Part 1: Needs Assessment

U.S. health trends and the role of the employer

Approximately 129 million US adults are overweight or obese (Mattke et al 2012). Overweight and obesity are associated with an increased prevalence and risk of chronic diseases such as diabetes, cardiovascular disease and asthma (Li et al 2015). Higher BMI values are consistently associated with chronic diseases. Interestingly,  across populations, the most prevalent chronic diseases are the same regardless of BMI classification. These top chronic diseases associated with obesity are still occurring in populations with a “normal” BMI classification.  (Li et al. 2015). Thus, health interventions which target the risk factors of these chronic diseases is desirable in the entire adult population, not only individuals who carry excess weight.

Costs associated with chronic disease extend further than the hospital—employers have a stake in improved health as well. Individuals with diabetes lost more than 8 days of work per year (Mattke et al 2012). Additionally, through their provision of healthcare benefit packages, employers should acknowledge that health care utilization as well as costs increase with increasing BMI values (Heithoff et al 1997). An analysis of business costs revealed that 62.7 million visits to physician offices were due to conditions associated with obesity (Mattke et al 2012). At the population level, hypertensive diseases, dyslipidemia and GERD were reported as three of the top five most common chronic diseases in all BMI ranges, and these are associated with the highest healthcare costs (Li et al 2015). Considering these these diseases are directly affected by lifestyle factors, it is encouraging that approximately half of U.S. employers with 50 or more employees offer wellness programs which typically address health behaviors (Mattke et al 2012). The efficacy of interventions depends on the study design, however interventions in this analysis will be in the university setting.

Worksite wellness campaigns are one possible strategy to intervene and potentially reduce healthcare costs. Typically, wellness programs include screening activities, preventive interventions and health promotion activities (Mattke et al 2012).  Some programs focus on smoking cessation while others focus on increasing physical activity (PA) or improving nutrition. In a systematic review by Osilla et al., healthcare costs were evaluated in eight studies and all but one study reported significant decreases in healthcare costs. Values ranged from $176 to $1,539 per participant per year. Analyses of the return on investment revealed a $1.65 to $6.00 savings for every dollar invested in the program (2012).

Georgia residents and University of Georgia employees

More than two in three adults in Georgia are overweight or obese and only about a quarter of adults achieve the PA recommendations. Additionally, less than one fifth consume the recommended servings of fruits and vegetables. These behaviors are associated with chronic disease risk, especially heart disease, which was the leading cause of death in Georgia in 2010. Heart disease related complications resulted in over 87,000 hospitalizations and 3.9 billion in health care claims (Georgia DPH). These modifiable habits could have a large impact on their overall health, and are areas in which intervention may positively influence behavior. Many factors affect how individuals respond to, accept and implement health interventions. Additionally, there are different health interests, problems and priorities depending on age, gender, ethnicity and many other factors, thus insight into the different sub-populations of UGA employees aids in the tailoring of the worksite wellness campaign to this specific population.

The University of Georgia Office of Institutional Research provides insight into University of Georgia (UGA) employees. Racial and ethnic breakdown of UGA employees are as follows: 72% white, 12.8% African American, 5.1% Asian, 3.2% Hispanic and 0.8% other. Men comprise of 47.2% of employees. Age analyses of employees were only performed for full-time faculty members, thus excluding “other professionals”, “executive/administration”, “service/maintenance”, “skilled crafts”, “technical/paraprofessional” and “clerical/secretarial” employees. Thus, it is important to note that these ages may not be reflective of UGA employees as a whole: the majority of full-time professional faculty are between the ages of 50-59 (29%). The next largest group is individuals is 40-49 years old (26%), followed by >60 year olds (24%). The smallest groups are the 30-39 year olds (19%) and 20-29 year olds, who make up 1% of UGA’s faculty. Full time faculty members represent only 26.7% of full time employees. “Full time faculty” is not the largest group, either, as “Other professionals” have nearly 4,000 employees and make up the largest group of occupational classification (UGA Fact Book 2015). University of Michigan reported demographic data of their worksite wellness participants after a 5-year duration. Their trends revealed that the majority of the 20,237 employees in the continuously enrolled sample were female (65%), white (77%), non-union (89%), and staff members (86%). Men, faculty, employees earning < $35,000 annually were less likely to participate (Beck et al 2016). Understanding the demographic profile of UGA employees as well as active worksite wellness participants in the literature is important when designing the ideal intervention for this population.

UGA currently offers wellness services to their employees in addition to benefits such as health and dental insurance. These wellness services include affordable memberships to the Ramsey recreation center with free parking. The UGA golf course offers discounted membership rates. There is also a weight loss club that meets once a week and an active Walk Georgia group on UGA’s campus. Employees have access to the ASPIRE clinic which offers free individual nutrition counseling as well as healthy cooking classes at the wellness center (UGA Human Resources).

