Worksite follow-up and engagement strategies for initiating health risk behavior changes

Workplace interventions for smoking cessation

BACKGROUND

The workplace has potential as a setting through which large groups of people can be reached to encourage smoking cessation.

OBJECTIVES

1. To categorize workplace interventions for smoking cessation tested in controlled studies and to determine the extent to which they help workers to stop smoking.2. To collect and evaluate data on costs and cost effectiveness associated with workplace interventions.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialized Register (July 2013), MEDLINE (1966 - July 2013), EMBASE (1985 - June 2013), and PsycINFO (to June 2013), amongst others. We searched abstracts from international conferences on tobacco and the bibliographies of identified studies and reviews for additional references.

SELECTION CRITERIA

We selected interventions conducted in the workplace to promote smoking cessation. We included only randomized and quasi-randomized controlled trials allocating individuals, workplaces, or companies to intervention or control conditions.

DATA COLLECTION AND ANALYSIS

One author extracted information relating to the characteristics and content of all kinds of interventions, participants, outcomes and methods of the studies, and a second author checked them. For this update we have conducted meta-analyses of the main interventions, using the generic inverse variance method to generate odds ratios and 95% confidence intervals.

MAIN RESULTS

We include 57 studies (61 comparisons) in this updated review. We found 31 studies of workplace interventions aimed at individual workers, covering group therapy, individual counselling, self-help materials, nicotine replacement therapy, and social support, and 30 studies testing interventions applied to the workplace as a whole, i.e. environmental cues, incentives, and comprehensive programmes. The trials were generally of moderate to high quality, with results that were consistent with those found in other settings. Group therapy programmes (odds ratio (OR) for cessation 1.71, 95% confidence interval (CI) 1.05 to 2.80; eight trials, 1309 participants), individual counselling (OR 1.96, 95% CI 1.51 to 2.54; eight trials, 3516 participants), pharmacotherapies (OR 1.98, 95% CI 1.26 to 3.11; five trials, 1092 participants), and multiple intervention programmes aimed mainly or solely at smoking cessation (OR 1.55, 95% CI 1.13 to 2.13; six trials, 5018 participants) all increased cessation rates in comparison to no treatment or minimal intervention controls. Self-help materials were less effective (OR 1.16, 95% CI 0.74 to 1.82; six trials, 1906 participants), and two relapse prevention programmes (484 participants) did not help to sustain long-term abstinence. Incentives did not appear to improve the odds of quitting, apart from one study which found a sustained positive benefit. There was a lack of evidence that comprehensive programmes targeting multiple risk factors reduced the prevalence of smoking.

AUTHORS' CONCLUSIONS

1. We found strong evidence that some interventions directed towards individual smokers increase the likelihood of quitting smoking. These include individual and group counselling, pharmacological treatment to overcome nicotine addiction, and multiple interventions targeting smoking cessation as the primary or only outcome. All these interventions show similar effects whether offered in the workplace or elsewhere. Self-help interventions and social support are less effective. Although people taking up these interventions are more likely to stop, the absolute numbers who quit are low.2. We failed to detect an effect of comprehensive programmes targeting multiple risk factors in reducing the prevalence of smoking, although this finding was not based on meta-analysed data. 3. There was limited evidence that participation in programmes can be increased by competitions and incentives organized by the employer, although one trial demonstrated a sustained effect of financial rewards for attending a smoking cessation course and for long-term quitting. Further research is needed to establish which components of this trial contributed to the improvement in success rates.4. Further research would be valuable in low-income and developing countries, where high rates of smoking prevail and smoke-free legislation is not widely accepted or enforced.

A systematic review of selected interventions for worksite health promotion. The assessment of health risks with feedback

BACKGROUND

Many health behaviors and physiologic indicators can be used to estimate one's likelihood of illness or premature death. Methods have been developed to assess this risk, most notably the use of a health-risk assessment or biometric screening tool. This report provides recommendations on the effectiveness of interventions that use an Assessment of Health Risks with Feedback (AHRF) when used alone or as part of a broader worksite health promotion program to improve the health of employees.

EVIDENCE ACQUISITION

The Guide to Community Preventive Services' methods for systematic reviews were used to evaluate the effectiveness of AHRF when used alone and when used in combination with other intervention components. Effectiveness was assessed on the basis of changes in health behaviors and physiologic estimates, but was also informed by changes in risk estimates, healthcare service use, and worker productivity.

EVIDENCE SYNTHESIS

The review team identified strong evidence of effectiveness of AHRF when used with health education with or without other intervention components for five outcomes. There is sufficient evidence of effectiveness for four additional outcomes assessed. There is insufficient evidence to determine effectiveness for others such as changes in body composition and fruit and vegetable intake. The team also found insufficient evidence to determine the effectiveness of AHRF when implemented alone.

