CARDIOVASCULAR DISEASE PREVENTION
Effects of a Worksite Program to Improve the Cardiovascular Health of Female Health Care Workers Vivian Low, MPH, BSN, RN-BC; Bonnie Gebhart, MBA, BSN, RN-BC; Christine Reich, BSN, RN-BC
■ PURPOSE: Reducing cardiovascular risk for female health care workers supports self-care and facilitates a culture of health promotion. We examined the effect of individualized motivational communications on risk and measured program participation at a busy hospital, utilizing cardiac rehabilitation resources.
K E Y
■ METHODS: Women (40-65 years old) who self-identified as having increased cardiovascular risk and ready for change were randomly assigned to weekly motivational counseling or control. All participants were offered classes (weight/diet, stress, exercise, and smoking cessation) and gym access. Physical and perceptual measures were recorded before and after the 6-month program to measure change. Followup 1 year later measured current weight, stress, and physical activity.
health promotion
■ RESULTS: Participants (n = 57) ranked weight as their greatest concern (42%). Compared with control, the intervention group resulted in greater: weight loss (7.2 vs 3.8 pounds); stress reduction (6.5 vs 4.7; Cohen stress scale); and exercise days per week (1.4 vs 1.2). Differences were not statistically significant in this small sample, but all changes consistently favored the intervention. Program participation was low, as was participation in the 1-year followup, although those responding indicated maintenance or further improvement. ■ CONCLUSIONS: These consistent and positive findings are promising but only suggestive because of the small sample size. Future studies should focus on how to get more buy-in from employees, to help insure persistence toward health goals. Study results assisted development of a comprehensive Web-based employee wellness motivational program to address the issues of on-site participation. Attention to health risks in health care workers remains an important area of study.
Cardiovascular disease (CVD) is the leading cause of death among women in the United States.1 Representing nearly 80% of the health care workforce,2 women are viewed as the frontline in health promotion. Yet they may ignore their own health risks despite knowledge of health, disease, risk factors, and prevention.3 Peate4 admonishes nurses with modifiable risk factors for counseling patients while not following the advice themselves. Barriers to maintaining
W O R D S
cardiovascular disease health care personnel
hospital-based wellness program
Author Affiliation: Cardiac and Pulmonary Wellness Center, El Camino Hospital, Mountain View, California. The authors declare no conflicts of interest. Correspondence: Bonnie Gebhart, MBA, BSN, RN-BC, Cardiac and Pulmonary Wellness Center, El Camino Hospital, Mountain View, 2500 Grant Rd, Mountain View, CA 94040 (Bonnie_ [email protected]). DOI: 10.1097/HCR.0000000000000116
personal health to model healthy behaviors must be identified. The American Heart Association's scientific statement on worksite programs for cardiovascular risk reduction provides support for a comprehensive program with individual and organizational components.5 Research has previously demonstrated the effectiveness of interventions at the worksite.6,7 However, we recognize the difficulty facing women
342 / Journal of Cardiopulmonary Rehabilitation and Prevention 2015;35:342-347
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in general4,8 and those in the health care field to implement such interventions.9 Utilizing resources of our cardiac rehabilitation department and the hospital's strategic priorities for women's cardiovascular health, this project investigated initial steps in moving toward a culture of wellness for our hospital employees. The aim of our study was to measure (1) the effect of weekly motivational communications in addition to availability of a health promotion program on cardiovascular risks; and (2) participation initiated and maintained at a busy hospital.
METHODS Study Design and Sample This unblinded randomized trial tested the effectiveness of the addition of weekly motivational communications concerning the availability of health promotion classes and an on-site gymnasium on CVD risk. A 300-bed community hospital in northern California was the site of the study. The Stages of Change model formed the basis for sample selection,10 focusing on individuals indicating they were ready for change and thus likely at highest risk.11 Female employees received a promotional flyer with a phone number to call if interested in participating in the project. Eligibility included being aged 40 to 65 years with ≥1 risk (overweight, high stress level, lack of physical activity, or smoking). Those with systolic blood pressure ≥200 mm Hg, diastolic blood pressure ≥110 mm Hg, blood glucose levels ≥300 mg/dL (unless primary care physician approved participation), resting heart rate ≤40 bpm or symptomatic resting heart rate ≤50 bpm, chest pain, unstable angina, or dizziness were excluded. Sample size was limited to 60 on the basis of resources and was determined to be sufficient to test risk reduction between study groups. Eligibility, consent, and enrollment occurred during May and June 2011 with followup in 2012. The hospital’s institutional review board approved the protocol.
