Abstract
Objective: We evaluated the short-term effect of a worksite-based walking incentive program to promote physical activity and well-being in employees of a private healthcare clinic.
Design: A prospective, observational follow-up study.
Setting: The study was conducted at Marshfield Clinic, a large private multispecialty group practice healthcare institution in Marshfield,Wisconsin, USA.
Patients: Subjects for this study were Marshfield Clinic physicians and staff.
Methods: From March 31, 2005 to August 20, 2005, physical activity level, body mass index (BMI) and other well-being characteristics were observed pre- and post-program among 191 female participants from the Marshfield Clinic. A brief Web site-accessible, self-reported survey assessed the effectiveness of the exercise program.
Results: Our data show a statistically significant (p <0.0001) increase in participants’ physical activity level, while a significant (p = 0.021) decrease in mean BMI was observed. However, there was no evidence of our incentive program reducing participants’ blood pressure.
Conclusion: Preliminary findings of our study suggest that the goal of worksite programs designed to support employees in their efforts to improve or maintain their level of wellness is potentially achievable. Continuing research is needed to further assess whether persistent health benefits can be induced by worksite wellness programs.
It has been noted that worksite health promotion programs can help reduce employee absenteeism1,2 and turnover,3,4 as well as control health care costs.5 Many studies have shown that consistent walking may provide a variety of health benefits, including weight loss,6 lower body mass index (BMI),7 blood pressure/hypertension control,8–10 potentially decreased caloric intake,11,12 and sense of well-being13 (specifically anxiety and tension reduction)8,14 or mental health improvement.15 However, findings are not always consistent. One study questioned the effectiveness of worksite physical activity interventions,16 while other studies indicated only a small proportion of participants exercise regularly.17–19
To improve the understanding of the health benefits of regular, as well as strenuous walking, the Marshfield Clinic’s Work/Life Program offered a 20-week walking incentive program designed to support staff and physicians in their efforts to improve or maintain their level of wellness. Our goal was to provide employees with a safe and effective exercise (walking) program, which was referred to as “Steps to a Better You”. The main points of the program included: 1) providing physicians and staff with a structured walking program based on the results of each participant’s pre-program 1-mile walk test (i.e., fitness level as measured by maximal oxygen consumption [VO2max]), 2) providing incentive to participants to meet minimum physical activity levels as recommended by the Centers for Disease Control and Prevention (i.e., 5 or more days per week for 30 to 60 minutes each day), 3) providing bi-weekly e-mails with information on how to increase physical activity, make healthy food choices and provide motivation to maintain an activity program that fits with individuals’ lifestyles and 4) reviewing participants’ comments and obtaining biometric measures (e.g., BMI and VO2max) to determine if Web-based programs can have an impact on personal health and well-being.
The main purpose of the structured walking program was to increase participants’ levels of aerobic fitness. By providing participants with this program, they had the opportunity to not only improve their aerobic fitness levels but also to gain confidence in beginning and maintaining an exercise program, to manage or lose body fat, as well as to experience other beneficial side effects of improved wellness. A secondary aim of the program was to determine whether a self-guided, Web-based walking program can be a useful tool in motivating participants to increase their level of aerobic fitness, as measured by VO2max.
Methods
Worksite
Marshfield Clinic is one of the largest independent, non-profit medical clinics in the United States, serving 41 locations in 38 communities across central, northern and western Wisconsin. The Work/Life Program, staffed by 3 full-time employees and one seasonal intern, was established in 1997 to offer programs, services and resources to improve the work/life balance and wellness of staff and physicians. Volunteer liaisons at each of the regional centers assist with the promotion of the programs and distribution of program materials.
Program Description
The goals of our “Steps to a Better You” program were to increase self-reported moderate-intensity physical activity, decrease the incidence of those overweight and obese, and assist participants in maintaining a healthy weight. All employees of Marshfield Clinic were eligible to participate in the program and were recruited through e-mail and articles published in the Clinic’s weekly employee newsletter. The contents of the program evaluation questionnaire are presented in appendix 1.
Prior to subject recruitment, this study was reviewed and approved by the Marshfield Clinic Institutional Review Board. The 20-week program took place between March 31, 2005 and August 20, 2005. Participants who volunteered for the program ranged in age from 18 to 68 years. All participant data were collected via online forms hosted on Marshfield Clinic’s secure intranet site using Microsoft FrontPage 2000. Marshfield Clinic is a multi-site organization covering a large geographic area in central, northern and northwestern Wisconsin. With only one wellness staff person responsible for planning, managing and evaluating the programs, a Web-based approach was determined to be the best method for reaching, surveying and evaluating wellness program offerings. All participant data were then transferred from a FrontPage text file to a Microsoft Office 2000 Access database and Excel files to manage the program data. To protect participant confidentiality, personal identifiers were deleted and each participant’s record was coded before forwarding the data for statistical analysis.
