The Healthy Worker Project: a work-site intervention for weight control and smoking cessation

Effects of occupational health promotion interventions on health-related outcomes among employees of small businesses and self-employed individuals: A systematic review

BACKGROUND

Compared to workers of larger companies it is less clear what health promoting interventions might be beneficial for employees of small businesses and self-employed individuals.

OBJECTIVE

Our aim was to critically appraise trials investigating health promotion programs among small business workers and self-employed individuals, by means of a systematic review.

METHODS

We conducted a search of primary studies using MEDLINE, Web of Science, LIVIVO and the Cochrane library. Our assessment followed the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions and PRISMA.

RESULTS

We identified six trials including 5,854 participants from Asia, North America and Australia. Most were of moderate methodological quality, only one was of low quality. Some of the supervised psycho-educational lifestyle programs focusing on individual behavior changes showed benefits in terms of stress reduction and increased physical activity levels among small enterprise employees.

CONCLUSIONS

There is a huge knowledge gap on evidence-based health promotion interventions for self-employed and for small business workers, especially in Europe.

Society for Research on Nicotine and Tobacco as an Outgrowth of the 1988 Surgeon General's Report on Nicotine Addiction: Reflections of the Early Presidents

INTRODUCTION

The Society for Research on Nicotine and Tobacco began in the United States as a scientific organization "to stimulate the generation and dissemination of new knowledge concerning nicotine and tobacco in all its manifestations." Now in its 30th year, the Society is taking on new challenges in tobacco control, nicotine vaping, product regulation, and public policy.

AIMS AND METHODS

This Review describes the formative years of the Society from the perspective of researchers who were in leadership positions during that time, documenting how biobehavioral and clinical research in the first 10 years was a continuation of the scientific mission of the 1988 United States Surgeon General's Report on Nicotine Addiction and summarizing organizational innovations during each president's term of office.

CONCLUSIONS

The Society's promotion of scientific research served as a catalyst for funding, policy, and regulation, setting the stage for its influence and credibility.

IMPLICATIONS

This Commentary provides context and an overview of the scientific research and the organizational innovations that occurred during the early years of the Society for Research on Nicotine and Tobacco using publications and available documentation. The Society was able to thrive because biobehavioral research on nicotine addiction provided the scientific underpinnings for the tobacco control enterprise as a whole. The objective of this Commentary is to describe formative events in the Society's history based on the accomplishments of its early leaders.

Effectiveness of workplace wellness programmes for dietary habits, overweight, and cardiometabolic health: a systematic review and meta-analysis

Background

The workplace offers a unique opportunity for effective health promotion. We aimed to comprehensively study the effectiveness of multicomponent worksite wellness programmes for improving diet and cardiometabolic risk factors.

Methods

We did a systematic literature review and meta-analysis, following PRISMA guidelines. We searched PubMed-MEDLINE, Embase, the Cochrane Library, Web of Science, and Education Resources Information Center, from Jan 1, 1990, to June 30, 2020, for studies with controlled evaluation designs that assessed multicomponent workplace wellness programmes. Investigators independently appraised the evidence and extracted the data. Outcomes were dietary factors, anthropometric measures, and cardiometabolic risk factors. Pooled effects were calculated by inverse-variance random-effects meta-analysis. Potential sources of heterogeneity and study biases were evaluated.

Findings

From 10 169 abstracts reviewed, 121 studies (82 [68%] randomised controlled trials and 39 [32%] quasi-experimental interventions) met the eligibility criteria. Most studies were done in North America (57 [47%]), and Europe, Australia, or New Zealand (36 [30%]). The median number of participants was 413·0 (IQR 124·0–904·0), and median duration of intervention was 9·0 months (4·5–18·0). Workplace wellness programmes improved fruit and vegetable consumption (0·27 servings per day [95% CI 0·16 to 0·37]), fruit consumption (0·20 servings per day [0·11 to 0·28]), body-mass index (−0·22 kg/m² [−0·28 to −0·17]), waist circumference (−1·47 cm [−1·96 to −0·98]), systolic blood pressure (−2·03 mm Hg [−3·16 to −0·89]), and LDL cholesterol (−5·18 mg/dL [−7·83 to −2·53]), and to a lesser extent improved total fat intake (−1·18% of daily energy intake [−1·78 to −0·58]), saturated fat intake (−0·70% of daily energy [−1·22 to −0·18]), bodyweight (−0·92 kg [−1·11 to −0·72]), diastolic blood pressure (−1·11 mm Hg [−1·78 to −0·44]), fasting blood glucose (−1·81 mg/dL [−3·33 to −0·28]), HDL cholesterol (1·11 mg/dL [0·48 to 1·74]), and triglycerides (−5·38 mg/dL [−9·18 to −1·59]). No significant benefits were observed for intake of vegetables (0·03 servings per day [95% CI −0·04 to 0·10]), fibre (0·26 g per day [−0·15 to 0·67]), polyunsaturated fat (−0·23% of daily energy [−0·59 to 0·13]), or for body fat (−0·80% [−1·80 to 0·21]), waist-to-hip ratio (−0·00 ratio [−0·01 to 0·00]), or lean mass (1·01 kg [−0·82 to 2·83]). Heterogeneity values ranged from 46·9% to 91·5%. Between-study differences in outcomes were not significantly explained by study design, location, population, or similar factors in heterogeneity analyses.

Interpretation

Workplace wellness programmes are associated with improvements in specific dietary, anthropometric, and cardiometabolic risk indicators. The heterogeneity identified in study designs and results should be considered when using these programmes as strategies to improve cardiometabolic health.

BWHealthy Weight Pilot Study: A randomized controlled trial to improve weight-loss maintenance using deposit contracts in the workplace

Objective

Deposit contracts, where participants “bet” on achieving a goal and get their money back only if successful, have been shown to be effective for short-term weight-loss. This pilot study examined their effect on weight-loss maintenance.

Methods

From 2016 to 2018, we conducted a pilot, 50-week randomized controlled trial among 42 hospital employees (19 intervention and 23 control), in Boston, Massachusetts, who lost ≥10 lb (4.5 kg) in the two years prior to enrollment. Participants were recruited primarily in-person. Both control and intervention participants were asked to attend a weigh in weekly and received weekly email communication. Intervention participants also entered into a deposit contract to maintain baseline weight within ≤2 lb (0.9 kg). We examined weight change from baseline to 50 weeks (primary outcome) and maintenance of baseline weight at 50 weeks (secondary outcome; binary – yes v. no). Participants completed baseline and follow-up surveys and received incentives for completion.

Results

At baseline, mean (SD) weight was 83.2 (15.5 kg) among intervention and 80.7 (14.5 kg) among control participants. After 50 weeks, intervention participants had slightly less but non-significant weight gain (adjusted β −1.12 kg; 95% CI −5.28, 3.05) than control participants; 73.7% of intervention v. 39.1% of control participants met their weight-loss maintenance goal by study end (adjusted OR 4.78; 95% CI 1.01, 22.71).

Conclusions

A deposit contract was not associated with differences in weight but led to more participants meeting their weight-loss maintenance goals; a deposit contract for weight-loss maintenance should be tested in a full-scale intervention. Most intervention participants viewed the deposit contract as acceptable.

Incentives for smoking cessation

BACKGROUND

Financial incentives, monetary or vouchers, are widely used in an attempt to precipitate, reinforce and sustain behaviour change, including smoking cessation. They have been used in workplaces, in clinics and hospitals, and within community programmes.

OBJECTIVES

To determine the long-term effect of incentives and contingency management programmes for smoking cessation.

SEARCH METHODS

For this update, we searched the Cochrane Tobacco Addiction Group Specialised Register, clinicaltrials.gov, and the International Clinical Trials Registry Platform (ICTRP). The most recent searches were conducted in July 2018.