CONCLUSIONS

The results of these reviews indicate that AHRF is useful as a gateway intervention to a broader worksite health promotion program that includes health education lasting > or =1 hour or repeating multiple times during 1 year, and that may include an array of health promotion activities. These reviews form the basis of the recommendations by the Task Force on Community Preventive Services presented elsewhere in this supplement.

Workplace interventions for smoking cessation

BACKGROUND

The workplace has potential as a setting through which large groups of people can be reached to encourage smoking cessation.

OBJECTIVES

To categorize workplace interventions for smoking cessation tested in controlled studies and to determine the extent to which they help workers to stop smoking or to reduce tobacco consumption.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group Specialized Register in April 2008, MEDLINE (1966 - April 2008), EMBASE (1985 - Feb 2008) and PsycINFO (to March 2008). We searched abstracts from international conferences on tobacco and the bibliographies of identified studies and reviews for additional references.

SELECTION CRITERIA

We selected interventions conducted in the workplace to promote smoking cessation. We included only randomized and quasi-randomized controlled trials allocating individuals, workplaces or companies to intervention or control conditions.

DATA COLLECTION AND ANALYSIS

Information relating to the characteristics and content of all kinds of interventions, participants, outcomes and methods of the study was abstracted by one author and checked by another. Because of heterogeneity in the design and content of the included studies, we did not attempt formal meta-analysis, and evaluated the studies using qualitative narrative synthesis.

MAIN RESULTS

We include 51 studies covering 53 interventions in this updated review. We found 37 studies of workplace interventions aimed at individual workers, covering group therapy, individual counselling, self-help materials, nicotine replacement therapy and social support. The results were consistent with those found in other settings. Group programmes, individual counselling and nicotine replacement therapy increased cessation rates in comparison to no treatment or minimal intervention controls. Self-help materials were less effective. We also found 16 studies testing interventions applied to the workplace as a whole. There was a lack of evidence that comprehensive programmes reduced the prevalence of smoking. Incentive schemes increased attempts to stop smoking, though there was less evidence that they increased the rate of actual quitting.

AUTHORS' CONCLUSIONS

1. We found strong evidence that interventions directed towards individual smokers increase the likelihood of quitting smoking. These include individual and group counselling and pharmacological treatment to overcome nicotine addiction. All these interventions show similar effects whether offered in the workplace or elsewhere. Self-help interventions and social support are less effective. Although people taking up these interventions are more likely to stop, the absolute numbers who quit are low.2. There was limited evidence that participation in programmes can be increased by competitions and incentives organized by the employer.3. We failed to detect an effect of comprehensive programmes in reducing the prevalence of smoking.

Workplace interventions for smoking cessation

BACKGROUND

The workplace has potential as a setting through which large groups of people can be reached to encourage smoking cessation.

OBJECTIVES

To categorize workplace interventions for smoking cessation tested in controlled studies and to determine the extent to which they help workers to stop smoking or to reduce tobacco consumption.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group Specialized Register in October 2004, MEDLINE (1966 - October 2004), EMBASE (1985 - October 2004) and PsycINFO (to October 2004). We searched abstracts from international conferences on tobacco and we checked the bibliographies of identified studies and reviews for additional references.

SELECTION CRITERIA

We categorized interventions into two groups: a) Interventions aimed at the individual to promote smoking cessation and b) interventions aimed at the workplace as a whole. We applied different inclusion criteria for the different types of study. For interventions aimed at helping individuals to stop smoking, we included only randomized controlled trials allocating individuals, workplaces or companies to intervention or control conditions. For studies of smoking restrictions and bans in the workplace, we also included controlled trials with baseline and post-intervention outcomes and interrupted times series studies.

DATA COLLECTION AND ANALYSIS

Information relating to the characteristics and content of all kinds of interventions, participants, outcomes and methods of the study was abstracted by one author and checked by two others. Because of heterogeneity in the design and content of the included studies, we did not attempt formal meta-analysis, and evaluated the studies using qualitative narrative synthesis.

MAIN RESULTS

Workplace interventions aimed at helping individuals to stop smoking included ten studies of group therapy, seven studies of individual counselling, nine studies of self-help materials and five studies of nicotine replacement therapy. The results were consistent with those found in other settings. Group programmes, individual counselling and nicotine replacement therapy increased cessation rates in comparison to no treatment or minimal intervention controls. Self-help materials were less effective.Workplace interventions aimed at the workforce as a whole included 14 studies of tobacco bans, two studies of social support, four studies of environmental support, five studies of incentives, and eight studies of comprehensive (multi-component) programmes. Tobacco bans decreased cigarette consumption during the working day but their effect on total consumption was less certain. We failed to detect an increase in quit rates from adding social and environmental support to these programmes. There was a lack of evidence that comprehensive programmes reduced the prevalence of smoking. Competitions and incentives increased attempts to stop smoking, though there was less evidence that they increased the rate of actual quitting.

