Effect of a Workplace-Based Multicomponent Intervention on Hypertension Control: A Randomized Clinical Trial

Design, rationale, and characterization of the mobile health based occupational cardiovascular risk intervention study (mHealth-OPEN study)

BACKGROUND

The substantial workforce and suboptimal cardiovascular health highlights the urgent need for workplace interventions. This ongoing cluster-randomized trial aims to evaluate the effectiveness, feasibility, and acceptability of a mobile health (mHealth) based comprehensive intervention program to improve cardiovascular health among employees.

METHODS AND RESULTS

We conducted a 1-year, 2-arm, parallel-group, cluster-randomized controlled multicenter trial involving 10,000 participants (aged 18-65, including 1,600 participants with high cardiovascular risk) across 20 workplaces. Workplaces were randomly assigned in a 1:1 ratio to either the intervention or control group. We established a mHealth based multifaceted cardiovascular risk management system that enables intelligent management. The intervention groups received a mHealth-based management with primary prevention inventions for all participants and additional cardiovascular risk interventions for participants with high cardiovascular risk via the system. The control groups received usual care. Primary outcomes included percentage changes in hypertension, diabetes, and dyslipidemia control rates among participants with high cardiovascular risk, and percentage changes in the rate of regular physical activity among all the participants, from baseline to 12-month follow-up. Secondary outcomes included changes in blood pressure, glucose, lipid, treatment adherence, behavioral factors, questionnaire scores, and incidence of major cardiovascular events. By now, baseline recruitment has been completed, with comparable characteristics between management and control groups.

CONCLUSIONS

This rigorous designed mHealth-based workplace intervention demonstrates potential for nationwide implementation, offering cardiovascular benefits for employees.

CLINICAL TRIAL REGISTRATION

www.chictr.org.cn. Identifier: ChiCTR2200066196.

Effect of population-based sodium reduction interventions on blood pressure: a systematic review and meta-analysis of randomized trials

This systematic review and meta-analysis included cluster randomized controlled trials that compared population-based sodium reduction interventions with usual care for blood pressure (BP) management. We searched PubMed, Cochrane Central Register of Controlled Trials, and IchuShi-Web and utilized a random-effects meta-analysis of the weighted mean difference (MD) in the comparison groups to collect data from the included trials. The primary outcome includes the pooled MD of office BP from baseline to each follow-up period. This meta-analysis considered 36 articles with 66,803 participants to be eligible. The population-based sodium reduction interventions decreased office systolic BP (SBP) compared with usual care in 36 studies (MD: -2.64 mmHg [95% confidence interval: -3.48- to 1.80]), with evidence of heterogeneity. Office SBP exhibited significant benefits among in adults (30 studies) and adults/children (1 study) but not in children (5 studies). Furthermore, office diastolic BP demonstrated comparable benefits with office SBP. Sensitivity analyses by cluster type in adults revealed that the workplace-based intervention exerted a greater SBP-lowering effect than the clinic/facility-based intervention. However, no significant difference was observed in the SBP-lowering effect by intervention type. The interventions were more effective in hypertensive cohorts compared with non-hypertensive cohorts and in Asian cohorts compared with non-Asian cohorts. Additionally, the benefits for secondary outcomes, including salt (sodium chloride) intake, were similar to those for office BP. In conclusion, population-based sodium reduction interventions improved BP management compared with usual care. The benefits along with the observed heterogeneity should be considered prudent for implementation in public health and clinical practices. This meta-analysis considered 36 studies with 66,803 participants to be eligible. The population-based sodium reduction interventions decreased office BP compared with usual care in 36 studies, with evidence of heterogeneity. Sensitivity analyses by cluster type in adults (30 studies) revealed that community-, family-, school-, and workplace-based interventions reduced office SBP. Concerning intervention type, sodium reduction counseling, salt substitution, and monitoring decreased office SBP. Interventions were more effective in hypertensive cohorts compared with non-hypertensive cohorts. The benefits for salt intake (22 studies) and urinary sodium excretion (17 studies) were comparable to those for office BP. BP: blood pressure; DBP: diastolic blood pressure; MD: mean difference; Na: sodium; RR: risk ratio; SBP: systolic blood pressure.

The Effects of a 24-Week Combined Circuit Training and Mobility Program on the Physical Fitness and Body Composition of an Adult Academic Community

Workplace physical activity programs (WPAPs) are increasingly being recognized for improving employee health, though the results remain inconsistent. Universities provide favorable settings for WPAPs. This study examined the effects of a 24-week circuit training and mobility program on the physical fitness (PF) and body composition of university employees. Thirty-eight university employees (9 males and 29 females; 51.5 ± 12.6 years) followed a 24-week training program consisting of two circuit training sessions and one mobility session per week. PF (including cardiorespiratory fitness (CRF), grip strength, shoulder mobility, core endurance, lower limb strength, and balance) body composition, anthropometric variables, and physical activity (PA) levels were assessed at baseline (T0), 12 weeks (T1), and 24 weeks (T2). CRF, strength, mobility, and core endurance significantly improved. A body composition analysis indicated a decrease in fat mass and an increase in lean mass at T2. Minor changes were observed in anthropometric variables. Furthermore, PA levels increased throughout the intervention. The 24-week WPAP improved the PF and body composition of university employees.

