Promoting worksite smoking control policies and actions: the Community Intervention Trial for Smoking Cessation (COMMIT) experience. The COMMIT Research Group

Strategies to improve the implementation of workplace-based policies or practices targeting tobacco, alcohol, diet, physical activity and obesity

BACKGROUND

Given the substantial period of time adults spend in their workplaces each day, these provide an opportune setting for interventions addressing modifiable behavioural risk factors for chronic disease. Previous reviews of trials of workplace-based interventions suggest they can be effective in modifying a range of risk factors including diet, physical activity, obesity, risky alcohol use and tobacco use. However, such interventions are often poorly implemented in workplaces, limiting their impact on employee health. Identifying strategies that are effective in improving the implementation of workplace-based interventions has the potential to improve their effects on health outcomes.

OBJECTIVES

To assess the effects of strategies for improving the implementation of workplace-based policies or practices targeting diet, physical activity, obesity, tobacco use and alcohol use.Secondary objectives were to assess the impact of such strategies on employee health behaviours, including dietary intake, physical activity, weight status, and alcohol and tobacco use; evaluate their cost-effectiveness; and identify any unintended adverse effects of implementation strategies on workplaces or workplace staff.

SEARCH METHODS

We searched the following electronic databases on 31 August 2017: CENTRAL; MEDLINE; MEDLINE In Process; the Campbell Library; PsycINFO; Education Resource Information Center (ERIC); Cumulative Index to Nursing and Allied Health Literature (CINAHL); and Scopus. We also handsearched all publications between August 2012 and September 2017 in two speciality journals: Implementation Science and Journal of Translational Behavioral Medicine. We conducted searches up to September 2017 in Dissertations and Theses, the WHO International Clinical Trials Registry Platform, and the US National Institutes of Health Registry. We screened the reference lists of included trials and contacted authors to identify other potentially relevant trials. We also consulted experts in the field to identify other relevant research.

SELECTION CRITERIA

Implementation strategies were defined as strategies specifically employed to improve the implementation of health interventions into routine practice within specific settings. We included any trial with a parallel control group (randomised or non-randomised) and conducted at any scale that compared strategies to support implementation of workplace policies or practices targeting diet, physical activity, obesity, risky alcohol use or tobacco use versus no intervention (i.e. wait-list, usual practice or minimal support control) or another implementation strategy. Implementation strategies could include those identified by the Effective Practice and Organisation of Care (EPOC) taxonomy such as quality improvement initiatives and education and training, as well as other strategies. Implementation interventions could target policies or practices directly instituted in the workplace environment, as well as workplace-instituted efforts encouraging the use of external health promotion services (e.g. gym membership subsidies).

DATA COLLECTION AND ANALYSIS

Review authors working in pairs independently performed citation screening, data extraction and 'Risk of bias' assessment, resolving disagreements via consensus or a third reviewer. We narratively synthesised findings for all included trials by first describing trial characteristics, participants, interventions and outcomes. We then described the effect size of the outcome measure for policy or practice implementation. We performed meta-analysis of implementation outcomes for trials of comparable design and outcome.