AUTHORS' CONCLUSIONS

We found: 1. Strong evidence that interventions directed towards individual smokers increase the likelihood of quitting smoking. These include advice from a health professional, individual and group counselling and pharmacological treatment to overcome nicotine addiction. Self-help interventions are less effective. All these interventions are effective whether offered in the workplace or elsewhere. Although people taking up these interventions are more likely to stop, the absolute numbers who quit are low. 2. Limited evidence that participation in programmes can be increased by competitions and incentives organized by the employer. 3. Consistent evidence that workplace tobacco policies and bans can decrease cigarette consumption during the working day by smokers and exposure of non-smoking employees to environmental tobacco smoke at work, but conflicting evidence about whether they decrease prevalence of smoking or overall consumption of tobacco by smokers. 4. A lack of evidence that comprehensive approaches reduce the prevalence of smoking, despite the strong theoretical rationale for their use. 5. A lack of evidence about the cost-effectiveness of workplace programmes.

Changes in health risks among the participants in the United Auto Workers--General Motors LifeSteps Health Promotion Program

PURPOSE

To examine health risk changes among participants of a multicomponent worksite health promotion program.

DESIGN

A study using health risk changes among health risk appraisal (HRA) participants linked to program participation records. Baseline risk and participation in multiple programs were examined in relation to risk change in multivariate models.

SETTING

Worksite health promotion programming sponsored by the United Auto Workers (UAW) and General Motors (GM).

SUBJECTS

Active employees (12,984) who voluntarily participated in an HRA in each of two program years.

INTERVENTION

The nationwide program was a mailed HRA and a 1-800 nurse line. A pilot program (implemented in two cities) added screening, wellness programs, a materials resource, and, for high risk participants, health coaching and vouchers for medical office visits.

MEASURES

Using 13 selected health risk factors from the HRA, changes in overall health risks were measured as program outcomes in three ways: one-directional, net, and risk status change.

RESULTS

A greater decrease in the number of health risks was observed with increased program participation. The decrease was significantly related to the number of baseline risk factors and eligibility for high risk programs. Associated with program participation, the number of people at low risk status increased from 70.1% to 71.3% at year 2 among nationwide participants and from 52.4% to 58.9% among pilot participants.

CONCLUSIONS

Participation was associated with a significant impact on health risk. Baseline risk of participants and eligibility for high risk programs were necessary factors to control when measuring program effects on health risk changes.

Conceptual framework, critical questions, and practical challenges in conducting research on the financial impact of worksite health promotion

A conceptual framework to guide research on the financial impact of health promotion programs is described. Important questions that must be answered within this framework are discussed and brief summaries of the research addressing these questions are summarized. Key issues and challenges that are encountered in designing and implementing financial outcome research are reviewed.

A review and analysis of the clinical and cost-effectiveness studies of comprehensive health promotion and disease management programs at the worksite: 1995-1998 update (IV)

The fourth in a series of critical reviews, this study examines the clinical and cost outcome evaluations of 10 worksite health promotion programs that were comprehensive, multifactorial, and directed at risk management. The studies, conducted between 1994 and 1998, indicate favorable clinical and cost outcomes and suggest characteristics of worksite interventions that may be critical for effectiveness.

Clinical and cost outcomes of multifactorial, cardiovascular risk management interventions in worksites: a comprehensive review and analysis

This paper is a critical review of the clinical and cost outcome evaluation studies of multifactorial, comprehensive, cardiovascular risk management programs in worksites. A comprehensive international literature search conducted under the auspices of the National Heart, Lung and Blood Institute identified 17 articles based on 12 studies that examined the clinical outcomes of multifactorial, comprehensive programs. These articles were identified through MEDLINE, manual searches of recent journals, and through direct inquiries to worksite health promotion researchers. All studies were conducted between 1978 and 1995, with 1978 being the date of the first citation of a methodologically rigorous evaluation. Of the 12 research studies, only 8 utilized the worksite as both the unit of assignment and as the unit of analysis. None of the studies analyzed adequately for cost effectiveness. Given this limitation, this review briefly considers the relevant worksite research that has demonstrated cost outcomes. Worksite-based, multifactorial cardiovascular intervention programs reviewed for this article varied widely in the comprehensiveness, intensity, and duration of both the interventions and evaluations. Results from randomized trials suggest that providing opportunities for individualized, cardiovascular risk reduction counseling for high-risk employees within the context of comprehensive programming may be the critical component of an effective worksite intervention. Despite the many limitations of the current methodologies of the 12 studies, the majority of the research to date indicates the following: (1) favorable clinical and cost outcomes; (2) that more recent and more rigorously designed research tends to support rather than refute earlier and less rigorously designed studies; and (3) that rather than interpreting the methodological flaws and diversity as inherently negative, one may consider it as indicative of a robust phenomena evident in many types of worksites, with diverse employees, differing interventions, and varying degrees of methodological sophistication. Results of these studies reviewed provide both cautious optimism about the effectiveness of these worksite programs and insights regarding the essential components and characteristics of successful programs.

