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Review
The impact of onsite workplace health-enhancing physical activity interventions on worker productivity: a systematic review Michelle Jessica Pereira,1 Brooke Kaye Coombes,1 Tracy Anne Comans,2 Venerina Johnston1 1
Discipline of Physiotherapy, The University of Queensland, School of Health and Rehabilitation Sciences, St Lucia, Queensland, Australia 2 Centre for Applied Health Economics, School of Medicine, Griffith University, Meadowbrook, Queensland, Australia Correspondence to Michelle Jessica Pereira, Discipline of Physiotherapy, The University of Queensland, School of Health and Rehabilitation Sciences, St Lucia, QLD 4072, Australia; michelle.j.pereira@uqconnect. edu.au Received 2 November 2014 Revised 10 February 2015 Accepted 21 February 2015 Published Online First 16 March 2015
ABSTRACT The aim of this study is to investigate the effects of onsite workplace health-enhancing physical activity (HEPA) programmes on worker productivity. The PROSPERO registration number is CRD42014008750. A search for controlled trials or randomised controlled trials (RCTs) that investigated the effects of onsite workplace HEPA programmes on productivity levels of working adults was performed. Risk of bias of included studies was assessed, and the inter-rater reliability of the quality assessment was analysed. Qualitative synthesis of available evidence is presented. Eight studies were included in the review. There is consistent evidence that onsite workplace HEPA programmes do not reduce levels of sick leave. There appears to be inconsistent evidence of the impact of onsite workplace HEPA programmes on worker productivity. A high-quality study of an onsite combination (aerobic, strengthening and flexibility) HEPA regime and a moderate-quality study of a Tai Chi programme improved worker productivity measured with questionnaires in female laundry workers and older female nurses, respectively. Two high-quality studies and four moderate-quality studies did not show benefit. Studies that showed benefit were mainly those designed with productivity measures as primary outcomes, delivered to occupations involved with higher physical loads, and had higher compliance and programme intensity. The small number of studies and the lack of consistency among studies limited further analyses. There is inconsistent evidence that onsite workplace HEPA programmes improve self-reported worker productivity. Future high-quality RCTs of onsite workplace HEPA programmes should be designed around productivity outcomes, target at-risk groups and investigate interventions of sufficient intensity. High attendance with improved recording is needed to achieve significant results in augmenting worker productivity.
INTRODUCTION
To cite: Pereira MJ, Coombes BK, Comans TA, et al. Occup Environ Med 2015;72:401–412.
Physical inactivity is prevalent globally1 and has been linked to increased risk of developing chronic diseases.2 3 As a result, many health authorities and governments have developed health promotion and disease prevention guidelines to encourage higher levels of physical activity (PA).4 5 One reason for the decrease in PA is the ubiquitous use of technology during work and activities of daily living, reducing opportunities for PA and creating an increasingly sedentary population.4 The increase in sedentary lifestyle is of particular concern in working populations in developed countries.6
A common reason for low levels of PA is a lack of time due to work or personal commitments.7 8 This barrier may be addressed by the proximity of exercise facilities or convenient access to amenities,9 10 with recommendations that building design and office planning include supportive environments, such as exercise rooms, shower rooms or accessible stairwells, or by providing access to fitness equipment to facilitate PA,11–13 but a potential barrier may be the costs borne by the employer for the implementation and maintenance of these facilities.13 PA has been linked with improved physical and mental health, as well as better health-related quality of life, of which work functioning is a subdomain.14 The presence of physical and mental health conditions, and lower health-related quality of life, have been linked to reduced work productivity.15 16 Workplace health-enhancing PA (HEPA)17 interventions have been reported to have positive results on employee health outcomes,18 but the relationship between PA and productivity is less clear.19 Studies have shown that vigorous general PA decreases rates of absenteeism,20 21 however, work-related PA such as frequent walking, climbing stairs and heavy strenuous occupational tasks of carrying heavy loads, increases likelihood of sickness absences.22 Employers have a vested economic interest in maintaining better health among workers as health-related productivity loss is the largest financial source of employee health-related expenditure.23 Thus promotion of HEPA is advocated as an important component of an organisation’s business plan to improve worker health and productivity,24 despite the mixed evidence surrounding the effects of PA on productivity. Productivity is a complex construct to measure, which may partially explain the current state of evidence for the benefits of HEPA or general PA on productivity. Simply put, a worker’s productivity is the ratio of the worker’s outputs against efforts,25 with sick leave or absenteeism often used to represent health-related productivity losses. However, there is increasing recognition that ‘presenteeism’ (being at work but not performing optimally due to ill-health26) is a significant problem in the workforce.27 28 The negative economic impact of presenteeism has been cited to be up to seven times larger than that of absenteeism.23 Importantly, from an employer’s perspective, evidence of productivity outcomes is imperative to demonstrate the financial benefit and efficacy of any onsite interventions in order to ensure management support.23 29
Pereira MJ, et al. Occup Environ Med 2015;72:401–412. doi:10.1136/oemed-2014-102678
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Review The inability of establishing the exact impact of presenteeism lies in the difficulty in quantifying productivity losses due to presenteeism.30 There are a number of self-report subjective qualitative measurement tools for health-related productivity at work,31 32 although current research does not strongly support any to be the gold standard.33 This is in spite of the increasing evidence for the economic and health benefits of workplace health promotion (including HEPA) interventions.34 35 There have been considerable efforts by researchers to consolidate available evidence in this area of research. A recent systematic review evaluated the impact of various health promotion initiatives on presenteeism.27 Another two reviews looked at the impact of workplace HEPA programmes on a wide range of health-related and work-related outcomes.18 36 Comparatively, the current review synthesises recent evidence for the effects of onsite workplace HEPA interventions, a health promotion activity, distinct from work-related PA. This was done with a focus on the employer’s perspective, inclusive of all known outcome measures of worker productivity.
databases. Keywords used included PA, exercise, workplace, occupational health, workload, sick leave, absenteeism, exercise and other closely related terms. A full electronic search strategy for PubMed is included (figure 1). Subsequently, the reference lists of included publications were examined to identify additional studies, to ensure that any relevant primary studies were not missed.
Screening the literature All citations of titles and abstracts identified through the search strategy were exported using a reference management system. Two reviewers (MJP and BKC) independently screened titles and abstracts of exported records. Subsequently, full papers of citations that met all inclusion criteria were extracted. Full papers were then examined in greater detail for inclusion in this review. Consensus of studies selected between the two reviewers was reached through discussion, with the involvement of a third reviewer (TAC), when necessary.
Quality assessment
METHODS This systematic review was registered in the International Prospective Register of Systematic Reviews ((PROSPERO)—http:// www.crd.york.ac.uk/PROSPERO/ with Registration number CRD42014008750) and was prepared in consultation with the PRISMA guidelines.37
Eligibility criteria The criteria for included studies were: (1) controlled or randomised controlled trials (RCTs) that investigated adult workers older than 18 years; (2) studies that contrasted the effects of any type of onsite workplace structured HEPA programmes undertaken outside of normal work duties, to a comparator. Programmes could be conducted during or outside of paid work time; (3) studies that had any form of productivity measurement, including self-reported or actual sickness absences, or quantitative measurements of job performance or qualitative questionnaires of work ability, whether these outcomes were the primary or secondary outcomes. There were no restrictions on the length of follow-up, but the studies needed to have documented the intervention process. Only publications in the English language from January 2000 to 10 January 2015 were eligible. This time period was chosen because this review aimed to consolidate recent evidence surrounding this growing and evolving subject area and it extends the timeframe covered by Proper et al.36 Criteria for exclusion were: (1) studies that examined employees who were on sick leave and not working at their usual duties or workplaces at the time of delivery of the PA interventions; (2) programmes that needed workers to travel offsite, outside of company grounds, as this has been linked to lower participation rates38 and (3) studies that investigated, solely, the alteration of structural facilities to encourage PA without incorporating any structured PA programmes in conjunction with the structural modification.
