Kwak, Lydia PhD; Hagströmer, Maria PhD; Jensen, Irene PhD; Karlsson, Malin Lohela PhD; Alipour, Akbar MD, PhD; Elinder, Liselotte Schäfer PhD
The workplace is considered an ideal setting for health promotion due to the considerable amount of time individuals spend at work and because workplaces provide many opportunities to adopt and maintain health behaviors.1,2 Despite the growing body of evidence for the effectiveness of worksite health promotion programs,2 few worksites to date offer programs of this kind to their employees.3 One way to support health promotion at the worksite is through the occupational health services (OHS). Even though traditionally their task has mainly been to protect the health of workers in relation to the work environment, in the last decades it has also involved health promotion and education, including that regarding health behaviors.4 The OHS have the possibility to reach “at risk” groups, to target its efforts according to employees' needs and to offer services, which are accessible and free of charge to all employees. The OHS role in promoting health behaviors should, therefore, not be underestimated.5
Regular physical activity and healthy dietary habits are two important factors in the prevention of overweight, obesity, and their related diseases, that is, type 2 diabetes, cardiovascular disease (CVD), and of certain types of cancer.6,7 Despite the OHS involvement in various health-promoting activities, such as the promotion of a healthy diet and physical activity,8 little is known regarding the scientific basis of these activities. With the growing emphasis on the use of evidence-based practice, also within the OHS setting,9 more knowledge is needed regarding the extent, range, and nature of the research conducted within this field. A decision was, therefore, made to conduct a scoping review. Scoping reviews are defined as projects that systematically map the literature on a topic, identifying the key concepts, theories, sources of evidence, and gaps in the research. They are often conducted prior to full syntheses, when feasibility is a concern—either because the potentially relevant literature is thought to be especially vast and diverse or because little literature exists in this field.10
The aim of this scoping review was to identify and map the literature that has evaluated the effects of health promotion interventions aimed at physical activity and/or dietary behavior, which have been implemented by the OHS. The findings of this review inform researchers about the current level of evidence and where further research is needed. Moreover, it provides practitioners with a summary of the evidence available for health promotion interventions aimed at physical activity and/or dietary behavior, which have been implemented by the OHS. To be able to increase the use of evidence-based practice within the OHS, it is imperative that the effectiveness of health promotion interventions is tested within the setting in which they will be used and implemented by the practitioners who will be using them. The findings of this review will, therefore, be a valuable complement to the knowledge gained from reviews of worksite health promotion interventions that are currently not implemented by the OHS.
The review was guided by Arkesy and O'Malley's11 methodological framework, which identifies the following five stages: (1) identifying the research question(s); (2) identifying relevant studies; (3) study selection; (4) charting the data; and (5) collating, summarizing, and reporting results. In stage 1, the following research questions were identified: What is known from the existing literature about (1) interventions implemented by the OHS to promote physical activity and/or healthy dietary behavior amongst employees and (2) the effectiveness and cost-effectiveness of these interventions? Scoping reviews have been criticized for not assessing the methodological quality of the included studies. It has been argued that this lack of quality assessment makes the results of scoping reviews more challenging to interpret and limits the uptake of scoping findings in practice. A decision was, therefore, made to do a quality assessment of the studies included in this review.
Stage 2: Identifying Relevant Studies
A comprehensive search was conducted using a multistage process. First, the electronic databases PubMed, EMBASE and CINAHL were searched for peer-reviewed articles. The search strategies included appropriate key words indexed by the specific databases (Mesh for PubMed; EMTREE for EMBASE; Headings for CINAHL). The search strategies are presented in Table 1. The second step in the search process was an on-line hand search of two key journals within this field, namely Occupational and Environmental Medicine (OEM), and Scandinavian Journal of Work Environment and Health (SJWEH). In OEM, a manual search through its on-line database was conducted with the following search criteria: Occupational health (as a phrase) in the title or abstract in combination with (1) physical activity, (2) physical exercise, (3) physical inactivity, (4) diet, (5) nutrition, or (6) lifestyle in the full text. In SJWEH, a search through its on-line database was performed by searching their existing list of key words. The search was refined by only searching for articles under key words, which were any combination with occupational health, physical activity, physical exercise, physical inactivity, nutrition, lifestyle, or dietary. The final step in the search process was the screening of the reference lists of the selected articles for additional relevant papers. All searches were limited to studies published in English, Swedish, or Dutch and conducted up to February 2013, without a set starting date.