To measure the participants’ changes in activity levels and the benefits of the program, participants were asked to complete online pre- and post-program surveys. Both surveys were modeled after the American Cancer Society Active for Life program and Healthy People 2010 activity goals. Because our employee incentive program has not been validated scientifically, participants’ comments were intended to be used solely for evaluating trends and determining areas in which programming could be focused to positively impact employee wellness.
To measure change in self-reported activity levels, participants were asked to indicate their current level of activity from four choices: 1) I do not exercise or walk regularly now, but I have been thinking about starting, 2) I exercise or walk 1 to 2 days each week for at least 30-minutes (time can be accumulated throughout the day) at a moderate pace or more, 3) I exercise or walk 3 to 4 days each week for at least 30-minutes (time can be accumulated throughout the day) at a moderate pace or more, 4) I exercise or walk 5 or more days each week for at least 30-minutes (time can be accumulated throughout the day) at a moderate pace or more.
Each participant earned a point for every 1 minute spent doing moderate-intensity physical activity. Total points were equivalent to the total number of minutes spent doing moderate-intensity physical activity. For example, a participant earned 3000 points if she walked 5 days a week for 30 minutes a day for the entire program (20 weeks).
Participants were questioned with regards to their motivation to complete the program (e.g., scale from 1 to 10, with 1 = not motivated at all and 10 = highly motivated), their top three reasons for participating in the program, their perceived benefits from participating in the program, and their self-reported biometric measures (optional) including blood pressure and BMI. The participants, using a link from the survey form to the National Heart, Lung and Blood Institute BMI calculator,20 performed their own BMI calculation.
To measure cardiovascular improvement, participants were asked to complete the Rockport Fitness Walking Test (RFWT) at the beginning of the program and again at the end of the 20-week program. RFWT is a maximal paced 1-mile walk test used to evaluate cardiorespiratory fitness through the estimation, or prediction, of VO2max in adults.21,22 It is considered to be a useful field test to accurately measure VO2max.
Due to the large (>700) number of subjects, participants were given instructions on how to self-administer the RFWT. Once they completed the test, they were asked to enter their walk time, age, weight and 1-minute heart rate into an on-line calculator to determine their VO2max. Once VO2max was determined, participants then submitted their results to Work/Life via an on-line form and chose from one of five walking programs (appendix 2) to follow during the program based on their VO2max measured by RFWT. The goal was to complete the walking program on at least 3 days each week.
Employees preferring an activity other than walking were also invited to participate in the program and could set an alternate program goal in minutes of moderate-intensity physical activity based upon the model introduced by the American Cancer Society in their Active for Life Program. It was recommended they choose a goal of at least 150 minutes of moderate-physical activity per week, which is in line with the current recommendation of 5 or more days per week for at least 30-minutes each day by the Centers for Disease Control and Prevention.23
A total of 756 employees registered for the program, of which 724 were female. With only 32 men registering for the program and the Marshfield Clinic workforce being predominantly female (76%), this study was limited to female participants. Of 724 registered women, 191 (26%) completed the program and the online survey. Although no known reasons were given, it is hypothesized that the remaining 533 women did not complete their evaluations because of a loss of motivation to continue in the program or because they did not reach their goals.
Data Analysis
Only women who completed both the program and the online evaluation (191 females) were included in the study for data analyses. The distributions of subject characteristics in categorical scales were presented with observed frequency counts and percentages. Ninety-five percent confidence intervals (CI) were constructed for the purpose of demonstrating the reliability of the observed percentages. McNemar tests were performed for pre- and post-program comparison. For the continuous scale characteristics, means and standard deviations were reported among participants who provided pre- and post-program data. Due to the skewed distribution, the pre- and post-program comparisons were performed using the Wilcoxon signed rank test for paired data. A p-value of <0.05 was considered statistically significant. All analyses were performed using SAS (SAS Institute, Cary, NC).
Results
Table 1⇓ shows characteristics of the 191 women who completed the 20-week walking incentive program, including self-reported pre- and post-program activity levels, pre-program reasons for participation and post-program participation benefits. Participants were Marshfield Clinic physicians, nurses and other staff. The age range of these participants at the start of the program was from 22 to 68 years with a mean age of 45 years (data not shown). Seventy-three percent of these women were age 40 years or more. Before attending the program, 35% had very low activity levels (i.e., less than 3 to 4 days/week for 30 minutes). Up to 85% of these women felt it was important to improve their physical health, appearance and mental health. Upon completing the program, only 8.1% had very low activity levels. Eighty-nine percent of these women met their goals, and all of them indicated they would encourage others to participate in the future. Of all participants, 97.4% felt they were supported in the program, 94.3% indicated they would participate again, and 84.3% reported feeling better with 72.8% feeling increased energy. Conversely, more than 50% of our participants did not experience the effectiveness/benefits of a fitness partner, winning a prize, exercising with co-workers, weight loss, a better body image, more productivity, better work relations, decreased calories or better sleep (data not shown). There was also no evidence that the consumption of fruits and vegetables was increased among our 191 female participants at the end of the program.
