A model for worksite cancer prevention: integration of health protection and health promotion in the WellWorks Project

OBJECTIVES. To describe a theoretic approach and rationale for the integration of health protection and health promotion in worksite cancer prevention programs and to describe an intervention study designed to implement this integration. METHODS. Twenty-four worksites were recruited to participate in this randomized, controlled study. The theoretically based intervention model integrates health promotion and health protection through (1) joint worker-management participation in program planning and implementation, (2) consultation on worksite changes, and (3) educational programs targeting health behavior change. RESULTS. Although the primary purpose of this paper is to describe a theoretic approach to the integration of health promotion and health protection, preliminary results are also noted. In these predominantly manufacturing worksites, many workers faced the double jeopardy of exposures to occupational carcinogens and personal risks such as smoking or poor dietary habits. Production workers' job responsibilities frequently limited their full participation. Barriers to participation were identified early in the project, and strategies were developed to facilitate maximal worker involvement and worksite changes. CONCLUSIONS. Lifestyle changes such as smoking cessation or dietary changes may be more effectively promoted among blue collar audiences when programs also encourage management actions to reduce occupational exposures. Public health professionals trained in health promotion and health protection must work together to effectively address the health concerns of this population.     

Impact of a community health promotion program on existing organizations: the Minnesota Heart Health Program.

A community organization strategy was used in the delivery of health education programs by the Minnesota Heart Health Program (MHHP). The effectiveness of the approach was evaluated to determine whether an enhanced health promotion delivery system had developed in MHHP communities by the end of the intervention period or whether the intervention had suppressed community efforts. 'Social connectedness' among providers, as measured by health promotion network size, also was expected to be higher in intervention communities. Six Midwestern communities were studied: the MHHP communities of Mankato, MN and Fargo, ND--Moorhead, MN with two matched comparison communities for each (Winona, MN, St Cloud, MN and Eau Claire, WI, Sioux Falls, SD). Nine areas of health promotion were assessed, including the five heart disease risk factor areas where education campaigns had been implemented (smoking cessation, weight loss, eating patterns, exercise, and heart disease education and screening) and four other areas where community programs are common (chemical dependency; home, personal and drivers' safety; stress management; and cancer education and screening). Indicators of the health promotion delivery system were developed (program options and program participation), and data were collected in separate surveys of 438 community organization providers and 320 larger worksites in the six communities. Results showed no suppression of health promotion delivery systems in MHHP communities. Instead, the survey of larger worksites showed that there was greater participation in heart disease health promotion and greater 'social connectedness' among worksites in both intervention communities. Also, there were more heart disease health promotion programs in the larger intervention community of Fargo-Moorhead. In the community organization survey, results favored the larger intervention community over its comparison communities in heart disease health promotion program options and in 'social connectedness' but not in program participation. However, survey results favored one of the comparison communities (Winona) over the smaller intervention community (Mankato) on all indicators in this survey. The greater impact of the MHHP intervention at worksites suggests that institutionalization may be more likely in stable organizations whose current needs and interests fit the goals of the intervention activity.     

Implementing a year-long, worksite-based incentive program for smoking cessation

BACKGROUND. There have been few reports of the process of implementing ongoing worksite health promotion programs. This article describes the implementation of a year-long smoking cessation program in nine worksites employing a total of approximately 700 smokers. METHODS. Issues discussed include: forming a partnership with organizations, design of the multicomponent incentive intervention, program promotion, maintaining participation, and the need to modify program components over time. RESULTS. The program produced high participation rates (29% of smokers joined the program) and moderate cessation rates among participants (during the last half of the program, monthly cessation rates averaged 20%). There was marked variability across worksites on both participation and cessation, and qualitative features of organizations associated with outcome are discussed. DISCUSSION. The importance of working with employee steering committees to tailor health promotion programs to fit the organization is discussed. The article concludes with recommendations for implementation of similar programs.     