Two reviewers independently assessed risk of bias of the included studies using a simplified version of the Downs and Black39 checklist. This assessment tool was chosen as it is valid and reliable in ascertaining risk of bias in health-related interventional studies.39 Item 27 was simplified to consider whether or not a power estimation had been reported by the study’s investigating team.40 The study received a point on this item if a power estimation had been reported and sufficient participants were recruited or zero if not giving a maximum possible score of 28 of the simplified checklist. Consensus of all items in the checklist for all selected studies between the two reviewers was reached through discussion, with the involvement of a third reviewer (TAC), when necessary. Studies that scored 20 or more of 28 were ranked as high-quality studies, and those that scored below 20 were ranked as moderate-quality studies. Studies with scores of 13 and below have been determined by other researchers to be of low quality.41 The assigned level of quality was used to enable evidence-based recommendations to be constructed.
Coding of literature A single reviewer (MJP) extracted data from eligible articles into an Excel spreadsheet, which was used to build evidence tables. A second reviewer (BKC) independently crosschecked all extracted data to ensure accuracy. Data extracted included study characteristics such as participant population, intervention and comparator details, scheduling of intervention delivery (paid or
Literature search Three authors (MJP, TAC and VJ) agreed on the literature search method. A reference librarian reviewed and provided input to the search strategy. The literature search included a computerised and comprehensive database search and a reference search. The literature search was performed in PubMed, CINAHL, PsycInfo, EconLit and ABI/Inform Complete. One reviewer (MJP) entered the search strategy into five selected 402
Figure 1
Full electronic search strategy for PubMed database.
Pereira MJ, et al. Occup Environ Med 2015;72:401–412. doi:10.1136/oemed-2014-102678
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Review unpaid work time); and outcomes, including attendance rates, follow-up time points and results of relevant outcome measures of productivity. When insufficient information was presented in the articles, primary authors were contacted via email. It was originally intended that a meta-analysis would be performed; however, the included studies were not sufficiently homogenous, rendering only a qualitative synthesis of findings possible. Sub-group analyses were also planned to compare interventions conducted during paid or unpaid work time, different occupations, or various types of onsite workplace HEPA interventions (Yoga, Tai Chi, aerobic, or strengthening regimes); however, due to the small number of included studies, this was not possible.
Data management and statistical analysis A Cohen’s κ coefficient was calculated to determine inter-rater reliability for the quality assessment of included studies.
RESULTS Flow of literature search The process of selection of relevant studies is presented in figure 2. The initial computerised search of selected databases identified 774 possible citations. After removing duplicates, 765 citations remained. Full papers of 25 citations that appeared to meet the inclusion criteria were retrieved for closer review. Finally, nine articles from eight studies that fulfilled all inclusion criteria were included in this qualitative review. Citations of ineligible full papers, including reasons for exclusion, are provided in figure 2.
Methodological quality Methodological quality scores, using the simplified assessment checklist, of the eight included studies ranged from 14 to 23 points (mean 19.22 (SD=3.11)). The results of individual items of the simplified Downs and Black checklist are included in table 1. Only three of the eight included studies were assessed to be of high quality, scoring 20 or more.42–45 Five studies scored less than 20 and were considered to have a moderate risk of bias.46–49 Many (6 of 8) studies did not comment on the presence of adverse events. There were issues of generalisability with the results in some studies, as five of the eight studies recruited from participant populations were not representative of the general population. All the studies with moderate risk of bias did not perform a power estimation and were not sufficiently powered. Inter-rater reliability of quality assessment of the included studies between the two raters was high with κ=0.975, p16 on the 10-item Perceived Stress Scale. Mixture of salaried and hourly rate workers
Wolever et al49
Participants given a list of resources available to all employees, including resources to aid physical activity and mental well-being (N=56)
Some participants engaged in intervention during unpaid time
Per protocol
Programme length: 9 weeks 1. ‘Walking routes’: participants asked to complete at least 15 min of continuous, brisk walking every work day (N=19) 2. ‘Walking while working’: participants were encouraged to fit additional step counts into work routine (N=25) 9-month ‘Integrated Health Programme’ (N=19) including:Physical exercise (to improve physical capacity, strength and flexibility) exercises, 3-hourly sessions weekly 1. Health education sessions, 15 weekly hour-long sessions 2. An examination of the participants’ workplace Programme length: 12 weeks 1. Therapeutic yoga weekly hour-long sessions, 12 h total (N=90) 2. Mindfulness-based intervention weekly hour-long sessions and a 2 h mindfulness intensive practice at week 10, 14 h total (N=96)
Intention to treat
407
Review
*Studies with productivity as primary outcome.
Puig-Ribera et al48
Analysis
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Table 2 Characteristics of individual studies
Authors
Attendance 42
Blangsted et al
Regular participation (at least weekly attendance): intervention group i: 54%, intervention group ii: 31%, comparator: 16% during the 1st half of the intervention period; and 35%, 28%, and 9%, respectively, during the second half
Per cent followed up; time point 80% at 1 year
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Sick leave
Productivity
Participants’ baseline mean sick leave 1.5 days during preceding 3 months and when multiplied by 4, not statistically different to 5.3 days during year of intervention (p=0.45)
No statistically significant interactions between mean total WAI scores (SD) and types of intervention (maximum score 42), exact p values not reported Comparator group Males: Baseline 37.1 (3.11) → postintervention 37.2 (1.53) Females: Baseline 36.7 (3.30) → postintervention 36.5 (3.18) Intervention (i) Strengthening Males: Baseline 37.7 (2.75) → postintervention 38.0 (1.20) Females: Baseline 37.4 (3.23) → postintervention 36.9 (2.69) Intervention (ii) Aerobic exercises Males: Baseline 37.4 (2.62) → postintervention 36.8 (3.17) Females: Baseline 37.1 (2.88) → postintervention 36.6 (2.56) No numerical data or p values reported No statistically significant changes in self-rated productivity on a single question 0–10 ordinal scale “How do you perceive your overall job performance in the past 4 weeks?” Not measured
Not measured
Brox and Froystein46
Intervention attendance: average of 12 (range 0–26) sessions; 10% did not attend any session, 10% completed all sessions
100% at 6 months
Jorgensen et al 51
Reported to be low (Exact figures unavailable)
52% at 1 year
Nurminen et al43*
Intervention group: 75% participated in >half of guided group exercise sessions, and ∼ 50% took part in >2/3 of the sessions
100% at 3 months 94% at 8 months 92% at 12 months 90% at 15 months
