Frank J. van Lenthe

Determinants of participation in worksite health promotion programmes: a systematic review

BackgroundThe workplace has been identified as a promising setting for health promotion, and many worksite health promotion programmes have been implemented in the past years. Research has mainly focused on the effectiveness of these interventions. For implementation of interventions at a large scale however, information about (determinants of) participation in these programmes is essential. This systematic review investigates initial participation in worksite health promotion programmes, the underlying determinants of participation, and programme characteristics influencing participation levels.MethodsStudies on characteristics of participants and non-participants in worksite health promotion programmes aimed at physical activity and/or nutrition published from 1988 to 2007 were identified through a structured search in PubMed and Web of Science. Studies were included if a primary preventive worksite health promotion programme on PA and/or nutrition was described, and if quantitative information was present on determinants of participation.ResultsIn total, 23 studies were included with 10 studies on educational or counselling programmes, 6 fitness centre interventions, and 7 studies examining determinants of participation in multi-component programmes. Participation levels varied from 10% to 64%, with a median of 33% (95% CI 25–42%). In general, female workers had a higher participation than men (OR = 1.67; 95% CI 1.25–2.27]), but this difference was not observed for interventions consisting of access to fitness centre programmes. For the other demographic, health- and work-related characteristics no consistent effect on participation was found. Pooling of studies showed a higher participation level when an incentive was offered, when the programme consisted of multiple components, or when the programme was aimed at multiple behaviours.ConclusionIn this systematic review, participation levels in health promotion interventions at the workplace were typically below 50%. Few studies evaluated the influence of health, lifestyle and work-related factors on participation, which hampers the insight in the underlying determinants of initial participation in worksite health promotion. Nevertheless, the present review does provide some strategies that can be adopted in order to increase participation levels. In addition, the review highlights that further insight is essential to develop intervention programmes with the ability to reach many employees, including those who need it most and to increase the generalizability across all workers.

Socioeconomic differences in lack of recreational walking among older adults: the role of neighbourhood and individual factors

BackgroundPeople with a low socioeconomic status (SES) are more likely to be physically inactive than their higher status counterparts, however, the mechanisms underlying this socioeconomic gradient in physical inactivity remain largely unknown. Our aims were (1) to investigate socioeconomic differences in recreational walking among older adults and (2) to examine to what extent neighbourhood perceptions and individual cognitions regarding regular physical activity can explain these differences.MethodsData were obtained by a large-scale postal survey among a stratified sample of older adults (age 55–75 years) (N = 1994), residing in 147 neighbourhoods of Eindhoven and surrounding areas, in the Netherlands. Multilevel logistic regression analyses assessed associations between SES (i.e. education and income), perceptions of the social and physical neighbourhood environment, measures of individual cognitions derived from the Theory of Planned Behaviour (e.g. attitude, perceived behaviour control), and recreational walking for ≥10 minutes/week (no vs. yes).ResultsParticipants in the lowest educational group (OR 1.67 (95% CI, 1.18–2.35)) and lowest income group (OR 1.40 (95% CI, 0.98–2.01)) were more likely to report no recreational walking than their higher status counterparts. The association between SES and recreational walking attenuated when neighbourhood aesthetics was included in the model, and largely reduced when individual cognitions were added to the model (with largest effects of attitude, and intention regarding regular physical activity). The assiation between poor neighbourhood aesthetics and no recreational walking attenuated to (borderline) insignificance when individual cognitions were taken into account.ConclusionBoth neighbourhood aesthetics and individual cognitions regarding physical activity contributed to the explanation of socioeconomic differences in no recreational walking. Neighbourhood aesthetics may explain the association between SES and recreational walking largely via individual cognitions towards physical activity. Intervention and policy strategies to reduce socioeconomic differences in lack of recreational walking among older adults would be most effective if they intervene on both neighbourhood perceptions as well as individual cognitions.