Stage 3: Study Selection
The selection of studies was conducted in two stages. First, two reviewers (L.K. and M.L.K.) screened the titles and abstracts for potentially relevant studies. Our initial search showed that very few abstracts provided information on who implemented the intervention. A decision was, therefore, made to select all abstracts that described an intervention study that evaluated an intervention aimed at physical activity and/or dietary behavior targeting healthy employees. Healthy employees included those with identified risk factors for chronic diseases (ie, overweight, elevated blood lipids, cholesterol, or systolic blood pressure). Exclusion criteria at this stage were studies (1) not presenting original data, (2) not describing an intervention study, (3) not aimed at physical activity and/or dietary behavior, (4) not presenting any outcomes (ie protocols), and (5) not aimed at healthy employees. Abstracts were scored positive if exclusion criteria were not met, negative when 1 or more exclusion criteria were met, and unclear if there was insufficient information for a decision. Disagreements between the two reviewers were discussed with an independent researcher until consensus was reached.
During the second stage, the full articles of the abstracts that scored positive or unclear were retrieved and read by the first author. At this stage, studies were excluded if (1) the intervention was not implemented by the OHS; (2) the study did not report physical activity-related behaviors, dietary-related behaviors, and/or biological risk factors of CVDs as outcomes; and (3) the study targeted employees with work-related injuries, that is, back pain, shoulder pain, or unhealthy employees. An initial search of the literature showed that few studies have been conducted in this field; therefore, no limitations were set for the study design, study duration, intervention strategies, follow-up period, control condition, or whether physical activity was assessed subjectively or objectively.
Stage 4: Charting the Data
A data extraction form was completed for all included studies. Data were recorded on country of origin, the number of OHS, type of worksite, participant characteristics, study design, intervention and control conditions, intervention period, follow-up period, measurement methods, study outcome measures, and reported results.
Two reviewers (L.K. and M.H.) independently evaluated the methodological quality of the studies by using an existing checklist (Table 2). The checklist was based on the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions and has previously been pilot-tested and used to assess the methodological quality of studies testing the effectiveness of worksite physical activity and dietary behavior interventions.12 The checklist contains 12 criteria for internal validity that are related to selection bias (2 items), performance bias (3 items), attrition bias (2 items), and detection bias (5 items). Per article, criteria were scored as positive if the criterion was met, negative if the criterion was not met, or zero if insufficient information was provided for judgment. Each article received a quality judgment on the basis of the number of positively scored criteria: excellent (10 to 12), good (7 to 9), fair (5 to 6), and poor (0 to 4). When opinions between the reviewers differed, consensus on ratings was reached through discussion.
Stage 5: Collating, Summarizing, and Reporting the Results
Figure 1 shows the flowchart of the studies identified and subsequently excluded or included. During the first stage, 948 potentially relevant articles were identified. The manual search of the two key journals identified 11 articles and 5 were found in the reference lists. During the first stage, 626 were excluded, because of the following reasons: (1) not original data (n = 41), (2) not describing an intervention study (n = 297), (3) not presenting any effect outcomes (ie, protocols, process evaluation) (n = 116), (4) not aimed at physical activity and/or dietary behavior (n = 109), and (5) not aimed at healthy employees (n = 63). The two authors (L.K. and M.L.K.) disagreed on 2% (n = 19) of the potentially relevant publications, after discussion with an independent researcher consensus was reached with regard to all abstracts. In the next stage, 338 publications were selected for further screening of the full-text articles. Of these, 20 could not be retrieved, as we had no access to the journals, which published these articles. In total, 318 full-text articles were retrieved and screened. At this stage, 305 were excluded, resulting in 14 relevant studies being included in the review. The reasons for exclusion were as follows: (1) the intervention was not implemented by the OHS (n = 267), (2) the study did not report physical activity-related behaviors, dietary-related behaviors, and/or biological risk factors of CVDs as outcomes (n = 33); and (3) the study targeted employees with work-related injuries, that is, back pain, shoulder pain, or unhealthy employees (n = 4). The 14 articles described 10 interventions.13–25
Concerning the methodological quality assessment, the authors (L.K. and M.H.) agreed on 92% of criteria. After a consensus meeting, and a rereading of the papers, disagreement was resolved and the scoring process completed. Recurrent methodological limitations were inadequate description of similarity of groups, unclear description of blinding of participants, no description of presence of cointerventions, and no reporting of an intention-to-treat analysis.