MAIN RESULTS

We included six trials, four of which took place in the USA. Four trials employed randomised controlled trial (RCT) designs. Trials were conducted in workplaces from the manufacturing, industrial and services-based sectors. The sample sizes of workplaces ranged from 12 to 114. Workplace policies and practices targeted included: healthy catering policies; point-of-purchase nutrition labelling; environmental supports for healthy eating and physical activity; tobacco control policies; weight management programmes; and adherence to guidelines for staff health promotion. All implementation interventions utilised multiple implementation strategies, the most common of which were educational meetings, tailored interventions and local consensus processes. Four trials compared an implementation strategy intervention with a no intervention control, one trial compared different implementation interventions, and one three-arm trial compared two implementation strategies with each other and a control. Four trials reported a single implementation outcome, whilst the other two reported multiple outcomes. Investigators assessed outcomes using surveys, audits and environmental observations. We judged most trials to be at high risk of performance and detection bias and at unclear risk of reporting and attrition bias.Of the five trials comparing implementation strategies with a no intervention control, pooled analysis was possible for three RCTs reporting continuous score-based measures of implementation outcomes. The meta-analysis found no difference in standardised effects (standardised mean difference (SMD) -0.01, 95% CI -0.32 to 0.30; 164 participants; 3 studies; low certainty evidence), suggesting no benefit of implementation support in improving policy or practice implementation, relative to control. Findings for other continuous or dichotomous implementation outcomes reported across these five trials were mixed. For the two non-randomised trials examining comparative effectiveness, both reported improvements in implementation, favouring the more intensive implementation group (very low certainty evidence). Three trials examined the impact of implementation strategies on employee health behaviours, reporting mixed effects for diet and weight status (very low certainty evidence) and no effect for physical activity (very low certainty evidence) or tobacco use (low certainty evidence). One trial reported an increase in absolute workplace costs for health promotion in the implementation group (low certainty evidence). None of the included trials assessed adverse consequences. Limitations of the review included the small number of trials identified and the lack of consistent terminology applied in the implementation science field, which may have resulted in us overlooking potentially relevant trials in the search.

AUTHORS' CONCLUSIONS

Available evidence regarding the effectiveness of implementation strategies for improving implementation of health-promoting policies and practices in the workplace setting is sparse and inconsistent. Low certainty evidence suggests that such strategies may make little or no difference on measures of implementation fidelity or different employee health behaviour outcomes. It is also unclear if such strategies are cost-effective or have potential unintended adverse consequences. The limited number of trials identified suggests implementation research in the workplace setting is in its infancy, warranting further research to guide evidence translation in this setting.

Multisector Health Policy Networks in 15 Large US Cities

CONTEXT

Local health departments (LHDs) have historically not prioritized policy development, although it is one of the 3 core areas they address. One strategy that may influence policy in LHD jurisdictions is the formation of partnerships across sectors to work together on local public health policy.

DESIGN

We used a network approach to examine LHD local health policy partnerships across 15 large cities from the Big Cities Health Coalition.

SETTING/PARTICIPANTS

We surveyed the health departments and their partners about their working relationships in 5 policy areas: core local funding, tobacco control, obesity and chronic disease, violence and injury prevention, and infant mortality.

OUTCOME MEASURES

Drawing on prior literature linking network structures with performance, we examined network density, transitivity, centralization and centrality, member diversity, and assortativity of ties.

RESULTS

Networks included an average of 21.8 organizations. Nonprofits and government agencies made up the largest proportions of the networks, with 28.8% and 21.7% of network members, whereas for-profits and foundations made up the smallest proportions in all of the networks, with just 1.2% and 2.4% on average. Mean values of density, transitivity, diversity, assortativity, centralization, and centrality showed similarity across policy areas and most LHDs. The tobacco control and obesity/chronic disease networks were densest and most diverse, whereas the infant mortality policy networks were the most centralized and had the highest assortativity. Core local funding policy networks had lower scores than other policy area networks by most network measures.

CONCLUSION

Urban LHDs partner with organizations from diverse sectors to conduct local public health policy work. Network structures are similar across policy areas jurisdictions. Obesity and chronic disease, tobacco control, and infant mortality networks had structures consistent with higher performing networks, whereas core local funding networks had structures consistent with lower performing networks.

A qualitative evidence synthesis of employees' views of workplace smoking reduction or cessation interventions

BACKGROUND

The need to reduce smoking rates is a recognised public health policy issue in many countries. The workplace offers a potential context for offering smokers' programmes and interventions to assist smoking cessation or reduction. A qualitative evidence synthesis of employees' views about such programmes might explain why some interventions appear effective and others not, and can be used to develop evidence-based interventions for this population and setting.

METHODS

A qualitative evidence synthesis of primary research exploring employees' views about workplace interventions to encourage smoking cessation, including both voluntary programmes and passive interventions, such as restrictions or bans. The method used was theory-based "best fit" framework synthesis.