SELECTION CRITERIA

We considered only randomised controlled trials, allocating individuals, workplaces, groups within workplaces, or communities to smoking cessation incentive schemes or control conditions. We included studies in a mixed-population setting (e.g. community, work-, clinic- or institution-based), and also studies in pregnant smokers.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. The primary outcome measure in the mixed-population studies was abstinence from smoking at longest follow-up (at least six months from the start of the intervention). In the trials of pregnant women we used abstinence measured at the longest follow-up, and at least to the end of the pregnancy. Where available, we pooled outcome data using a Mantel-Haenzel random-effects model, with results reported as risk ratios (RRs) and 95% confidence intervals (CIs), using adjusted estimates for cluster-randomised trials. We analysed studies carried out in mixed populations separately from those carried out in pregnant populations.

MAIN RESULTS

Thirty-three mixed-population studies met our inclusion criteria, covering more than 21,600 participants; 16 of these are new to this version of the review. Studies were set in varying locations, including community settings, clinics or health centres, workplaces, and outpatient drug clinics. We judged eight studies to be at low risk of bias, and 10 to be at high risk of bias, with the rest at unclear risk. Twenty-four of the trials were run in the USA, two in Thailand and one in the Phillipines. The rest were European. Incentives offered included cash payments or vouchers for goods and groceries, offered directly or collected and redeemable online. The pooled RR for quitting with incentives at longest follow-up (six months or more) compared with controls was 1.49 (95% CI 1.28 to 1.73; 31 RCTs, adjusted N = 20,097; I² = 33%). Results were not sensitive to the exclusion of six studies where an incentive for cessation was offered at long-term follow up (result excluding those studies: RR 1.40, 95% CI 1.16 to 1.69; 25 RCTs; adjusted N = 17,058; I² = 36%), suggesting the impact of incentives continues for at least some time after incentives cease.Although not always clearly reported, the total financial amount of incentives varied considerably between trials, from zero (self-deposits), to a range of between USD 45 and USD 1185. There was no clear direction of effect between trials offering low or high total value of incentives, nor those encouraging redeemable self-deposits.We included 10 studies of 2571 pregnant women. We judged two studies to be at low risk of bias, one at high risk of bias, and seven at unclear risk. When pooled, the nine trials with usable data (eight conducted in the USA and one in the UK), delivered an RR at longest follow-up (up to 24 weeks post-partum) of 2.38 (95% CI 1.54 to 3.69; N = 2273; I² = 41%), in favour of incentives.

AUTHORS' CONCLUSIONS

Overall there is high-certainty evidence that incentives improve smoking cessation rates at long-term follow-up in mixed population studies. The effectiveness of incentives appears to be sustained even when the last follow-up occurs after the withdrawal of incentives. There is also moderate-certainty evidence, limited by some concerns about risks of bias, that incentive schemes conducted among pregnant smokers improve smoking cessation rates, both at the end of pregnancy and post-partum. Current and future research might explore more precisely differences between trials offering low or high cash incentives and self-incentives (deposits), within a variety of smoking populations.

Starchy Carbohydrates in a Healthy Diet: The Role of the Humble Potato

Potatoes have been an affordable, staple part of the diet for many hundreds of years. Recently however, there has been a decline in consumption, perhaps influenced by erroneous reports of being an unhealthy food. This review provides an overview of the nutritional value of potatoes and examines the evidence for associations between potato consumption and non-communicable diseases. Potatoes are an important source of micronutrients, such as vitamin C, vitamin B6, potassium, folate, and iron and contribute a significant amount of fibre to the diet. However, nutrient content is affected by cooking method; boiling causes leaching of water-soluble nutrients, whereas frying can increase the resistant starch content of the cooked potato. Epidemiological studies have reported associations between potato intake and obesity, type 2 diabetes and cardiovascular disease. However, results are contradictory and confounded by lack of detail on cooking methods. Indeed, potatoes have been reported to be more satiating than other starchy carbohydrates, such as pasta and rice, which may aid weight maintenance. Future research should consider cooking methods in the study design in order to reduce confounding factors and further explore the health impact of this food.

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.

Paying people to lose weight: the effectiveness of financial incentives provided by health insurers for the prevention and management of overweight and obesity - a systematic review

Curbing the obesity epidemic is likely to require a suite of interventions targeting the obesogenic environment as well as individual behaviour. Evidence suggests that the effectiveness of behaviour modification programmes can be enhanced by financial incentives that immediately reward weight loss behaviour. This systematic review investigated the effectiveness of incentives with a focus on assessing the relative effectiveness of incentives that target different behaviours as well as factors of importance when implementing these programmes in real-world settings (health insurer settings). A narrative review of the academic and grey literature including a variety of study designs was undertaken. Twenty studies met inclusion criteria and were assessed using the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies. Results suggest that incentivizing weight loss is effective in the short term while the incentives are in place. There are various incentive designs, and although the relative effectiveness of each of these on weight loss is not clear, it appears that positive incentives increase the uptake into programmes and may reduce dropouts. As with other weight loss initiatives, there is a need to explore ways to maintain weight loss in the longer term - incentives for weight maintenance could play a role.

Worksite Health Promotion for Low-Wage Workers: A Scoping Literature Review

OBJECTIVE

To determine: (1) What research has been done on health promotion interventions for low-wage workers and (2) what factors are associated with effective low-wage workers' health promotion programs.

DATA SOURCE

This review includes articles from PubMed and PsychINFO published in or before July 2016. Study Inclusion/Exclusion Criteria: The search yielded 130 unique articles, 35 met the inclusion criteria: (1) being conducted in the United States, (2) including an intervention or empirical data around health promotion among adult low-wage workers, and (3) measuring changes in low-wage worker health.

DATA EXTRACTION

Central features of the selected studies were extracted, including the theoretical foundation; study design; health promotion intervention content and delivery format; intervention-targeted outcomes; sample characteristics; and work, occupational, and industry characteristics.

DATA ANALYSIS

Consistent with a scoping review, we used a descriptive, content analysis approach to analyze extracted data. All authors agreed upon emergent themes and 2 authors independently coded data extracted from each article.

RESULTS

The results suggest that the research on low-wage workers' health promotion is limited, but increasing, and that low-wage workers have limited access to and utilization of worksite health promotion programs.

CONCLUSION

Workplace health promotion programs could have a positive effect on low-wage workers, but more work is needed to understand how to expand access, what drives participation, and which delivery mechanisms are most effective.

Interventional study plan to investigate the training effects on physical and psychological outcomes awareness of smoking in teenagers

BACKGROUND

Studies have found that nearly 90% of the first use of tobacco takes place before high school graduation (teenagers) and training discussion due to prevention can be useful, therefore, here, we aimed to determine the effects of training on awareness of cigarette outcomes (physical and psychological) in male teenagers.

MATERIALS AND METHODS

We conducted an interventional study using Solomon's four-group plan, which used a two-stage cluster sampling in four groups (two experimental groups and two control groups). The three sessions of at least 2 h of education intervention including visual displaying using photo, film, and short scientific texts were held for the interventional group. After 1 month, all four groups took posttest, and research groups were followed up after 8 months of intervention. All data were analyzed using one-way analysis of variance and covariance in SPSS.

RESULTS

According to the results, the mean of posttest scores had increased rather than pretest scores, and generally, a significant difference was observed (P ≤ 0.001). These results were significant in the aspect of both physical and psychological outcomes awareness. The difference between the mean of scores in follow-up period and posttest was not statistically significant, and it shows training retention after 8 months (P < 0.666).

CONCLUSIONS

It can be concluded that through the training, it is possible to increase the awareness of teenagers about physical and psychological outcomes of cigarette smoking that this can have an important role in smoking prevention.

