Asian Nursing Research 7 (2013) 74e82

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Asian Nursing Research

journal homepage: www.asian-nursingresearch.com

Research Article

Effects of a Workplace Multiple Cardiovascular Disease Risks Reduction Program

Jing-Juin Huang, RN, MSN, 1 Huey-Shyan Lin, PhD, 2 Miaofen Yen, PhD, RN, 3 Wai-Ming Kan, PhD, 4 Bih-O. Lee, PhD, 5 Ching-Huey Chen, PhD, RN 3, *
1 2

Institute of Allied Health Sciences, National Cheng Kung University, Chung Hwa University of Medical Technology, Tainan, Taiwan School of Nursing, Fooyin University, Kaohsiung, Taiwan 3 Department of Nursing and Institute of Allied Health Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan 4 Department of Pharmacology, College of Medicine, National Cheng Kung University, Tainan, Taiwan 5 Department of Nursing, Chang Gung University of Science and Technology, Chia-Yi, Taiwan

a r t i c l e i n f o
Article history: Received 7 April 2012 Received in revised form 17 February 2013 Accepted 20 March 2013

s u m m a r y
Purpose: Interventions targeting multiple risk behaviors have the potential to offer greater health benets on public health. The purpose of this study was to evaluate the effects of a Workplace Multiple Cardiovascular Disease Risks Reduction Program (WMCVDRRP) on male participants at high risk for cardiovascular disease. Methods: One group pretest-posttest design was applied in this study. No control group was assigned as this study was the rst one in Taiwan conducted to promote participants health using WMCVDRRP and thus with the nature of a pilot study. The program design was based on the collaboration between the health clinic at the corporation and a nursing school targeting six health behaviors. Of the 465 individuals who participated, data from 283 participants were included in the analysis. The change in any of six health behaviors and eight physical indicators were tested as the effect of the WMCVDRRP. Results: Nearly 40% of the participants improved their regular exercise, diet control, stress management, and medication adherence. Although the improvement in drinking behaviors did not show statistical signicance, 21% of the participants changed in alcohol consumption and 21% quit smoking. Eight physical indicators including systolic and diastolic blood pressure, total cholesterol, triglyceride, body mass index, waist-hip ratio, body fat, and muscle weight improved signicantly. Conclusion: Dual collaboration between the industry and nursing schools could establish a cost-effective program to improve health behaviors and health status of participants. Copyright 2013, Korean Society of Nursing Science. Published by Elsevier. All rights reserved.

Keywords: health behaviors health promotion risk behavior workplace

Introduction Health promotion is a key component of the public health agenda. The objectives of Healthy People 2020 indicate that health promotion will continue to be an important agenda over the next few decades (Koh, 2010). Adults spend most of their waking time at work, which makes the workplace ideal for providing health promotion education (Lusk & Raymond III, 2002; McEachan, Lawton, Jackson, Conner, & Lunt, 2008). The World Health Organization (WHO) has declared the workplace as a priority target area for health interventions (Quintiliani, Sattelmair, & Sorensen, 2007; WHO, 2012). In Taiwan, national surveys of workplace

* Correspondence to: Ching-Huey Chen, RN, PhD, Department of Nursing and Institute of Allied Health Sciences, National Cheng Kung University, No. 1 University Road, Tainan City 701, Taiwan. E-mail address: sugar@mail.ncku.edu.tw

organizations have clearly documented a growing interest in workplace health promotion programs (Chen, 2005; Xu, Chen, & Wu, 2004). In a time of economic recession, the design of a costeffective program to promote the health of the employees has become a workplace challenge. Cardiovascular disease (CVD) is a leading cause of global morbidity and mortality and is responsible for one in every three deaths (Roger et al., 2011; WHO, 2010). The majority of the individuals who develop heart attack and stroke each year have at least one or more cardiovascular risk factors: hypertension, diabetes, smoking, physical inactivity, high-calorie and saturated fat diet, high stress or obesity (Haskell, 2003; Roger et al., 2011; WHO, 2010). The American Heart Association (AHA) points out that for ideal cardiovascular health, one should practice the following four health behaviors: never smoke or quit smoking within the last year, maintain body mass index (BMI) at <25 kg/m2, exercise more than 150 minutes per week with moderate intensity or more than 75 minutes per week with vigorous intensity or combinations of the

1976-1317/$ e see front matter Copyright 2013, Korean Society of Nursing Science. Published by Elsevier. All rights reserved. http://dx.doi.org/10.1016/j.anr.2013.04.001