No statistically significant differences in mean total sick leave days (95% CI) between groups: 4.7 (−5.7 to 15.1) (p=0.64) Comparator group: Baseline mean (SD) 0.4 (22.0) → postintervention 14.4 (22.9) Exercise group: Baseline mean (SD) 6.8 (14.6) → postintervention 15.6 (28.4) No statistically significant changes in accumulated sick leave or number of sick leave periods from baseline to postintervention between groups (data for mean sick leave days and SD for all absenteeism outcomes unavailable) Intervention i) Physical training: Sick leave days (median) baseline 4.0 → 1 year follow-up 4.25 Sick leave periods (mean) baseline 1.622 → 1.356 Intervention ii) Cognitive training: Sick leave days (median) 3.0 → 1 year follow-up 3.0 Sick leave periods (mean) Baseline 1.281 → 1.354 Comparator group: Sick leave days (median) baseline 3.0 → 1 year follow-up 2.0 Sick leave periods (mean) baseline 1.64 → 1.281 No statistically significant changes at 8, 12 and 15 months of follow-up in baseline adjusted differences between intervention groups for cumulative sick leave in hours (95% CI). Positive differences are in favour of the comparator group. 8 months: 5.7 h (−16.9 to 28.3) 12 months: 12.0 h (−15.8 to 39.7) 15 months: 22.5 h (−13.8 to 58.8)
No significant differences in self-assessed mean work ability (SD) on a single question comparing present work ability to lifetime best (0–10 ordinal scale) Intervention (i) Physical training: Baseline 7.6 (2.0) → 1-year follow-up 7.8 (1.9) Intervention (ii) Cognitive training: Baseline 7.5 (2.1) → 1-year follow-up 7.5 (2.1) Comparator group: Baseline 7.3 (2.2) → 1-year follow-up 7.4 (2.4)
No significant baseline adjusted differences in mean total WAI (95% CI) between groups at 3, 8, 12 and 15 months of follow-up 3 month: 0.5 (−0.6 to 1.7) 8 months: 0.5 (−0.7 to 1.7) 12 months: 0.02 (−1.51 to 1.47) 15 months: −0.01 (−1.4 to 1.4) At the postintervention 8-month follow-up, more workers in the intervention group had an optimistic opinion of their work ability after 2 years due to their health state, a component of the WAI Continued
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Pedersen et al44
Review
408
Table 3 Attendance, follow-up and results across individual studies
Authors
Attendance
Per cent followed up; time point
Sick leave
Palumbo et al (2010) *
Mean attendance 82% across all offered classes
79%
4-month average (SD) unscheduled combined time off over previous year was compared to unscheduled combined time off (SD) during intervention without statistical analysis Control group: 3 h (3) →10 h (14) Intervention group: 3 h (7) → 0 h (0)
Puig-Ribera et al48
Mean change of step counts per day (SD): Comparator: −191 (1620) Intervention i: +86 (2629) Intervention ii: +12(2426)
87% at 9 weeks
Not measured
Tveito and Eriksen45 (2009)
Data unavailable
73% at 9 months
Wolever et al49
Data unavailable
86% at 12 weeks
No statistically significant differences between groups for annual mean sick leave days at baseline (p=0.931), postintervention (p=0.963) and 1-year follow-up (p=0.945). Group means (SD) reported Comparator group: Baseline 20.6 (31.00) → postintervention 35.2 (40.94) → 1-year follow-up 52.6 (68.86) Exercise group: Baseline 19.7 (29.06) → postintervention 36.0 (48.50) → 1-year follow-up 54.4 (75.50) Not measured
Baseline adjusted differences in proportions (%) between groups (95% CI) 8.1 (0.5 to 16.3) At 12-month follow-up, effectiveness of intervention represented by an increased proportion of workers with ‘good’ (37–43) or ‘excellent’ (44–49) WAI scores in intervention group Baseline adjusted differences in proportions (%) between groups (95% CI) 11.0 (0.2 to 21.9) Significantly greater reduction in mean WLQ scores (maximum 100, indicating greatest possible negative impact of health on work ability), p value 0.03 Mean (SD) change from baseline Comparator group: −0.8 (1.4) Tai Chi group: −3.1 (1.2) No statistically significant differences between groups in WLQ (modified and translated version) scores. Mean change (SD) in each WLQ subscale reported. No p values were reported. A decrease in the subscale scores represents an improvement in job productivity Comparator group: Time: −5.5 (4.4), Mental-interpersonal: +0.5 (4), Output demand: −5 (4) ‘Walking routes’ group: Time: −2.5 (3), mental-interpersonal: +1 (3.2), output demand: −2 (3) ‘Walking while working’ group: Time: −0.9 (2.5), mental-interpersonal: −1.43 (2.1), output demand: −0.8 (1.9) Not measured
No statistically significant group by time (pre and post) interaction Mean WLQ (SD) (maximum 100) Comparator group: Baseline 5.59 (4.15) → postintervention 4.29 (3.91) Intervention (i) Yoga: Baseline 4.87 (4.17) → postintervention 3.91 (3.75) Intervention (ii) Mindfulness: Baseline 5.54 (4.12) → postintervention 3.60 (3.80)
409
Review
*Studies reporting significant positive results for physical activity interventions. WAI, Work Ability Index; WLQ, Work Limitations Questionnaire.
Productivity
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Table 3 Continued
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Review DISCUSSION This review found that onsite workplace HEPA programmes do not benefit worker absenteeism and there is inconsistent evidence of benefit for worker self-reported presenteeism outcomes. These findings echo the conflicting evidence among recent literature for the impact of workplace HEPA programmes. While there are many clear benefits from workplace HEPA programmes on clinical outcomes, for example, physical fitness, PA behaviours and health profiles such as diabetes risk and lipid levels,18 the situation regarding productivity outcomes is not as apparent. Proper et al36 concluded that there is limited evidence on absenteeism, however, a study published in 200918 found that workplace HEPA interventions had low levels of benefit on absenteeism. This conflict also exists when productivity was measured with presenteeism outcomes.27 36 The strength of this review is the comprehensiveness of productivity outcomes considered. Nevertheless, there was some variability in the productivity measures used with most (5 of 8) studies using the WAI or WLQ. These questionnaires were extrapolated from studies with disease populations.33 The WLQ55 has demonstrated validity and reliability as a measure of work productivity losses in chronic disease populations such as asthma and psychiatric disorders, while the WAI has been used to document changes in work abilities of an older working population.53 It may be possible that these questionnaires are less sensitive to changes in a healthy working population, accounting for the lack of clear benefit. Studies that reported baseline values of productivity42 43 49 demonstrated that workers were close to the best possible productivity levels at baseline (table 3). The population groups in these studies did not demonstrate low levels of productivity that could benefit from an intervention or the measurement tools had a ceiling effect.42 49 Hence the measurement tools utilised may not have been able to capture improvements due to the intervention. The lack of consistency in the measurement tool used may be due to lack of a single valid gold standard for presenteeism measure for the working population across occupations and age groups. Given the great variety of occupations and the varying nature of work as new technologies, systems and processes are introduced, qualitative studies of working adults, in various occupational groups, should be considered in order to investigate the factors that constitute workplace productivity. Future research regarding the validity and reliability of potential measurement tools in a reasonably healthy, working population needs to be conducted to guide researchers in the selection of appropriate presenteeim measures, a recommendation echoed by authors in a related review.27 Another important consideration for the lack of clear benefit is the choice of participants recruited. The inclusion of all participants rather than those at risk, such as those with high sick leave, physically demanding work or past ill-health, may explain the inconsistent evidence for benefit of onsite workplace HEPA. Interestingly, workers involved in studies showing benefit43 47 had occupations requiring higher physical demands when compared with sedentary jobs. It is possible that as a result of the intervention, the discrepancy between physical abilities and job demands was reduced,22 and hence these studies were able to demonstrate benefits of onsite workplace HEPA programmes. Future studies of onsite workplace HEPA programmes may consider selecting participant populations based on identified needs. Matching interventions with identified needs of the workers is not new. Recently, a group of researchers have suggested using occupation-specific training by customising interventions to ensure a balance between the individual’s physical capacity and the occupation-related physical demands.56 Tailoring of 410