Factors influencing participation in worksite smoking cessation and weight loss programs: the Healthy Worker Project

Worksite intervention for health behavior change has attracted much recent interest as a potentially cost-effective way to promote healthier behaviors in the general population. In evaluating the impact of health promotion activities, it is essential to consider the entire work force rather than just self-selected participants. Overall, recruitment results reported to date have varied widely. There are a large number of factors pertaining to both employee and worksite characteristics that could contribute to variability in how well worksite health promotion programs attract employees. A critical issue that has received little research attention is the dynamics of participation in employee health promotion programs as they are offered repeatedly over time. The present study examined participation rates and contributing factors in worksite health promotion programs for weight loss and smoking cessation in the Healthy Worker Project, a randomized trial of worksite intervention conducted among 16 intervention and 16 control worksites in the Minneapolis/St. Paul metropolitan area between 1987 and 1990. Data analyses focused on characterizing individuals enrolling in worksite health promotion programs in comparison to those in the worksite population as a whole who would be considered in need of such programs.     

Participation rates in worksite-based intervention studies: health promotion context as a crucial quality criterion

Recently, a set of specific quality evaluation criteria for health promotion research has been proposed in this journal. One of the quality criteria identified is the 'health promotion context'. With this paper we would like to contribute to the dialogue by specifying the importance of this criterion on the basis of our on experience with worksite-based obesity prevention interventions. We advocate the reporting of participation rates among approached worksites in publications on worksite intervention effects. Such information will help to draw conclusions on the practical relevance of the shown effectiveness of the intervention. Health promotion practice is advised to adopt and disseminate evidence-based interventions, accompanied by a diffusion study with a minimal research burden for participants.     

Factors related to participatory employee advisory boards in small, blue-collar worksites

PURPOSE: To identify factors related to formation, participation, and characteristics of employee advisory boards (EABs) in blue-collar worksites. DESIGN: This study used a nonexperimental qualitative design to assess EAB formation, activity, and enthusiasm levels and examined those factors relative to employee participation in worksite-wide health promotion activities. SETTING: Twenty-two blue-collar worksites with a total of 113 EAB members in the greater Seattle area. SUBJECTS: Individuals who agreed to serve on EABs in the intervention worksites. INTERVENTION: Participants received training in involving employees in the 5-A-Day project intervention activities. MEASURES: Measures include type of worksite, number of EAB members, method of EAB recruitment, and variables describing EAB functioning, including attendance at meetings, assistance at project activities, and level of enthusiasm. RESULTS: All worksites formed EABs. There was no association between the way the EAB was formed and subsequent EAB attendance at meetings, participation in project activities, representativeness of the EAB, or level of EAB enthusiasm. Enthusiasm of the EAB was associated with employee participation, and EABs with a higher level of enthusiasm showed more participation by employees than worksites with less enthusiastic EABs. CONCLUSIONS: It is possible to develop participatory structures in small, blue-collar worksites. More information is needed about factors related to levels of enthusiasm of EABs.     

The Working Healthy Project: a worksite health-promotion trial targeting physical activity, diet, and smoking.