RESULTS

Five relevant theories on workplace smoking cessation were identified and used as the basis for an a priori framework. A comprehensive literature search, including interrogation of eight databases, retrieved 747 unique citations for the review. Fifteen primary research studies of qualitative evidence were found to satisfy the inclusion criteria. The synthesis produced an evidence-based conceptual model explaining employees' experiences of, and preferences regarding, workplace smoking interventions.

CONCLUSION

The synthesis suggests that workplace interventions should employ a range of different elements if they are to prove effective in reducing smoking among employees. This is because an employee who feels ready and able to change their behaviour has different needs and preferences from an employee who is not at that stage. Only a multi-faceted intervention can satisfy the requirements of all employees.

The ACTIVATE Study: Results from a Group-Randomized Controlled Trial Comparing a Traditional Worksite Health Promotion Program with an Activated Consumer Program

Purpose.

This study compares a traditional worksite-based health promotion program with an activated consumer program and a control program

Design.

Group randomized controlled trial with 18-month intervention.

Setting.

Two large Midwestern companies.

Subjects.

Three hundred and twenty employees (51% response).

Intervention.

The traditional health promotion intervention offered population-level campaigns on physical activity, nutrition, and stress management. The activated consumer intervention included population-level campaigns for evaluating health information, choosing a health benefits plan, and understanding the risks of not taking medications as prescribed. The personal development intervention (control group) offered information on hobbies. The interventions also offered individual-level coaching for high risk individuals in both active intervention groups.

Measures.

Health risk status, general health status, consumer activation, productivity, and the ability to evaluate health information.

Analysis.

Multivariate analyses controlled for baseline differences among the study groups.

Results.

At the population level, compared with baseline performance, the traditional health promotion intervention improved health risk status, consumer activation, and the ability to recognize reliable health websites. Compared with baseline performance, the activated consumer intervention improved consumer activation, productivity, and the ability to recognize reliable health websites. At the population level, however, only the activated consumer intervention improved any outcome more than the control group did; that outcome was consumer activation. At the individual level for high risk individuals, both traditional health coaching and activated consumer coaching positively affected health risk status and consumer activation. In addition, both coaching interventions improved participant ability to recognize a reliable health website. Consumer activation coaching also significantly improved self-reported productivity.

Conclusion.

An effective intervention can change employee health risk status and activation both at the population level and at the individual high risk level. However, program engagement at the population level was low, indicating that additional promotional strategies, such as greater use of incentives, need to be examined. Less intensive coaching can be as effective as more intensive, albeit both interventions produced modest behavior change and retention in the consumer activation arm was most difficult. Further research is needed concerning recruitment and retention methods that will enable populations to realize the full potential of activated consumerism.

Worksite tobacco prevention in the Canton of Zurich: stages of change, predictors, and outcomes

OBJECTIVES

This study provides information about the prevalence of tobacco prevention (TP) and the stages of change with respect to the introduction of TP among companies in the Canton of Zurich (n = 1,648). It explores the factors that predict restrictiveness of smoking policies, number of individual support measures, interest in services to promote TP, and the relationship between TP and health outcomes.

METHODS

Data were gathered by means of a written questionnaire and analysed using ordinal regression models.

RESULTS

Whereas many companies maintain smoke-free policies, only few provide cessation-courses. Health and welfare organisations have strictest, and building and hospitality companies have least strict policies. Company size predicts number of individual support measures but not policy restrictiveness. Both measures are predicted by personal concern of the representative. Interest in services is predicted by tobacco-related problems and medium stages of change. Finally, stricter policies are associated with lower proportion of smokers and less tobacco-related problems.

CONCLUSIONS

Health professionals should support less advanced companies in their endeavour to implement TP. The findings provide a baseline to evaluate the implementation of the forthcoming smoke-free legislation.