Material, psychosocial, and behavioural factors in the explanation of educational inequalities in mortality in the Netherlands

Study objectives: To assess the direct and indirect contributions of material, behavioural, and psychosocial factors to the explanation of educational inequalities in mortality simultaneously. Design: Prospective observational study (1991–1998). Setting: General population from south east Netherlands. Participants: 3979 men and women aged 15–74 years without severe chronic disease at baseline (1991). Main results: Material factors (type of health insurance, financial problems, and housing tenure), psychosocial factors (life events and external locus of control), and behavioural factors (smoking habits and physical activity) together reduced the relative risk of mortality of the lowest educated group from 2.57 (95%CI 1.43 to 4.64) to 1.01 (95%CI 0.50 to 2.03). Of these three groups of factors, material factors contributed most to the educational inequalities. Part of the contribution of material factors was via psychosocial factors and part via behavioural factors. Psychosocial factors contributed to educational inequalities, partly via behavioural factors. Behavioural and psychosocial factors contributed only marginally to the explanation independent of material factors. Conclusion: Educational inequalities in mortality were explained by material, psychosocial, and behavioural factors. Material factors contributed most to the explanation, partly via psychosocial and behavioural factors. Improving the material situation of lower educated people may substantially reduce educational inequalities in mortality, partly via the psychosocial and behavioural consequences of improved material circumstances.

Workplace health promotion: a meta-analysis of effectiveness

CONTEXT An unhealthy lifestyle may contribute to ill health, absence due to sickness, productivity loss at work, and reduced ability to work. Workplace health promotion programs (WHPPs) aim to improve lifestyle and consequently improve health, work ability, and work productivity. However, systematic reviews on intervention studies have reported small effects, and the overall evaluation of effectiveness of WHPPs is hampered by a large heterogeneity in interventions and study populations. This systematic review aims to investigate the influence of population, study and intervention characteristics, and study quality on the effectiveness of workplace health promotion programs. EVIDENCE ACQUISITION A systematic literature search was conducted identifying RCTs, published before June 2012, evaluating the effect of a WHPP aimed at smoking cessation, physical activity, healthy nutrition, and/or obesity on self-perceived health, work absence due to sickness, work productivity, or work ability. Studies were included in the meta-analyses if quantitative information was present to calculate an effect size (ES). A meta-analysis, stratified meta-analyses, and meta-regression analyses were performed in Spring 2012 using Comprehensive Meta-analysis software 2.0 and PAWS 17.0.2. EVIDENCE SYNTHESIS In 18 studies describing 21 interventions, the overall effect of a WHPP was small (ES=0.24, 95% CI=0.14, 0.34). The effectiveness of a WHPP was larger in younger populations, in interventions with weekly contacts, and in studies in which the control group received no health promotion. A 2.6-fold lower effectiveness was observed for studies performing an intention-to-treat analysis and a 1.7-fold lower effectiveness for studies controlling for confounders. Studies of poor methodologic quality reported a 2.9-fold higher effect size of the WHPP. CONCLUSIONS The effectiveness of a WHPP is partly determined by intervention characteristics and statistical analysis. High-quality RCTs reported lower effect sizes. It is important to determine the effectiveness of WHPPs in RCTs of high quality.

Socioeconomic status and ischaemic heart disease mortality in 10 western European populations during the 1990s

Objective: To assess the association between socioeconomic status and ischaemic heart disease (IHD) mortality in 10 western European populations during the 1990s. Design: Longitudinal study. Setting: 10 European populations (95 009 822 person years). Methods: Longitudinal data on IHD mortality by educational level were obtained from registries in Finland, Norway, Denmark, England/Wales, Belgium, Switzerland, Austria, Turin (Italy), Barcelona (Spain), and Madrid (Spain). Age standardised rates and rate ratios (RRs) of IHD mortality by educational level were calculated by using Poisson regression. Results: IHD mortality was higher in those with a lower socioeconomic status than in those with a higher socioeconomic status among men aged 30–59 (RR 1.55, 95% confidence interval (CI) 1.51 to 1.60) and 60 years and over (RR 1.22, 95% CI 1.21 to 1.24), and among women aged 30–59 (RR 2.13, 95% CI 1.98 to 2.29) and 60 years and over (RR 1.36, 95% CI 1.33 to 1.38). Socioeconomic disparities in IHD mortality were larger in the Scandinavian countries and England/Wales, of moderate size in Belgium, Switzerland, and Austria, and smaller in southern European populations among men and younger women (p < 0.0001). For elderly women the north–south gradient was smaller and there was less variation between populations. No socioeconomic disparities in IHD mortality existed among elderly men in southern Europe. Conclusions: Socioeconomic disparities in IHD mortality were larger in northern than in southern European populations during the 1990s. This partly reflects the pattern of socioeconomic disparities in cardiovascular risk factors in Europe. Population wide strategies to reduce risk factor prevalence combined with interventions targeted at the lower socioeconomic groups can contribute to reduce IHD mortality in Europe.