Study Procedures Participants were assessed at baseline on sociodemographic and work-related factors (age, race/ethnicity, marital/partner status, education, the number of dependents, years, hours and position worked at the hospital, commuting distance, and participation in other health promotion activities). They ranked risks (weight, stress, physical activity, and smoking) according to their level of concern and desire to lower risk www.jcrpjournal.com
(yes or no). For each factor they wanted to change, participants marked where they were on a readiness to change ruler with hash marks from 0 (not ready) to 10 (very ready). Baseline physical measures included weight, height, blood pressure, heart rate, cholesterol (total, low-density lipoprotein-cholesterol, and high-density lipoproteincholesterol), triglycerides, and nonfasting blood glucose Categories were used for body mass index (normal 21-25 kg/m2, overweight >25-30 kg/m2, and obese > 30 kg/m2) and total cholesterol (normal 239 mg/dL). Weight management behaviors (days per week recording caloric intake and days per week weighing themselves), stress (the Cohen perceived stress scale12 grouped above or below the 13.7 norm for women), exercise (days per week, minutes per session, and intensity [no, leisurely, moderate, or vigorous exercise]), and current smoking (yes or no) were collected using self-report. Following baseline data collection, participants were randomly assigned to 1 of 2 study groups. All participants were offered risk reduction classes (weight loss/nutrition, stress management, exercise training, and smoking cessation), access to an on-site gymnasium, and organized group walks. The intervention group participants were told that they would receive weekly communication via phone or e-mail, incorporating goal-setting and suggestions for overcoming obstacles. Classes, gymnasium availability, organized walks, and the intervention (ie, weekly communication) continued for 6 months. Data were collected on class attendance. At the end of the program, the risk data collected at baseline were collected again. A followup survey was also conducted 1 year after program completion.
Data Analysis Baseline data were summarized to describe the sample and to evaluate study group equivalence using the chi-square, the Fisher exact, or t tests as appropriate. Intervention effectiveness was determined by comparing change from baseline to study end. Change in each risk factor was analyzed, both in an intention-to-treat model using the entire sample and in those who ranked the risk as their highest concern. We explored covariates, including readiness to change, for their contribution to risk changes, and those significant at α ≤ 0.10 were included in a linear regression model. Program evaluation included the number of classes attended, participation in walks, and attendance at the hospital gymnasium. The final survey included current concern (yes or no) about CVD, current health (better, about the same as when I Worksite Female CV Health Program / 343
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JCRP-D-14-00096_LR 343
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T a b l e 1 • Sociodemographic, Work-Related, and Health Characteristics at Baseline Intervention (n = 28)
Control (n = 29)
Total (n = 57)
a
n (%) Race/ethnicity White
18 (64)
23 (79)
41 (72)
Asian
4 (14)
2 (7)
6 (11)
Latina
4 (14)
1 (3)
5 (9)
Filipina/Pacific Islander
1 (4)
2 (7)
3 (5)
African American
1 (4)
1 (3)
2 (3)
Married/partnered
21 (75)
21 (72)
42 (74)
Divorced or separated
6 (21)
7 (24)
13 (23)
Never married
1 (4)
1 (4)
2 (3)
Administrative
16 (57)
16 (55)
32 (56)
Clinical
12 (43)
13 (45)
25 (44)
No
26 (93)
24 (83)
50 (88)
Yes
2 (7)
5 (17)
7 (12)
Marital status
Job category
Enrolled in another health program
Mean ± SD Age, y
51 ± 6.5
53 ± 6.0
52 ± 6.3
Education, y
15 ± 2.1
17 ± 1.8
15 ± 2.0
Worked at ECH, y
16 ± 11.1
16 ± 11.7
16 ± 11.3
Hours worked/week
41 ±6.7
39 ± 9.2
40 ± 8.0
One-way commute, miles
10 ±8.9
15 ± 17.9
12 ± 14.3
Weight, lb
192 ± 45.3
194 ± 58.4
193 ± 51.9
Resting HR, bpm
71 ± 11.6
71 ± 8.6
71 ± 10.1
Total cholesterol, mg/dL
200 ± 31.8
195 ± 37.2
198 ± 34.4
LDL-C, mg/dL
115 ± 24.4
104 ± 28.3
110 ± 26.8
HDL-C, mg/dL
52 ± 14.2
55 ± 14.7
53 ± 14.4
Triglycerides, mg/dL
179 ± 96.4
185 ± 98.2
182 ± 96.5
Blood glucose, mg/dL
104 ± 58.2
108 ± 59.7
106 ± 58.5
2 ± 2.2
2 ± 2.0
2 ± 2.1
31 ± 26.1
24 ± 21.6
27 ± 24.0
20.5 ± 5.8
19.6 ± 7.4
20.0 ± 6.6
Exercise/week, days Exercise time/session, min b
Stress scale
Abbreviations: ECH, El Camino Hospital; HDL-C, high-density lipoprotein-cholesterol; HR, heart rate; LDL-C, low-density lipoprotein-cholesterol. a
Some percentage totals do not equal 100% because of rounding.