The "Best of 2024 List" of Health Promotion Researchers

Each year the editorial team of the American Journal of Health Promotion selects our "Best of the Year List" of health promotion studies from the prior year. This editorial features the Editor's Picks Awards, the Editor in Chief Awards, the Michael P. O'Donnell Award and the Dorothy Nyswander Award for the best research and writing published in 2024 in this journal. Our criteria for selection includes: whether the study addresses a topic of timely importance in health promotion, the research question is clearly stated and the study methods used are well executed; whether the paper is often cited and downloaded; if the study findings offer a unique contribution to the literature; and if the paper is well-written and enjoyable to read. Awardees in 2024 offered new insights into research methods, the impact of COVID-19 on individuals and groups, brain health and mental health assessment, climate change perceptions and the role of diversity, equity and inclusion in advancing employee health. This "best of 2024 list" featured studies based in health systems, workplaces and communities and includes case studies and qualitative and quantitative research methods that enabled researchers to better explain what amplifies or hampers well-being.

Association Between the Improvement of Knowledge, Attitude and Practice of Hypertension Prevention and Blood Pressure Control-A Cluster Randomized Controlled Study

BACKGROUND

Hypertension-related knowledge, attitude and practice (KAP) of hypertensive patients can affect the awareness, treatment and control of hypertension. However, little attention has been paid to the association between the change of hypertension preventive KAP and blood pressure (BP) control in occupational population using longitudinal data. We assess the effectiveness of a workplace-based multicomponent hypertension intervention program on improving the level of KAP of hypertension prevention, and the association between improvement in KAP and BP control during intervention.

METHODS

From January 2013 to December 2014, workplaces across 20 urban regions in China were randomized to either the intervention group (n = 40) or control group (n = 20) using a cluster randomized control method. All employees in each workplace were asked to complete a cross-sectional survey to screen for hypertension patients. Hypertension patients in the intervention group were given a 2-year workplace-based multicomponent hypertension intervention for BP control. The level of hypertension prevention KAP and BP were assessed before and after intervention in the two groups.

RESULTS

Overall, 3331 participants (2658 in the intervention group and 673 in the control group) were included (mean [standard deviation] age, 46.2 [7.7] years; 2723 men [81.7%]). After 2-year intervention, the KAP qualified rate was 63.2% in the intervention groups and 50.1% in the control groups (odds ratio = 1.65, 95% CI, 1.36∼2.00, P < .001). Compared with the control group decreased in the qualified rate of each item of hypertension preventive KAP questionnaire, all the items in the intervention group increased to different degrees. The increase of KAP score was associated with the decrease of BP level after intervention. For 1 point increase in KAP score, systolic blood pressure (SBP) decreased by .28 mmHg and diastolic blood pressure (DBP) decreased by .14 mmHg [SBP: β = -.28, 95%CI: -.48∼-.09, P = .004; DBP: β = -.14, 95%CI: -.26∼-.02, P = .024]. SBP and DBP was significantly in manual labor workers (SBP: β = -.34, 95%CI: -.59∼-.09, P = .008; DBP: β = -.23, 95%CI: -.38∼-.08, P = .003), workers from private enterprise, state-owned enterprise (SOE) (SBP: β = -.40, 95%CI: -.64∼-.16, P = .001; DBP: β = -.21, 95%CI: -.36∼-.06, P = .005) and a workplace with an affiliated hospital (SBP: β = -.31, 95%CI: -.52∼-.11, P = .003; DBP: β = -.16, 95%CI: -.28∼-.03, P = .016). The improvement of knowledge (SBP: β = -.29, 95%CI: -.56∼-.02, P = .038; DBP: β = -.12, 95%CI: -.29∼.05, P = .160), as well as attitude (SBP: β = -.71, 95%CI: -1.25∼-.18, P = .009; DBP: β = .18, 95%CI: -.23∼.59, P = .385) and behavior (SBP: β = -.73, 95%CI: -1.22∼-.23, P = .004; DBP: β = -.65, 95%CI: -.97∼-.33, P < .001) was gradually strengthened in relation to BP control.

CONCLUSION

This study found that workplace-based multicomponent hypertension intervention can effectively improve the level of hypertension preventive KAP among employees, and the improvement of KAP levels were significantly associated with BP control.

TRIAL REGISTRATION

Chinese Clinical Trial Registry No. ChiCTR-ECS-14004641.

Multifaceted Intensive Blood Pressure Control Model in Older and Younger Individuals With Hypertension: A Randomized Clinical Trial

Importance

The sustainable effectiveness and safety of a nonphysician community health care practitioner-led intensive blood pressure intervention on cardiovascular disease have not, to the authors' knowledge, been studied, especially in the older adult population.

Objective

To evaluate such a multifaceted model with a more stringent blood pressure treatment goal (<130/80 mm Hg) among patients aged 60 years and older with hypertension.

