Glorian Sorensen

Work site-based cancer prevention: primary results from the Working Well Trial.

OBJECTIVES This paper presents the behavioral results of the Working Well Trial, the largest US work site cancer prevention and control trial to date. METHODS The Working Well Trial used a randomized, matched-pair evaluation design, with the work site as the unit of assignment and analysis. The study was conducted in 111 work sites (n = 28,000 workers). The effects of the intervention were evaluated by comparing changes in intervention and control work sites, as measured in cross-sectional surveys at baseline and follow-up. The 2-year intervention targeted both individuals and the work-site environment. RESULTS There occurred a net reduction in the percentage of energy obtained from fat consumption of 0.37 percentage points (P = .033), a net increase in fiber densities of 0.13 g/1000 kcal (P = .056), and an average increase in fruit and vegetable intake of 0.18 servings per day (P = .0001). Changes in tobacco use were in the desired direction but were not significant. CONCLUSIONS Significant but small differences were observed for nutrition. Positive trends, but no significant results, were observed in trial-wide smoking outcomes. The observed net differences were small owing to the substantial secular changes in target behaviors.

Model for incorporating social context in health behavior interventions: applications for cancer prevention for working-class, multiethnic populations

BACKGROUND This article proposes a conceptual framework for addressing social contextual factors in cancer prevention interventions, and describes work that operationalizes this model in interventions for working class, multiethnic populations. METHODS The Harvard Cancer Prevention Program Project Includes Three Studies: (1) an intervention study in 25 small businesses; (2) an intervention study in 10 health centers; and (3) a computer simulation modeling project that translates risk factor modifications into gains in life expectancy and number of cancers averted. The conceptual framework guiding this work articulates pathways by which social context may influence health behaviors, and is used to frame the interventions and guide evaluation design. RESULTS Social contextual factors cut across multiple levels of influence, and include individual factors (e.g., material circumstances, psychosocial factors), interpersonal factors (e.g., social ties, roles/responsibilities, social norms), organizational factors (e.g., work organization, access to health care), and neighborhood/community factors (e.g., safety, access to grocery stores). Social context is shaped by sociodemographic characteristics (e.g., social class, race/ethnicity, gender, age, language) that impact day-to-day realities. CONCLUSIONS By illuminating the pathways by which social contextual factors influence health behaviors, it will be possible to enhance the effectiveness of interventions aimed at reducing social inequalities in risk behaviors.

The effects of a health promotion-health protection intervention on behavior change: the WellWorks Study

OBJECTIVES This study assessed the effects of a 2-year integrated health promotion-health protection work-site intervention on changes in dietary habits and cigarette smoking. METHODS A randomized, controlled intervention study used the work site as the unit of intervention and analysis; it included 24 predominantly manufacturing work sites in Massachusetts (250-2500 workers per site). Behaviors were assessed in self-administered surveys (n = 2386; completion rates = 61% at baseline, 62% at final). Three key intervention elements targeted health behavior change: (1) joint worker-management participation in program planning and implementation, (2) consultation with management on work-site environmental changes, and (3) health education programs. RESULTS Significant differences between intervention and control work sites included reductions in the percentage of calories consumed as fat (2.3% vs 1.5% kcal) and increases in servings of fruit and vegetables (10% vs 4% increase). The intervention had a significant effect on fiber consumption among skilled and unskilled laborers. No significant effects were observed for smoking cessation. CONCLUSIONS Although the size of the effects of this intervention are modest, on a populationwide basis effects of this size could have a large impact on cancer-related and coronary heart disease end points.