b
Cohen Perceived Stress Scale.
completed the study, or worse), and questions about current weight, stress, and exercise (more, about the same as when I finished the study, or
less). Analyses were performed using SPSS (IBM, Chicago, IL), with an α ≤ 0.05 for determining statistical significance.
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RESULTS Characteristics and Health Status Sixty-two women enrolled and baseline characteristics did not differ by study group. Five individuals dropped out (“too busy,” relocation or family issues not related to CVD risk) resulting in a final sample of 57. Baseline sociodemographic, work-related and health characteristics by study group are summarized in Table 1. Participant aged 40 to 63 years, and education was high school (5%), some college (36%), associate degree (20%), college (32%), and Master's degree (7%). Most (72%) had no children younger than 18 years living with them. Years of work at the hospital ranged from 0.5 to 42 and hours worked per week ranged from 25 to 60. Commuting distance to work ranged from 1 to 40 miles. Participant health measures are summarized in Table 1 and Figure 1. Baseline weight ranged from 109 to 358 pounds, with 77% categorized as overweight or obese. Total cholesterol was 117 to 274 mg/dL, with 44% categorized as borderline or high. Blood glucose ranged from 61 to 366 mg/dL. About half (51%) reported no or only leisurely exercise. The Cohen stress scale ranged from 6 to 33, with internal consistency (Crohnbach α = 0.88). Over three-quarters (82%) had stress levels above the normative mean for women. Body weight was ranked by 42% of the participants as the factor of highest concern, followed by stress (30%) and exercise (25%). As only 3 individuals were current smokers, with 2 listing smoking as their primary concern, no further analysis of smoking was done. Readiness to change levels were high, 7.9 or higher on the scale from 0 to 10.
Effect of Study Group on Cardiovascular Risk Factors Weight loss was greater in the intervention group (mean = 7.2 ± 14.0 lb) compared with the control
Figure 1. Health characteristics of 57 female health care workers at baseline. www.jcrpjournal.com
group (3.8 ± 10.3 lb), although this was not statistically significant. Only race/ethnicity was associated with weight change, with whites losing 8.6 ± 12.5 lb, and women of color gaining 1.9 ± 8.6 lb (P = .006), and race/ethnicity remained significantly associated with weight change with the intervention group included in the analysis (P = .004). Among those ranking weight as their highest concern, the intervention group lost 13.5 ± 4.9 lb compared with 2.7 ± 13.0 in the control group (P = .101). The intervention group reported a greater but not significant decrease in stress as measured by the Cohen stress scale (6.5 ± 6.7) compared with the control group (4.7 ± 7.3). Readiness to change was positively but weakly correlated with a reduction in stress (r = 0.09; not significant). Those with longer commutes had less stress reduction (r = −0.34; P = .017), remaining statistically significant when taking into account study group (P = .024). Numbers were too small to analyze among those listing stress as their highest level of concern. The intervention group increased their days per week of exercise more than the control group, but this was not a statistically or clinically important difference (1.4 ± 2.6 days vs 1.2 ± 1.3 days, respectively) and time exercising increased by about 1 hour per week in both study groups. There was no correlation between readiness to change and the amount of change in exercise at the end of the study. Triglycerides were strongly and positively associated with increases in exercise days per week (r = 0.49; P = .000), remaining significant when taking into account study group (P = .000). All participants increased their exercise intensity with 32%, reporting no exercise at baseline compared with 6% at study end. Numbers were too small to analyze among those listing physical activity as their highest level of concern.
Program Evaluation: Participation and Maintenance Attendance did not differ by study group, and, in both groups, attendance at the first lecture corresponded with participants’ ranking of the topic—weight loss ranked highest among 42%, and 47% attended the introductory lecture; stress management ranked highest among 30%, and 21% attended this first lecture; and physical activity ranked highest among 25%, and 26% attended the first lecture. Attendance at later classes was considerably lower—participants attended on average 0.6 of 4 nutrition classes; 2.1 of 12 stress classes. Only 3 joined a group walk once; and gymnasium use ranged from 0 to 20 days over the period (average use was 2.4 days). Worksite Female CV Health Program / 345
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The final survey, 1 year after the program, had few responses—only 16 (28%) of the sample responded, 9 from the intervention group and 7 from the control group. All of those responding indicated continuing concern about CVD risk and 94% reported their health as the same or better. More in the intervention group (67%) than in the control group (57%) reported they were continuing to make progress on their goals. For the 3 specific areas of concern, participants reported weight as the same or less (81%), and exercise as the same or greater (81%), with no difference by study group. For stress, however, all in the intervention group reported stress the same or lower compared with 57% of those in the control group (P = .063).