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two, and practice a healthy diet (Lloyd-Jones et al., 2010). In addition, for people at high risk for cardiovascular events, medications regimens must be incorporated into their daily life to minimize the risk of heart attack or stroke, particularly in persons with conditions such as hypertension or hyperlipidemia (Cohen & KataokaYahiro, 2009; Erhardt, 2005; EUROASPIRE II Study Group, 2001). A policy statement from the AHA further emphasized that workplace CVD prevention programs should include at least seven health behaviors including tobacco cessation, regular physical activity, stress management, early detection/screening, nutrition education and promotion, weight management, and disease management (Carnethon et al., 2009). Previous study has shown that unhealthy behaviors often coexisted (Prochaska, Spring, & Nigg, 2008). For example, smokers have on average, a higher fat diet and more sedentary lifestyle (Laaksonen, Luoto, Helakorpi, & Uutela, 2002). People with multiple unhealthy behaviors tend to suffer from chronic disease, disability or even premature death (Prochaska, 2008). Many studies suggested that success in changing one behavior may motivate individuals to take action to change other unhealthy behaviors (Noar, Chabot, & Zimmernan, 2008). Therefore, interventions targeting multiple risk behaviors may have greater benets on public health than any single-behavior intervention (Nigg & Long, 2012; Prochaska et al., 2008). For people with CVD or diabetes, a review study also showed that multiple behaviors interventions had better outcomes than those targeting a single risk behavior (Goldstein, Whitolck, & DePue, 2004). Prochaska (2008) suggested that multiple health behaviors research would become the main focus of preventive medicine in near future. One of the challenges for preventive medicine is to integrate the research and practice into developing cost-effective multiple health behavior interventions (Prochaska, 2008). Many workplace health promotion programs have aimed at reducing cardiovascular risk factors (Carnethon et al., 2009; Haskell, 2003; Lloyd-Jones et al., 2010; Prior et al., 2005). However, very few studies were conducted in Asia, especially in Taiwan. Sociocultural factors may signicantly inuence the decisions in conducting health behaviors (Donnelly et al., 2011). Therefore, the purpose of this study was to examine the effects of the Workplace Multiple Cardiovascular Disease Risks Reduction Program (WMCVDRRP) that aimed at modifying six risk behaviors associated with CVD over a 6-month period. Methods Study design One group pretest-posttest design was applied in this study. No control group was assigned because this research was a pilot study in nature. However, several strategies were used to increase the internal validity of this study. Firstly, peer review was used to minimize the inuences of confounding factors in a study (Hennekens, Buring, & Mayrent, 1987; Wikipedia, 2013). After the researcher introduced the WMCVDRRP by oral presentations with PowerPoint in formal meetings, the research team, unit executive and industry manager discussed together how to encourage employees to attend the program and how to control for possible confounding factors. The strategies included the following: (a) The company did not allow other health programs during the study period. (b) To exclude the potential confounding factor of other diseases, the target population included individuals with hypertension and hyperlipidemia, and excluded employees with serious renal diseases, liver diseases and lung diseases. (c) The executive and manager of the corporation created a supportive environment. For example, each unit executive supported their members by

giving employees exible shifts to participate the programs, which were held during working hours and near the employees working areas. (d) To avoid the effect of tests, the interval between the pretest and the posttest was set to 6 months. (e) To avoid the effect due to instrument, the InBody 3.0 (Biospace Co. Ltd, Seoul, Korea) machine was proofread to make sure it reached 100% accuracy before use. (f) To increase compliance for behavior modications and to remind the participants of not being involved in other health-related programs during the study period, the researcher made phone calls to the participants to monitor the progress of the program and provide them with the information related to problem solving during the WMCVDRRP. Thus, the participants did not register in other hospital-based health programs. (g) To complement the weak proofs of the study ndings derived from a onegroup pretest-posttest study design, the researchers also evaluated participants satisfaction of the health promotion course and the follow-up phone calls, and collected their qualitative opinions to understand the effect of the WMCVDRRP. Secondly, staff nurses and nursing students were well-trained to follow the procedure for collecting data consistently, operate the InBody machine accurately during the intervention process, and to conduct the follow-up phone call consultation. Lastly, in data analysis stage, Chi-square tests of goodness-of-t were used to critically assess the sample representativeness to the population. Workplace Multiple Cardiovascular Disease Risks Reduction Program WMCVDRRP was a collaboration between a manufacturing corporation which employed, over 8,000 male employees and one nursing school in Taiwan. It was part of the welfare policy for employees working in the corporation. The board of directors invited the corresponding author to design a series of health promotion programs for their employees. The researchers and staff in the industry health center discussed and nalized the design and details of the program . After analyzing the corporation employees annual health examination data, the researchers found that hypertension and hyperlipidemia were the top two health problems of the employees. Since the average age of the employees is close to 50 years, those with hypertension and hyperlipidemia were at risk of CVD. Therefore, the rst health promotion program was aimed at reducing the numbers of the cardiovascular risk factors for the employees with hypertension or hyperlipidemia. Prior to the implementation of the program, a factory tour was arranged for all the members conducting the WMCVDRRP including the researchers and participating students from the nursing school, so that they might have a better understanding of the work environment at the factory. The WMCVDRRP was implemented over a 6-month period and consisted of two phases (Figure 1). The program focus on the theme Retire in Health and Wealth. Phase 1 was a 3.5-hour health promotion class. Based on the suggestion of AHA in workplace health programs for CVD prevention (Carnethon et al., 2009), six health behaviors (i.e., smoking cessation, alcohol consumption, regular exercise, healthy diet, stress management and medication adherence) were included. Early detection/screening behavior was not included in the program because all employees were required to have yearly health examinations. In Taiwan, alcohol abuse was quite common among middle-aged blue collar workers especially during social gatherings. Alcohol consumption and the prevalence of alcoholism increased rapidly in the past 40 years in Taiwan (Yang, 2002). Therefore, alcohol consumption was included. The issue of weight management was integrated into nutrition education. Since all of the participants had either hypertension or hyperlipidemia, medication adherence was also included. Researchers developed a brochure which summarized the important