Description of the Studies
A full description of the characteristics of the 14 studies is reported in Table 3. Studies originated from six different countries: the Netherlands (n = 4), Finland (n = 3), the United States (n = 3), Ireland (n = 1), Japan (1), and Sweden (n = 1). Most interventions were aimed at men and women with specific risk factors, including unhealthy physical activity and/or dietary behaviors, overweight, high cholesterol levels, high fasting glucose, and large waist circumferences. Two interventions were tested among males only.15–17,19 The number of participants ranged from 68 to 1393. Half of the interventions were conducted among specific occupational groups: office workers,25 oil refinery workers,20 construction workers,15–17 civil servants,13 and manufacturing workers.23,26
TABLE 3-a. Character...Image Tools
Eight of the 14 studies conducted a randomized controlled trial (RCT),14–17,19,21,22,25 4 a controlled trial,18,20,23,26 and 2 noncontrolled studies.13,24 Seven of the RCTs were classified as good-quality studies.15–17,19,21,22,25 One RCT14 and three of the four controlled trials20,23,26 were graded as fair-quality studies. The remaining controlled trial18 and the uncontrolled studies13,24 were ranked as poor-quality studies. Control conditions varied greatly between studies and included no intervention,14 usual care, which often included minimal interventions,15,16,18,20,22 and untailored e-mails.23,26 The two uncontrolled studies conducted pre/postassessments in a single group.13,24 Outcomes included physical activity-related behaviors, dietary-related behaviors, body weight–related outcomes, biomedical risk factors, movement in physical activity stages of change, and outcomes related to cost-effectiveness. Measurement methods included mostly self-reported methods with regard to physical activity and dietary behavior; two studies used objective methods (pedometers14 and accelerometers26) to measure the amount of steps per day. Biological CVD risk factors were assessed with objective methods in all studies.
TABLE 3-b. Character...Image Tools
Description of Intervention Components
Of the 10 unique interventions described in the 14 studies, 9 targeted individuals13–20,23–26 and 1 was a multilevel intervention aimed at both the individual and the worksite environment.21,22 The main intervention component used in the included studies was counseling, which was used in 7 of the 10 interventions.14–22,24 Three of the 10 interventions did not include counseling. The main component of two of these interventions was tailored written information.13,23,26 The other intervention consisted of self-monitoring, logbooks, and monthly e-mail messages.25
A clear description of the counseling procedure, which included duration, frequency, and method used, was given for three of the seven interventions.14–17,21,22 Counseling varied greatly in duration, frequency, and methods used. Methods used were motivational interviewing (MI;15–17), an adapted form of MI suitable for brief consultation21,22 and a counseling style based on the Transtheoretical Model.14 Sessions were given both face-to-face and by telephone and were performed by an occupational nurse (ON),14–17,19 occupational physician (OP),15–17,21,22 dietician,18 or health promotion staff.24 For two interventions, training sessions on the counseling procedure for the ON14 or OP21,22 were reported. Supporting strategies used during counseling included information brochures,14–17 pedometer,19 and feedback on an individual fitness profile based on fitness tests and self-monitoring devices (ie, diaries).14
Two of the seven interventions were multicomponent interventions.20–22 In one of these interventions, counseling was combined with advice to the employer. The advice was based on an environmental scan of the worksite, which assessed environmental risk factors for weight gain.21,22 In the other intervention, counseling was combined with a 10-week exercise program and lectures given by an ON regarding dietary habits, obesity, blood pressure, and/or serum lipids.20
In three interventions, written information was provided. As part of two of these interventions, tailored information was provided either in paper form13 or through e-mails.23,26 In one of these studies, participants received a printed personalized analysis of their lifestyle behaviors, including suggestions to change.13 In the other study, tailored e-mail messages were sent once a week for 6 weeks and were based on the participants' identified stages of change according to the Transtheoretical Model. In this study, participants also had access to a comprehensive Web site with both physical activity and nutritional information.23,26 In the third study, participants received monthly e-mail messages encouraging them to increase their number of daily steps. This was combined with self-monitoring of physical activity with a pedometer and logbook.25
Effectiveness of Interventions
Individual Counseling as a Key Intervention Component