Conclusion
Worksite wellness campaigns can be effective in reducing weight as a result of campaigns to improve nutrition, PA or both (Anderson et al. 2009). Additionally, evidence suggests they can influence nutrition behaviors such as fruit and vegetable consumption as well as fat and energy intake (Osilla et al 2012). Though each population brings unique characteristics and challenges, the workplace is an effective environment to facilitate health behavior change (Anderson et al 2009, Osilla et al 2012).

References

  1. Anderson LM, Quinn TA, Glanz K, Ramirez G, Kahwati LC, Johnson DB, Buchanan LR. The effectiveness of worksite nutrition and physical activity interventions for controlling employee overweight and obesity: a systematic review. American journal of preventive medicine. 2009;37:4:340-357.
  2. Beck AJ, Hirth RA, Jenkins KR, Sleeman KK, and Zhang W. Factors Associated With Participation in a University Worksite Wellness Program. American journal of preventive medicine. 2016;51:1:e1-e11.
  3. Cooper K and Barton GC. An exploration of physical activity and wellbeing in university employees. Perspectives in public health2015: doi: 10.1177/1757913915593103.
  4. Georgia Department of Public Health. Strategic Direction for Chronic Disease Prevention: 2014-2019. July 21, 2014. Atlanta, GA.
  5. Haines DJ, Davis L, Rancour P, Robinson M, Neel-Wilson T, and WagnerS. A pilot intervention to promote walking and wellness and to improve the health of college faculty and staff. Journal of American College Health. 2007;55:4:219-225.
  6. Heithoff KA, Cuffel BJ, Kennedy S, Peters J. The association between body mass and health care expenditures. Clinical Therapy 1997;19:4:811-820
  7. Li Q, Blume SW, Huang JC, Hammer M, Ganz ML (2015) Prevalence and healthcare costs of obesity-related comorbidities: evidence from an electronic medical records system in the United States, Journal of Medical Economics. 2015;18:12
  8. Mattke S, Schnyer C, Van Busum KR. A Review of the U.S. Workplace Wellness Market RAND Corporation, Arlington, VA (2012).
  9. Osilla KC, Van Busum K, Schnyer C, Larkin JW, Eibner C, and Mattke S. Systematic review of the impact of worksite wellness programs. The American journal of managed care 2012;18:2:e68-81.
  10. Racette SB, Deusinger SS, Inman CL, Burlis TL, Highstein GR, Buskirk TD, Steger-May K, Peterson LR. Worksite Opportunities for Wellness (WOW): effects on cardiovascular disease risk factors after 1 year. Prev Med. 2009:49(2–3):108–114.
  11. University of Georgia Human Resources. Physical Health and Wellness. July 2016. Internet; http://ajcn.nutrition.org/site/misc/ifa_format.xhtml. (accessed September 5, 2016).
  12. US Department of Health and Human Services. Prevention Makes Common “Cents”. 2003.

 

Stakeholder Role in Intervention Questions from Stakeholder Effect on Stakeholder of a Successful Program Effect on Stakeholder of an Unsuccessful Program
 UGA Human Resources  Facilitate benefits packages (health insurance) as well as outline the health-related resources for UGA employees:
http://www.hr.uga.edu/uga-affiliated-health-wellness-resources		  1) How long before we see a return on investment?

2) What health outcomes are we analyzing?

3) What is the short term relationship between health outcomes and healthcare costs?

4) How are we defining success in the intervention?

 – Potentially a decrease in healthcare costs

– Potential increase in costs associated with preventative programs

 – No change in healthcare costs

– “Waste” of money on initial intervention
 Departmental Directors/Managers  Promote participation to staff within their offices. 1) What percentage of time will this take from the office work?

2) If our office has highest participation/most significant change in health related behaviors, what do we get?

3) Will “saved” money from decreased healthcare costs be allocated to departments?

 – In a “challenge” scenario – could be incentivized (healthy lunch, exercise bike to keep in the office for staff use, etc)

– Healthier, happier, more productive staff members

 – Perceived ‘waste’ of work time
 Faculty/Staff  Participate in wellness program (weekly challenges, Lunch time walks, PA at home, nutrition lessons) 1) Are there incentives/will I be compensated?

2) Is participation required?

3) To what extent do I have to participate?

4) What services are being provided? Do I have to pay for them?

5) Can I use blood work from a recent doctor’s appointment?

 – Improved health (biochemical, anthropometric)

– Loss in weight

– Increased PA

– Improved nutrition

– Decreased stress

 – Exposure to health related behaviors

– Future interventions which could benefit their health may not become implemented

– Future intervention could be more tailored to correct flaws of previous intervention
UGA Health Center

 

  Blood work/health assessments of employees 1) Will we accept outside-of-UGA health insurance?

2) Who is paying for the labs to be run?

3) Will we need to measure anthropometric measurements?

 – Insight to staff health to tailor wellness campaigns  – ‘waste’ of resources for testing
On campus dining Provide nutrition data for analyses in order to recommend specific healthy (will follow the American heart association guidelines) options employees can get from campus dining halls and eateries 1) Will these highlight foods available in all of our dining facilities?

2) How will you determine which foods will be featured?