Worksites are a key channel for delivery of interventions designed to reduce chronic disease among adult populations. Although some evaluations of worksite physical-activity interventions have been conducted, to date very few randomized trials of worksite health promotion have included the goal of increasing physical-activity levels as part of a comprehensive multiple risk factor approach to worksite health promotion. This article presents the results regarding behavior change found among the cohort of 2055 individuals who completed three health-behavior assessments as part of their worksites' participation in The Working Healthy Project (WHP), a multiple risk factor intervention implemented in 26 manufacturing worksites. In this study, a randomized matched-pair design was used. Fifty-one percent (n = 2,761) of the employees who completed the baseline assessment also completed the interim survey. Eighty-three percent of those who completed the interim assessment also completed the final survey. The WHP intervention targeted smoking, nutrition, and physical activity. At baseline, 38% of the sample reported engaging in regular exercise, and subjects reported consuming an average of 2.7 servings of fruits and vegetables per day, 7.9 grams of fiber per 1000 kilocalories, and 35.4% calories from fat per day; 28% of the sample were smokers. By the time of both the interim (intervention midpoint) and final (end of intervention) assessments, participants in the intervention condition had significantly increased their exercise behavior, compared with the control condition. There was also increased consumption of fruits and vegetables and fiber in the intervention condition by the time of the final assessment, compared with the control condition. No differences by condition were found with regard to percentage of calories from fat consumed or smoking cessation. These results suggest that among a cohort of participants in a worksite health promotion study, there were significant health behavior changes across two risk factors over time. These data suggest that further investigation of multiple risk factor worksite health promotion is warranted, particularly with a focus on ways to increase participation in these programs and to diffuse intervention effects throughout the entire workforce.     

Recruiting worksites to participate in a health promotion research study

PURPOSE: In this study, the type and size of participating and nonparticipating worksites in a health promotion research trial were examined. DESIGN: In-person and telephone contacts were made with representatives from a random sample of eligible worksites recruited to participate in a research trial to increase fruit and vegetable consumption. SETTING: Worksites that had 250 to 2000 employees and a worksite cafeteria were recruited. SUBJECTS: Eighty-one worksites were contacted. MEASURES: A census of eligible worksites (N = 109) formed the recruitment base, and a random selection of worksites (N = 81) was personally contacted and asked to participate in the research. Information on size, type of worksite, and a worksite representative was obtained from a privately compiled list covering the greater Puget Sound area. Eligibility for the project included the presence of an onsite cafeteria at the worksite as assessed by a brief telephone call. RESULTS: Thirty-six of the contacted worksites (44.5%) agreed to participate. There were no significant differences in participation by type or size of worksite. DISCUSSION: Worksites can be recruited to participate in research trials. No particular type or size of worksite is more likely to participate. Instituting pre-randomization participation conditions may reduce post-randomization dropout by ascertaining compliance with research requirements before randomization.     

The shape up challenge: a community-based worksite exercise competition

PURPOSE: To assess organizational and employee participation during three community-wide worksite exercise competitions in two communities. DESIGN: A one-group, posttest-only design was used. Lack of controls, exercise baseline, and the short-term nature of the interventions were limitations. SETTING: The Minnesota Heart Health Program conducted annual exercise campaigns between 1982 and 1989 within three intervention communities to reduce behavioral risk for cardiovascular disease. The Shape Up Challenge was a worksite exercise competition designed, in conjunction with other campaign activities, to increase levels of physical activity. SUBJECTS: A total of 119 participating companies in two Minnesota communities, and 17,626 employees within these worksites, composed the subjects in this study. INTERVENTION: Eligible worksites were invited to participate in a month-long competition during which employees recorded minutes spent daily in aerobic activities. Incentives were established to promote intragroup cooperation and intergroup competition. Companies competed for awards that were based on average minutes of exercise per employee versus per participant. MEASURES: Numbers of companies recruited and participating, campaign activities, minutes of exercise, and costs were recorded on implementation logs. Companies completed surveys describing business type, number and sex of employees, existing health promotion programs, and perceived benefits of participation. RESULTS: Of the 365 companies invited to participate, 33% participated (range 15% to 50%). Participating companies were more likely than nonparticipating companies to offer other health promotion programs and perceived greater benefits from participation. Women and smaller companies had significantly greater participation rates than men and larger companies. Average employee participation rates ranged from as high as 84% in smaller organizations to as low as 16% as organization size increased. CONCLUSIONS: Community-based worksite exercise competitions appear to be a viable strategy for promoting employee exercise, particularly in smaller companies. Group-based contingencies applied in natural work units may facilitate employee participation. Further research is needed to assess the relative efficacy of this approach, compare alternative incentives, and identify strategies to enhance exercise maintenance after the intervention has ceased.     