DISCUSSION The consistent and positive findings of this preliminary study are promising for risk reduction at the worksite in general and the use of individualized motivational messages in particular. Despite high levels of variability among the study sample, those who had weekly encouragement showed improvements, particularly in weight management and stress reduction. Numbers were small and results were therefore only suggestive. Our findings are similar to a study comparing in-person with Internet-based interventions,13 and weight management outcomes are comparable to those found in a systematic review of programs.6 Differences in weight loss by race/ethnicity raise important questions for future, larger studies. With new health promotion opportunities available to all, it is not surprising that both groups showed improvements. Finally, improvements may have been influenced by the Hawthorne effect of being in a study. Program evaluations revealed that on-site activities were not well attended, comparable to results found by Flannery et al14 for attendance at first classes but lower in our sample for the remainder of the program. Long commute distances and anecdotal comments about time and work schedules suggest that workers, initially highly motivated, found that realistically they could not continue to comply with the program. Study subjects did not remain persistent in their participation, and questions about program structure and other mechanisms for health promotion remain unanswered. Future studies should focus on how to get more buyin from higher risk female health care workers, both to encourage initial participation and to ensure their persistence toward health goals. Study results contributed to the development of a comprehensive Webbased employee wellness motivational program aimed at addressing the difficulty of on-site participation.
Overall, improvements were maintained 1 year after program completion, although very few women responded to the final survey. The intervention appeared to help maintain stress level reduction. The small number precludes conclusions except to say that, in this small group, we were gratified that perceptions of improvement were maintained a year after program completion.
CONCLUSIONS Wellness for health care workers is an important area for continued investigation. Participants were indeed in poor health, with profiles similar to results from the American Nurses Association's Healthy Nurse Questionnaire,15 raising concerns about the health of our workforce. There are challenges and barriers, but to improve the health of our patients, we need to look to our own health to empower ourselves to better care for others.4 Wellness programs with individualized support and encouragement should be considered, and this study could serve as an example for other hospitals to conduct similar studies or to justify additional staff for employee wellness services.
—Acknowledgments— This study was supported with funding from Hope to Health (H2H), devoted to improving women's lives by providing hope, resources, and education, from the El Camino Hospital Foundation and Women's Hospital. The authors thank Dr Catherine Collings, MD; Craig Clemens, MA, RCEP; Esther Agustin, MA, RCEP; Debby Hagenmaier, MSN, RN; Jodi Bjurman, RD, CDE; Missy Von Luehrte, BSN, RN; Karen Halverson, Senior Librarian; and Lynne Rock, MBA, for their expertise.
References 1. American College of Cardiology. Women and heart disease: learn about heart disease. https://www.cardiosmart.org/HeartConditions/Women-and-Coronary-Artery-Disease. Published 2010. Accessed April 29, 2014. 2. Centers for Disease Control and Prevention. Workplace safety & health topics. http://www.cdc.gov/niosh/topics/healthcare/. Accessed April 29, 2014. 3. Mosca L, Mochari-Greenberger H, Dolor RJ, Newby LK, Robb KJ. Twelve-year follow-up of American women's awareness of cardiovascular diseases risk and barriers to heart health. Circ Cardiovasc Qual Outcomes. 2010;3:120-127. 4. Peate I. Do as I say, not as I do. Br J Nur. 2012;21:1009. 5. Carnethon M, Whitsel LP, Franklin BA, et al. Worksite wellness programs for cardiovascular disease prevention: a policy statement from the American Heart Association. Circulation. 2009;120:1725-1741. 6. Anderson LM, Quinn TA, Glanz K, et al. The effectiveness of worksite nutrition and physical activity interventions for
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7.
8.
9.