The effectiveness of the interventions (Table 4), which included counseling as their core component, was evaluated in seven studies.14–19,24 Four of these studies included physical activity as an outcome measure.14,15,19,24 Of these three (two good quality and one poor quality) reported a significant increase in physical activity.15,19,24 Only one of the good-quality studies applied appropriate statistical analysis to compare the changes in the intervention and control groups. A favorable effect was observed only in the obese subgroup.15 One study (fair quality) observed a favorable effect at 12 months for time spent sitting during a nonworking day among inactive employees with the intention to be more physically active. These employees received counseling that included feedback on their fitness test.14 The two good-quality studies also included dietary behavior as an outcome measure.15,19 Favorable effects were reported for snack and fruit intake at 6 months, with a sustained effect for snack intake at 12 months among those aged 18 to 44 years.15 Significant changes in dietary intake between baseline and 6 months were also observed in the intervention group in the study by Nanri et al.19 Nevertheless, no statistical analyses were conducted to compare the changes between the intervention group and the control group.
TABLE 4-a. Character...Image Tools
Three studies (two good quality and one poor quality) tested the effectiveness of their intervention on biological CVD risk factors.16,18,19 Favorable effects were observed in one of the good-quality studies for glycated hemoglobin at 6 months19 and in the poor-quality study for cholesterol at 12 to 13 months.18 Both good-quality studies reported significant intervention effects on body composition measures; favorable effects were observed for body weight and body mass index at 6 and 12 months16 and for body weight, body mass index, and waist circumference at 6 months.19
Two studies reported the results related to costs of the intervention.17,25 One study conducted a thorough cost-effectiveness analysis. The mean intervention costs were €605 (SD = 230) per intervention group participant. The incremental cost-effectiveness ratio was €145/kg weight loss, meaning that for one additional kilogram of body weight loss the additional societal cost was €145; however, the uncertainty around this incremental cost-effectiveness ratio was large. For the intervention to be regarded as cost-effective, the society needs to be willing to pay €2000. When analyses were performed from the employer's perspective, the employer had a net loss of €254 (95% CI: −1070 to 1536) as a result of the intervention.17 Aittasalo and colleagues25 reported the direct costs of the intervention, which were €5337, which was approximately €43 per participant of the project.
Individual Counseling in a Multicomponent Intervention
The effectiveness of the interventions, applying a multicomponent and/or multilevel approach, which included counseling, was tested in three studies (two good quality and one fair quality).20–22 Two of these tested the effectiveness on measures of physical activity. In the fair-quality study, a significant effect on physical activity was reported.20 The good-quality study observed positive intervention effects at 6 months on sedentary behavior at work on weekdays and among obese participants for moderate physical activity.22 This study also tested the intervention effectiveness on dietary behavior and reported favorable effects for fruit intake at 6 months.22 None of the three studies observed significant intervention effects on any of the measured body composition measures,20–22 neither blood pressure nor cholesterol levels.20,21
Interventions Providing Written Information
Four studies tested the effectiveness of written information (one good quality, two fair quality, and one poor quality).20,23,25,26 The effectiveness of tailored information was tested in three studies (two fair quality and one poor quality).13,23,26 Only one of the fair-quality studies reported a significant intervention effect. At 6 weeks, more individuals in the intervention group (tailored e-mails) had moved forward from the contemplation stage than those in the control group. No significant changes were found between the groups with regard to physical activity.23 The poor-quality study conducted by Addley and colleagues13 did not conduct any statistical analyses. The good-quality study, which tested the effectiveness of e-mail messages and self-monitoring of physical activity, reported significant changes at 2 months in walking for transport and at 2 and 6 months in the mean duration of using stairs and in walking for leisure.25
To our knowledge, this scoping review is the first attempt to “map” relevant literature on (1) interventions implemented by the OHS to promote physical activity and/or healthy dietary behavior among employees and (2) the effectiveness and cost-effectiveness of these interventions. In accordance with our initial concern, the literature in this field is scarce and diverse. In total, 14 studies were included, describing 10 interventions. Studies varied in study designs, study populations, control conditions, outcomes measures, and methods used to assess outcomes. Most studies were conducted in Europe and mostly in the Netherlands. Nearly all studies were aimed at individuals with specific risk factors. All studies were published after 1998. Ten of the 14 studies were classified as being of fair to good quality.