Design, Setting, and Participants

This was a 48-month follow-up study of the China Rural Hypertension Control Project (CRHCP), an open-cluster randomized clinical trial, conducted from 2018 to 2023. Participants 60 years and older and younger than 60 years with a diagnosis of hypertension from the CRHCP trial were included for analysis. Individuals were recruited from 326 villages in rural China.

Interventions

The well-trained, nonphysician, community health care practitioner implemented a multifaceted intervention program (eg, initiation or titration of antihypertensive medications) to achieve a blood pressure level of less than 130/80 mm Hg, supervised by primary care physicians.

Main Outcomes and Measures

Cardiovascular disease (a composite of myocardial infarction, stroke, heart failure requiring hospitalization, and cardiovascular disease death).

Results

A total of 22 386 individuals 60 years and older with hypertension and 11 609 individuals younger than 60 years with hypertension were included in the analysis. The mean (SD) age of the participants was 63.0 (9.0) years and included 20 825 females (61.3%). Among the older individuals with hypertension, a total of 11 289 patients were randomly assigned to the intervention group and 11 097 to the usual-care group. During a median (IQR) of 4.0 (4.0-4.1) years, there was a significantly lower rate of total cardiovascular disease (1133 [2.7%] vs 1433 [3.5%] per year; hazard ratio [HR], 0.75; 95% CI, 0.69-0.81; P < .001) and all-cause mortality (1111 [2.5%] vs 1210 [2.8%] per year; HR, 0.90; 95% CI, 0.83-0.98; P = .01) in the intervention group than in the usual-care group. For patients younger than 60 years, the risk reductions were also significant for total cardiovascular disease (HR, 0.64; 95% CI, 0.56-0.75; P < .001), stroke (HR, 0.64; 95% CI, 0.55-0.76; P < .001), heart failure (HR, 0.39; 95% CI, 0.18-0.87; P = .02), and cardiovascular death (HR, 0.54; 95% CI, 0.37-0.77; P < .001), with all interaction P values for age groups greater than .05. In both age categories, the incidences of injurious falls, symptomatic hypotension, syncope, and the results for kidney outcomes did not differ significantly between groups.

Conclusions and Relevance

In both the aging and younger general population with hypertension, the nonphysician health care practitioner-led, multifaceted, intensive blood pressure intervention model could effectively and safely reduce the risk of cardiovascular disease and all-cause death.

Trial Registration

ClinicalTrials.gov Identifier: NCT03527719.

A retrospective cohort study of a community-based primary care program's effects on pharmacotherapy quality in low-income Peruvians with type 2 diabetes and hypertension

Little is known about the effects of the Chronic Care Model (CCM) and community health workers (CHWs) on pharmacotherapy of type 2 diabetes and hypertension in resource-poor settings. This retrospective cohort implementation study evaluated the effects of a community-based program consisting of CCM, CHWs, guidelines-based treatment protocols, and inexpensive freely accessible medications on type 2 diabetes and hypertension pharmacotherapy quality. A door-to-door household survey identified 856 adults 35 years of age and older living in a low-income Peruvian community, of whom 83% participated in screening for diabetes and hypertension. Patients with confirmed type 2 diabetes and/or hypertension participated in the program's weekly to monthly visits for < = 27 months. The program was implemented as two care periods employed sequentially. During home care, CHWs made weekly home visits and a physician made treatment decisions remotely. During subsequent clinic care, a physician attended patients in a centralized clinic. The study compared the effects of program (pre- versus post-) (N = 262 observations), and home versus clinic care periods (N = 211 observations) on standards of treatment with hypoglycemic and antihypertensive agents, angiotensin converting enzyme inhibitors, and low-dose aspirin. During the program, 80% and 50% achieved hypoglycemic and antihypertensive standards, respectively, compared to 35% and 8% prior to the program, RRs 2.29 (1.72-3.04, p <0.001) and 6.64 (3.17-13.9, p<0.001). Achievement of treatment standards was not improved by clinic compared to home care (RRs 1.0 +/- 0.08). In both care periods, longer retention in care (>50% of allowable time) was associated with achievement of all treatment standards. 85% compared to 56% achieved the hypoglycemic treatment standard with longer and shorter retention, respectively, RR 1.52 (1.13-2.06, p<0.001); 56% compared to 27% achieved the antihypertensive standard, RR 2.11 (1.29-3.45, p<0.001). In a dose-dependent manner, the community-based program was associated with improved guidelines-based pharmacotherapy of type 2 diabetes and hypertension.

Gender-Specific Clustering of Lifestyle Behaviors and Its Impacts on Cardiovascular Health

BACKGROUND

Unhealthy lifestyle behaviors associated with cardiovascular risk manifest a clustering pattern.

OBJECTIVE

Our aim was to identify behavioral clusters by using 5 unhealthy lifestyle behaviors among the Korean population and examine the impacts of identified behavioral clusters on cardiovascular health (CVH).

METHODS

A cross-sectional study was conducted using data from the sixth Korea National Health and Nutrition Examination Survey. The participants were 7898, aged 19 to 64 years. The cluster analysis was performed using the behaviors of current smoking, binge drinking, physical inactivity, insufficient fruit intake, and sugar-sweetened beverage drinking. Cardiovascular health was defined as a composite modified z score calculated using biophysical factors.