Worksite study promoting activity and changes in eating (PACE): design and baseline results

OBJECTIVE

Based on previous worksite-wide intervention studies and an ecological framework, we created a behavioral intervention program to maintain or reduce weight through healthy eating and physical activity. The design and evaluation plan of the group-randomized trial and the recruitment of worksites are described. Preliminary results regarding the dietary and physical activity behaviors associated with BMI are discussed.

RESEARCH METHODS AND PROCEDURES

The intervention used an ecological framework modified by qualitative methods that identified salient barriers and facilitators of behavioral change. Approximately 30 transportation, manufacturing, utilities, personal, household, and miscellaneous service companies in the greater Seattle area are being recruited to the trial. The study population for the present analysis consists of 18 worksites from the first two randomization waves. Dietary behavior was assessed, not by calories, but by behavioral measures related to BMI. Physical activity behaviors were surveyed. BMI is derived from reported height and weight at baseline.

RESULTS

The intervention has been developed with a specified minimum suite of strategies within the defined framework. Response rates to the baseline survey among the 18 worksites are 81% on average. After adjusting for age, gender, race, and education, BMI was associated with frequency of intensity-adjusted physical activity, sweat-inducing exercise, fast food meals, soft drinks, eating while doing another activity, and fruit and vegetable intake.

DISCUSSION

Worksite-wide intervention strategies can be adapted to target obesity prevention. Employees are willing to participate in surveys at high rates. Several measures of physical activity and eating choices are associated with baseline BMI.

[Evaluation of a workplace anti-smoking program at a company with 640 employees]

OBJECTIVES

Awareness of the health risks of passive smoking for non-smokers has led to the development of workplace interventions for smokers, although they are still few in our setting. The objective of this study was to evaluate the efficacy of an anti-smoking program among the workers of a company, in function of changes in the pre- and post-intervention prevalence of smoking in the study population.

METHOD

A pre-intervention questionnaire on smoking (prevalence and attitudes) was administered at a company with 640 employees (92% men, 8% women). An anti-smoking program was carried out inside the company during working hours over the next nine months. The questionnaire was then repeated (post-intervention) in order to evaluate its efficacy based on changes. For employees who answered both questionnaires, paired variables were analyzed.

RESULTS

The pre-intervention questionnaire was answered by 388 employees (60%), 357 men (92%) and 31 women (8%); their mean age was 48.4 years (SD 9.36). The prevalence of smoking was 55%, including daily smokers, sporadic smokers and others. The mean number of cigarettes per day was 17.86 (SD 2.45). The mean level of nicotine dependence measured by the Fagerström test was 3.3 (SD 2.8) out of 10. The post-intervention questionnaire was answered by 206 employees (32%). Among employees who answered both questionnaires (83), analysis of paired data showed a decrease in the prevalence of smoking of 4% and in the number of cigarettes per day from 17.4 (pre-intervention) to 16.4 (post-intervention). The differences were not statistically significant.

CONCLUSIONS

Although the workplace is an appropriate setting for anti-smoking interventions that would contribute to improving the health of smokers, such programs are currently underutilized.

Community interventions for reducing smoking among adults

BACKGROUND

Since smoking behaviour is determined by social context, the best way to reduce the prevalence of smoking may be to use community-wide programmes which use multiple channels to provide reinforcement, support and norms for not smoking.

OBJECTIVES

To assess the effectiveness of community interventions for reducing the prevalence of smoking.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group specialised register, MEDLINE (1966-August 2001) and EMBASE (1980-August 2001) and reference lists of articles.

SELECTION CRITERIA

Controlled trials of community interventions for reducing smoking prevalence in adult smokers. The primary outcome was smoking behaviour.

DATA COLLECTION AND ANALYSIS

Data were extracted by one person and checked by a second.