10.
controlling employee overweight and obesity: a systematic review. Am J Prev Med. 2009;37:340-357. Conn VS, Hafdahl AR, Cooper PS, Brown LM, Lusk SL. Metaanalysis of workplace physical activity interventions. Am J Prev Med. 2009;37:330-339. Yancey AK, McCarthy WJ, Harrison GG, Wong WK, Siegel JM, Leslie J. Challenges in improving fitness: results of a community-based, randomized, controlled lifestyle change intervention. J Women Health. 2006;15:412-429. Tucker SJ, Lanningham-Foster LM, Murphy JN, et al. Effects of a worksite physical activity intervention for hospital nurses who are working mothers. AAOHN J. 2011;59:377-386. Zimmerman GL, Olsen CG, Bosworth MF. A “stages of change” approach to helping patients change behavior. Am Fam Physician. 2000;61:1409-1416.
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11. Thorndike AN, Healey E, Sonnenberg L, Regan S. Participation and cardiovascular risk reduction in a voluntary worksite nutrition and physical activity program. Prev Med. 2011;52:164-166. 12. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983;24:385-396. 13. Bruno M, Touger-Decker R, Byham-Gray L, Denmark RJ. Workplace weight loss program: impact on quality of life. Occup Environ Med. 2011;53:1396-1403. 14. Flannery K, Resnick B, Galik E, Lipscomb J, McPhaul K, Shaughnessy M. The Worksite Heart Health Improvement Project (WHHIP): feasibility and efficacy. Public Health Nurs. 2012;29:455-466. 15. American Nurses Association. “Healthy Nurse” Questionnaire. website. http://www.nursingworld.org/MainMenuCategories/ WorkplaceSafety/Healthy-Nurse. Accessed April 29, 2014.
Worksite Female CV Health Program / 347
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JCRP-D-14-00096_LR 347
19/08/15 7:45 AM
Effects of a Worksite Program to Improve the Cardiovascular Health of Female Health Care Workers Vivian Low, MPH, BSN, RN-BC; Bonnie Gebhart, MBA, BSN, RN-BC; Christine Reich, BSN, RN-BC
■ PURPOSE: Reducing cardiovascular risk for female health care workers supports self-care and facilitates a culture of health promotion. We examined the effect of individualized motivational communications on risk and measured program participation at a busy hospital, utilizing cardiac rehabilitation resources.
K E Y
■ METHODS: Women (40-65 years old) who self-identified as having increased cardiovascular risk and ready for change were randomly assigned to weekly motivational counseling or control. All participants were offered classes (weight/diet, stress, exercise, and smoking cessation) and gym access. Physical and perceptual measures were recorded before and after the 6-month program to measure change. Followup 1 year later measured current weight, stress, and physical activity.
health promotion
■ RESULTS: Participants (n = 57) ranked weight as their greatest concern (42%). Compared with control, the intervention group resulted in greater: weight loss (7.2 vs 3.8 pounds); stress reduction (6.5 vs 4.7; Cohen stress scale); and exercise days per week (1.4 vs 1.2). Differences were not statistically significant in this small sample, but all changes consistently favored the intervention. Program participation was low, as was participation in the 1-year followup, although those responding indicated maintenance or further improvement. ■ CONCLUSIONS: These consistent and positive findings are promising but only suggestive because of the small sample size. Future studies should focus on how to get more buy-in from employees, to help insure persistence toward health goals. Study results assisted development of a comprehensive Web-based employee wellness motivational program to address the issues of on-site participation. Attention to health risks in health care workers remains an important area of study.
Cardiovascular disease (CVD) is the leading cause of death among women in the United States.1 Representing nearly 80% of the health care workforce,2 women are viewed as the frontline in health promotion. Yet they may ignore their own health risks despite knowledge of health, disease, risk factors, and prevention.3 Peate4 admonishes nurses with modifiable risk factors for counseling patients while not following the advice themselves. Barriers to maintaining
W O R D S
cardiovascular disease health care personnel
hospital-based wellness program
Author Affiliation: Cardiac and Pulmonary Wellness Center, El Camino Hospital, Mountain View, California. The authors declare no conflicts of interest. Correspondence: Bonnie Gebhart, MBA, BSN, RN-BC, Cardiac and Pulmonary Wellness Center, El Camino Hospital, Mountain View, 2500 Grant Rd, Mountain View, CA 94040 (Bonnie_ [email protected]). DOI: 10.1097/HCR.0000000000000116
personal health to model healthy behaviors must be identified. The American Heart Association's scientific statement on worksite programs for cardiovascular risk reduction provides support for a comprehensive program with individual and organizational components.5 Research has previously demonstrated the effectiveness of interventions at the worksite.6,7 However, we recognize the difficulty facing women
342 / Journal of Cardiopulmonary Rehabilitation and Prevention 2015;35:342-347
www.jcrpjournal.com
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
JCRP-D-14-00096_LR 342
19/08/15 7:45 AM
in general4,8 and those in the health care field to implement such interventions.9 Utilizing resources of our cardiac rehabilitation department and the hospital's strategic priorities for women's cardiovascular health, this project investigated initial steps in moving toward a culture of wellness for our hospital employees. The aim of our study was to measure (1) the effect of weekly motivational communications in addition to availability of a health promotion program on cardiovascular risks; and (2) participation initiated and maintained at a busy hospital.