Engagement in health and wellness: An online incentive-based program

Increasingly, corporate health promotion programs are implementing wellness programs integrating principles of behavioral economics. Employees of a large firm were provided a customized online incentive program to design their own commitments to meet health goals. This study examines patterns of program participation and engagement in health promotion activities. Subjects were US-based employees of a large, nondurable goods manufacturing firm who were enrolled in corporate health benefits in 2010 and 2011. We assessed measures of engagement with the workplace health promotion program (e.g., incentive points earned, weight loss). To further examine behaviors indicating engagement in health promotion activities, we constructed an aggregate, employee-level engagement index. Regression models were employed to assess the association between employee characteristics and the engagement index, and the engagement index and spending. 4220 employees utilized the online program and made 25,716 commitments. Male employees age 18-34 had the highest level of engagement, and male employees age 55-64 had the lowest level of engagement overall. Prior year health status and prior year spending did not show a significant association with the level of engagement with the program (p > 0.05). Flexible, incentive-based behavioral health and lifestyle programs may reach the broader workforce including those with chronic conditions and higher levels of health spending.

Applying economic incentives to increase effectiveness of an outpatient weight loss program (TRIO) - A randomized controlled trial

The prevalence of overweight and obesity has more than doubled in the past three decades, leading to rising rates of non-communicable diseases. This study tests whether adding a payment/rewards (term reward) program to an existing evidence-based weight loss program can increase weight loss and weight loss maintenance. We conducted a parallel-group randomized controlled trial from October 2012 to October 2015 with 161 overweight or obese individuals randomized to either control or reward arm in a 1:2 ratio. Control and reward arm participants received a four month weight loss program at the LIFE (Lifestyle Improvement and Fitness Enhancement) Centre at Singapore General Hospital. Those in the reward arm paid a fee of S$165.00 (1US$ = 1.35S$) to access a program that provided rewards of up to S$660 for meeting weight loss and physical activity goals. Participants could choose to receive rewards as guaranteed cash payments or a lottery ticket with a 1 in 10 chance of winning but with the same expected value. The primary outcome was weight loss at months 4, 8, and 12. 161 participants were randomized to control (n = 54) or reward (n = 107) arms. Average weight loss was more than twice as great in the reward arm compared to the control arm at month 4 when the program concluded (3.4 kg vs 1.4 kg, p < 0.01), month 8 when rewards concluded (3.3 kg vs 1.8 kg, p < 0.05), and at month 12 (2.3 kg vs 0.8 kg, p < 0.05). These results reveal that a payment/rewards program can be used to improve weight loss and weight loss maintenance when combined with an evidence-based weight loss program. Future efforts should attempt to replicate this approach and identify how to cost effectively expand these programs to maximize their reach. This study is registered at www.clinicaltrials.gov (Identifier: NCT01533454).

CVD Prevention Through Policy: a Review of Mass Media, Food/Menu Labeling, Taxation/Subsidies, Built Environment, School Procurement, Worksite Wellness, and Marketing Standards to Improve Diet

Poor diet is the leading cause of cardiovascular disease in the USA and globally. Evidence-based policies are crucial to improve diet and population health. We reviewed the effectiveness for a range of policy levers to alter diet and diet-related risk factors. We identified evidence to support benefits of focused mass media campaigns (especially for fruits, vegetables, salt), food pricing strategies (both subsidies and taxation, with stronger effects at lower income levels), school procurement policies (for increasing healthful or reducing unhealthful choices), and worksite wellness programs (especially when comprehensive and multicomponent). Evidence was inconclusive for food and menu labeling (for consumer or industry behavior) and changes in local built environment (e.g., availability or accessibility of supermarkets, fast food outlets). We found little empiric evidence evaluating marketing restrictions, although broad principles and large resources spent on marketing suggest utility. Widespread implementation and evaluation of evidence-based policy strategies, with further research on other strategies with mixed/limited evidence, are essential “population medicine” to reduce health and economic burdens and inequities of diet-related illness worldwide.

Act Healthy: promoting health behaviors and self-efficacy in the workplace

Chronic health conditions and multiple health risk factors afflict Americans and burden employers, but effective, affordable, workplace-based health promotion interventions have not been widely implemented. This is the first study to adapt the empirically validated Chronic Disease Self-Management Program for a general employee population in a workplace setting with an emphasis on disease prevention and health promotion. A quasi-experimental, wellness standard of care comparison, prospective cohort design was used among employee participants at a large University employer. Ninety-one individuals participated in the program. Participants reported significantly increased health behavior frequency and self-efficacy after the intervention, compared with their pre-intervention scores, and improvements were sustained at 3-month follow-up [self-rated abilities for health practices scale (SRA): F = 30.89, P < 0.001; health promoting lifestyle profile-II (HPLP-II): F = 36.30 P < 0.001]. Individuals in the intervention group reported improved self-efficacy and health behaviors compared with the wellness standard of care comparison group at post intervention (SRA: F = 12.45, P < 0.001; HPLP-II: F = 25.28, P < 0.001). Adapting lay-facilitated self-management for the workplace offers promise as a replicable, scalable, affordable model for culture change in organizations.

Incentives for smoking cessation

BACKGROUND

Material or financial incentives are widely used in an attempt to precipitate or reinforce behaviour change, including smoking cessation. They operate in workplaces, in clinics and hospitals, and to a lesser extent within community programmes. In this third update of our review we now include trials conducted in pregnant women, to reflect the increasing activity and resources now targeting this high-risk group of smokers.

OBJECTIVES

To determine whether incentives and contingency management programmes lead to higher long-term quit rates.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, with additional searches of MEDLINE, EMBASE, CINAHL and PsycINFO. The most recent searches were in December 2014, although we also include two trials published in 2015.

SELECTION CRITERIA

We considered randomised controlled trials, allocating individuals, workplaces, groups within workplaces, or communities to experimental or control conditions. We also considered controlled studies with baseline and post-intervention measures. We include studies in a mixed-population setting (e.g. community-, work-, institution-based), and also, for this update, trials in pregnant smokers.

DATA COLLECTION AND ANALYSIS

One author (KC) extracted data and a second (JH-B) checked them. We contacted study authors for additional data where necessary. The main outcome measure in the mixed-population studies was abstinence from smoking at longest follow-up, and at least six months from the start of the intervention. In the trials of pregnant smokers abstinence was measured at the longest follow-up, and at least to the end of the pregnancy.

MAIN RESULTS

Twenty-one mixed-population studies met our inclusion criteria, covering more than 8400 participants. Ten studies were set in clinics or health centres, one in Thai villages served by community health workers, two in academic institutions, and the rest in worksites. All but six of the trials were run in the USA. The incentives included lottery tickets or prize draws, cash payments, vouchers for goods and groceries, and in six trials the recovery of money deposited by those taking part. The odds ratio (OR) for quitting with incentives at longest follow-up (six months or more) compared with controls was 1.42 (95% confidence interval (CI) 1.19 to 1.69; 17 trials, [20 comparisons], 7715 participants). Only three studies demonstrated significantly higher quit rates for the incentives group than for the control group at or beyond the six-month assessment: One five-arm USA trial compared rewards- and deposit-based interventions at individual and group level, with incentives available up to USD 800 per quitter, and demonstrated a quit rate in the rewards groups of 8.1% at 12 months, compared with 4.7% in the deposits groups. A direct comparison between the rewards-based and the deposit-based groups found a benefit for the rewards arms, with an OR at 12 months of 1.76 (95% CI 1.22 to 2.53; 2070 participants). Although more people in this trial accepted the rewards programmes than the deposit programmes, the proportion of quitters in each group favoured the deposit-refund programme. Another USA study rewarded both participation and quitting up to USD 750, and achieved sustained quit rates of 9.4% in the incentives group compared with 3.6% for the controls. A deposit-refund trial in Thailand also achieved significantly higher quit rates in the intervention group (44.2%) compared with the control group (18.8%), but uptake was relatively low, at 10.5%. In the remaining trials, there was no clear evidence that participants who committed their own money to the programme did better than those who did not, or that contingent rewards enhanced success rates over fixed payment schedules. We rated the overall quality of the older studies as low, but with later trials (post-2000) more likely to meet current standards of methodology and reporting.Eight of nine trials with usable data in pregnant smokers (seven conducted in the USA and one in the UK) delivered an adjusted OR at longest follow-up (up to 24 weeks post-partum) of 3.60 (95% CI 2.39 to 5.43; 1295 participants, moderate-quality studies) in favour of incentives. Three of the trials demonstrated a clear benefit for contingent rewards; one delivered monthly vouchers to confirmed quitters and to their designated 'significant other supporter', achieving a quit rate in the intervention group of 21.4% at two months post-partum, compared with 5.9% among the controls. Another trial offered a scaled programme of rewards for the percentage of smoking reduction achieved over the course of the 12-week intervention, and achieved an intervention quit rate of 31% at six weeks post-partum, compared with no quitters in the control group. The largest (UK-based) trial provided intervention quitters with up to GBP 400-worth of vouchers, and achieved a quit rate of 15.4% at longest follow-up, compared to the control quit rate of 4%. Four trials confirmed that payments made to reward a successful quit attempt (i.e. contingent), compared to fixed payments for attending the antenatal appointment (non-contingent), resulted in higher quit rates. Front-loading of rewards to counteract early withdrawal symptoms made little difference to quit rates.

