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Journal of Nursing Administration:
doi: 10.1097/NNA.0b013e31821c464d
Departments: Staff Issues

Physical Activity and Diet-Focused Worksite Health Promotion for Direct Care Workers

Flannery, Kelly MS, RN; Resnick, Barbara PhD, FAANP, FAAN, CRNP; Galik, Elizabeth PhD, CRNP; Lipscomb, Jane PhD, FAAN, RN

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Author Information

Author Affiliations: Doctoral Student (Ms Flannery), Professor (Dr Resnick), Assistant Professor (Dr Galik), Professor (Dr Lipscomb), School of Nursing, University of Maryland Baltimore.

Correspondence: Ms Flannery, 655 W Lombard Street, Room 390, Baltimore, MD 21201 (

Direct care workers (DCWs), defined as nursing assistants, home health aides, and/or personal home care assistants, are at risk for cardiovascular disease (CVD). Worksite health promotion (WHP) programs can significantly reduce DCWs' CVD risk factors. Nurse executives should advocate for WHP as an innovative way to improve the health of workers, generate savings, and possibly reduce DCW turnover. Evidence- and theory-based recommendations and examples are provided to improve upon prior limitations.

Affecting more than 81 million Americans, CVD causes approximately one-third of their deaths. African Americans and Hispanics have a disproportionally higher incidence of many CVD risk factors and African Americans often have multiple CVD risk factors.1

Physical inactivity and poor nutrition are major public health problems that increase the risk of CVD. For example, when looking at African American women, only 36.1% exercise regularly, only 8.7% meet the guidelines for sodium intake, and only 40.1% meet the guidelines for saturated fat intake. A major barrier to adhering to CVD risk factor recommendations is the lack of information and resources.1

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Worksite Health Promotion

Worksite health promotion programs increase workers' opportunities for physical activity, healthy food, and health resources,2 which is particularly important for workers with limited information and resources. Participation in WHP programs with diet and/or physical activity interventions has resulted in weight loss2,3 and improvement in diabetes risk, lipid panel, and physical activity.3 For employers, WHP is cost-effective because it can reduce healthcare costs,2 reduce absenteeism,3 reduce job-related stress,3 reduce musculoskeletal complaints,4,5 improve productivity,2 improve employee attitudes about pay and supervision,6 and thereby decrease turnover.7

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Direct Care Workers

Nationally, there are more than 3 million DCWs, and more than half are women (88%) and a member of a minority group (52%).8 These individuals tend to be at risk for CVD because of excess body weight,9,10 high body fat,9 and low levels of physical activity.10,11

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Previous WHP Research

Previous studies were done testing the impact of WHP on DCWs in acute care,5 home health,4,9 and geriatric long-term care.11,12 Findings have consistently demonstrated improvements in muscle strength,5,9,11,12 and there was some evidence to show improvements in cardiorespiratory fitness,5,9 body weight,9 body fat,9 musculoskeletal symptoms,4,5 job strain,12 work-related fatigue,5 adjustment into geriatric work,12 and workability.9 To date, 5 WHP studies with workers have been done,4,5,9,11,12 and none were guided by a theoretical framework.

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Challenges and Solutions

Challenges to getting DCWs' participation in WHP are a persistent belief that they engage in sufficient physical activity as part of the job responsibilities,10 patient care responsibilities that are time dependent and require constant coverage,4,11 and multiple family and personal responsibilities outside the work setting.10 To address these challenges, WHP should be guided by the social ecological model and self-efficacy theory. The social ecological model includes 4 levels: individual, social and cultural, organizational, and community.13 When implementing individual-level interventions in the social ecological model, self-efficacy theory should be used to address participant motivation.14

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Best Practices in WHP

Worksite health promotion for DCWs should include The Community Guide's15 recommendations and specifically incorporate health education, policy and environmental changes, and behavioral and social interventions. Table 1 provides an operationalization of these recommendations guided by the social ecological model and self-efficacy theory. The evidence-based intervention components presented in Table 1 detail the intervention of pilot work (Worksite Heart Health Improvement Project) conducted by the authors with 24 nursing assistants in a geriatric long-term care facility. This physical activity and diet WHP pilot study was approved by University of Maryland's institutional review board and was funded by Sigma Theta Tau International.

Table 1
Table 1
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Implications for Practice

Nurse executives should advocate for WHP programs because they are an innovative way to improve the health of DCWs and generate savings through improved productivity, improved overall job satisfaction/attitude, reduced healthcare cost, reduced job stress, reduced absenteeism, and reduced turnover. In addition, WHP may also translate into better patient outcomes because DCWs will likely transfer their new physical activity, diet knowledge, and engagement in healthy behaviors to their patients.

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1. Lloyd-Jones D, Adams RJ, Brown TM, et al. Heart disease and stroke statistics-2010 update: a report from the American Heart Association. Circulation. 2010;121(17):e46-e215.

2. Anderson LM, Quinn TA, Glanz K, et al. The effectiveness of worksite nutrition and physical activity interventions for controlling employee overweight and obesity: a systematic review. Am J Prev Med. 2009;37(4):340-357.

3. Conn VS, Hafdahl AR, Cooper PS, Brown LM, Lusk SL. Meta-analysis of workplace physical activity interventions. Am J Prev Med. 2009;37(4):330-339.

4. Gerdle B, Brunlin C, Elert J, Eliasson P, Granlund B. Effects of a general fitness programme on musculoskeletal symptoms, clinical status, physiological capacity, and perceived work environment among home care service personnel. J Occup Rehabil. 1995;5:1-16.

5. Härmä MI, Ilmarinen J, Knauth P, Rutenfranz JH, Hänninen O. Physical training intervention in female shift workers, I: the effects of intervention on fitness, fatigue, sleep, and psychosomatic symptoms. Ergonomics. 1988;31(1):39-50.

6. Holzbach RL, Piserchia PV, McFadden DW, Hatwell TD, Herrman A, Fielding JE. Effect of a comprehensive health promotion program on employee attitudes. J Occup Med. 1990;32(10):973-978.

7. Health Resources and Services Administration. Nursing aides, home health aides, and related health care occupations-national and local workforce shortages and associated data needs. Available at Updated 2004. Accessed February 28, 2010.

8. Paraprofessional Healthcare Institute. Who are direct-care workers? Facts. 2009;3:1-4.

9. Pohjonen T, Ranta R. Effects of worksite physical exercise intervention on physical fitness, perceived health status, and work ability among home care workers: five-year follow-up. Prev Med. 2001;32(6):465-475.

10. Nelson MA. Health practices and role involvement among low-income working women. Health Care Women Int. 1997;18(2):195.

11. Skargren E, Oberg B. Effects of an exercise program on musculoskeletal symptoms and physical capacity among nursing staff. Scand J Med Sci Sports. 1996;6(2):122-130.

12. Dehlin O, Berg S, Hedenrud B, Andersson G, Grimby G. Muscle training, psychological perception of work and low-back symptoms in nursing aides. The effect of trunk and quadriceps muscle training on the psychological perception of work and on the subjective assessment of low-back insufficiency. A study in a geriatric hospital. Scand J Rehabil Med. 1978;10(4):201-209.

13. Sallis JF, Glanaz K. Physical activity and food environments: solutions to the obesity epidemic. Milbank Q. 2009;87(1):123.

14. Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev. 1977;84(2):191-215.

15. The Community Guide. Obesity prevention and control: worksite programs. Available at Updated 2010. Accessed January 18, 2011.

© 2011 Lippincott Williams & Wilkins, Inc.