemplation, contemplation, preparation, action, maintenance) was derived from information provided by helpline callers at baseline and follow up.7 The rate of successful follow up at one year in the panel study was 58%. The sociodemographic profile of respondents at one year was similar to that at baseline, except for a slightly higher attrition rate for younger people.

    Campaign awareness was highest in the primary target group (socioeconomic groups C2DE). There was before/after evidence of an impact on the general adult population's knowledge and beliefs about walking as a form of exercise, the biggest increase being in knowledge of exercise equivalence information specific to the campaign. This is evidence of success of the major campaign objective of “repositioning” walking in the minds of the public. Also, in the panel study there was a discernible shift in stage of change (in the right direction) between baseline and follow up. Furthermore, 48% of the helpline callers successfully contacted at one year reported being more active.

    The panel study of helpline callers was of course potentially open to initial self selection bias, and to subsequent drop out and “desire to please” bias. Suppose for the sake of argument that almost 2000 people (48% of 4036) were motivated and helped to become more active through the advertisement and helpline. Even in the absence of any such effect on people who viewed the advert but did not call the helpline—and disregarding the important informing and agenda setting roles of the campaign—this would be a worthwhile outcome and indeed would represent good value for money. However, this amount of behavioural change would not be detectable even in a fairly substantial survey of the general population. In evaluation we therefore need to tap into “captive populations” (such as helpline callers) where they exist, and to manage potential bias through study design and analysis.

    In any case, Gavin, with repeated showings, has undoubtedly caught the attention of the people of Scotland. Awareness of the advertisement in the adult general population runs consistently at around 90%, and I have referred to its centrality to people's awareness of HEBS. In 1997 Gavin was voted favourite advertisement in a readers' poll conducted by The Scottish Sun as part of the Scottish Advertising Awards. This is no mean feat, and its significance in evaluation terms should not be underestimated. It is evidence that health education advertising can have a wide appeal and become part of the fabric of the nation, more than holding its own with more expensive and less socially useful advertising.

    The campaign and other health education efforts—in schools, through the workplace and health service, and in other settings—are of course but pieces in a jigsaw of factors affecting the nation's levels of activity. Policies and action in areas such as community safety, transport, pollution control, urban and rural planning, and access to facilities are needed to make it more appealing and more feasible for people to build physical activity into their everyday lives at all stages and ages.

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