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The effectiveness of multi-faceted health promotion interventions in the workplace to reduce chronic disease |
Micucci S, Thomas H |
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CRD summary This review assessed multifaceted workplace interventions for the prevention of a number of chronic diseases. The authors concluded that there was insufficient evidence to recommend or not recommend the implementation of such interventions. This conclusion reflects the weak and conflicting evidence and is likely to be reliable. Authors' objectives To determine the effectiveness of multifaceted interventions in the workplace in the reduction of the incidence of, or risk factors for, the following chronic diseases: cardiovascular disease, cancer, chronic obstructive lung disease and diabetes. Searching CCINFOweb, CINAHL, the Cochrane CENTRAL Register, EMBASE, EconLit, HealthSTAR, PubMed, Nursing and Health Sciences (SAGE Publications), and PsycINFO were searched from 1990 to 2006. Government websites of Canada, USA, Australia, UK and the Netherlands were also searched, as were the websites of the following organisations: the Health Communication Unit, Canadian Centre for Occupational Health and Safety, Institute for Work and Health, Healthy Workplace Week, Alberta Centre for Active Living, National Quality Institute and the U.S. Task Force on Community Preventive Services. Eight relevant journals were handsearched from 2003 to 2006, in addition to the references of included studies, works of predominant authors, and articles suggested by a writing group. Experts were contacted. Study selection Randomised controlled trials (RCTs) of primary prevention programmes directed at changing behaviour in working adults were eligible for inclusion. Studies were required to assess an intervention aimed at changing at least two of the following: diet and nutrition, physical activity, and smoking cessation through the provision of education, skill building and a supportive environment. Pharmaceutical interventions were excluded from the review, as were government legislation or other policy interventions implementing workplace smoking bans. Programmes aimed only at high-risk individuals were also excluded. Studies had to be undertaken in Canada, the USA, Australia, New Zealand or Northwestern Europe. Eligible outcomes were changes in chronic disease rates, changes in intermediate biomarkers (a range of surrogate outcomes were defined in the report), or behaviour affecting such biomarkers. Changes in knowledge or attitudes were excluded from the review.
The included studies were either individually randomised or cluster randomised trials. Populations varied, with female only, male only and mixed populations, while both blue-collar and white-collar employees were represented. A range of worksites were targeted, including government services, insurance providers, fire services and manufacturing companies. A number of different theoretical models underpinned the studies (full details provided in the report). The interventions included distribution of educational material, professional instruction, and team and individually targeted strategies, and were carried out for between 6 and 30 months. Only one study reported follow-up beyond completion of the intervention phase. None of the included studies assessed the primary outcome of incidence of chronic disease; a range of biomarkers and behavioural measures were reported instead.
Two reviewers independently assessed studies for inclusion in the review, and any differences were resolved through consensus. Assessment of study quality Validity was assessed using a tool developed by the Effective Public Health Practice Project. This assesses studies using the following criteria: selection bias, allocation bias, control of confounders, blinded assessment, data collection methods, and the treatment of withdrawals and drop-outs. The studies were rated as strong, moderate or weak on each criterion and then assessed for overall strength based on these ratings.
Two reviewers independently assessed validity, with any differences resolved through consensus or consultation with a third reviewer. Data extraction Data were extracted on significant and non significant outcomes considered relevant using a standardised form. Data on the theoretical framework for the study were also extracted.
The authors did not state how many reviewers performed the data extraction. Methods of synthesis The studies were combined in a narrative, although meta-analysis was planned if the studies had shown sufficient clinical homogeneity. The studies were grouped by the outcomes reported and differences were discussed in the text, as were common factors in studies showing significant changes on outcome measures. Results of the review Thirteen RCTs, including 2 studies which were sub-studies of a larger project, were included in the review.
All of the studies were assessed as being methodologically weak. The number of participants involved was reported as varying greatly but could not be calculated.
Statistically significant decreases were reported for the following biomarkers: body mass index (2 out of 5 RCTs; 1 RCT showed a significant increase), weight (all 3 RCTs), percentage body fat (2 out of 3 RCTs), cholesterol (3 out of 5 RCTs), high-density lipoproteins (1 out of 3 RCTs), low-density lipoproteins (2 out of 3 RCTs). No significant effects were found for blood-pressure (3 RCTs) or triglycerides (2 RCTs).
Statistically significant changes were observed for the following nutritional outcomes: increases in fruit and vegetable consumption (3 out of 7 RCTs) and fibre consumption (1 out of 3 RCTs), and decreases in fat consumption (4 out of 6 RCTs), meat consumption (1 out of 2 studies) and sodium consumption (1 RCT). No significant increase in grain consumption was found (1 RCT).
Four out of 6 RCTs found a significant increase in physical activity or exercise. Maximum oxygen uptake, aerobic capacity and heart rate were also assessed, with conflicting results.
Eleven studies assessed smoking cessation and none found an overall significant effect of the intervention. Three RCTs assessed smoking quit attempts and also found no statistically significant effects.
The populations and intervention components associated with successful interventions were also reported, as was the fact that studies of interventions lasting 9 months or less were most successful, with longer periods showing returns to baseline values. Authors' conclusions Interventions which incorporated distribution of educational material and professional instructions were more successful than interventions that did not. Longer follow-up periods are required to substantiate this conclusion. There was insufficient evidence to recommend or not recommend multifaceted strategies for primary chronic disease prevention at the organisational level. CRD commentary The review question was clear and the inclusion criteria explicit. The authors searched a wide range of sources, thereby reducing the chance of publication bias or the omission of relevant studies. The authors reported using methods to reduce reviewer bias and error in the selection of studies and assessment of validity, but not in the extraction of data. The validity assessment used appropriate criteria and was used to inform the synthesis. In view of the clinical heterogeneity of the included studies, the use of a narrative synthesis was appropriate. Data pertaining to statistical significance were not included in the synthesis but were reported in the accompanying tables. All but one study used healthy volunteers, which may limit the generalisability of the results. This was a generally well-conducted review and the authors' cautious conclusions represent an accurate reflection of the limited quality and conflicting nature of the evidence. They are therefore likely to be reliable. Implications of the review for practice and research Practice: The authors stated that adequate resourcing of public health agencies is required to supply complex interventions appropriately to a diverse range of workplaces.
Research: The authors stated that funding should be given to research studies of interventions to reduce chronic disease which are of sufficient intensity, which take place over several years, and which are comprehensive, well-coordinated and multi-level. They specifically recommended that agencies should be used to ensure blinding as well as adequate follow-up. The outcomes reported should focus on biomarkers and behaviours identified as being affected by behavioural variables. Funding Ontario Ministry of Health and Long Term Care; Hamilton Public Services PHRED Program. Bibliographic details Micucci S, Thomas H. The effectiveness of multi-faceted health promotion interventions in the workplace to reduce chronic disease. Dundas, ON, Canada: City of Hamilton, Public Health and Community Services Department. Effective Public Health Practice Project. 2007 Indexing Status Subject indexing assigned by CRD MeSH Chronic Disease /prevention & Health Promotion; Humans; Occupational Health; Workplace; control AccessionNumber 12007008493 Date bibliographic record published 09/08/2008 Date abstract record published 23/12/2008 Record Status This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn. |
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