MAIN RESULTS

Thirty two studies were included, of which seventeen included only one intervention and one comparison community. Only four studies used random assignment of communities to either the intervention or comparison group. The population size of the communities ranged from a few thousand to over 100,000 people. Change in smoking prevalence was measured using cross-sectional follow-up data in 27 studies. The estimated net decline ranged from -1.0% to 3.0% for men and women combined (10 studies). For women, the decline ranged from -0.2% to + 3.5% per year (n=11), and for men the decline ranged from -0.4% to +1.6% per year (n=12). Cigarette consumption and quit rates were only reported in a small number of studies. The two most rigorous studies showed limited evidence of an effect on prevalence. In the US COMMIT study there was no differential decline in prevalence between intervention and control communities, and there was no significant difference in the quit rates of heavier smokers who were the target intervention group. In the Australian CART study there was a significantly greater quit rate for men but not women.

REVIEWER'S CONCLUSIONS

The failure of the largest and best conducted studies to detect an effect on prevalence of smoking is disappointing. A community approach will remain an important part of health promotion activities, but designers of future programmes will need to take account of this limited effect in determining the scale of projects and the resources devoted to them.

State-specific trends in smoke-free workplace policy coverage: the current population survey tobacco use supplement, 1993 to 1999

We examined trends in smoke-free workplace policies among all indoor workers in the United States using the National Cancer Institute's Tobacco Use Supplement to the Census Bureau's Current Population Survey (total n = 270,063). Smoke-free was defined as smoking not permitted in public or common areas or in work areas of a worksite. Nationally, we found that nearly 70% of the US workforce worked under a smoke-free policy in 1999. At the state level, a greater than 30-percentage-point differential existed in the proportion of workers with such policies. Although significant progress has been made to reduce worker exposure to environmental tobacco smoke on the job, we predict further progress may be difficult unless comprehensive regulations to protect all workers are implemented at the national, state, or local level.

A review of collaborative partnerships as a strategy for improving community health

Collaborative partnerships (people and organizations from multiple sectors working together in common purpose) are a prominent strategy for community health improvement. This review examines evidence about the effects of collaborative partnerships on (a) community and systems change (environmental changes), (b) community-wide behavior change, and (c) more distant population-level health outcomes. We also consider the conditions and factors that may determine whether collaborative partnerships are effective. The review concludes with specific recommendations designed to enhance research and practice and to set conditions for promoting community health.

Evaluation of a workplace brief intervention for excessive alcohol consumption: the workscreen project

BACKGROUND

The workplace provides a useful setting for early identification and intervention with individuals who have unhealthy lifestyles. The objective was to evaluate the effects of a workplace-based lifestyle intervention (Workscreen) to reduce excessive drinking.

METHOD

There were eight Australia Post networks randomly allocated to experimental and control conditions, comprising 67 worksites and 1206 employees. The experimental condition involved a broad spectrum lifestyle campaign, incorporating support from management, employee awareness of health, and brief interventions for high-risk behaviors, including excessive alcohol use. Focus groups identified relevant cultural factors. Changes in workplace culture and employee behavior were assessed 10 months after baseline. Males and females were analyzed separately.

RESULTS

Over half of APOST employees participated at each screening point. In the experimental condition 61% of employees overall and 58% of those identified as excessive drinkers in Phase 1 responded to the lifestyle campaign by attending health assessments. Analyses focusing on the organization as a whole did not reveal significant reductions in excessive alcohol consumption among men or women. However, a significant reduction in number of drinks was observed in the experimental condition among women for whom completion of baseline and follow-up could be confirmed (P < 0.001).

CONCLUSIONS

The present study indicates that a workplace-based lifestyle campaign can assist self-selected employees in reducing their alcohol consumption. There was a moderately high level of participation among those identified as drinking excessively, which supports our approach of embedding a low-intensity alcohol program within the context of a broader health promotion campaign.

Impact of the Working Well Trial on the worksite smoking and nutrition environment

This article reports the effect of a worksite cancer control intervention on aspects of the physical and social environment related to dietary and smoking behaviors of employees. Data are from 111 intervention and control worksites that participated in the Working Well Trial. Employee surveys and interviews with key organizational informants assessed environmental and normative changes relevant to nutrition and tobacco use. Results indicated significant effects of the intervention on all nutrition outcomes: access to healthy food, nutritional information at work, and social norms regarding dietary choice. Significant benefits were not found for smoking norms or smoking policies. However, changes occurred in both the control and intervention sites on these variables. This first large analysis of environmental and normative effects of a worksite intervention is consistent with the employee behavior change findings for the trial and serves as a model for future analyses of multilevel worksite health promotion programs.