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Preprogram (1 week before program)

1. Physical measures: BP, total cholesterol, and triglycerides Inbody (BMI, WHR, body fat, and muscle weight) 2. Questionnaire (1) Demographic data : age, education, marital status, and disease conditions (2) HBCSQ and DSMS

Health promotion course: Retire in Health and Wealth

Topic Health as Wealth Health in debt Accruing health Saving Buy in low (stock) Break Buy in low (stock) Excellent stock Saving the health Life-long savings Explore resources & reduce expenditures New start
1520

Minutes
20 20 10

Content Why health? How hypertension & hyperlipidemia damage health? Stretching exercise I (standing) Adherence to prescription (I) Relax & enjoy healthy snacks Adherence to prescription (II) Healthy diet, refrain from smoking/drinking Stretching exercise II (sitting) Regular physical exercise Strategies to relieve stress & gain energy New life-goal setting & class evaluation

20 10 20 30 10 30 20

Pamphlet: Retire with Health and Wealth

Individual phone call (every 2 weeks for 6 months)

6 months follow-up postprogram

1. Physical measures: BP, total cholesterol, and triglycerides Inbody (BMI, WHR, body fat, and muscle weight) 2. Questionnaire (1) Demographic data: age, education, marital status, and disease conditions (2) HBCSQ, DSMS, and PSQ

Figure 1. The Workplace Multiple Cardiovascular Disease Risks Reduction Program, Note. BP blood pressure; BMI body mass index; WHR waist to hip ratio; HBCSQ Health Behavioral Change Stage Questionnaire; DSMS Diet, Stress management, Medication adherence Scales; PSQ Program Satisfaction Questionnaire.

information of the class; this was given to all participants for their reference. Class instructors included a program coordinator and a pharmacologist. In the beginning of the education class, each participant received a report of their physical indicators needing improvement. At the end of the course, time was allocated to participants to write down their behavioral modication goals selected from any one of the six health behaviors. Participants were asked to provide a phone number and designate a convenient time to be called. In Phase 2, participants received a follow-up phone call every 2 weeks by nursing students for a period of 6 months to remind and encourage participants to achieve their goals. The follow-up phone calls were conducted by senior nursing students enrolled in a community health course at the nursing school. The 13 female nursing students, who also attended the

WMCVDRRP classes, were trained to conduct the phone call with a standardized interview guide. During the phone call, the participant was reminded and encouraged to adhere to the behavioral modication goals previously selected. In addition, during each phone call, information was obtained and documented about any behavioral changes or special life events that inuenced the participants maintenance or modication of healthy behaviors. To monitor the quality of the phone call service, the principal investigator checked the records of the phone calls monthly. To avoid any misunderstanding from the participants spouse, the nursing students were constantly reminded of their proper conversation manners and they should use any opportunity possible to invite the participants spouse to join the monitoring and facilitating of the behavioral modication plan. A meeting was held once a month among the nursing students and