Characteristics of participants in a cancer prevention intervention designed for multiethnic workers in small manufacturing worksites

PURPOSE: To examine worker characteristics explicated in our social-contextual intervention model that might be associated with participation in a cancer prevention intervention. These characteristics included sociodemographic variables, mediating mechanisms, and modifying conditions. METHODS: Randomized, controlled study in 24 small multiethnic manufacturing worksites. Analyses were conducted on an embedded cohort of 456 employees in the intervention condition, incorporating the clustering of respondents in worksites using generalized linear mixed modeling methods. The intervention was based on an inclusive, comprehensive social-contextual model targeting fruit, vegetable, and red meat consumption, multivitamin use, and physical activity. RESULTS: Gender (p = .02) and self-efficacy (p < .01) were associated with participation. There were no differences in participation by race/ethnicity or occupational status. We observed no associations between participation of individual workers in intervention activities and health behavior change. CONCLUSIONS: The intervention attracted workers across racial/ethnic and occupational groups. The combination of a comprehensive intervention with wide diffusion of program messages may have been more powerful in influencing participation and behavior change than characteristics of individual employees.     

Peer Reviewed: Promising Practices in Promotion of Healthy Weight at Small and Medium-Sized US Worksites

Introduction

We developed a new evaluation method to identify promising practices for promoting healthy weight among employees at small and medium-sized worksites.

Methods

We used a structured rating and selection process to select 9 worksites with approximately 100 to 3,000 employees from a pool of worksites with health promotion programs reputed to be exemplary. A site visit over 2 sequential half-days at each site included interviews with senior management, program staff, vendors, and wellness committees; observation guided by a written environmental assessment; and structured review of program data on health outcomes of wellness program participants. The team corroborated findings from interviews, observations, and reviews of aggregate data on health outcomes of participants. Using the site visit reports, the project team and a separate panel of experts identified worksite health promotion practices that were promising, innovative, feasible to implement in a variety of settings, sustainable, and relevant for public health.

Results

Innovative practices included peer coaching, wellness screening coupled with motivational interviewing and follow-up, free access to fitness facilities, and incentives such as days of paid leave for participation in wellness programs. Introduction of incentives was associated with higher participation rates. To build the business case for their programs, staff at several worksites used aggregate data on decreases in high blood pressure, serum cholesterol concentrations, and body weight in longitudinal samples of program participants.

Conclusion

The evaluation method identified promising practices implemented at small and medium-sized worksites to promote healthy weight and related favorable health outcomes.     

Assessment of worksite health promotion environments]

Organizational intervention rather than the individual approach is gaining greater attention in worksite health promotion, but little research has been done on the health promotion environment. The purpose of this study was to investigate the actual conditions in health promotion environments at worksites, and determine which environmental items in each health promotion area at worksites need. A survey was conducted by mailing a questionnaire to occupational physicians at 450 worksites in Japan. The questionnaire contained 182 items including 6 areas in a health promotion environment; tobacco control, healthy diet, physical activity and exercise, stress management, health screening, and health administration. 142 physicians (32.7%) responded to our survey, the number of employees was more than three hundred and 71.1% of respondents were working at manufacturing worksites. The mean rate of positive answers in 6 areas was highest in the 'health screening' (72.5%), followed by 'stress management'. The lowest rate was seen in 'tobacco control'. Popular facilities for health promotion were a stress counseling room, cafeteria, rest room and outdoor exercise field, but the rate of positive answers to promote utilization of these facilities was relatively low. Among the health education programs, the practice rate for exercise promotion was the highest (63.6%), but those for healthy food and body weight control were relatively low. The number of employees positively correlated with the rate of positive answers to all items and in the stress managing area. Manufacturing worksites had more items for enhancing physical activity than other types of industrial worksites. The results of this survey had determined the environmental intervention items in each health promotion area at worksites.     