RESULTS

Men manifested 4 clusters (ie, risky binge drinkers, dominant smokers, dominant sugar-sweetened beverage drinkers, and nonsubstance/low-fruit eaters) characterized predominantly by substance use; women had 4 clusters (ie, substance users, physically inactive/low-fruit eaters, physically inactive/fruit eaters, and active adherers) characterized predominantly by physical inactivity. Among men, the clusters of dominant smokers and risky binge drinkers had significantly lower CVH scores than those with poor eating behaviors. Among women, the clusters of substance users and physically inactive/low-fruit eaters had significantly lower CVH scores than the active adherers. All the clusters in men had lower CVH scores than the worst cluster in women.

CONCLUSIONS

There was a gender difference in the clustering pattern. The clusters with smoking and binge drinking in men and women were associated with negative impacts on CVH. Healthcare professionals should pay attention to the clustering pattern to design an efficient lifestyle intervention for cardiovascular disease prevention.

Types and Effectiveness of Community-Based Cardiovascular Disease Preventive Interventions in Reducing Alcohol Consumption: A Systematic Review and Meta-Analysis

Cardiovascular disease (CVD) poses a global health challenge, with modifiable risk factors, notably alcohol consumption, impacting its onset and progression. This review synthesizes evidence on the types and effectiveness of community-based interventions (CBIs) aimed at reducing alcohol consumption for CVD prevention. Electronic databases were systematically searched until October 31, 2019, with updates until February 28, 2023. Given the heterogeneity in outcome measures, we narratively synthesized the effectiveness of CBIs, adhering to the synthesis without meta-analysis (SWiM) guidelines for transparent reporting. For selected homogenous studies, a random-effects meta-analysis was utilized to estimate the effects of CBIs on alcohol consumption. Twenty-two eligible studies were included, with 16 demonstrating that CBIs reduced alcohol consumption compared to controls. Meta-analysis findings revealed reductions in above moderate-level alcohol consumption (pooled odds ratio (OR)=0.50, 95% confidence interval (CI): 0.37, 0.68), number of alcohol drinks per week (standardized mean difference=-0.08, 95% CI: -0.14, -0.03), and increased odds of low-risk drinking (pooled OR=1.99, 95% CI: 1.04, 3.81) compared to the control groups. Multi-component interventions (particularly those combining health education, awareness, and promotion activities) and those interventions with a duration of 12 months or more were notably effective. The beneficial effects of CBIs focusing on achieving a reduction in alcohol consumption showed promising outcomes. Implementing such interventions, especially multicomponent interventions, could play a significant role in mitigating the increasing burden of CVDs. Future studies should also consider employing standardized and validated tools to measure alcohol consumption outcomes to enhance the consistency and comparability of findings.

Cost-Effectiveness of a Workplace-Based Hypertension Management Program in Real-World Practice in the Kailuan Study

BACKGROUND

In 2009, a workplace-based hypertension management program was launched among men with hypertension in the Kailuan study. This program involved monitoring blood pressure semimonthly, providing free antihypertensive medications, and offering personalized health consultations. However, the cost-effectiveness of this program remains unclear.

METHODS AND RESULTS

This analysis included 12 240 participants, with 6120 in each of the management and control groups. Using a microsimulation model derived from 10-year follow-up data, we estimated costs, quality-adjusted life years (QALYs), life-years, and incremental cost-effectiveness ratios (ICERs) for workplace-based management compared with routine care in both the study period and over a lifetime. Analyses are conducted from the societal perspective. Over the 10-year follow-up, patients in the management group experienced an average gain of 0.06 QALYs with associated incremental costs of $633.17 (4366.85 RMB). Projecting over a lifetime, the management group was estimated to increase by 0.88 QALYs or 0.92 life-years compared with the control group, with an incremental cost of $1638.64 (11 301.37 RMB). This results in an incremental cost-effectiveness ratio of $1855.47 per QALY gained and $1780.27 per life-year gained, respectively, when comparing workplace-based management with routine care. In probabilistic sensitivity analyses, with a threshold willingness-to-pay of $30 765 per QALY (3 times 2019 gross domestic product per capita), the management group showed a 100% likelihood of being cost-effective in 10 000 samples.

CONCLUSIONS

Workplace-based management, compared with routine care for Chinese men with hypertension, could be cost-effective both during the study period and over a lifetime, and might be considered in working populations in China and elsewhere.