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the researchers to discuss and resolve any difculties in communicating with the participants. At the end of the program, each participant received a letter clearly stating all of the measured data and their meaning to their health conditions. The program coordinator reported the overall results of the program to the board of directors of the corporation. Participants that needed continuous attention were marked and referred to the staff nurses in the health center for further follow-up. Setting and samples Employees who had one or more of the following risk factors were invited to participate: systolic blood pressure (SBP) over 140 mmHg, diastolic blood pressure (DBP) over 90 mmHg, serum cholesterol over 200 mg/dL, or triglycerides over 150 mg/dL. Of the eligible 646 employees, 465 (72%) employees joined the program. Finally, 283 participants were analyzed and 182 participants who failed to supply complete data were excluded. Over 90% of the missing data came from the post-program measure of the Health Behavioral Change Stage Questionnaire. A goodness-of-t test was used to assess sample representativeness to the population. There were no signicant differences in age, education, marital status, disease conditions (diabetes mellitus, kidney disease, and liver disease etc.), and the six healthy behaviors in pretest between participants and the 646 employees (p < .05). Measurements The measurements applied in the study included demographic data (age, education, and disease conditions), physical indicators, Health Behavioral Change Stage Questionnaire, diet, stress management and medication adherence scales, and Program Satisfaction Questionnaire. Physical indicators Physical indicators contained measurements of body components, SBP, DBP, and blood samples for analysis of total cholesterol and triglycerides. Body components including body weight, BMI, the percentage of body fat and muscle weight, and waist to hip ratio (WHR), were measured by InBody, which is a multi-frequency segmental bioelectrical impedance analysis device. Bioelectrical impedance analysis offers precision and accurate estimates of body composition in obese and healthy subjects (Bedogni et al., 2002; Salmi, 2003). Blood pressure was measured by an automatic sphygmomanometer. Both the InBody and the automatic sphygmomanometer were calibrated before the program. Health Behavioral Change Stage Questionnaire (HBCSQ) Participants reported the stage of change of six health behaviors: smoking cessation, alcohol consumption, regular exercise, healthy diet, stress management, and medication adherence. The instruments used to examine the stage of change of health behaviors were based on the Transtheoretical Model developed by Prochaska and DiClementi (1983). Stage was determined using one question per health behavior to classify subjects into one of the ve stages for each health behavior: precontemplation, contemplation, preparation, action, or maintenance. Precontemplation, which implies that there is no intention to change the behavior in the next 6 months; contemplation, which indicates that intention to change is present within 6 months; preparation, which is characterized by small or inconsistent changes; action, which describes active involvement in the behavior for less than 6 months; and maintenance, which is characterized by a sustained behavior change for at least 6 months (Prochaska & Sallis, 2004). The stage of change in the

Transtheoretical Model has been widely applied to various kinds of health behaviors, such as physical activity, smoking cessation, fruit and vegetable intake, weight loss, and stress management. Both the reliability and validity have been conrmed in previous studies (Spencer, Pagell, Hallion, & Adams, 2002). Diet, Stress management, Medication adherence Scales (DSMS) Three scales were used to evaluate diet, stress management and medication adherence. Diet behaviors were evaluated using the 12-item scale developed by Hu, Chen, Lee, and Chang (2001). The Stress Management Behavior Scale, developed by Huang and Chiou (1996) contains 6 items. The Medication Compliance Behavioral Scale developed by Hu, Tai, Yu, Yu, and Tseng (1999) contains 10 items. All three scales use a 5-point Likert scale ranging from 1 (never) to 5 (always). The higher the scores, the better behaviors were; scores ranges varied in diet (12 e60), stress management (6e60) and adherence to medication (10e50). The validity and reliability of these scales had been tested and validated in previous studies (Hu et al., 2001; Hu et al., 1999; Huang & Chiou, 1996). The internal consistency Cronbachs alpha of these instruments (for diet, stress management, and medication adherence behaviors) were .70, .82, and .99, respectively. Program Satisfaction Questionnaire (PSQ) The researchers developed two program satisfaction questionnaires to evaluate participants satisfaction with the health promotion course and the follow-up phone calls. For the health promotion program, the questionnaire contains 9 items to rate the course and the supplemental written material. For the follow-up phone calls, a 5-point Likert-scale was used to rate the levels of satisfaction of the service, from 5 (very satised) to 1 (very unsatised). In addition, a multiple choice item rates the phone calls service as helpful by facilitating, encouraging, and providing useful suggestions. The information on the desired frequency for the follow-up phone call service was also obtained. Procedure This study was approved by the ethics review committee of Chung-Huwa University of Medical Technology. Ethical principles such as respect for human dignity, justice, and benecence were applied. The WMCVDRRP was managed by the staff nurses in the health center of the factory. The staff nurses reviewed all employees annual health examination records to determine the eligible participants. A total of 646 employees met the criteria. An invitation letter was sent to these eligible employees to encourage them to participate; the letter stressed the benets of this program for their health and emphasized that their attendance were considered as paid working hours. During initial contact, the purpose and procedure of the study including possible risks and benets were explained to the participants. The process allowed the participant to have sufcient time to ask questions and to consider whether or not to participate in this study. There was no penalty for employees who refused to attend the program. Nurses in the health center were in charge of assigning the eligible employees to any one of the 12 classes that was most suitable for their working schedule. To enhance the participation rate, invitation phone calls were also made by the staff nurses. Moreover, managers were also notied to arrange or reschedule the employees working hours to enhance class participation. Three nurses from the factorys health center were trained to operate the InBody machine, obtain blood samples, measure blood pressure, and assist participants in answering the questionnaires. One week before the health promotion class, the staff nurses at the health center called the participants to the health center at their