Using Theory to Understand the Multiple Determinants of Low Participation in Worksite Health Promotion Programs

Low participation at the employee or worksite level limits the potential public health impact of worksite-based interventions. Ecological models suggest that multiple levels of influence operate to determine participation patterns in worksite health promotion programs. Most investigations into the determinants of low participation study the intrapersonal, interpersonal, and institutional influences on employee participation. Community- and policy-level influences have not received attention, nor has consideration been given to worksite-level participation issues. The purpose of this article is to discuss one macrosocial theoretical perspective—political economy of health—that may guide practitioners and researchers interested in addressing the community- and policy-level determinants of participation in worksite health promotion programs. The authors argue that using theory to investigate the full spectrum of determinants offers a more complete range of intervention and research options for maximizing employee and worksite levels of participation.

A comprehensive worksite cancer prevention intervention: behavior change results from a randomized controlled trial (United States)

Objective: Workplace cancer prevention initiatives have been least successful with blue-collar workers. This study assesses whether an intervention integrating health promotion with occupational health and safety results in significant and meaningful increases in smoking cessation and consumption of fruits and vegetables, compared to a standard health promotion intervention, for workers overall and for blue-collar workers in particular. Methods: A randomized controlled design was used, with 15 manufacturing worksites assigned to a health promotion (HP) or a health promotion plus occupational health and safety intervention (HP/OHS), and compared from baseline (1997) to final (1999). The response rates to the survey were 80% at baseline (n = 9019) and 65% at final (n = 7327). Both groups targeted smoking and diet; the HP/OHS condition additionally incorporated reduction of occupational exposures. Results: Smoking quit rates among blue-collar workers in the HP/OHS condition more than doubled relative to those in the HP condition (OR = 2.13, p = 0.04), and were comparable to quit rates of white-collar workers. No statistically significant differences between groups were found for mean changes in fruits and vegetables. Conclusions: Integration of occupational health and safety and health promotion may be an essential means of enhancing the effectiveness of worksite tobacco control initiatives with blue-collar workers.

Promoting Behavior Change Among Working-Class, Multiethnic Workers: Results of the Healthy Directions—Small Business Study

OBJECTIVES We examined the efficacy of a cancer prevention intervention designed to improve health behaviors among working-class, multiethnic populations employed in small manufacturing businesses. METHODS Worksites were randomly assigned to an intervention or minimal-intervention control condition. The intervention targeted fruit and vegetable consumption, red meat consumption, multivitamin use, and physical activity. RESULTS Employees in the intervention group showed greater improvements for every outcome compared with employees in the control group. Differences in improvement were statistically significant for multivitamin use and physical activity. Intervention effects were larger among workers than among managers for fruit and vegetable consumption and for physical activity. CONCLUSIONS The social-context model holds promise for reducing disparities in health behaviors. Further research is needed to improve the effectiveness of the intervention.

Gender, social pressure, and smoking cessations: The Community Intervention Trial for Smoking Cessation (COMMIT) at baseline

This study was undertaken to examine gender differences in the perception of social constraints against smoking and to explore the role of other sociodemographic and smoking factors that influence the perception of social pressure. Baseline data from the 20 U.S. sites in the National Cancer Institutes Community Intervention Trial for Smoking Cessation (COMMIT) were analyzed. We found that women were less likely than men to be heavy smokers and to report that smoking had affected their health, but more likely to report behavior indicating physiological addiction (timing of first cigarette). At all smoking levels, women were about twice as likely as men to report feeling pressure to quit, after adjusting for education, income, ethnic group, age, and other factors. The source of pressure, however, was different: more women report pressure from their children, whereas more men report pressure from friends and coworkers. Women were equally likely as men to make quit attempts, after adjusting for other factors, but were less likely to remain abstinent for at least 10 days. Women, regardless of education, ethnicity, and age, reported a greater tendency to ask permission before smoking in non-restricted public places. College-educated men were less likely than men without college education to smoke without asking in non-restricted places, but education did not influence whether women asked permission. For both sexes, smoking level and nicotine dependence were significant predictors of lighting up without asking in public places, after adjustment for other variables. We discuss these findings and their implications for the gender gap in smoking cessation and womens conflicting pressures to stop/continue smoking. Tobacco control efforts are discussed within the context of gender differences in social norms, roles, socialization, and communication cultures.