interventions was undertaken more in successful workplace health promotion programmes on presenteeism outcomes compared with unsuccessful ones.27 Hence, these principles can be applied to onsite workplace HEPA interventions to enhance worker productivity, and these studies should be targeted in participant selection and be individualised to specific job requirements. There were several possible reasons for the inconsistent evidence for productivity outcomes. First, many of the high-quality studies may have not been adequately powered to detect a difference in productivity. We found most studies (5 of 8) examined health outcomes such as PA levels or physical capacity as the primary outcome.42 44–46 48 49 However, these outcomes may not be of interest to the employer, especially in a working population which is assumed to be reasonably healthy. Thus, more high-quality primary studies of onsite workplace HEPA programmes designed to be sufficiently powered to detect a difference in productivity outcomes from the employer’s perspective are needed. Second, all studies in this review used different forms of onsite workplace HEPA interventions, including body regionspecific strengthening, general cardiovascular exercise, combination exercises and therapeutic yoga. All of these forms of onsite workplace HEPA programmes were delivered to different populations ranging from sedentary office workers to female nurses, female laundry workers and female cleaners. The latter three groups of workers would be considered to perform physically demanding tasks as part of their usual workday. Given the variation in populations and regimes, it is difficult to recommend one over another. The most ideal form of onsite workplace HEPA to improve productivity might involve more than one specific exercise type or be multidimensional in nature. This is based on the evidence gathered in this review, as a highquality study showed that 1 h/week of cardiovascular, strengthening and stretching exercises is beneficial for female laundry workers.43 Thus, firm conclusions regarding which aspect of the combination programme was effective in improving productivity levels cannot be drawn. However, recently published HEPA guidelines in Australia recommend combining two times a week strengthening exercises with at least 75 min of vigorous or 150 min of moderate levels of HEPA.57 Hence a combination approach to onsite workplace HEPA may be necessary to elicit changes in worker productivity. Perhaps worker productivity requires a multimodal approach that can tap into the processes underpinning behavioural change to effectively institute and maintain these changes compared to a single-component exercise intervention that does not. As above, in the high-quality study by Nurminen et al,43 individualised exercise prescription and counselling was integrated with HEPA to positively impact on productivity. This result is similar to findings from another review that demonstrated the importance of combining cognitive strategies to effect change on work-related outcomes.58 Hence, multimodal interventions, incorporating cognitive strategies or improving work procedures, can be considered in order to better target worker productivity. Third, low attendance was a factor in all studies not reporting benefit of onsite workplace HEPA on productivity. Thus, it would be premature to conclude that onsite workplace HEPA programmes are ineffective in productivity outcomes when these interventions were not received in the intended dose to effect change. Importantly, most of the participants were given time away from work duties during work hours to participate. A closer scrutiny in future research of possible reasons why included participants were so poorly compliant, in spite of these
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Review programmes being delivered onsite, is pertinent to guide future trials. Authors reported participants’ attendance in a variety of ways (table 3). Three studies did not report exact attendance data and primary authors were either uncontactable or did not have data available anymore. There is a need to consider standardised reporting of attendance for each cohort of participants in the future. Recording the mean amount of attendance (in minutes) of all available interventions each week would ease comparison to available PA guidelines and enhance generalisability of results. This is significant as the amount of HEPA delivered is an important factor. The minimum amount of HEPA recommended per week is 75 min of vigorous activity or 150 min of moderate activity to maintain physical health and mental well-being.57 Attendance for more than 6 months in a regime is also recommended to achieve health benefits.5 It is worthy to note that in the studies included in this review, the weekly amount of HEPA in those showing benefit on presenteeism ranged from 60 to 90 min (mean 75 min). In comparison, the weekly amounts of HEPA in studies not showing benefit on presenteeism ranged from 5 min51 (latter 9 months of programme) to approximately 75 min48 (mean 51 min). The amounts in the latter group of studies fall short of the recommended amounts of HEPA, and especially so if the participants did not reach a vigorous level of exertion. Considering the dose-dependent relationship of exercise and quality of life improvements,59 this could explain the lack of effect of onsite workplace HEPA programmes on worker productivity. While all the above factors need to be considered in future studies, building infrastructure and associated conduciveness for onsite workplace HEPA, and the workplace culture, such as management support, have been cited as vital to the successful implementation of any worksite programme.60
programmes to better understand the actual effects of these programmes, and to achieve larger beneficial changes to levels of worker productivity. Correction notice This paper has been amended since it was published Online First. In the section titled “Sickness absences outcomes” the third sentence has been amended. Acknowledgements The authors thank Ms Julie Anne Hansen from the University of Queensland Library for her assistance with searching the literature and Dr Shaun Patrick O’Leary for reviewing the final manuscript. Contributors MJP, TAC and VJ formulated the research questions and outlined the research design. MJP reviewed the existing literature, performed the computerised database search and drafted the manuscript. MJP and BKC screened all citations and analysed all the included studies. BKC, TAC and VJ revised the manuscript. All authors read and approved the final manuscript. Funding Funding sources that supported this review include the Australian Postgraduate Award and the National Health and Medical Research Council. NHMRC grant number: APP1042508. Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1