3) how will you educate on proper portion sizes for the buffet items?

4) Do you want the foods highlighted in the dining halls?

 – Increased eating at dining halls – other foods may be perceived as “unhealthy”
The ASPIRE clinic Nutrition counseling as needed 1) How many employees are participating?

2) Will you require us to disclose nutrition topics covered to worksite wellness organizers?

3) How many sessions will be required by employees? Is it optional?

 – Increased client reach – n/a
(Possible, depending on program details)

Research lab in Foods and Nutrition/Kinesiology

 Anthropometric assessments at baseline/follow up 1) How many visits will be required?

2) Can data be used for future manuscripts/publications?

3) Is IRB approval possible for the intervention?

 – Research publications – insignificant data may be perceived as a waste of resources

 

Part 2: Intervention Identification

Background

Worksite wellness is broken into different categories in The Community Guide. “Obesity” interventions are recommended as of January 2007. “Diabetes: Self-Management” inerventions in worksites has insufficient evidence of it’s efficacy as of August 2000.  Obesity prevention and control findings defines the intervention as “programs [that] can include one or more approaches to support behavioral change including informational and education, behavioral and social, and policy and environmental strategies”.1 They reported that structured programs appear to be more effective than unstructured approaches.2 Additionally, information + behavioral counseling offers more benefit than providing information alone.3 The Community Guide also highlights beneficial strategies to promote physical activity; the use of incentives, a team approach and identifying normal patterns of behavior related to physical activity.4,5 Worksite wellness interventions have been completed in healthcare facilities, private industry, universities and numerous workplaces. Well designed programs can positively influence health behaviors such as smoking, diet, PA and even biochemical identifiers of health such as serum cholesterol.

All studies have been completed in adults. The inclusion ages are not restrictive and include anyone who works at the establishment. Mostly, participants are included regardless of health status; they can participate despite preexisting conditions or if they are metabolically healthy or already practice healthy habits. The university community is slightly different than the private sector program interventions, however, these theories can be applied to the existing infrastructure UGA has in place and create an intervention tailored to UGA employees. For an institution like UGA that already has many of these health resource programs in place, utilizing a team challenge-type intervention could raise awareness of programs that are currently available. One of the biggest barriers in the worksite wellness literature was access to the resources. UGA provides numerous health-related services that can optimize the health of employees. Combining the strategies The Community Guide recommends with evidence from currently literature can yield a program supported by evidence but also tailored to fit the environment of the University of Georgia.

Task Force Recommendation

The Task Force does not recommend “Assessment of Health Risks with Feedback (AHRF) to Change Employees Health” because there is insufficient evidence across studies. There are recurring flaws across correlational studies. They asserted a sound conclusion could not be drawn because of the inherent bias in the self-report nature of the interventions. Conversely, the task force recommends “AHRF plus health education with or without other interventions”. In addition to assessment and feedback features of the intervention, health intervention, easier access to PA, nutritious food or policy interventions are also included. Strong evidence supports the effectiveness of improving one or more health behaviors in populations of workers. Specifically, they recommended improving PA habits, reducing dietary fat, reducing blood pressure, total cholesterol and improving summary health risk estimates of at-risk participants. Competition-type interventions were recommended for smoking cessation and were recommended when paired with additional interventions.4

UGA Intervention Strategy

In order to manage the participation as efficiently as possible, the pilot intervention will include departments under the umbrella of “UGA Student Affairs”. A complete list of departments can be found at: https://studentaffairs.uga.edu/site/departments. Each department will be invited to participate; the team-centered approach and camaraderie will be encouraged to promote participation. Key features of the intervention are highlighted in the following section. The intervention will take place over 6 weeks. Outcome measures will include utilization of campus resources, fruit and vegetable intake compared to baseline, self-reported PA, weight, BMI, cholesterol and blood pressure measurements. A health satisfaction survey will also be taken at baseline and post-intervention. Each of the six weeks will have a different challenge component for the offices to gain “points”: (1) water intake, (2) fruits and veggies intake, (3) days/minutes of PA, (4) hours of sleep, (5) number of stair climbs, (6) number of servings of whole grains. These challenges will be in addition to a once-per-week event; events will include lunch hour seminars on campus (experts on nutrition, meditation, physical activity, diabetes prevention), 30 minute “scavenger hunts” during lunch hours, campus dining hall tours, etc. Finally, team members can earn points by utilizing the resources available on campus. Examples include: a nutrition consultation at the ASPIRE clinic, working out at the Ramsey center, attending Walk GA meetings, attending TOPS meetings. Points will be normalized as percentages according to total number of office workers to compensate for differing number of staff members across offices. The office with the most points earned wins the competition. Prizes are to be determined.