METHODS Study Design and Sample This unblinded randomized trial tested the effectiveness of the addition of weekly motivational communications concerning the availability of health promotion classes and an on-site gymnasium on CVD risk. A 300-bed community hospital in northern California was the site of the study. The Stages of Change model formed the basis for sample selection,10 focusing on individuals indicating they were ready for change and thus likely at highest risk.11 Female employees received a promotional flyer with a phone number to call if interested in participating in the project. Eligibility included being aged 40 to 65 years with ≥1 risk (overweight, high stress level, lack of physical activity, or smoking). Those with systolic blood pressure ≥200 mm Hg, diastolic blood pressure ≥110 mm Hg, blood glucose levels ≥300 mg/dL (unless primary care physician approved participation), resting heart rate ≤40 bpm or symptomatic resting heart rate ≤50 bpm, chest pain, unstable angina, or dizziness were excluded. Sample size was limited to 60 on the basis of resources and was determined to be sufficient to test risk reduction between study groups. Eligibility, consent, and enrollment occurred during May and June 2011 with followup in 2012. The hospital’s institutional review board approved the protocol.
Study Procedures Participants were assessed at baseline on sociodemographic and work-related factors (age, race/ethnicity, marital/partner status, education, the number of dependents, years, hours and position worked at the hospital, commuting distance, and participation in other health promotion activities). They ranked risks (weight, stress, physical activity, and smoking) according to their level of concern and desire to lower risk www.jcrpjournal.com
(yes or no). For each factor they wanted to change, participants marked where they were on a readiness to change ruler with hash marks from 0 (not ready) to 10 (very ready). Baseline physical measures included weight, height, blood pressure, heart rate, cholesterol (total, low-density lipoprotein-cholesterol, and high-density lipoproteincholesterol), triglycerides, and nonfasting blood glucose Categories were used for body mass index (normal 21-25 kg/m2, overweight >25-30 kg/m2, and obese > 30 kg/m2) and total cholesterol (normal 239 mg/dL). Weight management behaviors (days per week recording caloric intake and days per week weighing themselves), stress (the Cohen perceived stress scale12 grouped above or below the 13.7 norm for women), exercise (days per week, minutes per session, and intensity [no, leisurely, moderate, or vigorous exercise]), and current smoking (yes or no) were collected using self-report. Following baseline data collection, participants were randomly assigned to 1 of 2 study groups. All participants were offered risk reduction classes (weight loss/nutrition, stress management, exercise training, and smoking cessation), access to an on-site gymnasium, and organized group walks. The intervention group participants were told that they would receive weekly communication via phone or e-mail, incorporating goal-setting and suggestions for overcoming obstacles. Classes, gymnasium availability, organized walks, and the intervention (ie, weekly communication) continued for 6 months. Data were collected on class attendance. At the end of the program, the risk data collected at baseline were collected again. A followup survey was also conducted 1 year after program completion.