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CONCLUSIONS There is no benefit of onsite workplace HEPA programmes on worker absenteeism measures. There is inconsistent evidence regarding the effect of onsite workplace HEPA programmes on self-reported worker productivity measured with presenteeism measurement tools. One high-quality study of a combination programme incorporating cardiovascular, strengthening and flexibility exercises increased proportions of women laundry workers with more favourable WAI scores and a moderatequality study of a Tai Chi programme improved mean score on the WLQ in a population of older female nurses. Two highquality studies, one that compared strengthening and aerobic programmes and the other investigating the effects of a holistic health intervention that included a combination of aerobic, strengthening and flexibility exercises, did not show any benefit on productivity outcomes. Four moderate-quality studies of physical training exercise, walking or yoga programmes, did not show any benefit on productivity outcomes either. While there were no benefits on absenteeism, and inconsistent effects on presenteeism, no studies reported negative effects on productivity. The understanding of the concept of workplace productivity is still growing. Validity and reliability of various qualitative productivity outcomes need to be established. Primary studies of onsite workplace HEPA programmes of high quality and designed around appropriate participant populations and productivity outcomes are needed. Multimodal programmes that are occupation-specific in nature, and of sufficient intensity and duration, including HEPA, are worthwhile considerations. Thoughtful programme design keeping the perspective of the worker and employer in mind could aid researchers to enhance attendance rates, with improved recording of workplace
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Dumith SC, Hallal PC, Reis RS, III, et al. Worldwide prevalence of physical inactivity and its association with human development index in 76 countries. Prev Med 2011;53:24–8. Mukamal KJ, Ding EL, Djousse L. Alcohol consumption, physical activity, and chronic disease risk factors: a population-based cross-sectional survey. BMC Public Health 2006;6:118. Woolf K, Schmidt JL, Gilliatt-Wimberly MA, et al. Habitual physical activity reduces chronic disease risk factors in midlife and older women. Med Sci Sports Exerc 2003;35(5 Suppl 1):169. Haskell WL, Lee IM, Pate RR, et al. Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc 2007;39:1423–34. Fletcher GF, Balady G, Blair SN, et al. Statement on exercise: benefits and recommendations for physical activity programs for all Americans. Circulation 1996;94:340–4. Ng SW, Popkin BM. Time use and physical activity: a shift away from movement across the globe. Obes Rev 2012;13:659–80. Booth ML, Bauman A, Owen N, et al. Physical activity preferences, preferred sources of assistance, and perceived barriers to increased activity among physically inactive Australians. Prev Med 1997;26:131–7. Myers RS, Roth DL. Perceived benefits of and barriers to exercise and stage of exercise adoption in young adults. Am Psychol Assoc 1997;16:277–83. Reed JA, Phillips DA. Relationships between physical activity and the proximity of exercise facilities and home exercise equipment used by undergraduate university students. J Am Coll Health 2005;53:285–90. McCormack GR, Giles-Corti B, Bulsara M. The relationship between destination proximity, destination mix and physical activity behaviors. Prev Med 2008;46:33–40. Zimring C, Joseph A, Nicoll GL, et al. Influences of building design and site design on physical activity: research and intervention opportunities. Am J Prev Med 2005;28(2 Suppl 2):186–93. Watts AW, Masses LC. Is access to workplace amenities associated with leisure-time physical activity among Canadian adults? Can J Public Health 2012;104:e87–91. Kahn EB, Ramsey LT, Brownson RC, et al. The effectiveness of interventions to increase physical activity. A systematic review. Am J Prev Med 2002;22(4 Suppl):73–107. Penedo FJ, Dahn JR. Exercise and well-being: a review of mental and physical health benefits associated with physical activity. Curr Opin Psychiatry 2005;18:189–93. Boles M, Pelletier B, Lynch W. The relationship between health risks and work productivity. J Occup Environ Med 2004;46:737–45. Lamers LM. The relationship between productivity and health-related quality of life: an empirical exploration in persons with low back pain. Qual Life Res 2005;14:805–13. Martin BW, Kahlmeier S, Racioppi F, et al. Evidence-based physical activity promotion—HEPA Europe, the European Network for the promotion of health-enhancing physical activity. J Public Health 2006;14:53–7. Conn VS, Hafdahl AR, Cooper PS, et al. Meta-analysis of workplace physical activity interventions. Am J Prev Med 2009;37:330–9. Fonseca VR, Nobre MR, Pronk NP, et al. The association between physical activity, productivity, and health care utilization among employees in Brazil. J Occup Environ Med 2010;52:706–12.
411
Downloaded from http://oem.bmj.com/ on June 10, 2015 - Published by group.bmj.com
Review 20 21 22 23
24 25 26 27
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33 34 35 36
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40
41
412
Proper KI, van den Heuvel SG, De Vroome EM, et al. Dose-response relation between physical activity and sick leave. Br J Sports Med 2006;40:173–8. van den Heuvel SG, Boshuizen HC, Hildebrandt VH, et al. Effect of sporting activity on absenteeism in a working population. Br J Sports Med 2005;39:e15. Holtermann A, Hansen JV, Burr H, et al. The health paradox of occupational and leisure-time physical activity. Br J Sports Med 2012;46:291–5. Collins JJ, Baase CM, Sharda CE, et al. The assessment of chronic health conditions on work performance, absence, and total economic impact for employers. J Occup Environ Med 2005;47:547–57. Pronk NP, Kottke TE. Physical activity promotion as a strategic corporate priority to improve worker health and business performance. Prev Med 2009;49:316–21. Gontijo LA, Santana AMC. Measuring and enhancing productivity. Proc Hum Factors Ergon Soc Annu Meet 2000;44:6-249–52. Escorpizo R, Bombardier C, Boonen A, et al. Worker productivity outcome measures in arthritis. J Rheumatol 2007;34:1372–80. Cancelliere C, Cassidy JD, Ammendolia C, et al. Are workplace health promotion programs effective at improving presenteeism in workers? A systematic review and best evidence synthesis of the literature. BMC Public Health 2011;11:395. Aronsson G, Gustafsson K, Dallner M. Sick but yet at work. An empirical study of sickness presenteeism. J Epidemiol Community Health 2000;54:502–9. Goetzel RZ, Ozminkowski RJ. The health and cost benefits of work site health-promotion programs. Annu Rev Public Health 2008;29:303–23. Drummond M. Cost of illness studies. A major headache? Pharmacoeconomics 1992;2:1–4. Brown HE, Burton NW, Gilson ND, et al. Measuring presenteeism: which questionnaire to use in physical activity research? J Phys Act Health 2013;11:241–8. Lenneman J, Schwartz S, Giuseffi DL, et al. Productivity and health: an application of three perspectives to measuring productivity. J Occup Environ Med 2011;53:55–61. Beaton D, Bombardier C, Escorpizo R, et al. Measuring worker productivity: frameworks and measures. J Rheumatol 2009;36:2100–9. Mills PR, Kessler RC, Cooper J, et al. Impact of a health promotion program on employee health risks and work productivity. Am J Health Promot 2007;22:45–53. Parks KM, Steelman LA. Organizational wellness programs: a meta-analysis. J Occup Health Psychol 2008;13:58–68. Proper KI, Staal BJ, Hildebrandt VH, et al. Effectiveness of physical activity programs at worksites with respect to work-related outcomes. Scand J Work Environ Health 2002;28:75–84. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 2009;339:b2535. Lovato CY, Green LW. Maintaining employee participation in workplace health promotion programs. Health Educ Behav 1990;17:73–88. Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health 1998;52:377–84. MacLehose RR, Reeves BC, Harvey IM, et al. A systematic review of comparisons of effect sizes derived from randomised and non-randomised studies. Health Technol Assess 2000;3:1–154. Kemp JL, Collins NJ, Makdissi M, et al. Hip arthroscopy for intra-articular pathology: a systematic review of outcomes with and without femoral osteoplasty. Br J Sports Med 2012;46:632–43.