A review of health-related outcomes of multi-component worksite health promotion programs

PURPOSE

The purpose of this article is to critically review evaluation studies of the health-related effects (i.e., health risk modification and reduction in worker absenteeism) of multicomponent worksite health promotion programs.

SEARCH METHOD

A comprehensive literature search conducted under the auspices of the Centers for Disease Control and Prevention identified 36 articles that examined health-related outcomes of multi-component programs. The authors identified 11 additional articles through manual searches of recent journal issues and through personal contacts with worksite health promotion researchers. Forty-seven studies describing the results of 35 worksite health promotion programs were reviewed.

IMPORTANT FINDINGS

The worksite health promotion programs reviewed for this article varied tremendously in the comprehensiveness, intensity, and duration of the intervention activities. All of the programs provided health education to employees. In a majority of the programs, opportunities to learn and practice new skills were also offered. A smaller number of programs incorporated modifications in organizational policy or the physical work environment. Results from well-conducted randomized trials suggest that providing opportunities for individual risk reduction counseling for high risk employees within the context of comprehensive programming may be the critical component of an effective worksite health promotion program. Just offering low intensity, short duration programs aimed at increasing awareness of health issues for the entire employee population may not be sufficient to achieve desired outcomes.

MAJOR CONCLUSIONS

The results of the studies reviewed provide both cautious optimism about the effectiveness of these worksite programs and some general guidance as to the critical components and characteristics of successful programs. Overall, the evidence suggests that a rating of indicative/acceptable may best characterize this literature.

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.

The impact of worksite-based health risk appraisal on health-related outcomes: a review of the literature

PURPOSE

To provide a brief history of the development and evolution of health risk appraisal (HRA) and to review studies published in peer-reviewed journals that address the impact of worksite-based HRA on health-related outcomes.

METHOD

The Centers for Disease Control and Prevention conducted the primary literature search, identifying seven articles through a bibliographic search of major health databases, manual search of specific journals, and reference list search. We identified four additional studies from our personal experience and our manual search of previous reviews.

IMPORTANT FINDINGS

Several studies reported positive changes in seat-belt use and self-reported physical activity associated with HRA participation, and changes in other health-related outcomes after HRA participation were also reported. Evidence supporting causal inference is lacking, however, because of the many threats to internal validity in studies completed to date. Almost no research has addressed the impact of HRA on health-related outcomes in the early "prebehavioral" stages of the change process, despite the theoretical and applied focus of HRA on these types of outcomes.

CONCLUSIONS

On the basis of the small number of studies in the literature, evidence is weak regarding the impact of HRA itself on health-related outcomes. There is suggestive evidence for the effectiveness of HRA when it is used in a comprehensive worksite health promotion program. Future research should focus on the impact of HRA on variables in the early stages of the change process, such as awareness and commitment, rather than on behavioral outcomes. Research should also address specific characteristics of HRA instruments and implementation approaches.

Worksite wellness programs: incremental comparison of screening and referral alone, health education, follow-up counseling, and plant organization

BACKGROUND

Worksite wellness programs vary considerably in their design. This study tested four models to compare effectiveness at controlling high blood pressure, obesity, and cigarette smoking.

METHODS

Baseline screening was conducted in four manufacturing plants. Site 1 offered screening only, with referral recommendations for those found to have CVD risks. Site 2 also provided health education information and classes. Site 3 added routine follow-up counseling and a menu of intervention types, and Site 4 added social organization within the plant. Random samples of 400 to 500 employees were rescreened at the end of three years.

RESULTS

Major improvements in risk levels were found with the addition of routine follow-up counseling and a menu of interventions (Sites 3 and 4, compared with Sites 1 and 2). More hypertensives entered treatment and showed greater reductions in blood pressure. Participation in worksite weight loss and smoking cessation programs was significantly increased, and those who participated showed significantly better maintenance of improvements where follow-up was provided.

DISCUSSION

The program models that offered short-term interventions promoted through local media suffered in comparison with models that included personal outreach to people at risk, a variety of health improvement intervention modalities, and ongoing follow-up counseling to help people make decisions and sustain health improvements.