Cardiovascular Risk Factors in China

The Annual Report on Cardiovascular Health and Diseases in China (2022) intricate landscape of cardiovascular health in China. This section dissects cardiovascular risk factors in China which including hypertension, dyslipidemia, diabetes mellitus, chronic kidney disease, metabolic syndrome and air pollution. Hypertension prevalence has steadily increased in China, with efforts to control it facing challenges in achieving optimal rates, especially in rural areas. Interventions like salt substitutes and intensive blood pressure control show promise but need improvement. Abnormal lipid levels, indicative of dyslipidemia, have risen significantly, posing a risk for cardiovascular diseases. Despite efforts, many patients struggle to achieve target lipid levels, necessitating improved treatment strategies. Both type 1 and type 2 diabetes mellitus affect millions of adults in China, with long-term complications adding to the disease burden. Early intervention and effective management are crucial to mitigate its impact. Prevalent among older adults, chronic kidney disease is associated with diabetes mellitus, hypertension, and cardiovascular diseases, necessitating comprehensive management approaches. The prevalence of metabolic syndrome, characterized by a cluster of risk factors, has increased in both adults and adolescents, calling for lifestyle modifications and public health interventions. Ambient and household air pollution remain significant environmental risk factors, despite some improvements in air quality. Continued efforts to reduce emissions are essential for mitigating associated health risks. Addressing these risk factors requires a multifaceted approach, including public health initiatives, policy interventions, and individual-level strategies to promote healthy lifestyles and reduce environmental exposures. Surveillance and research efforts are crucial for monitoring trends and developing effective strategies to lessen the burden of cardiovascular diseases in China.

Workplace-based primary prevention intervention reduces incidence of hypertension: a post hoc analysis of cluster randomized controlled study

BACKGROUND

A workplace-based primary prevention intervention be an effective approach to reducing the incidence of hypertension (HTN). However, few studies to date have addressed the effect among the Chinese working population. We assessed the effect of a workplace-based multicomponent prevention interventions program for cardiovascular disease on reducing the occurrence of HTN through encouraging employees to adopt a healthy lifestyle.

METHODS

In this post hoc analysis of cluster randomized controlled study, 60 workplaces across 20 urban regions in China were randomized to either the intervention group (n = 40) or control group (n = 20). All employees in each workplace were asked to complete a baseline survey after randomization for obtaining sociodemographic information, health status, lifestyle, etc. Employees in the intervention group were given a 2-year workplace-based primary prevention intervention program for improving their cardiovascular health, including (1) cardiovascular health education, (2) a reasonable diet, (3) tobacco cessation, (4) physical environment promotion, (5) physical activity, (6) stress management, and (7) health screening. The primary outcome was the incidence of HTN, and the secondary outcomes were improvements of blood pressure (BP) levels and lifestyle factors from baseline to 24 months. A mix effect model was used to assess the intervention effect at the end of the intervention in the two groups.

RESULTS

Overall, 24,396 participants (18,170 in the intervention group and 6,226 in the control group) were included (mean [standard deviation] age, 39.3 [9.1] years; 14,727 men [60.4%]). After 24 months of the intervention, the incidence of HTN was 8.0% in the intervention groups and 9.6% in the control groups [relative risk (RR) = 0.66, 95% CI, 0.58 ~ 0.76, P < 0.001]. The intervention effect was significant on systolic BP (SBP) level (β =  - 0.7 mm Hg, 95% CI, - 1.06 ~  - 0.35; P < 0.001) and on diastolic BP (DBP) level (β =  - 1.0 mm Hg, 95% CI, - 1.31 ~  - 0.76; P < 0.001). Moreover, greater improvements were reported in the rates of regular exercise [odd ratio (OR) = 1.39, 95% CI, 1.28 ~ 1.50; P < 0.001], excessive intake of fatty food (OR = 0.54, 95% CI, 0.50 ~ 0.59; P < 0.001), and restrictive use of salt (OR = 1.22, 95% CI, 1.09 ~ 1.36; P = 0.001) in intervention groups. People with a deteriorating lifestyle had higher rates of developing HTN than those with the same or improved lifestyle. Subgroup analysis showed that the intervention effect of BP on employees with educational attainment of high school above (SBP: β =  - 1.38/ - 0.76 mm Hg, P < 0.05; DBP: β =  - 2.26/ - 0.75 mm Hg, P < 0.001), manual labor workers and administrative worker (SBP: β =  - 1.04/ - 1.66 mm Hg, P < 0.05; DBP: β =  - 1.85/ - 0.40 mm Hg, P < 0.05), and employees from a workplace with an affiliated hospital (SBP: β =  - 2.63 mm Hg, P < 0.001; DBP: β =  - 1.93 mm Hg, P < 0.001) were significantly in the intervention group.

CONCLUSIONS

This post hoc analysis found that workplace-based primary prevention interventions program for cardiovascular disease were effective in promoting healthy lifestyle and reducing the incidence of HTN among employees.

TRIAL REGISTRATION

Chinese Clinical Trial Registry No. ChiCTR-ECS-14004641.

Interventions and management on multimorbidity: An overview of systematic reviews

BACKGROUND

Multimorbidity poses an immense burden on the healthcare systems globally, whereas the management strategies and guidelines for multimorbidity are poorly established. We aim to synthesize current evidence on interventions and management of multimorbidity.

METHODS

We searched four electronic databases (PubMed, Embase, Web of Science, and the Cochrane Database of Systematic Reviews). Systematic reviews (SRs) on interventions or management of multimorbidity were included and evaluated. The methodological quality of each SR was assessed by the AMSTAR-2 tool, and the quality of evidence on the effectiveness of interventions was assessed by the grading of recommendations assessment, development and evaluation (GRADE) system.