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43
44
45 46
47 48
49
50 51
52
53 54
55 56
57 58
59 60
Blangsted AK, Sogaard K, Hansen EA, et al. One-year randomized controlled trial with different physical-activity programs to reduce musculoskeletal symptoms in the neck and shoulders among office workers. Scand J Work Environ Health 2008;34:55–65. Nurminen E, Malmivaara A, Ilmarinen J, et al. Effectiveness of a worksite exercise program with respect to perceived work ability and sick leaves among women with physical work. Scand J Work Environ Health 2002;28:85–93. Pedersen MT, Blangsted AK, Andersen LL, et al. The effect of worksite physical activity intervention on physical capacity, health, and productivity: a 1-year randomized controlled trial. J Occup Environ Med 2009;51:759–70. Tveito TH, Eriksen HR. Integrated health programme: a workplace randomized controlled trial. J Adv Nurs 2009;65:110–19. Brox JI, Frooystein O. Health-related quality of life and sickness absence in community nursing home employees: randomized controlled trial of physical exercise. Occup Med 2005;55:558–63. Palumbo MV, Wu G, Shaner-McRae H, et al. Tai Chi for older nurses: a workplace wellness pilot study. Appl Nurs Res 2012;25:54–9. Puig-Ribera A, McKenna J, Gilson N, et al. Change in work day step counts, wellbeing and job performance in Catalan university employees: a randomised controlled trial. Promot Educ 2008;15:11–16. Wolever RQ, Bobinet KJ, McCabe K, et al. Effective and viable mind-body stress reduction in the workplace: a randomized controlled trial. J Occup Health Psychol 2012;17:246–58. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977;33:159–74. Jorgensen MB, Faber A, Hansen JV, et al. Effects on musculoskeletal pain, work ability and sickness absence in a 1-year randomised controlled trial among cleaners. BMC Public Health 2011;11:840. van Poppel MNM, de Vet HCW, Koes BW, et al. Measuring sick leave: a comparison of self-reported data on sick leave and data from company records. Occup Med 2002;52:485–90. Ilmarinen J, Tuomi K, Klockars M. Changes in the work ability of active employees over an 11-year period. J Work Environ Health 1997;23(Suppl 1):49–57. van Tulder M, Furlan A, Bombardier C, et al., Group tEBotCCBR. Updated method guidelines for systematic reviews in the Cochrane collaboration back review group. Spine 2003;28:1290–9. Lerner D, Amick BC III, Rogers WH, et al. The work limitations questionnaire. Med Care 2001;29:72–85. Holtermann A, Jorgensen MB, Gram B, et al. Worksite interventions for preventing physical deterioration among employees in job-groups with high physical work demands: background, design and conceptual model of FINALE. BMC Public Health 2010;10:120. Health AGDo. Australia’s physical activity and sedentary behaviour guidelines. 2014. Schonstein E, Kenny DT, Keating JL, et al. Work conditioning, work hardening and functional restoration for workers with back and neck pain. Cochrane Database Syst Rev 2009;(1):CD001822. Martin CK, Church TS, Thompson AM, et al. Exercise dose and quality of life. A randomized controlled trial. Arch Intern Med 2009;169:269–78. Hopkins JM, Glenn BA, Cole BL, et al. Implementing organizational physical activity and healthy eating strategies on paid time: process evaluation of the UCLA WORKING pilot study. Health Educ Res 2012;27:385–98.
Pereira MJ, et al. Occup Environ Med 2015;72:401–412. doi:10.1136/oemed-2014-102678
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The impact of onsite workplace health-enhancing physical activity interventions on worker productivity: a systematic review Michelle Jessica Pereira, Brooke Kaye Coombes, Tracy Anne Comans and Venerina Johnston Occup Environ Med 2015 72: 401-412 originally published online March 16, 2015
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Review
The impact of onsite workplace health-enhancing physical activity interventions on worker productivity: a systematic review Michelle Jessica Pereira,1 Brooke Kaye Coombes,1 Tracy Anne Comans,2 Venerina Johnston1 1
Discipline of Physiotherapy, The University of Queensland, School of Health and Rehabilitation Sciences, St Lucia, Queensland, Australia 2 Centre for Applied Health Economics, School of Medicine, Griffith University, Meadowbrook, Queensland, Australia Correspondence to Michelle Jessica Pereira, Discipline of Physiotherapy, The University of Queensland, School of Health and Rehabilitation Sciences, St Lucia, QLD 4072, Australia; michelle.j.pereira@uqconnect. edu.au Received 2 November 2014 Revised 10 February 2015 Accepted 21 February 2015 Published Online First 16 March 2015
ABSTRACT The aim of this study is to investigate the effects of onsite workplace health-enhancing physical activity (HEPA) programmes on worker productivity. The PROSPERO registration number is CRD42014008750. A search for controlled trials or randomised controlled trials (RCTs) that investigated the effects of onsite workplace HEPA programmes on productivity levels of working adults was performed. Risk of bias of included studies was assessed, and the inter-rater reliability of the quality assessment was analysed. Qualitative synthesis of available evidence is presented. Eight studies were included in the review. There is consistent evidence that onsite workplace HEPA programmes do not reduce levels of sick leave. There appears to be inconsistent evidence of the impact of onsite workplace HEPA programmes on worker productivity. A high-quality study of an onsite combination (aerobic, strengthening and flexibility) HEPA regime and a moderate-quality study of a Tai Chi programme improved worker productivity measured with questionnaires in female laundry workers and older female nurses, respectively. Two high-quality studies and four moderate-quality studies did not show benefit. Studies that showed benefit were mainly those designed with productivity measures as primary outcomes, delivered to occupations involved with higher physical loads, and had higher compliance and programme intensity. The small number of studies and the lack of consistency among studies limited further analyses. There is inconsistent evidence that onsite workplace HEPA programmes improve self-reported worker productivity. Future high-quality RCTs of onsite workplace HEPA programmes should be designed around productivity outcomes, target at-risk groups and investigate interventions of sufficient intensity. High attendance with improved recording is needed to achieve significant results in augmenting worker productivity.
INTRODUCTION
To cite: Pereira MJ, Coombes BK, Comans TA, et al. Occup Environ Med 2015;72:401–412.
Physical inactivity is prevalent globally1 and has been linked to increased risk of developing chronic diseases.2 3 As a result, many health authorities and governments have developed health promotion and disease prevention guidelines to encourage higher levels of physical activity (PA).4 5 One reason for the decrease in PA is the ubiquitous use of technology during work and activities of daily living, reducing opportunities for PA and creating an increasingly sedentary population.4 The increase in sedentary lifestyle is of particular concern in working populations in developed countries.6
A common reason for low levels of PA is a lack of time due to work or personal commitments.7 8 This barrier may be addressed by the proximity of exercise facilities or convenient access to amenities,9 10 with recommendations that building design and office planning include supportive environments, such as exercise rooms, shower rooms or accessible stairwells, or by providing access to fitness equipment to facilitate PA,11–13 but a potential barrier may be the costs borne by the employer for the implementation and maintenance of these facilities.13 PA has been linked with improved physical and mental health, as well as better health-related quality of life, of which work functioning is a subdomain.14 The presence of physical and mental health conditions, and lower health-related quality of life, have been linked to reduced work productivity.15 16 Workplace health-enhancing PA (HEPA)17 interventions have been reported to have positive results on employee health outcomes,18 but the relationship between PA and productivity is less clear.19 Studies have shown that vigorous general PA decreases rates of absenteeism,20 21 however, work-related PA such as frequent walking, climbing stairs and heavy strenuous occupational tasks of carrying heavy loads, increases likelihood of sickness absences.22 Employers have a vested economic interest in maintaining better health among workers as health-related productivity loss is the largest financial source of employee health-related expenditure.23 Thus promotion of HEPA is advocated as an important component of an organisation’s business plan to improve worker health and productivity,24 despite the mixed evidence surrounding the effects of PA on productivity. Productivity is a complex construct to measure, which may partially explain the current state of evidence for the benefits of HEPA or general PA on productivity. Simply put, a worker’s productivity is the ratio of the worker’s outputs against efforts,25 with sick leave or absenteeism often used to represent health-related productivity losses. However, there is increasing recognition that ‘presenteeism’ (being at work but not performing optimally due to ill-health26) is a significant problem in the workforce.27 28 The negative economic impact of presenteeism has been cited to be up to seven times larger than that of absenteeism.23 Importantly, from an employer’s perspective, evidence of productivity outcomes is imperative to demonstrate the financial benefit and efficacy of any onsite interventions in order to ensure management support.23 29
Pereira MJ, et al. Occup Environ Med 2015;72:401–412. doi:10.1136/oemed-2014-102678
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Review The inability of establishing the exact impact of presenteeism lies in the difficulty in quantifying productivity losses due to presenteeism.30 There are a number of self-report subjective qualitative measurement tools for health-related productivity at work,31 32 although current research does not strongly support any to be the gold standard.33 This is in spite of the increasing evidence for the economic and health benefits of workplace health promotion (including HEPA) interventions.34 35 There have been considerable efforts by researchers to consolidate available evidence in this area of research. A recent systematic review evaluated the impact of various health promotion initiatives on presenteeism.27 Another two reviews looked at the impact of workplace HEPA programmes on a wide range of health-related and work-related outcomes.18 36 Comparatively, the current review synthesises recent evidence for the effects of onsite workplace HEPA interventions, a health promotion activity, distinct from work-related PA. This was done with a focus on the employer’s perspective, inclusive of all known outcome measures of worker productivity.