Review of pertinent interventions

Importance of flexibility

At Washington University, an 8-week worksite wellness program was implemented to employees on their main campus. Their exclusion criteria did not limit participants due to specific conditions; participants were >18 and were not limited by medication use or physical activity level. Their intervention was based on the health belief model and included health assessments, physical activities, wellness education sessions, and rewards. Weekly education sessions were led by health professionals and included presentations and discussions on health related topics. The best part of the intervention was the flexibility of the schedule. Their primary intervention was a walking intervention which included a pedometer and an online program that allowed them to track physical activity. Their outcome measures included pedometer steps, daily PA, self-efficacy, CVD risk factor assessment, and a post-program survey. Daily step counts increased from 6566 at baseline to 8605 at week 4 and 9107 at week 8; they significantly increased step count over time. Obese participants took significantly fewer steps than normal weight and overweight participants at baseline, however, they increased steps over time. Positive shifts in PA and cardiorespiratory fitness were observed over time. The primary reason people enrolled in the program was a desire to improve or maintain health and the free health assessments.6

Self-monitoring and embedded health campaigns

At an Australian university, a wellness program was comprised of six behavior change campaigns. Each campaign ranged in duration from 3-8 weeks and participants were given weekly tasks to complete. Each behavior change campaign lasted six to eight weeks with different tasks. Campaigns included healthy food choices, physical activity, sleep, weight and stress. These campaigns were science based and promoted awareness and tracking of specific habits. The campaigns were developed to support changing their home environment, their shopping patterns, identifying stressors as well as the incorporation of educational components. Their outcome measures included BMI, nutrition, PA, health status, smoking and life satisfaction. They saw significant improvements in whole grains, fruits, and vegetables. People who participated were less likely to be obese but there were no differences between blood pressure or cholesterol. Specifically, they saw a increase in exercise (67 min/wk), whole grain servings (0.2 servings/wk) and vegetable servings (0.3 servings/wk). There was no difference in BMI between the two time points, however, self-reported high blood pressure decreased from 22% to 15%.7

Access to multifaceted health promotion activities

Racette et al. conducted a cohort-randomized controlled trial that compared a health assessment versus an assessment plus an intervention for 12 months. All participants received personal health reports containing their assessment results at baseline. At the intervention site, there were improvements in BMI, fat mass, heart risk score and prevalence of metabolic syndrome. They collected anthropometrics, blood samples and assessed risk for heart disease in all participants. They used verified screening tools to assess risk. The intervention had a kick-off event focusing on nutrition, PA, and incentives to promote healthy dietary and PA behaviors.  They based the intervention off of the Transtheoretical Model of Behavior change. Intervention components included pedometers, a healthy snack cart, WeightWatchers group meetings, on site exercise programs, monthly lunchtime seminars, monthly newsletters, walking maps, team competitions, participation cards and rewards. A registered dietitian managed the rewards and attendance records at events. The only statistical difference between the intervention and control were the changes in BMI and fat mass. They found that many of the improvements were achieved with worksite health assessment alone (likely the raised awareness of their health), however, they were more modest. All in all, the intervention was associated with significant improvements in cardiovascular disease risk factors and physical fitness. For smaller companies, thorough health assessments may be enough to promote behavior change.8

Utilization of a points system

Group Health implemented a worksite wellness program which was delivered to over 9800 employees across it’s entire health care organization. All participants received pedometers; if they completed the program, they received additional promotional materials. Participants set physical activity goals and received points based on their participation. The point system also included points for eating fruits and vegetables up to a certain amount per week. Team captains were identified to aid in data collection; participants were more likely to drop out if their team captain was unable to complete their tasks. Those who were sedentary decreased from 23% to 6% and those meeting the CDC guidelines increased from 34% to 48%. At baseline, 46% of respondents reported eating at least 5 servings of fruits and vegetables per day, this increased to 73% at the 10-week follow up. BMI remained unchanged. Participants reported that setting a personal goal, making the commitment and having a pedometer to track steps were the three most highly motivating factors. Team captains reported that collecting team data was time consuming; removing these responsibilities from team captains can free up time for captains to problem solve, share success stories or organize team activities. Despite positive results, this study lacked a control group and all measures were subjective.9

Team Goal Setting

The benefits of a team-based approached were investigated in a worksite intervention that took place across numerous Home Depot locations. They based their intervention on management theory in order to assess perceived management support. They excluded participants with overt cardiovascular, pulmonary or metabolic disease. They randomized sites to a control arm and an intervention arm; participants enrolled on a volunteer basis. They based the intervention off of the Physical Activity Challenge implemented at the CDC and included personal goal setting. Employees were divided into teams with a team captain. Teams were organized by the employees and usually were aligned with workgroup structures; groups ranged from 5-20 people. Team captains served as motivators and served as liaisons between participants and site coordinators. Physical activity was measured using validated questionnaires and pedometers. Building on the social relationships inherent in the office were beneficial in employee perceptions of managerial support. Employee involvement increased at the intervention sites. Vigorous PA increased in the intervention arm increased significantly.10