RESULTS

A total of 30 SRs (464 unique underlying studies) were included, including 20 SRs of interventions and 10 SRs summarizing evidence on management of multimorbidity. Four categories of interventions were identified: patient-level interventions, provider-level interventions, organization-level interventions, and combined interventions (combining the aforementioned two or three- level components). The outcomes were categorized into six types: physical conditions/outcomes, mental conditions/outcomes, psychosocial outcomes/general health, healthcare utilization and costs, patients' behaviors, and care process outcomes. Combined interventions (with patient-level and provider-level components) were more effective in promoting physical conditions/outcomes, while patient-level interventions were more effective in promoting mental conditions/outcomes and psychosocial outcomes/general health. As for healthcare utilization and care process outcomes, organization-level and combined interventions (with organization-level components) were more effective. The challenges in the management of multimorbidity at the patient, provider and organizational levels were also summarized.

CONCLUSION

Combined interventions for multimorbidity at different levels would be favored to promote different types of health outcomes. Challenges exist in the management at the patient, provider, and organization levels. Therefore, a holistic and integrated approach of patient-, provider- and organization- level interventions is required to address the challenges and optimize care of patients with multimorbidity.

The Twenty Five Most Important Studies in Workplace Health Promotion

In what direction has workplace wellness research been evolving over the past 20 years? What proportion of occupational health researchers have been focusing on how health impacts work compared to researchers who ask how work affects health? This editorial poses an audacious, albeit largely subjective, question. That is, what have been the most important research studies about workplace wellness? Readers are invited to respond with their opinions about seminal studies we missed. Readers are also challenged with a thought experiment and exercise designed to organize the past decades of workplace wellness studies into a table that identifies trends in this research domain. Based on trends, I posit that researchers are waning in their interest in how health affects work productivity and healthcare costs and waxing in their considerations of how work affects well-being.

Effect of a Multicomponent Intervention Delivered on a Web-Based Platform on Hypertension Control: A Cluster Randomized Clinical Trial

IMPORTANCE

The prevalence of hypertension is high and still increasing across the world, while the control rate remains low in many countries. Emerging technology, such as telemedicine, may offer additional support to change the unsatisfactory situation.

OBJECTIVE

To establish a multicomponent intervention delivered on a web-based telemedicine platform and oriented with the Chinese hypertension management guidelines and to evaluate the effect of the intervention on blood pressure (BP) control for patients with hypertension.

DESIGN, SETTING, AND PARTICIPANTS

This cluster randomized clinical trial of a hypertension management program was conducted at 66 community health centers in China from October 1, 2018, to May 31, 2020, with a 12-month follow-up. Patients with hypertension were blinded to randomization and were randomized to either the intervention group or control group. Hypertension was diagnosed at mean systolic BP (SBP) and diastolic BP (DBP) readings higher than 140 and 90 mm Hg or with use of antihypertensive medication. Evaluation of the intervention effect was based on the principle of modified intention to treat.

INTERVENTIONS

Multicomponent intervention was delivered on a web-based platform and consisted of a primary prevention program for cardiovascular disease and standardized management for hypertension.

MAIN OUTCOMES AND MEASURES

The primary outcome was the change in BP control rate (SBP and DBP levels <140 and 90 mm Hg, or <130 and 80 mm Hg for patients with diabetes) from baseline to the 12-month follow-up among patients with hypertension in the intervention and control groups.

RESULTS

A total of 4118 patients (mean [SD] age, 61.6 [9.4] years; 2265 women [55.0%]) were included in the analysis, with 2985 in the intervention group and 1133 in the control group. The BP control rate at baseline was 22.8% in the intervention group and 22.5% in the control group. After 12 months of the intervention, the BP control rate for the intervention group compared with the control group was significantly higher (47.4% vs 30.2%; odds ratio, 1.18; 95% CI, 1.13-1.24; P < .001). The intervention effect on SBP level was -10.1 mm Hg (95% CI, -11.7 to -8.5 mm Hg; P < .001) and on DBP level was -1.8 mm Hg (95% CI, -2.8 to -0.8 mm Hg; P < .001).

CONCLUSIONS AND RELEVANCE

Results of this trial showed that a multicomponent intervention delivered on a web-based platform improved BP control rate and lowered BP level more than usual care alone. Such a telemedicine program may provide a new, effective way to treat patients with hypertension in the community and may generate public health benefits across diverse populations.

TRIAL REGISTRATION

Chinese Clinical Trial Registry Identifier: ChiCTR1800017791.

A novel blood pressure monitoring technique by smart HUAWEI WATCH: A validation study according to the ANSI/AAMI/ISO 81060-2:2018 guidelines

Background

Given the rapid innovation of wearable technology, additional physical indicators can be detected, and blood pressure (BP) has become the focus of many emerging medical-device manufacturers. This study aimed to validate the accuracy of the newly developed HUAWEI WATCH in BP monitoring, according to the American National Standards Institute/Association for the Advancement of Medical Instrumentation/International Organization for Standardization (ANSI/AAMI/ISO 81060-2:2018) guidelines.