AUTHORS' CONCLUSIONS

Incentives appear to boost cessation rates while they are in place. The two trials recruiting from work sites that achieved sustained success rates beyond the reward schedule concentrated their resources into substantial cash payments for abstinence. Such an approach may only be feasible where independently-funded smoking cessation programmes are already available, and within a relatively affluent and educated population. Deposit-refund trials can suffer from relatively low rates of uptake, but those who do sign up and contribute their own money may achieve higher quit rates than reward-only participants. Incentive schemes conducted among pregnant smokers improved the cessation rates, both at the end-of-pregnancy and post-partum assessments. Current and future research might continue to explore the scale, loading and longevity of possible cash or voucher reward schedules, within a variety of smoking populations.

A randomized comparative effectiveness study of Healthy Directions 2--a multiple risk behavior intervention for primary care

OBJECTIVE

To evaluate the effectiveness of the Healthy Directions 2 (HD2) intervention in the primary care setting.

METHODS

HD2 was a cluster randomized trial (conducted 3/09-11/11). The primary sampling unit was provider (n=33), with secondary sampling of patients within provider (n=2440). Study arms included: 1) usual care (UC); 2) HD2--a patient self-guided intervention targeting 5 risk behaviors; and 3) HD2 plus 2 brief telephone coaching calls (HD2+CC). The outcome measure was the proportion of participants with a lower multiple risk behavior (MRB) score by follow-up.

RESULTS

At baseline, only 4% of the participants met all behavioral recommendations. Both HD2 and HD2+CC led to improvements in MRB score, relative to UC, with no differences between the two HD2 conditions. Twenty-eight percent of the UC participants had improved MRB scores at 6 months, vs. 39% and 43% in HD2 and HD2+CC, respectively (ps≤.001); results were similar at 18 months (p≤.05). The incremental cost of one risk factor reduction in MRB score was $310 for HD2 and $450 for HD2+CC.

CONCLUSIONS

Self-guided and coached intervention conditions had equivalent levels of effect in reducing multiple chronic disease risk factors, were relatively low cost, and thus are potentially useful for routine implementation in similar health settings.

The effectiveness of financial incentives for health behaviour change: systematic review and meta-analysis

BACKGROUND

Financial incentive interventions have been suggested as one method of promoting healthy behaviour change.

OBJECTIVES

To conduct a systematic review of the effectiveness of financial incentive interventions for encouraging healthy behaviour change; to explore whether effects vary according to the type of behaviour incentivised, post-intervention follow-up time, or incentive value.

DATA SOURCES

Searches were of relevant electronic databases, research registers, www.google.com, and the reference lists of previous reviews; and requests for information sent to relevant mailing lists.

ELIGIBILITY CRITERIA

Controlled evaluations of the effectiveness of financial incentive interventions, compared to no intervention or usual care, to encourage healthy behaviour change, in non-clinical adult populations, living in high-income countries, were included.

STUDY APPRAISAL AND SYNTHESIS

The Cochrane Risk of Bias tool was used to assess all included studies. Meta-analysis was used to explore the effect of financial incentive interventions within groups of similar behaviours and overall. Meta-regression was used to determine if effect varied according to post-intervention follow up time, or incentive value.

RESULTS

Seventeen papers reporting on 16 studies on smoking cessation (n = 10), attendance for vaccination or screening (n = 5), and physical activity (n = 1) were included. In meta-analyses, the average effect of incentive interventions was greater than control for short-term (≤ six months) smoking cessation (relative risk (95% confidence intervals): 2.48 (1.77 to 3.46); long-term (>six months) smoking cessation (1.50 (1.05 to 2.14)); attendance for vaccination or screening (1.92 (1.46 to 2.53)); and for all behaviours combined (1.62 (1.38 to 1.91)). There was not convincing evidence that effects were different between different groups of behaviours. Meta-regression found some, limited, evidence that effect sizes decreased as post-intervention follow-up period and incentive value increased. However, the latter effect may be confounded by the former.

CONCLUSIONS

The available evidence suggests that financial incentive interventions are more effective than usual care or no intervention for encouraging healthy behaviour change.

TRIAL REGISTRATION

PROSPERO CRD42012002393.

Development of a Theoretically Driven mHealth Text Messaging Application for Sustaining Recent Weight Loss

Background

Mobile phone short message service (SMS) text messaging, has the potential to serve as an intervention medium to promote sustainability of weight loss that can be easily and affordably used by clinicians and consumers.

Objective

To develop theoretically driven weight loss sustaining text messages and pilot an mHealth SMS text messaging intervention to promote sustaining recent weight loss in order to understand optimal frequency and timing of message delivery, and for feasibility and usability testing. Results from the pilot study were used to design and construct a patient privacy compliant automated SMS application to deliver weight loss sustaining messages.

Methods

We first conducted a pilot study in which participants (N=16) received a daily SMS text message for one month following a structured weight loss program. Messages were developed from diet and exercise guidelines. Following the intervention, interviews were conducted and self-reported weight was collected via SMS text messaging.

Results

All participants (N=16) were capable of sending and receiving SMS text messages. During the phone interview at 1 month post-baseline and at 3 months post-baseline, 13/14 (93%) of participants who completed the study reported their weight via SMS. At 3 months post-baseline, 79% (11/14) participants sustained or continued to lose weight. Participants (13/14, 93%) were favorable toward the messages and the majority (10/14, 71%) felt they were useful in helping them sustain weight loss. All 14 participants who completed the interview thought SMS was a favorable communication medium and was useful to receive short relevant messages promptly and directly. All participants read the messages when they knew they arrived and most (11/14, 79%) read the messages at the time of delivery. All participants felt that at least one daily message is needed to sustain weight loss behaviors and that they should be delivered in the morning. Results were then used to develop the SMS text messaging application.

Conclusions

Study results demonstrated the feasibility of developing weight loss SMS text messages, and the development of an mHealth SMS text messaging application. SMS text messaging was perceived as an appropriate and accepted tool to deliver health promotion content.

Efficacy of a "small-changes" workplace weight loss initiative on weight and productivity outcomes

OBJECTIVE

The effect of weight reduction on workplace productivity is unknown. We have investigated a "small-changes" workplace weight loss intervention on weight and productivity outcomes.

METHODS

Overweight/obese employees at two New Zealand worksites (n = 102) received the 12-week intervention. One site received an extra 9-month weight-maintenance component. Magnitudes of effects on weight and productivity were assessed via standardization.

RESULTS

Both groups reduced weight at 12 weeks and maintained lost weight at 12 months. There were small possible improvements in productivity at one worksite and trivial reductions at the other by 12 weeks, with little subsequent change during maintenance in either group. At an individual level, weight change was associated with at most only small improvements or small reductions in productivity.

CONCLUSION

Workplace weight loss initiatives may need to be more intensive or multidimensional to enhance productivity.