References

  1. Community Preventive Services Task Force. Obesity Prevention and Control: Worksite Programs. Updated 23 Sept 2013.
  2. Task Force on Community Preventive Services. Recommendations for worksite-based interventions to improve workers’ health. Am J Prev Med 2010;38(2S):232-6.
  3. Anderson LM, Quinn TA, Glanz K, Ramirez G, Kahwati LC, Johnson DB, Buchanan LR. The effectiveness of worksite nutrition and physical activity interventions for controlling employee overweight and obesity: a systematic review. American journal of preventive medicine. 2009;37:4:340-357.
  4. Increasing physical activity. A report on recommendations of the Task Force on Community Preventive Services. MMWR Recomm Rep 2001;50(RR-18):1-14.
  5. Kahn EB, Ramsey LT, Brownson RC, Heath GW, Howze EH, Powell KE, et al. The effectiveness of interventions to increase physical activity. A systematic review. Am J Prev Med 2002;22:73-107.
  6. Butler CE, Clark BR, Burlis TL, Castillo JC, Racette SB. Physical activity for campus employees: A university worksite wellness program. Journal of physical activity & health 2015.12;4:470.
  7. Merrill, Ray M., Allison Anderson, and Steven M. Thygerson. Effectiveness of a worksite wellness program on health behaviors and personal health. Journal of Occupational and Environmental Medicine. 2011: 53;9:1008-1012.
  8. Racette SB, Deusinger SS, Inman CL, Burlis TL, Highstein GR, Buskirk TD, Steger-May K, Peterson LR. Worksite Opportunities for Wellness (WOW): effects on cardiovascular disease risk factors after 1 year. Preventive medicine. 2009 49;2:108-14.
  9. Green BB, Cheadle A, Pellegrini AS, Harris JR. Peer Reviewed: Active for Life: A Work-based Physical Activity Program. Preventing chronic disease. 2007 4;3.
  10. Dishman RK, DeJoy DM, Wilson MG, Vandenberg RJ. Move to improve: a randomized workplace trial to increase physical activity. American journal of preventive medicine. 2009;36(2):133-41.

Part 3: Intervention Fit

  • Provide a logic model and SMART Objectives for your intervention. You should have a SMART objective for each behavior you anticipate changing. (35 points; 10 points for SMART objectives, 25 points for the logic model)
  • Attend Weekly Wellness lunches
    • Participation: 50% of all participants will attend at least one Weekly Wellness lunch(es) during the 6-week intervention, as determined by a sign-in sheet.
    • Each Weekly Wellness lunch will have at least 25 participants, as measured by sign up sheet.
    • Knowledge: At the end of each lesson, participants will complete a 5 question quiz on the main topics covered in that Wellness lunch and 75% of them will score at least a 3/5.
  • Engage in healthy behaviors (weekly challenges)
    • At least 75% of enrolled staff members will participate in weekly challenges, as measured by collected weekly tally sheets generated by each participant.
  • Utilization of campus resources by participants
    • Self-reported total use of campus resources will increase by 20% across all participants between baseline and the 6-week end date of the intervention, as measured by surveys.
  • Participation in scavenger hunt lunch hours
    • Each scavenger hunt (2 total) will have at least 12 participants in attendance.
  • Participant satisfaction
    • 90% of participants will complete and return  baseline surveys before the start of week 2.
    • 50% of participants will complete and return follow-up surveys within two weeks of program completion.
    • 50% of participants will show improved scores from baseline to follow up in self-efficacy, outcome expectations and health satisfaction, as measured by a survey.
    • 50% of participants will express “satisfaction” with the program in surveys at follow-up.
  • Health behavior changes
    • At least 50% of participants will increase their average self-reported PA by at least 1 day/wk by
    • According to the follow-up survey, at least 50% of participants will report fruit and vegetable intake that meets the recommendation identified by the USDA.
    • According to the follow-up survey, at least 50% of participants will report water intake of ~1 mL/kcal consumed
    • According to the follow up survey, intake of sugar sweetened foods will account for <200 calories.
    • According to the follow-up survey, intake of saturated fat will account for <200 calories.
    • At least 75% of enrolled staff members will improve their score on a “Importance of Preventive Health Behaviors” quiz compared to baseline quiz.

 

Inputs/Resources Activities Outputs Short-term Outcomes Intermediate Outcomes Long-term Outcomes
Facilities

·       UGA Health Services

·       UGA Dining Halls

·       ASPIRE Clinic

·       Wellness services

·       Ramsey student center

Personnel

·       MSDI students at the ASPIRE Clinic

·       Team coordinators in each participating office

·       Experts to lead lunch talks

·       Undergrad volunteers to tally weekly points for the offices

Participants

·       UGA student services faculty and staff

·      Directors/managers of the offices

 “Weekly challenges”

·       Water intake

·       Fruit/Veg Intake

·       Days/minutes of PA

·       Hours of sleep

·       Number of stair climbs

·       Whole grains

Lunch hour seminars

Walk Scavenger hunts

Dining Hall Tours

 – >50% participation in weekly challenges among offices

– 25 attendees at lunch hour seminars

– 5 offices participating in lunch time scavenger hunts

– 10 staff members per dining hall tour

– 50% increase in campus wellness resources utilization

 – Awareness of on-campus health resources

– Increased satisfaction on health satisfaction survey

– Increase in reported self-efficacy for health behaviors from pre-post intervention

– Practicing at least one healthy behavior per week (attendance at Ramsey, participation in a healthy hour or a weekly challenge)

– Participation in intervention-sponsored events utilizing UGA resources

– Increase knowledge of health behaviors 

 Primary outcome:

·       Increased utilization of resources (as measured by participation and survey data)

Possible secondary outcomes

Improvement in:

·       Weight and/or BMI

·       LDL Cholesterol

·       Blood pressure

·       Adoption of health habits (as evidenced by participation in weekly challenges)

–Increase in knowledge of importance of preventative health behavior

Behavior changes:

– Increase in self-reported PA.