The Influence of Social Context on Changes in Fruit and Vegetable Consumption: Results of the Healthy Directions Studies

As part of the Harvard Cancer Prevention Program Project, we used a social contextual model of health behavior change to test an intervention targeting multiple risk-related behaviors in working-class, multiethnic populations. We examined the relationships between the social contextual factors in our conceptual model and changes in fruit and vegetable consumption from baseline to completion of intervention in health centers and small business studies. We analyzed change in fruit and vegetable consumption, measured at baseline and final assessments by self-report, in 2 randomized controlled prevention trials: 1 in small businesses (n = 974) and 1 in health centers (n = 1954). Stronger social networks, social norms that were more supportive, food sufficiency, and less household crowding were associated with greater change in fruit and vegetable intake. We also observed differences between our intervention sites. Social context can play an important role in promoting changes in fruit and vegetable consumption.

The Effect of Social Desirability Trait on Self-reported Dietary Measures among Multi-Ethnic Female Health Center Employees

PURPOSE To evaluate the effect of social desirability trait, the tendency to respond in a manner consistent with societal expectations, on self-reported fruit, vegetable, and macronutrient intake. METHODS A 61-item food frequency questionnaire (FFQ), 7-item fruit and vegetable screener, and a single question on combined fruit and vegetable intake were completed by 132 female employees at five health centers in eastern Massachusetts. Intake of fruit and vegetables derived from all three methods and macronutrients from the FFQ were fit as dependent variables in multiple linear regression models (overall and by race/ethnicity and education); independent variables included 3-day mean intakes derived from 24-hour recalls (24HR) and score on the 33-point Marlowe-Crowne Social Desirability scale (the regression coefficient for which reflects its effect on estimates of dietary intake based on the comparison method relative to 24HR). RESULTS Results are based on the 93 women with complete data and FFQ-derived caloric intake between 450 and 4500 kcal/day. In women with college education, FFQ-derived estimates of total caloric were associated with under-reporting by social desirability trait (e.g., the regression coefficient for total caloric intake was -23.6 kcal/day/point in that group versus 36.1 kcal/day/point in women with education less than college) (difference = 59.7 kcal/day/point, 95% confidence interval (CI) = 13.2, 106.2). Except for the single question on which women with college education tended to under-report (difference =.103 servings/day/point, 95% CI = 0.003, 0.203), there was no association of social desirability trait with self-reported fruit and vegetable intake. CONCLUSIONS The effect of social desirability trait on FFQ reports of macronutrient intake appeared to differ by education, but not by ethnicity or race. The results of this study may have important implications for epidemiologic studies of diet and health in women.

Social Disparities in Tobacco Use in Mumbai, India: The Roles of Occupation, Education, and Gender

OBJECTIVES We assessed social disparities in the prevalence of overall tobacco use, smoking, and smokeless tobacco use in Mumbai, India, by examining occupation-, education-, and gender-specific patterns. METHODS Data were derived from a cross-sectional survey conducted between 1992 and 1994 as the baseline for the Mumbai Cohort Study (n=81837). RESULTS Odds ratios (ORs) for overall tobacco use according to education level (after adjustment for age and occupation) showed a strong gradient; risks were higher among illiterate participants (male OR = 7.38, female OR = 20.95) than among college educated participants. After age and education had been controlled, odds of tobacco use were also significant according to occupation; unskilled male workers (OR = 1.66), male service workers (OR = 1.32), and unemployed individuals (male OR = 1.84, female OR = 1.95) were more at risk than professionals. The steepest education- and occupation-specific gradients were observed among male bidi smokers and female smokeless tobacco users. CONCLUSIONS The results of this study indicate that education and occupation have important simultaneous and independent relationships with tobacco use that require attention from policymakers and researchers alike.