Financial incentives and weight control

This paper reviews research studies evaluating the use of financial incentives to promote weight control conducted between 1972 and 2010. It provides an overview of behavioral theories pertaining to incentives and describes empirical studies evaluating specific aspects of incentives. Research on financial incentives and weight control has a history spanning more than 30 years. Early studies were guided by operant learning concepts from Psychology, while more recent studies have relied on economic theory. Both theoretical orientations argue that providing financial rewards for losing weight should motivate people to engage in behaviors that produce weight loss. Empirical research has strongly supported this idea. However, results vary widely due to differences in incentive size and schedule, as well as contextual factors. Thus, many important questions about the use of incentives have not yet been clearly answered. Weight-maintenance studies using financial incentives are particularly sparse, so that their long-term efficacy and thus, value in addressing the public health problem of obesity is unclear. Major obstacles to sustained applications of incentive in weight control are funding sources and acceptance by those who might benefit.

The Changing Environment and Population Obesity in the United States

The recent unexpected increases in the prevalence of obesity in the United States are widely agreed to be the result of changes in environmental conditions. This paper reviews the available data from diverse sources on environmental factors and obesity. Coverage includes descriptive data on temporal trends in the environment, cross-sectional and longitudinal studies of the association between environmental exposures and body weight, and experimental trials that have related environmental factors thought to be potentially important in influencing energy intake and expenditure and body weight. Over the period covered by the "obesity epidemic," a variety of environmental factors have changed dramatically. Some would seem to favor increased body weight (e.g., increased availability of convenience foods and increased use of automobiles and televised entertainment), and others would seem to favor decreased body weight (e.g., a lower-fat food supply and the increased availability of some forms of physical activity). Definitive conclusions about the relative contributions of energy intake and expenditure to increasing body weight or about the contribution of specific environmental exposures to increasing body weight are far from clear. Increased sophistication in methods for making valid inferences from existing environmental data would be helpful. Even more important, given the urgency of the problem, is experimental research on the question of what environmental changes would be necessary to reverse the obesity epidemic.

Dieting Status and Its Relationship to Weight, Dietary Intake, and Physical Activity Changes Over Two Years in a Working Population

The present study prospectively examined changes in dietary intake, physical activity and weight associated with self-reported efforts to lose weight in a cohort of 3671 men and women sampled from the general population. Dieting efforts, dietary intake, physical activity and weight were measured at two points in time, 24 months apart. At baseline, current dieters reported consuming fewer dairy products, sweets, meat, soft drinks and fried potatoes (all p's < .0001), and engaging more frequently in high-intensity physical activity (p < .0001) than those not currently dieting. At follow-up, current dieters reported consuming fewer sweets (p < .0001) and fried potatoes (p < .0008), and engaging more frequently in moderate-intensity physical activity (p < .02) than those not currently dieting. Prospectively, those who initiated weight-loss diets showed the largest decrease in consumption of sweets (p < .0001), soft drinks (p < .0001), and fried potatoes (p < .01), and increase in frequency of high-intensity physical activity (p < .0001) and moderate-intensity physical activity (p < .007). Those initiating weight-loss diets were the only group to lose weight (1 lb.). Those dieting at baseline but not at follow-up gained the most weight (4 lbs.). Self-reports of current dieting correspond to reported changes in dietary intake and physical activity, and to measured changes in weight over the same time period. Individuals who report dieting to lose weight have healthier eating and exercise patterns than those who do not report dieting.

HealthWorks: results of a multi-component group-randomized worksite environmental intervention trial for weight gain prevention

Background

U.S. adults are at unprecedented risk of becoming overweight or obese, and most scientists believe the primary cause is an obesogenic environment. Worksites provide an opportunity to shape the environments of adults to reduce obesity risk. The goal of this group-randomized trial was to implement a four-component environmental intervention at the worksite level to positively influence weight gain among employees over a two-year period. Environmental components focused on food availability and price, physical activity promotion, scale access, and media enhancements.

Methods

Six worksites in a U.S. metropolitan area were recruited and randomized in pairs at the worksite level to either a two-year intervention or a no-contact control. Evaluations at baseline and two years included: 1) measured height and weight; 2) online surveys of individual dietary intake and physical activity behaviors; and 3) detailed worksite environment assessment.

Results

Mean participant age was 42.9 years (range 18-75), 62.6% were women, 68.5% were married or cohabiting, 88.6% were white, 2.1% Hispanic. Mean baseline BMI was 28.5 kg/m² (range 16.9-61.2 kg/m²). A majority of intervention components were successfully implemented. However, there were no differences between sites in the key outcome of weight change over the two-year study period (p = .36).

Conclusions

Body mass was not significantly affected by environmental changes implemented for the trial. Results raise questions about whether environmental change at worksites is sufficient for population weight gain prevention.

Trial Registration

ClinicalTrials.gov: NCT00708461

Faster self-reported speed of eating is related to higher body mass index in a nationwide survey of middle-aged women

This study is the first nationwide population survey to explore the association between speed of eating and degree of obesity. The objective was to cross-sectionally examine the relationship between self-reported speed of eating and body mass index (BMI; calculated as kg/m(2)) in a nationally representative sample of New Zealand women. In May 2009, a sample of 2,500 New Zealand women aged 40 to 50 years was randomly selected from the nationwide electoral rolls. A 66% participation rate was achieved. Potential participants were mailed a self-administered questionnaire containing questions on self-reported speed of eating, demographics, health conditions, menopause status, physical activity, height, and weight. Univariate models were used to examine the associations between demographic, health and behavioral variables, and BMI, while a multivariate model was developed to investigate the relationship between self-reported speed of eating and BMI. After adjusting for age, smoking status, menopause status, thyroid condition, ethnicity, socioeconomic status, and physical activity, BMI statistically significantly increased by 2.8% (95% confidence interval: 1.5% to 4.1%; P<0.001) for each category increase in self-reported speed of eating. Although the direction of causality requires confirmation in longitudinal and randomized intervention studies, the results suggest that faster eating is associated with higher BMI in middle-aged women.

Meta-analyses of workplace physical activity and dietary behaviour interventions on weight outcomes

This meta-analytic review critically examines the effectiveness of workplace interventions targeting physical activity, dietary behaviour or both on weight outcomes. Data could be extracted from 22 studies published between 1980 and November 2009 for meta-analyses. The GRADE approach was used to determine the level of evidence for each pooled outcome measure. Results show moderate quality of evidence that workplace physical activity and dietary behaviour interventions significantly reduce body weight (nine studies; mean difference [MD]-1.19 kg [95% CI -1.64 to -0.74]), body mass index (BMI) (11 studies; MD -0.34 kg m⁻² [95% CI -0.46 to -0.22]) and body fat percentage calculated from sum of skin-folds (three studies; MD -1.12% [95% CI -1.86 to -0.38]). There is low quality of evidence that workplace physical activity interventions significantly reduce body weight and BMI. Effects on percentage body fat calculated from bioelectrical impedance or hydrostatic weighing, waist circumference, sum of skin-folds and waist-hip ratio could not be investigated properly because of a lack of studies. Subgroup analyses showed a greater reduction in body weight of physical activity and diet interventions containing an environmental component. As the clinical relevance of the pooled effects may be substantial on a population level, we recommend workplace physical activity and dietary behaviour interventions, including an environment component, in order to prevent weight gain.

Competitions and incentives for smoking cessation

BACKGROUND

Background Material or financial incentives may be used in an attempt to reinforce behaviour change, including smoking cessation. They have been widely used in workplace smoking cessation programmes, and to a lesser extent within community programmes. Public health initiatives in the UK are currently planning to deploy incentive schemes to change unhealthy behaviours. Quit and Win contests are the subject of a companion review.

OBJECTIVES

To determine whether competitions and incentives lead to higher long-term quit rates. We also set out to examine the relationship between incentives and participation rates.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group Specialized Register, with additional searches of MEDLINE, EMBASE, CINAHL and PsycINFO. Search terms included incentive*, competition*, contest*, reward*, prize*, contingent payment*, deposit contract*. The most recent searches were in November 2010.