– Regular fruit and vegetable intake (achieve recommended servings from USDA)

– Drink recommended level of H2O (1 mL/kcal)

– Reduction in added sugar intake to <10% kcals

– Reduction in saturated fat intake to <10% total kcals

 ·       Decreased chronic disease risk associated with improved biochemical markers.

·       Increase satisfaction in health and increase in self-efficacy

Increased long term utilization of wellness resources

Identify the importance of preventative health behaviors (outcome expectations)

Explain the logic of why this intervention may work. For example, why would teaching children about healthy eating change their actual eating behaviors? Or why would adding sidewalks increase physical activity for transportation or recreation? (15 points)

  • The primary goal of the intervention strategy is to increase the utilization of resources which are already in place. Considering the infrastructure is already in place and the programs are already being completed, it’s a matter of creating an intervention that is appealing to workers to inspire participation and utilization. With the utilization of program strategies that have worked in previous literature (flexibility, self-monitoring, access, competition “points” system, and team goal setting), increased utilization of resources can be the primary focus of the intervention.
  • Another key piece of the primary intervention is the inclusion of Student Services personnel at UGA. These offices often work together and know people outside of their individual office. This can be beneficial for the “competition” aspect of the program.
  • Finally, including an incentive for the winning office has been shown in the literature to promote participation (1, 2, 3). In a previous similar intervention (unpublished data), an exercise bike was donated for the winning office, which they kept in their break room to be utilized by staff members during their lunch hours or allotted daily 30 minute breaks.
  • In other worksite wellness programs, team captains served as motivators and served as liaisons between participants and research coordinators (4). Though team captains have more responsibility, their roles are central to prevent drop out of the team members (5).
  • Though this intervention does not specifically deal with behavior change theory (as personalized interventions are not taking place), this intervention surveys participants about their self-efficacy and outcome expectations. When it is possible to create a more individualized intervention, similar to Racette et al. or University of Michigan’s wellness program, this information will be extremely helpful in tailoring the intervention with excellent preliminary data of a subset of the target population (3, 6).
  • Increasing awareness of health behaviors and self-monitoring  was similarly effective in changing behavior; previous studies have reported increase in fruit, vegetable, and whole grain intakes (7).
  1. Increasing physical activity. A report on recommendations of the Task Force on Community Preventive Services. MMWR Recomm Rep 2001;50(RR-18):1-14.
  2. Kahn EB, Ramsey LT, Brownson RC, Heath GW, Howze EH, Powell KE, et al. The effectiveness of interventions to increase physical activity. A systematic review. Am J Prev Med 2002;22:73-107.
  3. Racette SB, Deusinger SS, Inman CL, Burlis TL, Highstein GR, Buskirk TD, Steger-May K, Peterson LR. Worksite Opportunities for Wellness (WOW): effects on cardiovascular disease risk factors after 1 year. Preventive medicine. 2009 49;2:108-14.
  4. Dishman RK, DeJoy DM, Wilson MG, Vandenberg RJ. Move to improve: a randomized workplace trial to increase physical activity. American journal of preventive medicine. 2009;36(2):133-41.
  5. Green BB, Cheadle A, Pellegrini AS, Harris JR. Peer Reviewed: Active for Life: A Work-based Physical Activity Program. Preventing chronic disease. 2007 4;3.
  6. Beck AJ, Hirth RA, Jenkins KR, Sleeman KK, Zhang W. Factors Associated With Participation in a University Worksite Wellness Program. American journal of preventive medicine. 2016 Mar 16.
  7. Merrill, Ray M., Allison Anderson, and Steven M. Thygerson. Effectiveness of a worksite wellness program on health behaviors and personal health. Journal of Occupational and Environmental Medicine. 2011: 53;9:1008-1012.