Data Analysis Baseline data were summarized to describe the sample and to evaluate study group equivalence using the chi-square, the Fisher exact, or t tests as appropriate. Intervention effectiveness was determined by comparing change from baseline to study end. Change in each risk factor was analyzed, both in an intention-to-treat model using the entire sample and in those who ranked the risk as their highest concern. We explored covariates, including readiness to change, for their contribution to risk changes, and those significant at α ≤ 0.10 were included in a linear regression model. Program evaluation included the number of classes attended, participation in walks, and attendance at the hospital gymnasium. The final survey included current concern (yes or no) about CVD, current health (better, about the same as when I Worksite Female CV Health Program / 343
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
JCRP-D-14-00096_LR 343
19/08/15 7:45 AM
T a b l e 1 • Sociodemographic, Work-Related, and Health Characteristics at Baseline Intervention (n = 28)
Control (n = 29)
Total (n = 57)
a
n (%) Race/ethnicity White
18 (64)
23 (79)
41 (72)
Asian
4 (14)
2 (7)
6 (11)
Latina
4 (14)
1 (3)
5 (9)
Filipina/Pacific Islander
1 (4)
2 (7)
3 (5)
African American
1 (4)
1 (3)
2 (3)
Married/partnered
21 (75)
21 (72)
42 (74)
Divorced or separated
6 (21)
7 (24)
13 (23)
Never married
1 (4)
1 (4)
2 (3)
Administrative
16 (57)
16 (55)
32 (56)
Clinical
12 (43)
13 (45)
25 (44)
No
26 (93)
24 (83)
50 (88)
Yes
2 (7)
5 (17)
7 (12)
Marital status
Job category
Enrolled in another health program
Mean ± SD Age, y
51 ± 6.5
53 ± 6.0
52 ± 6.3
Education, y
15 ± 2.1
17 ± 1.8
15 ± 2.0
Worked at ECH, y
16 ± 11.1
16 ± 11.7
16 ± 11.3
Hours worked/week
41 ±6.7
39 ± 9.2
40 ± 8.0
One-way commute, miles
10 ±8.9
15 ± 17.9
12 ± 14.3
Weight, lb
192 ± 45.3
194 ± 58.4
193 ± 51.9
Resting HR, bpm
71 ± 11.6
71 ± 8.6
71 ± 10.1
Total cholesterol, mg/dL
200 ± 31.8
195 ± 37.2
198 ± 34.4
LDL-C, mg/dL
115 ± 24.4
104 ± 28.3
110 ± 26.8
HDL-C, mg/dL
52 ± 14.2
55 ± 14.7
53 ± 14.4
Triglycerides, mg/dL
179 ± 96.4
185 ± 98.2
182 ± 96.5
Blood glucose, mg/dL
104 ± 58.2
108 ± 59.7
106 ± 58.5
2 ± 2.2
2 ± 2.0
2 ± 2.1
31 ± 26.1
24 ± 21.6
27 ± 24.0
20.5 ± 5.8
19.6 ± 7.4
20.0 ± 6.6
Exercise/week, days Exercise time/session, min b
Stress scale
Abbreviations: ECH, El Camino Hospital; HDL-C, high-density lipoprotein-cholesterol; HR, heart rate; LDL-C, low-density lipoprotein-cholesterol. a
Some percentage totals do not equal 100% because of rounding.
b
Cohen Perceived Stress Scale.
completed the study, or worse), and questions about current weight, stress, and exercise (more, about the same as when I finished the study, or
less). Analyses were performed using SPSS (IBM, Chicago, IL), with an α ≤ 0.05 for determining statistical significance.
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RESULTS Characteristics and Health Status Sixty-two women enrolled and baseline characteristics did not differ by study group. Five individuals dropped out (“too busy,” relocation or family issues not related to CVD risk) resulting in a final sample of 57. Baseline sociodemographic, work-related and health characteristics by study group are summarized in Table 1. Participant aged 40 to 63 years, and education was high school (5%), some college (36%), associate degree (20%), college (32%), and Master's degree (7%). Most (72%) had no children younger than 18 years living with them. Years of work at the hospital ranged from 0.5 to 42 and hours worked per week ranged from 25 to 60. Commuting distance to work ranged from 1 to 40 miles. Participant health measures are summarized in Table 1 and Figure 1. Baseline weight ranged from 109 to 358 pounds, with 77% categorized as overweight or obese. Total cholesterol was 117 to 274 mg/dL, with 44% categorized as borderline or high. Blood glucose ranged from 61 to 366 mg/dL. About half (51%) reported no or only leisurely exercise. The Cohen stress scale ranged from 6 to 33, with internal consistency (Crohnbach α = 0.88). Over three-quarters (82%) had stress levels above the normative mean for women. Body weight was ranked by 42% of the participants as the factor of highest concern, followed by stress (30%) and exercise (25%). As only 3 individuals were current smokers, with 2 listing smoking as their primary concern, no further analysis of smoking was done. Readiness to change levels were high, 7.9 or higher on the scale from 0 to 10.
Effect of Study Group on Cardiovascular Risk Factors Weight loss was greater in the intervention group (mean = 7.2 ± 14.0 lb) compared with the control
Figure 1. Health characteristics of 57 female health care workers at baseline. www.jcrpjournal.com
group (3.8 ± 10.3 lb), although this was not statistically significant. Only race/ethnicity was associated with weight change, with whites losing 8.6 ± 12.5 lb, and women of color gaining 1.9 ± 8.6 lb (P = .006), and race/ethnicity remained significantly associated with weight change with the intervention group included in the analysis (P = .004). Among those ranking weight as their highest concern, the intervention group lost 13.5 ± 4.9 lb compared with 2.7 ± 13.0 in the control group (P = .101). The intervention group reported a greater but not significant decrease in stress as measured by the Cohen stress scale (6.5 ± 6.7) compared with the control group (4.7 ± 7.3). Readiness to change was positively but weakly correlated with a reduction in stress (r = 0.09; not significant). Those with longer commutes had less stress reduction (r = −0.34; P = .017), remaining statistically significant when taking into account study group (P = .024). Numbers were too small to analyze among those listing stress as their highest level of concern. The intervention group increased their days per week of exercise more than the control group, but this was not a statistically or clinically important difference (1.4 ± 2.6 days vs 1.2 ± 1.3 days, respectively) and time exercising increased by about 1 hour per week in both study groups. There was no correlation between readiness to change and the amount of change in exercise at the end of the study. Triglycerides were strongly and positively associated with increases in exercise days per week (r = 0.49; P = .000), remaining significant when taking into account study group (P = .000). All participants increased their exercise intensity with 32%, reporting no exercise at baseline compared with 6% at study end. Numbers were too small to analyze among those listing physical activity as their highest level of concern.