databases. Keywords used included PA, exercise, workplace, occupational health, workload, sick leave, absenteeism, exercise and other closely related terms. A full electronic search strategy for PubMed is included (figure 1). Subsequently, the reference lists of included publications were examined to identify additional studies, to ensure that any relevant primary studies were not missed.
Screening the literature All citations of titles and abstracts identified through the search strategy were exported using a reference management system. Two reviewers (MJP and BKC) independently screened titles and abstracts of exported records. Subsequently, full papers of citations that met all inclusion criteria were extracted. Full papers were then examined in greater detail for inclusion in this review. Consensus of studies selected between the two reviewers was reached through discussion, with the involvement of a third reviewer (TAC), when necessary.
Quality assessment
METHODS This systematic review was registered in the International Prospective Register of Systematic Reviews ((PROSPERO)—http:// www.crd.york.ac.uk/PROSPERO/ with Registration number CRD42014008750) and was prepared in consultation with the PRISMA guidelines.37
Eligibility criteria The criteria for included studies were: (1) controlled or randomised controlled trials (RCTs) that investigated adult workers older than 18 years; (2) studies that contrasted the effects of any type of onsite workplace structured HEPA programmes undertaken outside of normal work duties, to a comparator. Programmes could be conducted during or outside of paid work time; (3) studies that had any form of productivity measurement, including self-reported or actual sickness absences, or quantitative measurements of job performance or qualitative questionnaires of work ability, whether these outcomes were the primary or secondary outcomes. There were no restrictions on the length of follow-up, but the studies needed to have documented the intervention process. Only publications in the English language from January 2000 to 10 January 2015 were eligible. This time period was chosen because this review aimed to consolidate recent evidence surrounding this growing and evolving subject area and it extends the timeframe covered by Proper et al.36 Criteria for exclusion were: (1) studies that examined employees who were on sick leave and not working at their usual duties or workplaces at the time of delivery of the PA interventions; (2) programmes that needed workers to travel offsite, outside of company grounds, as this has been linked to lower participation rates38 and (3) studies that investigated, solely, the alteration of structural facilities to encourage PA without incorporating any structured PA programmes in conjunction with the structural modification.
Two reviewers independently assessed risk of bias of the included studies using a simplified version of the Downs and Black39 checklist. This assessment tool was chosen as it is valid and reliable in ascertaining risk of bias in health-related interventional studies.39 Item 27 was simplified to consider whether or not a power estimation had been reported by the study’s investigating team.40 The study received a point on this item if a power estimation had been reported and sufficient participants were recruited or zero if not giving a maximum possible score of 28 of the simplified checklist. Consensus of all items in the checklist for all selected studies between the two reviewers was reached through discussion, with the involvement of a third reviewer (TAC), when necessary. Studies that scored 20 or more of 28 were ranked as high-quality studies, and those that scored below 20 were ranked as moderate-quality studies. Studies with scores of 13 and below have been determined by other researchers to be of low quality.41 The assigned level of quality was used to enable evidence-based recommendations to be constructed.
Coding of literature A single reviewer (MJP) extracted data from eligible articles into an Excel spreadsheet, which was used to build evidence tables. A second reviewer (BKC) independently crosschecked all extracted data to ensure accuracy. Data extracted included study characteristics such as participant population, intervention and comparator details, scheduling of intervention delivery (paid or
Literature search Three authors (MJP, TAC and VJ) agreed on the literature search method. A reference librarian reviewed and provided input to the search strategy. The literature search included a computerised and comprehensive database search and a reference search. The literature search was performed in PubMed, CINAHL, PsycInfo, EconLit and ABI/Inform Complete. One reviewer (MJP) entered the search strategy into five selected 402
Figure 1
Full electronic search strategy for PubMed database.
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Review unpaid work time); and outcomes, including attendance rates, follow-up time points and results of relevant outcome measures of productivity. When insufficient information was presented in the articles, primary authors were contacted via email. It was originally intended that a meta-analysis would be performed; however, the included studies were not sufficiently homogenous, rendering only a qualitative synthesis of findings possible. Sub-group analyses were also planned to compare interventions conducted during paid or unpaid work time, different occupations, or various types of onsite workplace HEPA interventions (Yoga, Tai Chi, aerobic, or strengthening regimes); however, due to the small number of included studies, this was not possible.
Data management and statistical analysis A Cohen’s κ coefficient was calculated to determine inter-rater reliability for the quality assessment of included studies.
RESULTS Flow of literature search The process of selection of relevant studies is presented in figure 2. The initial computerised search of selected databases identified 774 possible citations. After removing duplicates, 765 citations remained. Full papers of 25 citations that appeared to meet the inclusion criteria were retrieved for closer review. Finally, nine articles from eight studies that fulfilled all inclusion criteria were included in this qualitative review. Citations of ineligible full papers, including reasons for exclusion, are provided in figure 2.
Methodological quality Methodological quality scores, using the simplified assessment checklist, of the eight included studies ranged from 14 to 23 points (mean 19.22 (SD=3.11)). The results of individual items of the simplified Downs and Black checklist are included in table 1. Only three of the eight included studies were assessed to be of high quality, scoring 20 or more.42–45 Five studies scored less than 20 and were considered to have a moderate risk of bias.46–49 Many (6 of 8) studies did not comment on the presence of adverse events. There were issues of generalisability with the results in some studies, as five of the eight studies recruited from participant populations were not representative of the general population. All the studies with moderate risk of bias did not perform a power estimation and were not sufficiently powered. Inter-rater reliability of quality assessment of the included studies between the two raters was high with κ=0.975, p16 on the 10-item Perceived Stress Scale. Mixture of salaried and hourly rate workers
Wolever et al49
Participants given a list of resources available to all employees, including resources to aid physical activity and mental well-being (N=56)
Some participants engaged in intervention during unpaid time
Per protocol
Programme length: 9 weeks 1. ‘Walking routes’: participants asked to complete at least 15 min of continuous, brisk walking every work day (N=19) 2. ‘Walking while working’: participants were encouraged to fit additional step counts into work routine (N=25) 9-month ‘Integrated Health Programme’ (N=19) including:Physical exercise (to improve physical capacity, strength and flexibility) exercises, 3-hourly sessions weekly 1. Health education sessions, 15 weekly hour-long sessions 2. An examination of the participants’ workplace Programme length: 12 weeks 1. Therapeutic yoga weekly hour-long sessions, 12 h total (N=90) 2. Mindfulness-based intervention weekly hour-long sessions and a 2 h mindfulness intensive practice at week 10, 14 h total (N=96)
Intention to treat
407
Review
*Studies with productivity as primary outcome.