Discuss limitations of the selected strategy, and things to look out for/be mindful of along the way. Examples may be limitations of resources, community capacity, or anticipated effect of the intervention. (15 points)

  • Considering many of the intervention activities take place during the work day, there may be limited participation. If a director is not on board with the intervention, they may not be supportive of their staff leaving in the middle of the day to attend a lunch hour talk. Additionally, many employees “work through” lunch, which could be problematic in regards to participation. However, the events wont be happening every day, and participants will know about them in advance, so hopefully that barrier can be minimized.
  • Out of work participation (tracking weekly challenges) is a crucial component of the intervention. This part of the strategy is aimed to promote healthy competition between departments and hopefully inspire some participation in healthy behaviors. Participants may not be interested in the chosen interventions, or may believe that they will not “win” so it’s not worth the effort of tracking. However, hopefully a good director can be an ally in this potential scenario.
  • Consistency across weekly tracking of health behaviors is important, this can be alleviated by explicit directions on what is being tracked, including proper sizes of the items or behaviors being measured.
  • Trained undergraduate volunteers who will be tallying the weekly challenges may not be reliable/consistent across volunteers.
  • For long term behavior change to take hold, participants will need to assess the worth of the behavior changes. This could be a limitation if the intervention does not address the root behaviors which need to change. The duration of time of the intervention could influence this, participation could influence this, but most importantly, stage of change will influence whether or not the intervention “sticks”. If a participant is not even considering changing their behaviors at this time, it is unlikely that the intervention would result in lasting changes for the participant (the flip side could also be true, however, and if participants were ready to change, the intervention could help them implement healthy behaviors into their life).

What data would you collect to know if you are implementing the strategy the way it was intended (process evaluation/implementation monitoring)? Refer back to your logic model and the Logic Model module as needed. Be sure to cover dose, reach, fidelity, and implementation. (40 points)

  • Dose
    • Lunch participation
      • Email blasts to all participants of event; personalized email to bosses to encourage participation
      • Attendance sheets at the event which participants will mark their name and what department they are in
    • Participation of UGA resources (ASPIRE, Ramsey, etc.)
      • ASPIRE can not release their participant number–so this would rely on self-report from participants.
      • For participants who report going to Ramsey, run query’s to assess frequency of utilization for point allotment.
    • Drop outs
      • A drop out will be defined as anyone who participates in >1 but <5 activities of the intervention
        • Including: Scavenger hunts, Weekly challenges, Wellness lunches, pre-surveys.
      • Percentage of offices and of total cohort will be calculated
  • Reach
    • How well is the program reaching intended targets?
      • The implementation will only be presented to faculty/staff of the Student Services branch of UGA.
      • To assess whether or not the program is reaching targets, each office will have two points of contact with the study–the director of the department and an elected staff member. Having two points of contact can help the research team encourage individual participation for each staff member.
      • Weekly challenge participation tally sheets will aid in who is participating on a weekly basis; research team can communicate with the director or pre-identified staff member if a tally sheet is not received one week.
    • Who is being missed?
      • Weekly tally sheets will provide insight into which staff members are not participating.
    • What potential unintended groups is the program reaching?
      • There is a chance that staff members will have friends who work outside of the Student Services umbrella. Identifying them would be impossible unless they contacted the research team to participate.
  • Fidelity
    • How faithful is the program that is actually delivered to what was planned?
      • Pre and post-surveys will assess satisfaction with program and satisfaction with health outcomes
      • Review of frequency of Wellness Lunches
      • Review of utilization of campus resources (as described in Dose)
      • Research team members attendance at weekly lunches/intervention activities to assess what was planned was what was actually covered.
    • What elements are missing?
      • Feedback on surveys from participants
      • Research team reflection and evaluation of program
  • Implementation
    • To assess implementation, program objectives will be outlined specifically so at the conclusion of the program, researchers can assess the extent to which the program was implemented as planned.
    • Weekly wellness lunch guests will complete a checklist of material covered (developed by the research team).
    • Leaders of the scavenger hunt will have a checklist of instructions they are to read to participants. They will have a worksheet to complete which will outline total number of groups and the extent to which they identified scavenger hunt items.
    • Weekly challenge instructions will be sent to departmental directors with instructions on how to relay information to staff. Instruction sheet should be signed and returned with the weekly challenge tallies.
    • (Pending IRB approval): Utilize an Outlook plug in (such as mxHero) to deliver content to staff members. Information includes Ramsey information, Aspire clinic details, reminders for the walking club, etc. The plug in allows to evaluate how many of the emails are being opened (a way to assess whether or not the information the research team curated is being “read”). 