SELECTION CRITERIA

We considered randomized controlled trials, allocating individuals, workplaces, groups within workplaces, or communities to experimental or control conditions. We also considered controlled studies with baseline and post-intervention measures.

DATA COLLECTION AND ANALYSIS

Data were extracted by one author (KC) and checked by the second (RP). We contacted study authors for additional data where necessary. The main outcome measure was abstinence from smoking at least six months from the start of the intervention. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates where available. Where possible we performed meta-analysis using a generic inverse variance model, grouped by timed endpoints, but not pooled across the subgroups.

MAIN RESULTS

Nineteen studies met our inclusion criteria, covering >4500 participants. Only one study, the largest in our review and covering 878 smokers, demonstrated significantly higher quit rates for the incentives group than for the control group beyond the six-month assessment. This trial referred its participants to local smoking cessation services, and offered substantial cash payments (up to US$750) for prolonged abstinence. In the remaining trials, there was no clear evidence that participants who committed their own money to the programme did better than those who did not, or that contingent rewards enhanced success rates over fixed payment schedules. There is some evidence that recruitment rates can be improved by rewarding participation, which may be expected to deliver higher absolute numbers of successful quitters. Cost effectiveness analysis was not appropriate to this review, since the efficacy of most of the interventions was not demonstrated.

AUTHORS' CONCLUSIONS

With the exception of one recent trial, incentives and competitions have not been shown to enhance long-term cessation rates. Early success tended to dissipate when the rewards were no longer offered. Rewarding participation and compliance in contests and cessation programmes may have potential to deliver higher absolute numbers of quitters. The one trial that achieved sustained success rates beyond the reward schedule concentrated its resources into substantial cash payments for abstinence rather than into running its own smoking cessation programme. Such an approach may only be feasible where independently-funded smoking cessation programmes are already available. Future research might explore the scale and longevity of possible cash reward schedules, within a variety of smoking populations.

Systematic prevention of overweight and obesity in adults: a qualitative and quantitative literature analysis

To date, most interventions aimed at preventing obesity have underemphasized the application of systematic intervention development, implementation and evaluation. The present review provides a thorough insight in factors promoting implementation and/or effectiveness in interventions aimed at preventing overweight/obesity among adults. A total of 46 studies evaluating interventions aimed at preventing obesity were reviewed, followed by both qualitative and quantitative analyses. The Intervention Mapping protocol and the Environmental Research framework for weight Gain prevention (EnRG) were applied to analyse and classify the included studies. The interventions were categorized by setting (workplace, community, health care) and target group (ethnic minorities, pregnant women, [pre]menopausal women, smokers, people with intellectual disabilities). Generally, interventions were found to have potential in changing energy balance-related behaviours and anthropometric outcomes. Effect sizes for changes in body mass index ranged between -0.09 and 0.45. When the programme goal specifically aimed at weight management, the intervention was found to be more successful than interventions with programme goals that were aimed at preventing cardiovascular disease or improving general health status. Although a considerable part of studies included motivational interventions, only some actually assessed the effects on potential cognitive mediators. A general lack of reporting underlying theoretical models for behaviour change was observed as well as the inclusion of linkage groups and strategies to promote empowerment.

Worksite environment intervention to prevent obesity among metropolitan transit workers

OBJECTIVE

The results of an 18-month worksite intervention to prevent obesity among metropolitan transit workers are reported.

METHODS

Four garages in a major metropolitan area were randomized to intervention or control groups. Data were collected during the fall of 2005 prior to the start of the intervention and during the fall of 2007, after the intervention ended. Intervention program components at the garage included enhancement of the physical activity facilities, increased availability of and lower prices on healthy vending machine choices, and group behavioral programs. Mixed model estimates from cross-sectional and cohort samples were pooled with weights inverse to the variance of their respective estimates of the intervention effects.

RESULTS

Measurement participation rates were 78% at baseline and 74% at follow-up. The intervention effect on garage mean BMI change was not significant (-0.14 kg/m(2)). Energy intake decreased significantly, and fruit and vegetable intake increased significantly in intervention garages compared to control garages. Physical activity change was not significant.

CONCLUSION

Worksite environmental interventions for nutrition and physical activity behavior change may have limited impact on BMI among transit workers who spend most of their workday outside the worksite.

Worksite-based incentives and competitions to reduce tobacco use. A systematic review

The Guide to Community Preventive Service (Community Guide) methods for systematic reviews were used to evaluate the evidence of effectiveness of worksite-based incentives and competitions to reduce tobacco use among workers. These interventions offer a reward to individuals or to teams of individuals on the basis of participation or success in a specified smoking behavior change (such as abstaining from tobacco use for a period of time). The review team identified a total of 26 published studies, 14 of which met study design and quality of execution criteria for inclusion in the final assessment. Only one study, which did not qualify for review, evaluated the use of incentives when implemented alone. All of the 14 qualifying studies evaluated incentives and competitions when implemented in combination with a variety of additional interventions, such as client education, smoking cessation groups, and telephone cessation support. Of the qualifying studies, 13 evaluated differences in tobacco-use cessation among intervention participants, with a median follow-up period of 12 months. The median change in self-reported tobacco-use cessation was an increase of 4.4 percentage points (a median relative percentage improvement of 67%). The present evidence is insufficient to determine the effectiveness of incentives or competitions, when implemented alone, to reduce tobacco use. However, the qualifying studies provide strong evidence, according to Community Guide rules, that worksite-based incentives and competitions in combination with additional interventions are effective in increasing the number of workers who quit using tobacco. In addition, these multicomponent interventions have the potential to generate positive economic returns over investment when the averted costs of tobacco-associated illnesses are considered. A concurrent systematic review identified four studies with economic evidence. Two of these studies provided evidence of net cost savings to employers when program costs are adjusted for averted healthcare expenses and productivity losses, based on referenced secondary estimates.

The effectiveness of worksite nutrition and physical activity interventions for controlling employee overweight and obesity: a systematic review

This report presents the results of a systematic review of the effectiveness of worksite nutrition and physical activity programs to promote healthy weight among employees. These results form the basis for the recommendation by the Task Force on Community Preventive Services on the use of these interventions. Weight-related outcomes, including weight in pounds or kilograms, BMI, and percentage body fat were used to assess effectiveness of these programs. This review found that worksite nutrition and physical activity programs achieve modest improvements in employee weight status at the 6-12-month follow-up. A pooled effect estimate of -2.8 pounds (95% CI=-4.6, -1.0) was found based on nine RCTs, and a decrease in BMI of -0.5 (95% CI=-0.8, -0.2) was found based on six RCTs. The findings appear to be applicable to both male and female employees, across a range of worksite settings. Most of the studies combined informational and behavioral strategies to influence diet and physical activity; fewer studies modified the work environment (e.g., cafeteria, exercise facilities) to promote healthy choices. Information about other effects, barriers to implementation, cost and cost effectiveness of interventions, and research gaps are also presented in this article. The findings of this systematic review can help inform decisions of employers, planners, researchers, and other public health decision makers.

Worksite Opportunities for Wellness (WOW): effects on cardiovascular disease risk factors after 1 year

OBJECTIVE

To evaluate the effectiveness of a worksite health promotion program on improving cardiovascular disease risk factors.

METHODS

In St Louis, Missouri from 2005 to 2006, 151 employees (134 F, 17 M, 81% overweight/obese) participated in a cohort-randomized trial comparing assessments + intervention (worksite A) with assessments only (worksite B) for 1 year. All participants received personal health reports containing their assessment results. The intervention was designed to promote physical activity and favorable dietary patterns using pedometers, healthy snack cart, WeightWatchers(R) meetings, group exercise classes, seminars, team competitions, and participation rewards. Outcomes included BMI, body composition, blood pressure, fitness, lipids, and Framingham 10-year coronary heart disease risk.