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convenient time to complete the pre-program evaluations which included demographic data, blood pressure, physical indicators (BMI, WHR, body fat, and muscle weight), and questionnaires (DSMS and HMCSQ). The participants also were required to fast for at least 6 hours before blood samples were collected for laboratory analysis of serum total cholesterol and triglycerides. The same procedures were repeated 6 months later at the end of the WMCVDRRP. In addition, the Program Satisfaction Questionnaire was given to participants at the end of the health promotion class and at the end of 6 months to collect the questionnaire on the participants perception of the WMCVDRRP anonymously. The data le was anonymously coded and the researchers were unable to retrieve subjects name and identication. Data analysis SPSS for Windows (version 15.0; SPSS Inc., Chicago, IL, USA) was used for data analysis. Paired t tests were used to examine the differences between preprogram and postprogram measures in the three healthy behavioral scales (diet, stress management and medication adherence scales). Chi-square tests of goodness-of-t were applied to examine the differences between the sample and population in those internal confounding variables. Bowkers test of symmetry was employed to examine the differences between preprogram and postprogram measures in physical indicators and six behaviors in the Health Behavioral Change Stage Questionnaire. A p value less than .05 was considered statistically signicant. Results Demographics and satisfaction of the program All the participants were men and their age ranged from 31 to 60 years old (M 48.3, SD 5.1). The majority of them were married (95%, n 269) and had at least senior high school education (85%, n 241). Nearly half (n 132) of them had hyperlipidemia and 90.1% (n 255) were diagnosed with hypertension (Table 1). Over 90% of the 465 participants reported they were either satised or very satised with each topic of the course and the supplemental written materials. At least 87% (n 405) of them indicated they were satised or very satised with the follow-up phone calls. Participants reported that the follow-up phone calls were helpful by facilitating (59%, n 274), encouraging (54%, n 251), or
Table 1 Demographic Data of Participants (N 283) Demographic variable Age (yr) 31e35 36e40 41e45 46e50 51e55 56e60 Education Elementary school Junior high school Senior high school College/university/research institute Other Marital status Single/divorce/widower or widow Married Disease Hypertension (SBP > 140 mmHg or DBP > 90 mmHg) Hyperlipidemia (cholesterol > 200 mg/dL or triglycerides > 150 mg/dL) n 7 13 47 110 94 12 10 19 164 77 13 14 269 255 132 % 2.5 4.6 16.6 38.9 33.2 4.2 3.5 6.7 58.0 27.2 4.6 4.9 95.1 90.1 46.6

providing useful suggestions (45%, n 209) to them. While asking their opinion of desired frequency for the follow-up phone calls, 73% of participants suggested that once a month was sufcient. Of the 283 participants who supplied completed data their selfdetermined health behavioral modication goals after attending the class, 56 (20%) wanted to refrain from or quit smoking, 89 (31%) hoped to reduce alcohol consumption, 189 (67%) desired to eat healthier foods, 217 (77%) wished to participate in regular exercise, and 110 (39%) wanted to engage in more relaxing activities. Physical indicators Each physical indicator 6 months after the WMCVDRRP showed statistical and clinical improvement (Table 2). Of the physical parameters, the change in DBP was evident in the greatest percentage of participants. The number of participants with a DBP ! 100 mmHg dropped from 246 to 101. Participants with an SBP < 140 mmHg increased by 16.3%. Nearly 7% of participants triglyceride levels dropped from over to under 500 mg/dL, and 9.5% had lower triglycerides levels of <200 mg/dL. Participants BMI fell signicantly after 6 months, corresponding to body fat loss and WHR decrease. Seven percent of participants showed decreased BMI, 12.1% showed decreased body fat and 8.1% showed decreased WHR. Substantial increase in muscle weight was also demonstrated. Diet, stress management, medication adherence Healthy diet behaviors and stress management scores signicantly improved after WMCVDRRP (Table 3). The mean healthy diet score increased from 42.8 to 44.7; the mean stress management score increased from 18.5 to 19.3. While the mean score for medication adherence behavior improved from 40.4 to 41.2, the change was not signicant. Health behavioral change stage The changes of six health behaviors were shown in Table 4. For each health behavior, if the number at the right upper triangle of a cross-table was higher compared with the number at the symmetric position of the left lower triangle, this means more participants moved from no action stage to action stage. For example, in smoking cessation category, there was one participant who moved from precontemplation stage to action stage and ve participants from contemplation stage to action stage, but no participants moved from action stage to precontemplation stage or contemplation stage. Accordingly, ve of the six behaviors showed significant improvement in the stage of behavioral change. Quit drinking was the only behavior that did not show signicant improvement. Based on participants reports, 21% (n 29, total 137 reported having smoking behavior) improved in smoking cessation, 34% (n 95, total 283) in regular exercise, 36% (n 103, total 283) in healthy diet, 36% (n 101, total 283) in stress management and 40% (n 55, total 137 reported taking antihypertension or antihyperlipidemia medication) in medication adherence behavior. Discussion This study indicated positive changes in cardiovascular healthrisk behaviors and physical indicators among participants in the WMCVDRRP. The major studies of multiple behavior change focused on identifying gateways to other behavioral changes (Allegrante, Peterson, Boutin- Foster, Ogedegbe, & Charlson, 2008; Emmons, Marcus, Linnan, Rossi, & Abrams, 1994; Nigg et al., 1999).