Part 4: Reflection

  • Oftentimes when working with communities, the initial plan is not what ultimately happens. What would your second choice strategy be for your identified behavior and community? Why would you choose this strategy? In other words, in what ways would this strategy also address the needs of the community based on your assessment for Part 1? (25 points)
    • It is important that staff members take advantage of the numerous wellness resources that the University offers. However, the current plan may not be effective for numerous reasons. Primarily is the fact that many of the planned intervention activities take place during the workday. Many employees have very busy days, and cultivating motivation to leave the office to participate in activities may become difficult. Though there are “take-home” challenges, the primary outcome of increasing the use of University-sponsored wellness resources faces the time constraint barrier. This potential barrier was addressed in the development of a “competition” type intervention to promote camaraderie within offices and motivation to do things together as a group. However, if this is not successful, it may be more effective to adopt a more structured program:
      • In Athens-Clarke County (similar target audience: residents of Athens-Clarke county), the county health department has an extremely successful wellness program (not reported in the literature, I’ve worked with the director). It is not a short-term intervention type program, but rather, offer the organization structure to provide personal monetary incentives for participating employees. They get money back from the health department for participating in wellness lunches, tracking their physical activity or consumption fruits and vegetables. This requires a staff member whose entire focus is wellness, something my suggested intervention lacks. A more intensive program would require staff members to head the project, but could be more successful. This type of program has been implemented by University of Michigan1 (similar target audience: University employees); they created an integrated organizational wellness structure available to all employees. They offer risk reduction services, employee assistance programs, and occupational health services. Many of these services are currently being offered at UGA and could benefit from an all-encompassing wellness program. With a program in place, marketing materials can be created, email blasts can go out to the entire university, and policies can be put into place that creates personal incentives for workers who participate. Creation of a wellness program similar to University of Michigan’s ActiveU would still address the needs of this target audience—and even would utilize the components of this intervention (but on a larger scale for a longer duration). Furthermore, because of the long term duration and collection of biochemical data, analyses of employee health can be compared to their participation in the program. This creates an embedded layer of evaluation of program success within their own employee base. This also would allow for changes to be made if necessary which is a benefit that is not as achievable in a short term intervention. For lasting behavior changes, an intervention longer than six weeks is desirable. Ideally, a more all-encompassing program was the “end goal” of the intervention I planned. However, if a smaller scale intervention isn’t successful, a more all-encompassing program with greater reach would be desirable.

(1) Beck AJ, Hirth RA, Jenkins KR, Sleeman KK, Zhang W. Factors Associated With Participation in a University Worksite Wellness Program. American journal of preventive medicine. 2016 Mar 16.

  • Reflect on how you may use the Community Guide, Nutrition Education Library, and other resources in the future. What did you like about these resources? What didn’t you like? Provide suggestions on how you would make the sites easier for practitioners to use. (20 points)
    • I can see myself utilizing the Community Guide as the first step of a research project. I would go there to get the overarching recommendation. Maybe I wasn’t utilizing the website correctly but I had better luck finding pertinent papers from sources like PubMed and GoogleScholar. I found the website to be frustratingly limited* so I probably would just reference it to get the overarching theme of a project and whether or not it is recommended before diving into more detailed literature on my own. I find that with reference materials like this (similar to this is the Evidence Analysis Library by the Academy of Nutrition and Dietetics), they are often out of date. Combining their recommendations/conclusions with a more recent review or meta-analysis of the topic of interest is usually a sure-fire way to get up to date data as well as well-rounded conclusions and is likely what I will do in the future.
      • *In writing this today I went back and their website is no longer the beta version and it was much easier to parse through the information today than it was in my original searches.
    • I thought it was very helpful how many different topics were covered in the Community Guide. The most beneficial in my opinion is the interventions that are not recommended. Knowing what has not worked in the past is important when developing and perfecting the intervention plan.  Furthermore, as they report the reasoning why interventions were/were not recommended allows researchers to identify potential weaknesses in their plans. As my research is more clinical-based, I had never been exposed to this database before. I think it is a great place for researchers to go to help develop their interventions with evidence based programs that have been tested in the past. I also like that they linked other relevant recommendation topics within a given topic so you didn’t miss it simply because of a search-error. I also appreciated the “considerations for implementations” tab because it brought up really important topics that could have been overlooked (for example, breach of confidentiality of health records).
    • I thought the entire system was fairly counterintuitive to use–they have a banner page that asks you who you are and then you have to try to identify what your purpose is. I ended up clicking into what I thought was relevant (it wasn’t) but doing that led me to a page with a search box so I ended up just using the search function. I could have been missing good information simply because I couldn’t identify which “label” best suited my “purpose”.  I know they implemented that style webpage to try to increase usability but it made it more confusing for me. I also hate that you had to click into “read more” of each subsection–this made page searching the webpage for a key concept impossible. Beyond the technical difficulties, I had trouble finding pertinent information with the limited search function because I knew the type of intervention I wanted to do before I started the research for the project (that’s more a personal problem than a Community Guide problem but it still affected my experience). It was difficult once I identified the area of the Community Guide that I needed to look at because it didn’t align with the intervention that I had planned. This led me to cherry pick components of the different worksite wellness programs (for example, the “obesity” recommendation and the “assessment of health risks” recommendations). They were reviewed/recommended by different sections of the Community Guide and I just combined the separate intervention components together into my program. What I should have done is not come up with a program ahead of time. I should have looked at the guide and come up with an intervention afterward (I got too excited about/committed to my intervention idea!). That being said, in searching the literature, I was able to find an entire review of incentive-based/team focused worksite wellness interventions that had been completed. That is the biggest flaw of the Community Guide–keeping it up to date is nearly impossible.
    • There are so many things to click on for each page that I lost track of what I had looked at. I think this was my biggest complaint about the usability of the website–it was very difficult to keep all the pages straight. I also think that pages should open into a new window from the main search page since it is likely users will click into many of the results.