Interventions Implemented by the OHS
This review showed that the main intervention component evaluated was counseling. A major limitation of the studies included in the present review, however, is the shortage of information on the counseling protocols used. It was often unclear from the description, what type of counseling was performed, how many sessions were conducted, the duration of the sessions, and whether the quality of the counseling was monitored. Only one of the tested interventions included MI, this despite the considerable evidence for the effectiveness of MI across a wide range of health behaviors, including diet and exercise.27,28 MI is an attractive counseling approach; it can be delivered in a relatively short time and can be performed by a variety of health care professionals27 and has been shown to outperform traditional advice giving.29 Moreover, patients seem to prefer the client-centered approach of MI, in contrast to the traditional more directive advice giving, which has shown to create resistance to change.30,31 One potential explanation for the limited use of MI is that it can be very costly for the employer, not only with regard to the actual cost of the intervention, but also regarding the indirect costs such as production loss during the intervention. On the contrary, offering ineffective interventions to employees could also be regarded as inefficient use of economic resources. Future studies should test the effectiveness of MI aimed at promoting physical activity and healthy dietary behavior and implemented by the OHS and also evaluate the cost-effectiveness from the employer perspective. In addition, these studies should give a clear description of the counseling protocol used and the level of MI reached during counseling.
Another gap in the current OHS literature is the lack of studies that have tested exercise referral schemes or physical activity on prescription as a means to promote physical activity. In the present review, physical activity on prescription was not part of any of the evaluated interventions. Systematic reviews, which have examined the evidence base for physical activity on prescription, have concluded that it is a valuable primary care intervention for promoting physical activity, despite the lack of evidence of these schemes in several settings.32–34 The intervention, which is specifically aimed at promoting physical activity in sedentary individuals,35 usually contains some type of counseling and a referral from primary care to a third party for a program of physical exercise.36 As OPs have the authority to prescribe physical activity, it could be a potential valuable intervention for promoting physical activity also through the OHS. Future studies should test the effectiveness of physical activity on prescription when implemented by the OHS.
A third gap in the OHS literature to date is the shortage of multilevel interventions aimed at changing employees' behavior and facilitating these changes through environmental interventions at the workplace. The present review included one multilevel intervention with promising results. The individual component of this intervention was counseling based on an adapted form of MI. The environmental component was aimed at changing the worksite environment. Based on a worksite scan, goals were prioritized, and feasibility and barriers for implementation were discussed with the employer.21,22 In the field of worksite health promotion, multilevel interventions are much more common.1,12,37 As the traditional work performed by OHS is to protect the health of workers in relation to the work environment, including an environmental component into worksite health promotion, thus extending the individual-level intervention to a multilevel intervention, would fit well with their competence. This could also lead to a potentially more effective result with regard to the outcomes of interest. Future studies should test the effectiveness of multilevel interventions aimed at promoting physical activity and healthy dietary behavior implemented by the OHS.
The Effectiveness of Interventions Implemented by the OHS
Seven studies of good quality were identified among the 14 included. Of the seven studies, five reported favorable intervention effects on (1) dietary behavior,15,22 (2) physical activity,22,25 (3) sedentary behavior,22 or (4) biological CVD risk factors.16,19 Because of the heterogeneity of the studies, including study design and statistical analyses, it is not possible to draw any conclusions regarding effective intervention components. Promising results were observed in two good-quality RCTs,15,16,22 indicating that an intervention containing counseling, either as single component or combined with an environmental component, could be an effective way of promoting physical activity and healthy dietary behaviors within the OHS setting. Sustainable effects at 12 months were, for example, reported in male construction workers, with an elevated risk of CVD, for body composition measures and for snack intake among those who were 18 to 44 years old.15,16 As the risk of CVD increases not only due to unhealthy behaviors, but also as a consequence of a poor work environment (ie, excessive stress), effective multilevel interventions aimed at both the employee and their working environment are needed.