J.-J. Huang et al. / Asian Nursing Research 7 (2013) 74e82 Table 2 Physical Indicators before and 6 months after the WMCVDRRP (N 283) Physical indicator n Systolic blood pressure (mmHg) <120 120e139 140e159 ! 160 <80 80e89 90e99 !100 200 200e239 !240 <150 150e199 200e499 !500 !24 24e27 >27 0.90 >0.90 20 >20 <45.7 45.7e61.8 >61.8 7 29 152 95 6 17 14 246 166 94 23 131 50 68 34 49 125 109 95 188 27 256 30 233 20 Preprogram % 2.5 10.2 53.7 33.6 2.1 6.0 4.9 86.9 58.7 33.2 8.1 46.3 17.7 24.0 12.0 17.4 44.2 38.5 33.6 66.4 9.5 90.5 10.6 82.3 7.1 n 5 77 135 66 13 51 118 101 180 82 21 159 49 59 16 59 135 89 118 165 61 222 28 233 22 Postprogram % 1.8 27.2 47.7 23.3 4.6 18.0 41.7 35.7 63.6 29.0 7.4 56.2 17.3 20.8 5.7 20.9 47.7 31.5 41.7 58.3 21.6 78.4 9.9 82.3 7.8 140.2

79

c2

<.001

Diastolic blood pressure (mmHg)

142.0

<.001

Total cholesterol (mg/dL)

131.2

<.001

Triglycerides (mg/dL)

209.9

<.001

Body mass index (kg/m2)

1,057.6

<.001

Waist-hip ratio Body fat (%) Muscle weight (%)

172.1 89.08 362.6

<.001 <.001 <.001

Note. WMCVDRRP Workplace Multiple Cardiovascular Disease Risks Reduction Program.

Previous study has shown that smoking behavior was a key predictor to other behaviors (Emmons, Marcus, Linnan, Rossi, & Abrams, 1994; Laaksonen et al., 2002). More recently, research found physical activity to inuence changes in smoking, stress reduction, and dietary changes (Allegrante et al., 2008). Findings from this study revealed that the changes of the participants cardiovascular health-risk behaviors were clustered. In this study, nearly 40% participants who attempted to alter multiple health-risk behaviors in the complicated workplace. The WMCVDRRP guided the participants to plan for a healthier lifestyle and to make choices based on changes that are likely to be adopted easily and readily. Follow-up phone calls facilitated participants to achieve the goal set by themselves. In the follow-up stage, the researcher and staff nurses at the worksite health center provided consultations to the participants. Thus, the program signicantly improved the participants health behaviors including regular physical exercise, diet, stress management, and medication adherence behaviors. As a result, the health behaviors changed were accompanied by significant improvement in physical indicators. Our study showed that many worksite participants found it difcult to quit drinking or decrease alcohol consumption. Research indicated that social drinking is a Chinese tradition important for employees in facilitating interpersonal relationships, promoting their work position, and obtaining resources (Tung & Wang, 2004). Thus, intervention programs specic to quitting
Table 3 Healthy Diet Score, Stress Management Score and Medication Adherence Score before and after the WMCVDRRP (N 283) Healthy behavior scale (Range) Preprogram M SD Healthy diet (12e60) Stress management (6e30) Medication adherence (10e50) 42.8 6.1 18.5 4.4 40.4 5.8 Postprogram M SD 44.7 5.7 19.3 3.9 41.2 5.2 <.001 <.001 .101 p

Note. WMCVDRRP Workplace Multiple Cardiovascular Disease Risks Reduction Program.

drinking or decreasing alcohol consumption may be necessary in the future. Few studies focused on cost-effective ways to approach multiple health risk behavior change in worksite (Hyman, Pavlik, Taylor, Goodrick, & Moye, 2007). Previously, one similar study was conducted in Japan using a randomized controlled design to evaluate a workplace health promotion program in reducing the CVD risk factors among male employees. The program also included lectures and follow-up sessions and aimed at the modication of three behaviors at the same time: nutrition, physical activity, and stress management. In their study, the intervention group showed signicant improvement in BMI, SBP, levels of total cholesterol and triglycerides (Muto & Yamauchi, 2001). Their results were similar to our ndings. However, Muto and Yamauchi (2001) did not report on the change in health behaviors. Moreover, the mean cost per participant in the current study was approximately $300.00 (U.S. dollars) to $400.00 compared to $1000.00 per participant in Muto and Yamauchis study. Costs in this present study were moderated by a cooperative agreement with the school of nursing. The ndings further supported the suggestions by Haskell (2003) that nurse-coordinated or designed multifactor modication health promotion programs can effectively reduce CVD risk factors. Several factors contributed to the effects of the WMCVDRRP. First, corporate support was high, promoting class attendance as working hours. The study was initiated at the invitation of the industrys board of directors which recognized employees health as an organizational goal. The top-down decision process is an indispensable determinant of an effective worksite health promotion program (Weiner, Lewis, & Linnan, 2009). Despite corporate support, nearly 30% of the targeted employees refused to participate. Further research is needed to explore the barriers in joining a workplace health promotion program. Second, participant satisfaction with the design of the program is important. In the health promotion course, the participants were encouraged not because they were unhealthy but because they