Screening for unhealthy lifestyle factors in the workplace

OBJECTIVE

To examine (1) the prevalence of four lifestyle behaviours among Australia Post employees and (2) employees' perceptions of the role of the workplace in promotion of lifestyle change.

DESIGN

A cross-sectional survey using a self-administered questionnaire involved 688 employees working in Australia Post throughout metropolitan Sydney.

MAIN OUTCOME MEASURES

Prevalence related to age and sex of alcohol consumption, cigarette smoking, inadequate exercise, perception of excessive weight.

RESULTS

36% of men and 11% of women reported drinking alcohol at levels considered hazardous or harmful; 33% of men and 25% of women reported smoking; 51% of men and 62% of women thought they were overweight; 30% of men and 39% of women did not exercise regularly. Younger respondents were more likely to report drinking hazardously or harmfully, were smokers and had multiple risk factors. A majority of respondents thought that their employer should be interested in employee's lifestyle issues, particularly excessive drinking (63%). However, few considered seeking advice from the workplace regarding smoking (16%), weight (25%) and excessive alcohol consumption (12%).

CONCLUSIONS

These results show that many of Australia Post employees have unhealthy lifestyle behaviours. While employees perceive that the workplace has an important role in promoting healthy lifestyles among staff, few are presently willing to seek advice from the workplace regarding these issues. Promotion of healthy lifestyles in Australian workplaces is a potentially important public health advance that could reduce the incidence of diseases associated with high-risk lifestyle behaviours.

Implications of the results of community intervention trials

This paper examines the results of population-level interventions conducted in three settings: entire communities, worksites, and schools. Four major conclusions are discussed: (a) Directions for the next generation of community-based interventions include targeting multiple levels of influence; addressing social inequalities in disease risk; involving communities in program planning and implementation; incorporating approaches for "tailoring" interventions; and utilizing rigorous process evaluation. (b) In addition to randomized controlled trials, it is time to use the full range of research phases available, from hypothesis generation and methods development to dissemination research. (c) The public health research agenda may have contributed to observed secular trends by placing behavioral risk factors on the social and media agendas. (d) The magnitude of the results of community intervention trials must be judged according to their potential public health or population-level effects. Small changes at the individual level may result in large benefits at the population level.

Worksite characteristics and changes in worksite tobacco-control initiatives. Results from the COMMIT study

Few studies have prospectively examined the characteristics associated with worksite adoption of tobacco-control initiatives. Data were collected as part of the Community Intervention Trial (COMMIT) for Smoking Cessation, which conducted interventions in 11 communities. This smoking cessation intervention was based on community organization principles and delivered through multiple community channels, including worksites, health care providers, the media, and cessation resources. This article reports results from telephone interviews of intervention community worksites having 50 or more employees, conducted at baseline and the end of the intervention period. Among worksites that responded to both baseline and final surveys, 83% had not adopted a smoke-free policy at baseline, and 61% did not offer any cessation aid or quitting resources at baseline. By the final survey, 34% of those with no smoking ban at baseline had become smoke-free, and 36% of those offering no cessation assistance at baseline were offering cessation resources at the follow-up. The prevalence of policy adoption was higher among worksites employing more female employees and offering other health-promotion activities; manufacturing businesses were significantly less likely than businesses other than service and wholesale/retail businesses to adopt policies. Adoption of cessation programs was significantly more likely among worksites employing 100 to 249 workers, compared with those employing 50 to 99 workers; those predominantly employing men; those offering other types of health-promotion activities; and those with a higher rate of turnover. These results provide important information about the characteristics of worksites likely to engage in tobacco-control efforts. Health educators and others may choose to target those worksites most ready for adoption of tobacco control policies and programs, as indicated by these findings.