Materials and methods

The same arm sequential BP measurement was applied. One validation included four reference BP measurements taken simultaneously by two independent observers using a mercury sphygmomanometer, alternating with three test-watch measurements. Each test-watch measurement was compared against the average of the previous and subsequent reference BP readings. Two criteria were required for validation: (1) a mean BP difference of 5 mm Hg or less, with a standard deviation (SD) of 8 mm Hg or less for systolic blood pressure (SBP) and diastolic blood pressure (DBP) in the 255 pairs of measurements, and (2) an SD for the of 85 averaged BP differences within the threshold defined by the mean test-reference BP difference listed in the ANSI/AAMI/ISO 81060-2:2018 guidelines.

Results

The mean age of the 85 participants was 48 ± 18 years (range: 21–85), and 53 (62.4%) were male. The mean differences between the test and reference BPs were -0.25 ± 5.62 mm Hg and -1.33 ± 6.81 mm Hg for SBP and DBP, respectively (according to Criterion 1). The mean differences between the test BPs and reference BPs were -0.25 ± 5.00 mm Hg and -1.33 ± 6.31 mm Hg for SBP and DBP, respectively, according to Criterion 2.

Conclusion

Blood pressure measurement using the HUAWEI WATCH showed excellent consistency with reference BPs, and fulfilled both validation criteria of the guidelines, show its promise as a wearable device for BP self-monitoring.

Smoking causes the disorder of glucose metabolism under different levels of blood pressure in male occupational population

Smoking is an important modifiable factor in the risk of type 2 diabetes. Type 2 diabetes and hypertension overlap in the population. The present study investigated effects of smoking on glucose metabolism under different blood pressure (BP) levels in occupational population. A smoking survey among occupational groups was conducted in 2018. The general linear model was used to analyze the differences of glucose metabolism indexes and BP indexes influenced by different smoking intensity (never 0, mild <10, moderate <20, heavy ≥20 pack‐years). Odds ratios of developing diabetes and β‐cell deficiency were analyzed by using logistic regression model. BP was further taken into account in the relationship between smoking and glucose metabolism. As a result, 1730 male workers aged 21 to 60 years were included in the analysis finally. Compared to never smokers, heavy smokers had significantly increased fasting plasma glucose. Moderate and above smokers had significantly increased glycosylated hemoglobin, decreased fasting plasma insulin and β‐cell function, after adjustment for covariates. Further, smoking intensity was found to have a dose‐dependent relationship with impaired β‐cell function and diabetes. In conclusion, smoking has a positive dose‐dependent relationship with β‐cell deficiency and diabetes. Male smoking workers, especially the moderate or higher smoking, with high‐normal and high BP levels are at high risk of abnormal glucose metabolism.

Missed opportunities in hypertension risk factors screening in Indonesia: a mixed-methods evaluation of integrated health post (POSBINDU) implementation

OBJECTIVES

To assess the implementation and contextual barriers of POSBINDU, a community-based activity focusing on screening of non-communicable diseases (NCDs), mainly hypertension and diabetes, in Indonesia.

DESIGN

This was a concurrent mixed-methods study, with a cross-sectional analysis of secondary data and focus group discussions (FGDs) on stakeholder of POSBINDU.

SETTING

The study was conducted in seven districts in three provinces in Indonesia, with approximately 50% of the primary healthcare (PHC) were selected as areas for data collection (n PHC=100).

PARTICIPANTS

From 475 POSBINDU sites, we collected secondary data from 54 224 participants. For the qualitative approach, 21 FGDs and 2 in-depth interviews were held among a total of 223 informants.

PRIMARY OUTCOMES AND MEASURES

Proportion of POSBINDU visitors getting the hypertension screening and risk factors' assessment, and barriers of POSBINDU implementation.

RESULTS

Out of the 114 581 POSBINDU visits by 54 224 participants, most (80%) were women and adults over 50 years old (50%) showing a suboptimal coverage of men and younger adults. Approximately 95.1% of visitors got their blood pressure measured during their first visit; 35.3% of whom had elevated blood pressure. Less than 25% of the visitors reported to be interviewed for NCDs risk factors during their first visit, less than 80% had anthropometric measurements and less than 15% had blood cholesterol examinations. We revealed lack of resources and limited time to perform the complexities of activities and reporting as main barrier for effective hypertension screening in Indonesia.

CONCLUSIONS

This study showed missed opportunities in hypertension risk factors screening in Indonesia. The barriers include a lack of access and implementation barriers (capability, resources and protocols).