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Table 4 Effects of WMCVDRRP on Six Health Behavioral Stages of Change (N 283) Participants self-reported stage preprogram Baseline Quit smoking (n 137 ) PC C P A M Total Alcohol consumption (n 211a) PC C P A M Total Regular exercise PC C P A M Total Healthy diet PC C P A M Total Stress management PC C P A M Total Medication adherence (n 137b) PC C P A M Total
a

Participants self-reported stage postprogram n (%) PC 37 3 1 0 0 41 84 19 4 8 4 119 3 3 4 0 0 10 13 2 2 1 3 21 5 4 4 0 2 15 0 1 0 1 2 4 (27.0) (2.2) (0.7) (0.0) (0.0) (29.9) (39.8) (9.0) (1.9) (3.8) (1.9) (56.4) (1.1) (1.1) (1.4) (0.0) (0.0) (3.5) (4.6) (0.7) (0.7) (0.4) (1.1) (7.4) (1.8) (1.4) (1.4) (0.0) (0.7) (5.3) (0.0) (0.7) (0.0) (0.7) (1.5) (2.9) 5 12 3 0 0 20 15 19 5 0 2 41 1 15 4 0 0 20 3 26 7 1 1 38 7 48 16 0 2 73 2 2 7 1 0 12 C (3.6) (8.8) (2.2) (0.0) (0.0) (14.6) (7.1) (9.0) (2.4) (0.0) (0.9) (19.4) (0.4) (5.3) (1.4) (0.0) (0.0) (7.1) (1.1) (9.2) (2.5) (0.4) (0.4) (13.4) (2.5) (17.0) (5.7) (0.0) (0.7) (25.8) (1.5) (1.5) (5.1) (0.7) (0.0) (8.8) 3 5 1 0 0 9 1 2 2 0 0 5 1 16 49 5 3 74 3 21 29 3 12 68 7 22 47 2 15 93 1 4 6 3 1 15 P (2.2) (3.6) (0.7) (0.0) (0.0) (6.6) (0.5) (0.9) (0.9) (0.0) (0.0) (2.4) (0.4) (5.7) (13) (1.8) (1.1) (26.1) (1.1) (7.4) (10.2) (1.1) (4.2) (24.0) (2.5) (7.8) (16.6) (0.7) (5.3) (32.9) (0.7) (2.9) (4.4) (2.2) (0.7) (10.9) 1 5 4 1 0 11 4 3 1 3 2 13 3 9 18 5 6 41 4 15 11 11 13 54 3 4 17 1 5 30 0 8 7 3 3 21 A (0.7) (3.6) (2.9) (0.7) (0.0) (8.0) (1.9) (1.4) (0.5) (1.4) (0.9) (6.2) (1.1) (3.2) (6.4) (1.8) (2.1) (14.5) (1.4) (5.3) (3.9) (3.9) (4.6) (19.1) (1.1) (1.4) (6.0) (0.4) (1.8) (10.6) (0.0) (5.8) (5.1) (2.2) (2.2) (15.3) 0 2 3 1 50 56 10 1 0 9 13 33 0 5 33 9 91 138 5 7 21 13 56 102 6 6 26 3 31 72 1 6 12 14 52 85 M

Total

18.0* (0.0) (1.5) (2.2) (0.7) (36.5) (40.9) (4.7) (0.5) (0.0) (4.3) (6.2) (15.6) (0.0) (1.8) (11.7) (3.2) (32.2) (48.8) (1.8) (2.5) (7.4) (4.6) (19.8) (36.0) (2.1) (2.1) (9.2) (1.1) (11.0) (25.4) (0.7) (4.4) (8.8) (10.2) (38.0) (62.0) 46 27 12 2 50 137 114 44 12 20 21 211 8 48 108 19 100 283 28 71 70 29 85 283 28 84 110 6 55 283 4 21 32 22 58 137 (33.6) (19.7) (8.8) (1.5) (36.5) (100.0) 16.2 (54.0) (20.9) (5.7) (9.5) (10.0) (100.0) 59.9*** (2.8) (17.0) (38.2) (6.7) (35.3) (100.0) 33.5*** (9.9) (25.1) (24.7) (10.2) (30.0) (100.0) 28.9** (9.9) (29.7) (38.9) (2.1) (19.4) (100.0) 32.9*** (2.9) (15.3) (23.4) (16.1) (42.3) (100.0)