Program Evaluation: Participation and Maintenance Attendance did not differ by study group, and, in both groups, attendance at the first lecture corresponded with participants’ ranking of the topic—weight loss ranked highest among 42%, and 47% attended the introductory lecture; stress management ranked highest among 30%, and 21% attended this first lecture; and physical activity ranked highest among 25%, and 26% attended the first lecture. Attendance at later classes was considerably lower—participants attended on average 0.6 of 4 nutrition classes; 2.1 of 12 stress classes. Only 3 joined a group walk once; and gymnasium use ranged from 0 to 20 days over the period (average use was 2.4 days). Worksite Female CV Health Program / 345
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The final survey, 1 year after the program, had few responses—only 16 (28%) of the sample responded, 9 from the intervention group and 7 from the control group. All of those responding indicated continuing concern about CVD risk and 94% reported their health as the same or better. More in the intervention group (67%) than in the control group (57%) reported they were continuing to make progress on their goals. For the 3 specific areas of concern, participants reported weight as the same or less (81%), and exercise as the same or greater (81%), with no difference by study group. For stress, however, all in the intervention group reported stress the same or lower compared with 57% of those in the control group (P = .063).
DISCUSSION The consistent and positive findings of this preliminary study are promising for risk reduction at the worksite in general and the use of individualized motivational messages in particular. Despite high levels of variability among the study sample, those who had weekly encouragement showed improvements, particularly in weight management and stress reduction. Numbers were small and results were therefore only suggestive. Our findings are similar to a study comparing in-person with Internet-based interventions,13 and weight management outcomes are comparable to those found in a systematic review of programs.6 Differences in weight loss by race/ethnicity raise important questions for future, larger studies. With new health promotion opportunities available to all, it is not surprising that both groups showed improvements. Finally, improvements may have been influenced by the Hawthorne effect of being in a study. Program evaluations revealed that on-site activities were not well attended, comparable to results found by Flannery et al14 for attendance at first classes but lower in our sample for the remainder of the program. Long commute distances and anecdotal comments about time and work schedules suggest that workers, initially highly motivated, found that realistically they could not continue to comply with the program. Study subjects did not remain persistent in their participation, and questions about program structure and other mechanisms for health promotion remain unanswered. Future studies should focus on how to get more buyin from higher risk female health care workers, both to encourage initial participation and to ensure their persistence toward health goals. Study results contributed to the development of a comprehensive Webbased employee wellness motivational program aimed at addressing the difficulty of on-site participation.
Overall, improvements were maintained 1 year after program completion, although very few women responded to the final survey. The intervention appeared to help maintain stress level reduction. The small number precludes conclusions except to say that, in this small group, we were gratified that perceptions of improvement were maintained a year after program completion.
CONCLUSIONS Wellness for health care workers is an important area for continued investigation. Participants were indeed in poor health, with profiles similar to results from the American Nurses Association's Healthy Nurse Questionnaire,15 raising concerns about the health of our workforce. There are challenges and barriers, but to improve the health of our patients, we need to look to our own health to empower ourselves to better care for others.4 Wellness programs with individualized support and encouragement should be considered, and this study could serve as an example for other hospitals to conduct similar studies or to justify additional staff for employee wellness services.
—Acknowledgments— This study was supported with funding from Hope to Health (H2H), devoted to improving women's lives by providing hope, resources, and education, from the El Camino Hospital Foundation and Women's Hospital. The authors thank Dr Catherine Collings, MD; Craig Clemens, MA, RCEP; Esther Agustin, MA, RCEP; Debby Hagenmaier, MSN, RN; Jodi Bjurman, RD, CDE; Missy Von Luehrte, BSN, RN; Karen Halverson, Senior Librarian; and Lynne Rock, MBA, for their expertise.
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