Socioeconomic inequalities in occupational, leisure-time, and transport related physical activity among European adults: a systematic review.

BackgroundThis study systematically reviewed the evidence pertaining to socioeconomic inequalities in different domains of physical activity (PA) by European region.MethodsStudies conducted between January 2000 and December 2010 were identified by a systematic search in Pubmed, Embase, Web of Science, Psychinfo, Sportdiscus, Sociological Abstracts, and Social Service Abstracts. English-language peer-reviewed studies undertaken in the general population of adults (18–65 years) were classified by domain of PA (total, leisure-time including sport, occupational, active transport), indicator of socioeconomic position (education, income, occupation), and European region. Distributions of reported positive, negative, and null associations were evaluated.ResultsA total of 131 studies met the inclusion criteria. Most studies were conducted in Scandinavia (n = 47). Leisure-time PA was the most frequently studied PA outcome (n = 112). Considerable differences in the direction of inequalities were seen for the different domains of PA. Most studies reported that those with high socioeconomic position were more physically active during leisure-time compared to those with low socioeconomic position (68% positive associations for total leisure-time PA, 76% for vigorous leisure-time PA). Occupational PA was more prevalent among the lower socioeconomic groups (63% negative associations). Socioeconomic differences in total PA and active transport PA did not show a consistent pattern (40% and 38% positive associations respectively). Some inequalities differed by European region or socioeconomic indicator, however these differences were not very pronounced.ConclusionsThe direction of socioeconomic inequalities in PA in Europe differed considerably by domain of PA. The contradictory results for total PA may partly be explained by contrasting socioeconomic patterns for leisure-time PA and occupational PA.

Review and special articleWorkplace Health Promotion: A Meta-Analysis of Effectiveness

CONTEXT An unhealthy lifestyle may contribute to ill health, absence due to sickness, productivity loss at work, and reduced ability to work. Workplace health promotion programs (WHPPs) aim to improve lifestyle and consequently improve health, work ability, and work productivity. However, systematic reviews on intervention studies have reported small effects, and the overall evaluation of effectiveness of WHPPs is hampered by a large heterogeneity in interventions and study populations. This systematic review aims to investigate the influence of population, study and intervention characteristics, and study quality on the effectiveness of workplace health promotion programs. EVIDENCE ACQUISITION A systematic literature search was conducted identifying RCTs, published before June 2012, evaluating the effect of a WHPP aimed at smoking cessation, physical activity, healthy nutrition, and/or obesity on self-perceived health, work absence due to sickness, work productivity, or work ability. Studies were included in the meta-analyses if quantitative information was present to calculate an effect size (ES). A meta-analysis, stratified meta-analyses, and meta-regression analyses were performed in Spring 2012 using Comprehensive Meta-analysis software 2.0 and PAWS 17.0.2. EVIDENCE SYNTHESIS In 18 studies describing 21 interventions, the overall effect of a WHPP was small (ES=0.24, 95% CI=0.14, 0.34). The effectiveness of a WHPP was larger in younger populations, in interventions with weekly contacts, and in studies in which the control group received no health promotion. A 2.6-fold lower effectiveness was observed for studies performing an intention-to-treat analysis and a 1.7-fold lower effectiveness for studies controlling for confounders. Studies of poor methodologic quality reported a 2.9-fold higher effect size of the WHPP. CONCLUSIONS The effectiveness of a WHPP is partly determined by intervention characteristics and statistical analysis. High-quality RCTs reported lower effect sizes. It is important to determine the effectiveness of WHPPs in RCTs of high quality.