Frequency of health risk assessment activities at U.S. worksites

Data from the National Survey of Worksite Health Promotion Activities include information about health risk assessment (HRA) activities available at private sector worksites in the United States. HRA activities were found at 29.5% of all worksites. Of those worksites, 24% provided HRA questionnaires and 77.4% provided periodic health/physical examinations. Screening tests provided as part of the health/physical exams included blood pressure screening (55.4%), cancer screening (19.5%), blood tests for cholesterol (28.3%) and sugar (39%), and tests of physical fitness (15.1%). In most cases, the frequency increased as worksite size increased, regional variations were small, and there was significant variation among different industry types. HRA activities were overrepresented at worksites where the majority of workers were women, over 30 years of age, not blue collar, and not represented by a union. On-site health personnel increased the likelihood of the presence of HRA activities. At 85% of the worksites with HRA activities all permanent employees were eligible. The full costs of screening were paid by 87.9% of the worksites, activities were held on company time at 74.5%, and time off to participate was available at 78.2% of worksites. The most commonly mentioned benefit of HRA activities was improved employee health (47.1%). Other health promotion activities frequently found in association with HRA activities were smoking cessation (54.1%), care and prevention of back pain (50.8%), and stress management (49.6%).     

Lay health advisor activity levels: definitions from the field.

One type of lay health advisor model assumes that an effective mechanism for reaching the underserved is through informal advice-givers called natural helpers. Despite the growing use of this approach, few programs have defined what an active lay health advisor does within the natural helping process. To explore perceptions and definitions of lay health advisors' activity, we conducted semistructured, in-person interviews with four field staff who coordinate the advisors' activities in a breast cancer screening program. These staff viewed lay health advisor activity as fluctuating over the course of a year, occurring along a continuum of participation (inactive, moderately active, active, and superactive), and reflecting varying degrees of proactivity and participation in multiple activities. These results suggest an empirical process for refining the definition of an active lay health advisor, improving advisors' productivity in achieving outreach objectives, and managing and monitoring their ongoing activities.     

The helping network approach: Community promotion of mental health

The Galt Helping Network Project was a two-year program to augment mental health and community services in a rural California community through the use of natural or informal resources. The experiment made use of a preventive intervention model which identified important needs of local youth and families, board and care residents, the entire community for recreation and for mental health services, and the Mexican American Community for recognition and participation. It brought a number of volunteers into the provision of direct services and created a number of institutional forms by which continued services and enlarged voluntary participation in community affairs are continuing beyond the official end of the project. This article concludes that the Galt Helping Network Model can provide a major contribution to mental health maintenance and community involvement through the recognition of natural helpers and the involvement of the community in an active form of problem solving. Through these methods a community with limited fiscal resources can take a major step toward providing a caring and helping environment for its members.     

Health promotion trials at worksites and risk factors for cancer

Studies of worksite health promotion have frequently reported larger effects than those at the community level. Many of these studies have serious methodological problems. Forty-five worksite health promotion trials following specific quality criteria were selected and estimated for behavioral changes in cancer risk factors and the effectiveness of different intervention components. Tobacco control programs found quit rates of about 5% with relapse rates of 40% to 80% at 6 months after the intervention. Effectiveness increased with the duration of the intervention for at least 6 months, repeated contacts with the participants, continuous support, and tailored messages. There was less evidence for the long-term effectiveness of incentives. Trials on diet, alcohol, physical activity, overweight, and solar radiation showed the same positive trends. The overall evidence indicates a modest but positive effect of health promotion trials at worksites and the effect, for smoking cessation trials, is slightly larger than that of community-based trials. Many of the recommendations made to increase participation and effectiveness were not based on empirical data.     