RESULTS

123 participants, aged 45+/-9 yr, with BMI 32.9+/-8.8 kg/m(2) completed 1 year. Improvements (P< or =0.05) were observed at both worksites for fitness, blood pressure, and total-, HDL-, and LDL-cholesterol. Additional improvements occurred at worksite A in BMI, fat mass, Framingham risk score, and prevalence of the metabolic syndrome; only the changes in BMI and fat mass were different between worksites.

CONCLUSION

A multi-faceted worksite intervention promoted favorable changes in cardiovascular disease risk factors, but many of the improvements were achieved with worksite health assessments and personalized health reports in the absence of an intervention.

Paying for obesity: a changing landscape

BACKGROUND

Coverage for obesity related services is highly variable. Despite this, health plans, purchasers, and states have mounted numerous recent initiatives.

OBJECTIVE

To identify the range of approaches being used to address coverage and reimbursement for childhood obesity services.

METHODS

Key informant interviews were conducted using a semi-structured protocol to identify the types of activities they or their organization were engaged in to address childhood obesity, to learn about private payer policies and procedures, to identify best practices, potential resources and/or other key informants. Domains addressed in the protocol included scope of the respondent's organization's activities, the rationale for supporting obesity activities, the degree to which obesity services were a covered benefit and what if any barriers or challenges were encountered in implementation, the policy climate within which the organization operates (e.g. state legislation, initiatives or task forces), and any assessment of the impact and/or cost of implementing their initiatives. The individuals interviewed represented respondents from each of the following categories: employer, health plan, and state insurance programs and conducted by phone between November 2007 and March 2008. In addition to the information gathered by the key informant interviews we conducted a search of the relevant peer review and grey literature between 2005 and 2008 and input from a national expert advisory group.

RESULTS

Significant variation, as well as recent changes, were identified in both the private and public sector. Approaches included new benefits and incentives for parents and providers. Only anecdotal evidence of impact of the recent changes was available.

CONCLUSIONS

There is important forward movement in how public and private players are addressing paying for obesity related services. Medicaid and SCHIP programs have an opportunity to provide additional leadership. Substantial investments in evaluation and research are needed to learn which approaches are most effective.

Competitions and incentives for smoking cessation

BACKGROUND

Material or financial incentives may be used in an attempt to reinforce behaviour change, including smoking cessation. They have been widely used in workplace smoking cessation programmes, and to a lesser extent within community programmes. Quit and Win contests are the subject of a companion review.

OBJECTIVES

To determine whether competitions and incentives lead to higher long-term quit rates. We also set out to examine the relationship between incentives and participation rates.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group Specialized Register, with additional searches of MEDLINE, EMBASE, CINAHL and PsycINFO. Search terms included incentive*, competition*, contest*, reward*, prize*, contingent payment*, deposit contract*. The most recent searches were in December 2007.

SELECTION CRITERIA

We considered randomized controlled trials, allocating individuals, workplaces, groups within workplaces, or communities to experimental or control conditions. We also considered controlled studies with baseline and post-intervention measures.

DATA COLLECTION AND ANALYSIS

Data were extracted by one author and checked by the second. We contacted study authors for additional data where necessary. The main outcome measure was abstinence from smoking at least six months from the start of the intervention. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates where available. Where possible we performed meta-analysis using a generic inverse variance model, grouped by timed endpoints, but not pooled across the subgroups.

MAIN RESULTS

Seventeen studies met our inclusion criteria. None of the studies demonstrated significantly higher quit rates for the incentives group than for the control group beyond the six-month assessment. There was no clear evidence that participants who committed their own money to the programme did better than those who did not, or that different types of incentives were more or less effective. There is some evidence that although cessation rates have not been shown to differ significantly, recruitment rates can be improved by rewarding participation, which may be expected to deliver higher absolute numbers of successful quitters. Cost effectiveness analysis is not appropriate to this review, since the efficacy of the intervention has not been demonstrated.

AUTHORS' CONCLUSIONS

Incentives and competitions have not been shown to enhance long-term cessation rates, with early success tending to dissipate when the rewards are no longer offered. Rewarding participation and compliance in contests and cessation programmes may have more potential to deliver higher absolute numbers of quitters.

Insurance coverage and incentives for weight loss among adults with metabolic syndrome

OBJECTIVE

To describe how insured adults with metabolic syndrome respond to various options for insurance coverage and financial incentives for weight management.

METHODS AND PROCEDURES

Insured adults meeting the criteria for the metabolic syndrome were randomly identified through automated medical records and invited to participate in a telephone-based survey of the acceptability of various weight management programs-with different financial incentives and insurance coverage options-in a health maintenance organization. Multivariable logistic regression models were used to test the relationship between participant characteristics and the odds of being motivated by incentives.

RESULTS

One hundred and fifty-three adults with the metabolic syndrome completed the survey (i.e., 79% of telephone contacts). A hypothetical increase in insurance coverage from 10 to 100% led to a threefold increase among women and a sevenfold increase among men in the proportion reporting they were "very interested" in enrolling in a weight management program within the next 30 days. Most participants (76% of women and 57% of men) supported a health plan-sponsored financial incentive program tied to weight loss, and 41% believed such a program would motivate them to lose weight. The mean financial incentive proposed for a 15-pound weight loss was $591 (median: $125).

DISCUSSION

Although weight loss is an effective treatment for metabolic syndrome, standard health insurance rarely covers intensive behavioral treatment. The results of this study suggest that providing full insurance coverage and financial incentives for weight management increases the interest in participating in obesity treatment programs. Further research should determine how full coverage and incentives affect participation rates, long-term body weight changes, and costs.

Accounting for expected attrition in the planning of community intervention trials

Trials in which intact communities are the units of randomization are increasingly being used to evaluate interventions which are more naturally administered at the community level, or when there is a substantial risk of treatment contamination. In this article we focus on the planning of community intervention trials in which k communities (for example, medical practices, worksites, or villages) are to be randomly allocated to each of an intervention and a control group, and fixed cohorts of m individuals enrolled in each community prior to randomization. Formulas to determine k or m may be obtained by adjusting standard sample size formulas to account for the intracluster correlation coefficient rho. In the presence of individual-level attrition however, observed cohort sizes are likely to vary. We show that conventional approaches of accounting for potential attrition, such as dividing standard sample size formulas by the anticipated follow-up rate pi or using the average anticipated cohort size m pi, may, respectively, overestimate or underestimate the required sample size when cluster follow-up rates are highly variable, and m or rho are large. We present new sample size estimation formulas for the comparison of two means or two proportions, which appropriately account for variation among cluster follow-up rates. These formulas are derived by specifying a model for the binary missingness indicators under the population-averaged approach, assuming an exchangeable intracluster correlation coefficient, denoted by tau. To aid in the planning of future trials, we recommend that estimates for tau be reported in published community intervention trials.

Do cervical cancer screening rates increase in association with an intervention designed to increase mammography usage?

OBJECTIVES

To assess cervical cancer screening behaviors among underserved women participating in an intervention designed to increase mammography use.

METHODS

This was a randomized trial of 897 women from three racial groups (white, African American, Native American) living in a rural county in North Carolina. Baseline and followup surveys were completed by 815 women; 775 women provided data to be included in these analyses. The intervention group received an educational program focused on mammography delivered by a lay health advisor, and the control group received a physician letter/brochure focusing on Pap tests.

RESULTS

Women in both the intervention (OR 1.70; 1.31, 2.21, p < 0.001) and control groups (OR 1.38; 1.04, 1.82, p = 0.025) significantly increased cervical cancer screening rates within risk appropriate guidelines. No differences by racial group were documented. Women categorized in the high-risk group for developing cervical cancer (>2 sexual partners, age <18 years at first sexual intercourse, smoker; treated for sexually transmitted disease [STD] or partner with treated STD) significantly (OR 1.88; 1.54, 2.28, p < 0.001) increased Pap test completion. However, a nonsignificant increase (OR 1.25; 0.87, 1.79, p = 0.221) in Pap test completion was demonstrated in women categorized as low risk for cervical cancer.