Self-reported activity levels, reasons for participation and participation benefits for female participants who completed both the pre- and post-program questionnaires.
Table 2⇓ shows the comparisons in total points, BMI, and systolic and diastolic blood pressures among women who provided pre- and post-program information. Results indicated a statistically significant difference in total points and BMI.
Pre-and post-program comparison of total activity points, body mass index and blood pressure.
Of the 191 participants, 88 (47.3%) maintained the same activity level, 7 (3.8%) decreased their level of activity, while 91 (48.9%) increased their level of activity. Of those increased, 59% (54/91) became the most active individuals. Overall, there was a significant (p <0.0001) increase in post-program activity levels compared to pre-program levels (table 3⇓).
Change in activity level among female participants who provided both pre- and post-program data.
We found that at program completion, 30 female participants’ total points earned upon program completion compared with the total points they initially set up as their goal. It is noteworthy that each point corresponds to the completion of 1 minute of moderate-intensity physical activity. Overall, 93.3% (95% CI, 77.9–99.2) of these women had exceeded or met their own exercise or point goals. We also found that, of 73 women who provided pre- and post-program BMI data, 61 (83.6%) remained in the same categories (i.e., normal weight with BMI <25, overweight with 25 ≤BMI <30, and obese with BMI ≥30) while 7 (9.6%) had decreased BMI and 5 (6.8%) had increased BMI.
Discussion
The findings of our study have shown that the “Steps to a Better You” program provided a positive impact on activity levels, as well as BMI. In regard to consumption of fruits and vegetables, 50.8% (95% CI, 43.5–58.1) of 191 women reported an increased intake, but this could be a chance (50:50) finding. A study of 434,121 adults in the United States concluded that consumption of fruits and vegetables changed little from 1994 to 2000.24 If increases are to be achieved, additional efforts and new strategies will be needed.
This study showed that there was a significant increase in activity levels among 186 of 191 women who provided pre-and post-program data. Our findings of increased physical activity are supported by previous studies which also have shown an increase in physical activity among participants of worksite health-promotion programs.25,26
Our findings regarding BMI are consistent with the reports of other studies. Pritchard et al26 followed 58 workers from a business corporation who were participating in a worksite exercise program for weight loss over a 12-month period and found a −4.4% change in BMI. Similarly, Oden et al27 reported an 8% reduction in body fat among 45 blue-collar workers who participated in a 24-week employee fitness/walking program. Conversely, it should be noted that the findings of two other studies contradict ours;28,29 however, it is worth mentioning that both studies had a very small number of subjects included in the analysis (35 and 14, respectively, compared with 73 of ours), suggesting that they may have been statistically underpowered to detect a meaningful difference in BMI or body weight/fat.
We observed inconclusive results regarding changes in general well-being related to participation in the fitness program in the 191 women we studied. Similarly, a fitness program study of 139 bank employees’ absenteeism and general well-being also showed no significant effect on well-being.30 We found no improvement in blood pressure among our study subjects. Likewise, a study on 72 insurance workers also did not find any association between work place exercise programs and blood pressure.31
Limitations of the Study
Our study was limited by several factors. Although we found a significant improvement in participants’ levels of wellness, information such as activity level and BMI was based on self-reported, non-validated information. Another shortcoming of our study is the undesirably low participation rate with an even lower number of subjects reporting their post-program results. This may induce a systematic bias (e.g., subjects already involved in physical activity represent the largest part of the study population, and there is a lack of knowledge of the impact of the program on sedentary people). As a consequence, the results obtained cannot be generalized to the entire group of Marshfield Clinic employees, because the study population may not be representative. It is also not possible to evaluate the participants’ changes in habits such as eating, work relations and sleep because only a subjective assessment was done at the end of the program. Because we only included women in our study, the findings cannot necessarily be generalized to men. However, many health care institutions employ more female than male workers. A recent report by the US Department of Labor showed that, of 6.7 million total employed in the healthcare practitioner and technical occupations, 73.2% are women.32 Thus, we believe that our findings can be generalized to the women who volunteer to participate in the program. For example, we are 95% confident that the true percent of the highest activity level (i.e., 5+ days/week for 30 minutes) among all Marshfield Clinic employees who voluntarily participate in the program should fall within 43.7% to 58.5% upon completing the program and returning their survey results. Although the low (26%) response rate might have had an effect on the generalizability of the results, 49% of the pre- and post-program respondents were overweight or obese at baseline. This implies that an interesting subgroup exists which values the importance of worksite health promotion programs in terms of maintaining or improving BMI, and ultimately general well-being.