Effects of a tailored health promotion program for female blue-collar workers: health works for women

BACKGROUND: This study assessed the effects of the Health Works for Women (HWW) intervention on improving multiple behaviors including nutrition and physical activity among rural female blue-collar employees in North Carolina. METHODS: Nine small to mid-size workplaces were randomly assigned to either intervention or delayed intervention conditions. After a baseline survey, an intervention consisting of two computer-tailored magazines and a natural helpers program was conducted over 18 months. Delayed worksites received one tailored magazine. Approximately 77 and 76% of baseline respondents completed follow-up surveys at 6 and 18 months, respectively, and 538 women (63%) completed all three surveys. RESULTS: At the 18-month follow-up, the intervention group had increased fruit and vegetable consumption by 0.7 daily servings compared to no change in the delayed group (P < 0.05). Significant differences in fat intake were observed at 6 months (P < 0.05) but not at 18 months. The intervention group also demonstrated improvements in strengthening and flexibility exercise compared to the delayed group. The rates of smoking cessation and cancer screening did not differ between study groups. CONCLUSIONS: The HWW project was a successful model for achieving certain health behavior changes among blue-collar women.     

Community mobilization to reduce postpartum hemorrhage in home births in northern Nigeria

The purpose of this study is to demonstrate the importance of community mobilization in the uptake of a health intervention, namely, community-based distribution of misoprostol to prevent postpartum hemorrhage. Community mobilization to increase access to misoprostol for postpartum hemorrhage prevention was implemented in northwestern Nigeria in 2009. Theories of community participation and the current near-epidemic maternal mortality conditions underpin an approach using modest levels of community involvement. The study was undertaken in five communities around Zaria, Nigeria. Community leaders and selected community members participated in a series of dialogs. Additionally, community education, information and dramas sessions were held. Twenty nine community oriented resource persons (CORPs), 27 drug keepers and 41 traditional birth attendants (TBAs) were involved in the intervention. Postpartum interviews were used to assess the impact of community mobilization efforts and to track use of misoprostol. Multiple logistic regression was used to examine the association between correct use and receiving information regarding misoprostol from TBAs or CORPs. A total of 1875 women were enrolled in the study in 2009. Most women delivered at home (95%) and skilled attendance at delivery was low (7%). Community mobilization efforts reached most women with information about postpartum hemorrhage and misoprostol (88%), resulting in high comprehension of intervention messages. Women identified TBAs and CORPs as the single most important source of information about misoprostol 41% and 31% of the time, respectively. Availability of misoprostol at the community level gave 79% of enrolled women some protection against postpartum hemorrhage which they otherwise would not have had. Although high level community participation in health care interventions is the ideal, this study suggests that even in circumstances where only modest levels of participation can realistically be achieved, community mobilization can have a significant impact on the successful distribution and uptake of a potentially life-saving health intervention, in turn helping promote policy change.     

Worksite characteristics and environmental and policy supports for cardiovascular disease prevention in New York state

Introduction

Worksite policy and environmental supports that promote physical activity, healthy eating, stress management, and preventive health screenings can contribute to the prevention of cardiovascular disease and lower employer costs. This study examines the availability of these four categories of supports in a statewide survey of New York State worksites.

Methods

In 2002, we recruited a statewide sample of worksites in New York State with 75 or more employees to participate in a mailed survey assessing worksite policy and environmental supports for wellness and health promotion. The overall response rate was 34.8%. The analysis included data from 832 worksites.

Results

Worksite size was an independent predictor of health promotion supports with small (75–99 employees) and medium-small (100–199 employees) worksites reporting significantly fewer policy and environmental supports in all four categories than worksites with 300 or more employees. Worksites in which most employees were nonwhite reported fewer supports for physical activity, healthy eating, and stress management than worksites in which most employees were white. A wellness committee or wellness coordinator was associated with more health promotion supports, regardless of the size of the worksite or composition of its workforce.

Conclusion

Worksites with fewer than 200 employees have an increased need for assistance in establishing environmental and policy supports promoting cardiovascular health. Worksites that have a wellness committee or coordinator are better able to establish and sustain supports with the potential to improve the health of their workers.