CONCLUSIONS

This study suggests that women in an intensive behavioral intervention designed to increase mammography use may also increase Pap test completion, similar to a minimal intervention focused only on increasing Pap test completion. These results have implications for the design and evaluation of behavioral intervention studies.

Worksite environment physical activity and healthy food choices: measurement of the worksite food and physical activity environment at four metropolitan bus garages

Background

The present research describes a measure of the worksite environment for food, physical activity and weight management. The worksite environment measure (WEM instrument) was developed for the Route H Study, a worksite environmental intervention for weight gain prevention in four metro transit bus garages in Minneapolis-St. Paul.

Methods

Two trained raters visited each of the four bus garages and independently completed the WEM. Food, physical activity and weight management-related items were observed and recorded on a structured form. Inter-rater reliability was computed at the item level using a simple percentage agreement.

Results

The WEM showed high inter-rater reliability for the number and presence of food-related items. All garages had vending machines, microwaves and refrigerators. Assessment of the physical activity environment yielded similar reliability for the number and presence/absence of fitness items. Each garage had a fitness room (average of 4.3 items of fitness equipment). All garages had at least one stationary bike and treadmill. Three garages had at least one weighing scale available. There were no designated walking areas inside or outside. There were on average < 1 food stores or restaurants within sight of each garage. Few vending machine food and beverage items met criteria for healthful choices (15% of the vending machine foods; 26% of the vending machine beverages). The garage environment was perceived to be not supportive of healthy food choices, physical activity and weight management; 52% reported that it was hard to get fruits and vegetables in the garages, and 62% agreed that it was hard to be physically active in the garages.

Conclusion

The WEM is a reliable measure of the worksite nutrition, physical activity, and weight management environment that can be used to assess changes in the work environment.

Reflections on 30+ years of smoking cessation research: from the individual to the world

This is a personal retrospective in which I describe my career as a smoking cessation researcher and place cessation into an overall perspective of tobacco reduction. I spent approximately the first 15 years focusing primarily upon small group approaches to cessation emphasising relatively intensive behavioural interventions. It became apparent, however, that these types of approaches in isolation, even if broadly disseminated, would have relatively minimal impact on overall tobacco use. In part because I became discouraged with the potential of group programmes to reduce overall smoking prevalence, I began to focus more on population-based studies, especially in the context of 'teachable moments' including pregnancy, hospitalisation, forced abstinence in the military and existing smoking-related disease. I became concerned especially with the fact that there has been relatively little work with hard-core medically compromised smokers. It also became apparent that promoting cessation would be most likely to be effective with a comprehensive evidence-based tobacco reduction strategy including school and community-based prevention programmes, enforcement of ordinances restricting minors' access to tobacco, restrictions on tobacco advertising and promotion, counter advertising and strong smoke-free policies. In recent years I have become very concerned about the overall global tobacco epidemic and the projections of dramatically increasing tobacco morbidity and mortality in developing countries. I am now devoting my primary career emphasis to global tobacco reduction initiatives, including cessation research in India and Indonesia, cessation as part of broader tobacco reduction strategies and networking to increase resources and emphasis devoted to global tobacco reduction.

Factors related to participatory employee advisory boards in small, blue-collar worksites

PURPOSE

To identify factors related to formation, participation, and characteristics of employee advisory boards (EABs) in blue-collar worksites.

DESIGN

This study used a nonexperimental qualitative design to assess EAB formation, activity, and enthusiasm levels and examined those factors relative to employee participation in worksite-wide health promotion activities.

SETTING

Twenty-two blue-collar worksites with a total of 113 EAB members in the greater Seattle area.

SUBJECTS

Individuals who agreed to serve on EABs in the intervention worksites.

INTERVENTION

Participants received training in involving employees in the 5-A-Day project intervention activities.

MEASURES

Measures include type of worksite, number of EAB members, method of EAB recruitment, and variables describing EAB functioning, including attendance at meetings, assistance at project activities, and level of enthusiasm.

RESULTS

All worksites formed EABs. There was no association between the way the EAB was formed and subsequent EAB attendance at meetings, participation in project activities, representativeness of the EAB, or level of EAB enthusiasm. Enthusiasm of the EAB was associated with employee participation, and EABs with a higher level of enthusiasm showed more participation by employees than worksites with less enthusiastic EABs.

CONCLUSIONS

It is possible to develop participatory structures in small, blue-collar worksites. More information is needed about factors related to levels of enthusiasm of EABs.

[Is it possible to sustain health promotion programs in private companies? The case of four Quebec private companies of blue collar workers]

OBJECTIVE

Sustained health promotion programmes in the workplace (HPPW) continues to be a public health challenge. This article presents an evaluation of the implementation and sustainability of such programmes in private blue-collar companies in Quebec to shed light on issues specific to this type of setting.

METHOD

A multiple case (4 sites), longitudinal (7 years) and interpretive study method was used. The interpretation framework considered that the implementation and sustainability of HPPW in companies are the result of organizational learning in health promotion, determined by the strategies of individuals in a position of control who shape the decisional processes related to these programmes.

RESULTS

After seven years of observation, two of the four sites had continued their HPPW, although these programmes were no longer applied within these companies. The health promotion organizational learning processes in both sites were defined according to targeted organizational purposes set by the decision-makers who supported HPPW. However, these gains were largely lost when HPPW were no longer retained as a component of their organizational development strategy.

DISCUSSION

The organizational conditions that are conducive to HPPW are difficult to put together and sustain in companies like those in our study. Businesses implement these programmes mainly for the organizational benefits they expect to reap in the short term, whereas improvement in the health of workers in the longer term is not a priority.

Competitions and incentives for smoking cessation

BACKGROUND

Material or financial incentives may be used in an attempt to reinforce behaviour change, including smoking cessation. They have been widely used in workplace smoking cessation programmes, and to a lesser extent within community programmes. Quit and Win contests are the subject of a companion review.

OBJECTIVES

To determine whether competitions and incentives lead to higher long-term quit rates. We also set out to examine the relationship between incentives and participation rates.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group Specialized Register, with additional searches of MEDLINE (January 1966 to September 2004), EMBASE (1980 to 2004/8), CINAHL (1982 to 2004/8) and PsycINFO (1872 to 2004/6). Search terms included incentive*, competition*, contest*, reward*, prize*, contingent payment*, deposit contract*.

SELECTION CRITERIA

We considered randomized controlled trials, allocating individuals, workplaces, groups within workplaces, or communities to experimental or control conditions. We also considered controlled studies with baseline and post-intervention measures.

DATA COLLECTION AND ANALYSIS

Data were extracted by one author and checked by the second. We contacted study authors for additional data where necessary. The main outcome measure was abstinence from smoking for at least six months from the start of the intervention. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates where available. Where possible we performed meta-analysis using a generic inverse variance model, grouped by timed endpoints, but not pooled across the subgroups.

MAIN RESULTS

Fifteen studies met our inclusion criteria. None of the studies demonstrated significantly higher quit rates for the incentives group than for the control group beyond the six-month assessment. There was no clear evidence that participants who committed their own money to the programme did better than those who did not, or that different types of incentives were more or less effective. There is some evidence that although cessation rates have not been shown to differ significantly, recruitment rates can be improved by rewarding participation, which may be expected to deliver higher absolute numbers of successful quitters. Cost effectiveness analysis is not appropriate to this review, since the efficacy of the intervention has not been demonstrated.

AUTHORS' CONCLUSIONS

Incentives and competitions do not appear to enhance long-term cessation rates, with early success tending to dissipate when the rewards are no longer offered. Rewarding participation and compliance in contests and cessation programmes may have more potential to deliver higher absolute numbers of quitters.

Workplace interventions for smoking cessation

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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