Conclusion
In summary, the findings of the present study are encouraging and serve as a stimulus for further hypothesis generation. Our findings suggest that the goal of our exercise program, which was designed to support staff and physicians in their efforts to improve or maintain their level of wellness, is potentially achievable, at least in the short term. It has been pointed out that the potential of the worksite wellness program, including physical activity, is as yet largely unrealized.18 We have plans to continue an annual wellness program, with the objective of encouraging both men and women participants to strive to complete seven of nine wellness challenges to meet program goals (appendix 3).
Appendix 1 – “Steps to a Better You” Program Evaluation Questionnaire
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Last Name __________ First Name __________
-
Routing Location __________
Answer question 1 if you chose to follow the “Walking Program”
-
1. Did you meet the program goal? (Completed the walking program on 60 or more days)
□ Yes □ No
□ How many total days did you complete the walk program (Skip to question 3)
Answer question 2 if you chose to set your own “Total Point Goal”
-
2. I achieved my Total Point Goal during the program
□ Yes □ No
□ I didn’t keep track of points.
□ How many points did you achieve during the program?
-
3. Please read the following statements and check the box that best describes your current level of physical activity. (Check one)
□ I don’t exercise or walk regularly now, but I’ve been thinking about starting.
□ I exercise or walk 1–2 days per week for at least 30-minutes (time can be accumulated throughout the day), at a moderate pace or more.
□ I exercise or walk 3–4 days per week for at least 30-minutes (time can be accumulated throughout the day), at a moderate pace or more.
□ I exercise or walk 5 or more days per week for at least 30-minutes (time can be accumulated throughout the day), at a moderate pace or more.
-
4. Please indicate your level of agreement with the following statements regarding the Steps to a Better You Program. Choices: Strongly Agree; Agree; Disagree Strongly Disagree.
□ I would encourage others to participate ____________________
□ I felt good about myself as I participated ____________________
□ I felt positive support to participate ____________________
□ I am confident I will participate in the program again next year ____________________
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5. Were you matched with a “fitness partner” during the program?
□ Yes
□ No (Please go to question 6)
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5a. On average, how often did you communicate with your fitness partner during the program?
□ Less than 1 time per week
□ 1–4 times per week
□ 5 or more times per week
□ We did not stay in contact during the program (Skip to question 5c)
-
5b. How did you communicate with your fitness partner?
□ Telephone
□ E-mail
□ Both telephone and e-mail
-
5c. Was having a fitness partner beneficial to you?
□ Yes
□ No
Please Explain:
-
6. Please check the ways you have benefited by your participation in the program. (check all that apply).
□ I have increased energy
□ I feel better overall
□ I maintained my bodyweight
□ I lost bodyweight
□ I feel better about my body image
□ I am able to handle my stress levels more effectively
□ I feel more productive at work
□ I have a better working relationship with my peers
□ I increased the amount of fruits and vegetables I eat
□ I decreased the numbers of calories I eat
□ I sleep better
Other: (Please specify)
OPTIONAL BIOMETRIC INFORMATION
The questions listed below are optional, but valuable for “group” pre and post program measurements. All information will be kept confidential.
-
Enter your BMI (Body Mass Index) □ [BMI Calculator]
-
Blood Pressure □/□
Thank you for completing the Steps to a Better You Evaluation.
Appendix 3 – Annual Program Challenges
Meet 7 of the 9 wellness challenges during 2006 and win a prize. You will receive a personal log sheet to keep track of your progress during the program.
-
Be active. Submit a quarterly activity log showing that you have met your activity goal.
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Stay tobacco free OR verify enrollment in a cessation program.
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Wear your seatbelt 100% of the time.
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Receive an annual flu shot. You can still meet this requirement if you are unable to receive the flu shot due to medical reasons, or you were unable to get a flu shot due to short supply.
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Maintain a body mass index (BMI) in the recommended range, OR decrease BMI by 1 point during the calendar year, OR enroll in a Marshfield Clinic or community sponsored weight management class (i.e., HMR or Weight Watchers)
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Attend 3 or more wellness related Marshfield Clinic sponsored training sessions or presentations, OR utilize 3 or more self-directed learning resources available through Patient Education or Work/Life Program’s Lending Library.
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Participate in two Work/Life Program activity and healthy eating incentive programs.
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Complete 10 of 12 monthly “Wellness Bulletin Quizzes” with 80% accuracy.
The bulletins and online quiz will be e-mailed monthly. Each monthly quiz is comprised of 8–10 questions.
-
Return the end of the year program evaluation and register for the 2006 annual wellness program.
- Received June 6, 2006.
- Revision received August 3, 2006.
- Accepted September 25, 2006.
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