Note. WMCVDRRP Workplace Multiple Cardiovascular Disease Risks Reduction Program; PC precontemplation; C contemplation; P preparation; A action; M maintenance. *p < .05. **p < .01. ***p < .001. a Only participants who reported having smoking and drinking habits were included. b Only participants who were prescribed antihypertension or antihyperlipidemia medication were included.

deserved to regain their health in order to enjoy retirement. Motivation was enhanced when each participant received a report of their physical indicators needing improvement. Moreover, the program also used many strategies to motivate the participants to put effort into their health. The retirement age for laborers in Taiwan is 55e60 years. The mean age of the participants was 48 years, a time that is viewed as a turning point in life when workers sense a decline in their working capacity and are concerned with their retirement. For middle-aged individuals, health is as important as wealth in preparing for retirement. The slogan of the WMCVDRRP was Retire in Health and Wealth. Stock investment is a very popular activity in Taiwan. Therefore, the program used the concept of investment in the stock market to attract the attention of participants. For example, adherence to medication was presented as buying the stock while it was low in price to save money or save health; to eat a healthy diet was compared to holding growth stocks. Maintaining regular exercise was compared to accruing savings. Each lecture topic was limited to 30 minutes and with 10 minute breaks, healthy snack and stretching exercises were

arranged. Visual aids included food models and posters to demonstrate the ideal consumption of healthy portions. Exercise equipment was available for participants to experience. Each health behavior focused on three main themes: why, how, and overcoming barriers. Although the health promotion course lasted for 3.5 hours, multiple teaching strategies attracted participants interests and attention. Follow-up phone calls facilitated program effectiveness. Although six participants reported that the phone call interfered with their work and life, the vast majority of the participants found the calls helpful. This nding corresponds with a previous study by Jensen et al. (2009) that a nurse telephone intervention has the potential to improve awareness of CVD risk factors as well as encourage patients to implement cardioprotective strategies. A random sample of phone calls can be taped to assess the delity of the conversation in the future study. As participants suggested, the follow-up phone call can be reduced to once a month. Mailing tailored health related materials might also be an option to replace monthly calls. Alternatively, electronic (e-mail) communication

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may also be an efcient way for long term follow-up (Franklin, Rosenbaum, Carey, & Roizen, 2006). Among the six health behaviors, smoking and drinking showed the least improvement. These ndings suggest that smoking and drinking behaviors require extra consideration when designing a multifactor health promotion program. Haskell et al. (2006) evaluated a multifactor CVD risk reduction program for low-income patients. The program signicantly improved patients physical activity, nutrition and medication adherence behaviors but not smoking cessation and stress management. The original design of the WMCVDRRP assumed that health behaviors would inuence each other to create a more comprehensive and healthier lifestyle (Muto & Yamauchi, 2001). Further investigation is needed to examine why some behaviors changed while others remained unchanged. Strengths and limitations The study was conducted using a relatively innovative and integrated program to promote workers health by worksite-based interventions. By generating this covariation program, this study is benecial to effectively change workers health behaviors and physical indicators. The program for modifying cardiovascular health-risk behaviors was rarely described in the intervention study. Thus, this study is unique in Taiwan as well as in Asian countries. Furthermore, this study was the rst one conducted in Taiwan to promote employees health using the WMCVDRRP. Several limitations of this study should be considered in interpreting the ndings. Firstly, the ndings of this study were limited to a single manufacturing worksite in Taiwan. The culture issues needed to be addressed before applying to worksites in other countries. Secondly, without a control group, the effects of the WMCVDRRP demonstrated in this study may not be properly estimated. Thirdly, selection bias may have occurred because only the most motivated and susceptible stage (unhealthy lifestyle) individuals enrolled in programs when participation is voluntary. Lastly, behavioral changes were assessed only once, the long term effect of the WMCVDRRP in maintaining positive behavioral change is unknown. Implications The implications of this research are signicant. This study provides an example of collaboration between a nursing school and a corporation to promote the health of the laborers in their worksite. The collaboration and the design of the program addressed can be applicable to similar cooperation between the academia and the industry. In addition, the program integrated education, service and research. Through the training of conducting the follow-up phone calls consultation, 13 nursing students enrolled in a community nursing course experienced the process of developing worksite health promotion program and had the opportunity to play a role in health education. Conclusion WMCVDRRP is effective in changing employee behaviors toward smoking cessation, regular exercise, healthy diet, stress management and medication adherence but not alcohol consumption. Participants of a WMCVDRRP improved signicantly in major physical indicators over a 6-month period. Further research that explores the relationship among change in the 6 behaviors is needed. The long term effects of WMCVDRRP also require further investigation.

Conict of interest The authors have no conict of interest for this study. Acknowledgments We wish to acknowledge Professor Susan Fetzer for her expert advice and editing which were essential for the improvement of this manuscript. References
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