Application of P4 (Predictive, Preventive, Personalized, Participatory) Approach to Occupational Medicine

In recent years there has been a growth in the role of prevention in controlling the disease burden. Increasing efforts have been conveyed in the screening implementation and public health policies, and the spreading knowledge on risk factors reflects on major attention to health checks. Despite this, lifestyle changes are difficult to be adopted and the adherence to current public health services like screening and vaccinations remains suboptimal. Additionally, the prevalence and outcome of different chronic diseases and cancers is burdened by social disparities. P4 [predictive, preventive, personalized, participatory] medicine is the conceptualization of a new health care model, based on multidimensional data and machine-learning algorithms in order to develop public health intervention and monitoring the health status of the population with focus on wellbeing and healthy ageing. Each of the characteristics of P4 medicine is relevant to occupational medicine, and indeed the P4 approach appears to be particularly relevant to this discipline. In this review, we discuss the potential applications of P4 to occupational medicine, showing examples of its introduction on workplaces and hypothesizing its further implementation at the occupational level.

The "Best of 2021 List" of Health Promotion Researchers

Each year the editorial team of the American Journal of Health Promotion selects our "Best of the Year List" of health promotion studies from the prior year. This editorial features the Editor's Picks Awards, the Editor in Chief Awards, the Michael P. O'Donnell Award and the Dorothy Nyswander Award for the research and writing published in 2021 in this journal. Our criteria for selection includes: whether the study addresses a topic of timely importance in health promotion, the research question is clearly stated and the methodologies used are well executed; whether the paper is often cited and downloaded; if the study findings offer a unique contribution to the literature; and if the paper is well-written and enjoyable to read. Awardees in 2021 offered new insights into addressing discrimination against race or sexual identity, preferred sources of information about COVID-19 and the impact of community and workplace interventions on healthy lifestyles. This year's award winning research spans from character to culture relative to improving well-being.

Effectiveness of a Workplace-Based, Multicomponent Hypertension Management Program in Real-World Practice: A Propensity-Matched Analysis

Limited studies had investigated the potential benefits of workplace-based hypertension management programs on long-term blood pressure (BP) control and health outcomes. This study used the propensity score matching to examine the effectiveness of a workplace-based hypertension management program on BP control and risks of major adverse cardiovascular events and all-cause mortality. Within the Kailuan study, a workplace-based hypertension management program was initiated in 2009 among men with hypertension, which included regular BP measuring (twice a month), free antihypertensive medications, and individualized health consultation. Participants were followed until loss to follow-up, death, or December 31, 2019. Among 17 724 male hypertensives aged 18 to 60 years, 6400 participated in the program. The propensity score matching yielded 6120 participants in the management group and 6120 participants in the control group. Both systolic and diastolic BPs were significantly lower in the management group than in the control group over follow-up, and the mean between-group difference at the 10th year was -7.83 (95% CI, -9.06 to -6.62) mm Hg for systolic BP and -4.72 (95% CI, -5.46 to -3.97) mm Hg for diastolic BP. Participants in the program were more likely to achieve BP control (odds ratio, 1.70 [95% CI, 1.41-2.06]) and had significantly lower risks of major adverse cardiovascular events (hazard ratio, 0.83 [95% CI, 0.72-0.94]) and all-cause mortality (hazard ratio, 0.71 [95% CI, 0.58-0.86]), compared with those who were not in the program. A workplace-based hypertension management program was related to reduced BP levels and lower risks of major adverse cardiovascular events and mortality in Chinese men with hypertension.

External Validity and Worksite Wellness: Lessons From China and Illinois

This editorial describes recent randomized controlled trials of worksite wellness interventions and argues that fidelity to intervention designs should be contingent on careful consideration of internal and external validity. A China based hypertension management study which achieved impressive outcomes across 60 workplaces using a comprehensive approach is contrasted with the traditional wellness practices employed in other randomized controlled trials conducted in America. Why studies with negative findings receive more media and professional scrutiny than studies with positive findings is discussed. Three reasons are posited for why bad is stronger than good when it comes to capturing attention. Adoption of new evidence is discussed along with what health promotion professionals can do to advance best practices by considering adoption as an ongoing process.

Cluster-randomized controlled trial for the early promotion of clinic visits for untreated hypertension

Despite clear evidence of the benefits of lowering blood pressure among patients with hypertension, the treatment rate remains <40% worldwide. In the present trial, we aimed to investigate the effects of the early promotion of clinic visits among patients with untreated hypertension detected during annual health checkups. This was a worksite-based, parallel group, cluster-randomized trial with blinded outcome assessment. Employees of 152 Japanese supermarket stores found to have untreated hypertension (blood pressure levels ≥ 160/100 mmHg) during health checkups were assigned to an early promotion group (encouraged to visit a clinic in face-to-face interviews and provided with a referral letter to a physician as well as a leaflet) or a control group (received usual care), according to random assignment. The primary outcome was the completion of a clinic visit within 6 months. Odds ratios with 95% confidence intervals for the early promotion group versus the control group were estimated using multilevel logistic regression with random effects of clusters. A total of 273 participants (mean age 50.3 years, 55% women) from 107 stores were assigned to the early promotion group (138 from 55 stores) or control group (135 from 52 stores). During the 6-month follow-up, 47 (34.1%) participants in the early promotion group visited a clinic, as did 26 (19.3%) in the control group (odds ratio 2.33, 95% confidence interval 1.12-4.84, P = 0.024). Early promotion using a referral letter during health checkups significantly increased the number of clinic visits within 6 months completed by participants with untreated hypertension (UMIN000025411).