Socioeconomic Status and Stroke Incidence in the US Elderly The Role of Risk Factors in the EPESE Study

Background and Purpose— This study assesses the effect of socioeconomic status on stroke incidence in the elderly, and the contribution of risk factors to stroke disparities. Methods— Data comprised a sample of 2812 men and women aged 65 years and over from the New Haven cohort of the Established Populations for the Epidemiologic Studies of the Elderly. Individuals provided baseline information on demographics, functioning, cardiovascular and psychosocial risk factors in 1982 and were followed for 12 years. Proportional hazard models were used to model survival from initial interview to first fatal or nonfatal stroke. Results— Two hundred and seventy subjects developed incident stroke. At ages 65 to 74, lower socioeconomic status was associated with higher stroke incidence for both education (HRlowest/highest=2.07, 95% CI, 1.04 to 4.13) and income (HRlowest/highest=2.08, 95% CI, 1.01 to 4.27). Adjustment for race, diabetes, depression, social networks and functioning attenuated hazard ratios to a nonsignificant level, whereas other risk factors did not change associations significantly. Beyond age 75, however, stroke rates were higher among those with the highest education (HRlowest/highest=0.42, 95% CI, 0.22 to 0.79) and income (HRlowest/highest=0.43, 95% CI, 0.22 to 0.86), which remained largely unchanged after adjustment for risk factors. Conclusions— We observed substantial socioeconomic disparities in stroke at ages 65 to 74, whereas a crossover of the association occurred beyond age 75. Policies to improve social and economic resources at early old age, and interventions to improve diabetes management, depression, social networks and functioning in the disadvantaged elderly can contribute to reduce stroke disparities.

A systematic review of associations between environmental factors, energy and fat intakes among adults: is there evidence for environments that encourage obesogenic dietary intakes?

OBJECTIVE To review the literature examining associations between environmental factors, energy and fat intakes among adults, and to identify issues for future research. METHODS Literature searches of studies published between 1980 and 2004 were conducted in major databases (i.e. PubMed, Human Nutrition, Web of Science, PsychInfo, Sociofile). Additional articles were located by citation tracking. RESULTS Twenty-one articles met the inclusion criteria. No study provided a clear conceptualisation of how environmental factors may influence these dietary intakes. Availability, social, cultural and material aspects of the environment were relatively understudied compared with other factors such as seasonal/day of the week variation and work-related factors. Few studies examined the specific environmental factors implicated in the obesity epidemic, and there was little study replication. All studies were observational and cross-sectional. CONCLUSIONS It is too premature to conclude whether or not environmental factors play a role in obesogenic and unhealthy dietary intakes. More studies need to examine associations with those environmental factors thought to contribute to obesogenic environments. There needs to be more development in theories that conceptualise the relationship between environmental factors and dietary intakes.

Material, psychosocial, behavioural and biomedical factors in the explanation of relative socio-economic inequalities in mortality: evidence from the HUNT study

BACKGROUND Previous studies have assessed the relative importance of material, psychosocial and behavioural factors in the explanation of relative socio-economic inequalities in mortality, but research into the contribution of biomedical factors has been limited. Our study examines the relative contribution of (i) material, (ii) psychosocial, (iii) behavioural and (iv) biomedical factors in the explanation of relative socio-economic (educational and income) inequalities in mortality. METHODS Cohort study--baseline data from the Norwegian total county population-based HUNT 2 study linked to mortality data (1995/97 to 2003). In this analysis, 18 247 men and 18 278 women aged 24-80 without severe chronic disease at baseline were eligible. RESULTS No socio-economic inequalities in mortality among women were found. In men, educational- and income-related inequalities in mortality were found with a relative risk for the lowest educational group of 1.67 (1.29-2.15) and the lowest income quartile of 2.03 (1.57-2.70). Together, the four explanatory factors reduced the relative risk of mortality of the lowest educational group to 1.18 (0.90-1.55) and the relative risk of mortality in the lowest income quartile was attenuated to 1.17 (0.83-1.63). Known biomedical factors contributed least to both educational and income inequalities in mortality. CONCLUSIONS Material factors were the most important in explaining income inequalities in mortality amongst men, whereas psychosocial and behavioural factors were the most important in explaining educational inequalities. This suggests that improving the material, psychosocial and behavioural circumstances of men might bring more substantial reductions in relative socio-economic inequalities in mortality.