An overall limitation of the included studies is the lack of use of objective measures to assess changes in physical activity and dietary behavior. Two studies used objective measures to measure physical activity; however, neither study observed any significant effects on these measures.14,23 Dietary behavior was assessed by questionnaire in all related studies15,19–21 and self-report is currently the only realistic method for larger samples.
Cost-effectiveness of the Interventions
Two papers reported on intervention costs17,25 but only one included a cost-effectiveness and cost-benefit analysis.17 The observed results of the Health Under Construction Study are in line with those reported in a recent systematic review of the cost-effectiveness of worksite physical activity and/or nutrition programs. The findings of that systematic review showed that from various perspectives the reviewed programs were not only more costly but also more effective in reducing body weight compared to usual care.38 As noted in the systematic review, there are currently no set levels for how much stakeholders are willing to pay for reductions in body weight, it is up to the individual decision maker to judge whether or not programs offer value for money and whether they are cost-effective. Future studies should include information on cost-effectiveness and cost-benefit as the implementation of interventions depends, among others, on the societal and employer's willingness to pay, not only with regard to health measures but also considering business aspects relevant to the employer. In the area of OHS, this is of utmost importance because in many countries costs related to illness and sick leave are covered by the employer for an initial period. In addition, the employer is often responsible for the costs related to the intervention. A previous study investigating the incentives behind employers' decisions to engage in worksite health promotion concludes that economic incentives are important.39 To further motivate them to invest in worksite health promotion, the economic benefits also need to be addressed when evaluating the effect of the interventions. Studies in this area employing economic evaluation from both an employer and societal perspectives are needed.
Strengths and Limitations of the Review
There are some strengths and limitations of this study that need to be mentioned. A major strength of this review is the comprehensive search for articles, combing electronic databases, and hand searching of journals and reference lists of the included studies. Nevertheless, as promoting physical activity and dietary behavior within the OHS setting is still a relatively new field of health promotion research; there are probably unpublished trials that contain valuable information that was not included. A decision was, however, made to limit this scoping review to peer-reviewed articles. A second strength of this review is related to the first stage of our selection process and specifically to the decision to select all abstract that described an intervention study that evaluated an intervention aimed at physical activity and/or dietary behavior targeting healthy employees. This way the risk of excluding relevant studies that did not describe in their abstracts that the OHS was responsible for the implementation was kept to a minimum. Nevertheless, the fact that in the second stage of the selection process only the first author screened the full-text articles is a limitation of this review. By thoroughly following the exclusion criteria and contacting a second author in case of doubt, potential bias has been kept to a minimum. For the present review, we did not contact authors for article request and for further information. With regard to the article requests, this only concerned 2% of the potentially relevant studies; therefore, we do not believe that this has biased the findings. Moreover, a study conducted by Gibson and colleagues40 showed that two thirds of the authors did not respond to their request for additional information. A third strength of this review is the inclusion of a methodological quality assessment. This makes it easier to interpret the findings. Nevertheless, because of the limited information on the content of the interventions, the rating of the methodological quality of the included studies might be underestimated. A final limitation relates to the generalizability of our findings. Most studies were aimed at risk populations, such as individuals with a higher risk of CVD, and our findings, therefore, cannot be generalized to the general working population underlining the need for a screening instrument. This would suggest that the OHS is mostly used as a channel to reach those specifically in need of risk reduction.
This scoping review fills a gap of knowledge on the effectiveness and cost-effectiveness of health promotion interventions aimed at physical activity and/or dietary behavior, which have been implemented by the OHS. Overall study results on the effectiveness of health promotion through the OHS are promising, especially with regard to interventions containing counseling to individuals with one or more CVD risk factors, either as single component or combined with an environmental component. The good-quality studies reported positive intervention effects on physical activity, sedentary behavior, dietary behavior, and biological risk factors for CVD. Future studies should use objective measures as far as possible as well as economic measures to assess intervention outcomes. These studies should test the effectiveness and cost-effectiveness of interventions containing counseling, physical activity on prescription, and multilevel interventions aimed at the employee at risk as well as the worksite environment.
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