Puig-Ribera et al48
Analysis
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Table 2 Characteristics of individual studies
Authors
Attendance 42
Blangsted et al
Regular participation (at least weekly attendance): intervention group i: 54%, intervention group ii: 31%, comparator: 16% during the 1st half of the intervention period; and 35%, 28%, and 9%, respectively, during the second half
Per cent followed up; time point 80% at 1 year
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Sick leave
Productivity
Participants’ baseline mean sick leave 1.5 days during preceding 3 months and when multiplied by 4, not statistically different to 5.3 days during year of intervention (p=0.45)
No statistically significant interactions between mean total WAI scores (SD) and types of intervention (maximum score 42), exact p values not reported Comparator group Males: Baseline 37.1 (3.11) → postintervention 37.2 (1.53) Females: Baseline 36.7 (3.30) → postintervention 36.5 (3.18) Intervention (i) Strengthening Males: Baseline 37.7 (2.75) → postintervention 38.0 (1.20) Females: Baseline 37.4 (3.23) → postintervention 36.9 (2.69) Intervention (ii) Aerobic exercises Males: Baseline 37.4 (2.62) → postintervention 36.8 (3.17) Females: Baseline 37.1 (2.88) → postintervention 36.6 (2.56) No numerical data or p values reported No statistically significant changes in self-rated productivity on a single question 0–10 ordinal scale “How do you perceive your overall job performance in the past 4 weeks?” Not measured
Not measured
Brox and Froystein46
Intervention attendance: average of 12 (range 0–26) sessions; 10% did not attend any session, 10% completed all sessions
100% at 6 months
Jorgensen et al 51
Reported to be low (Exact figures unavailable)
52% at 1 year
Nurminen et al43*
Intervention group: 75% participated in >half of guided group exercise sessions, and ∼ 50% took part in >2/3 of the sessions
100% at 3 months 94% at 8 months 92% at 12 months 90% at 15 months
No statistically significant differences in mean total sick leave days (95% CI) between groups: 4.7 (−5.7 to 15.1) (p=0.64) Comparator group: Baseline mean (SD) 0.4 (22.0) → postintervention 14.4 (22.9) Exercise group: Baseline mean (SD) 6.8 (14.6) → postintervention 15.6 (28.4) No statistically significant changes in accumulated sick leave or number of sick leave periods from baseline to postintervention between groups (data for mean sick leave days and SD for all absenteeism outcomes unavailable) Intervention i) Physical training: Sick leave days (median) baseline 4.0 → 1 year follow-up 4.25 Sick leave periods (mean) baseline 1.622 → 1.356 Intervention ii) Cognitive training: Sick leave days (median) 3.0 → 1 year follow-up 3.0 Sick leave periods (mean) Baseline 1.281 → 1.354 Comparator group: Sick leave days (median) baseline 3.0 → 1 year follow-up 2.0 Sick leave periods (mean) baseline 1.64 → 1.281 No statistically significant changes at 8, 12 and 15 months of follow-up in baseline adjusted differences between intervention groups for cumulative sick leave in hours (95% CI). Positive differences are in favour of the comparator group. 8 months: 5.7 h (−16.9 to 28.3) 12 months: 12.0 h (−15.8 to 39.7) 15 months: 22.5 h (−13.8 to 58.8)
No significant differences in self-assessed mean work ability (SD) on a single question comparing present work ability to lifetime best (0–10 ordinal scale) Intervention (i) Physical training: Baseline 7.6 (2.0) → 1-year follow-up 7.8 (1.9) Intervention (ii) Cognitive training: Baseline 7.5 (2.1) → 1-year follow-up 7.5 (2.1) Comparator group: Baseline 7.3 (2.2) → 1-year follow-up 7.4 (2.4)
No significant baseline adjusted differences in mean total WAI (95% CI) between groups at 3, 8, 12 and 15 months of follow-up 3 month: 0.5 (−0.6 to 1.7) 8 months: 0.5 (−0.7 to 1.7) 12 months: 0.02 (−1.51 to 1.47) 15 months: −0.01 (−1.4 to 1.4) At the postintervention 8-month follow-up, more workers in the intervention group had an optimistic opinion of their work ability after 2 years due to their health state, a component of the WAI Continued
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Pedersen et al44
Review
408
Table 3 Attendance, follow-up and results across individual studies
Authors
Attendance
Per cent followed up; time point
Sick leave
Palumbo et al (2010) *
Mean attendance 82% across all offered classes
79%
4-month average (SD) unscheduled combined time off over previous year was compared to unscheduled combined time off (SD) during intervention without statistical analysis Control group: 3 h (3) →10 h (14) Intervention group: 3 h (7) → 0 h (0)
Puig-Ribera et al48
Mean change of step counts per day (SD): Comparator: −191 (1620) Intervention i: +86 (2629) Intervention ii: +12(2426)
87% at 9 weeks
Not measured
Tveito and Eriksen45 (2009)
Data unavailable
73% at 9 months
Wolever et al49
Data unavailable
86% at 12 weeks
No statistically significant differences between groups for annual mean sick leave days at baseline (p=0.931), postintervention (p=0.963) and 1-year follow-up (p=0.945). Group means (SD) reported Comparator group: Baseline 20.6 (31.00) → postintervention 35.2 (40.94) → 1-year follow-up 52.6 (68.86) Exercise group: Baseline 19.7 (29.06) → postintervention 36.0 (48.50) → 1-year follow-up 54.4 (75.50) Not measured
Baseline adjusted differences in proportions (%) between groups (95% CI) 8.1 (0.5 to 16.3) At 12-month follow-up, effectiveness of intervention represented by an increased proportion of workers with ‘good’ (37–43) or ‘excellent’ (44–49) WAI scores in intervention group Baseline adjusted differences in proportions (%) between groups (95% CI) 11.0 (0.2 to 21.9) Significantly greater reduction in mean WLQ scores (maximum 100, indicating greatest possible negative impact of health on work ability), p value 0.03 Mean (SD) change from baseline Comparator group: −0.8 (1.4) Tai Chi group: −3.1 (1.2) No statistically significant differences between groups in WLQ (modified and translated version) scores. Mean change (SD) in each WLQ subscale reported. No p values were reported. A decrease in the subscale scores represents an improvement in job productivity Comparator group: Time: −5.5 (4.4), Mental-interpersonal: +0.5 (4), Output demand: −5 (4) ‘Walking routes’ group: Time: −2.5 (3), mental-interpersonal: +1 (3.2), output demand: −2 (3) ‘Walking while working’ group: Time: −0.9 (2.5), mental-interpersonal: −1.43 (2.1), output demand: −0.8 (1.9) Not measured
No statistically significant group by time (pre and post) interaction Mean WLQ (SD) (maximum 100) Comparator group: Baseline 5.59 (4.15) → postintervention 4.29 (3.91) Intervention (i) Yoga: Baseline 4.87 (4.17) → postintervention 3.91 (3.75) Intervention (ii) Mindfulness: Baseline 5.54 (4.12) → postintervention 3.60 (3.80)
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*Studies reporting significant positive results for physical activity interventions. WAI, Work Ability Index; WLQ, Work Limitations Questionnaire.
Productivity
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Table 3 Continued
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Review DISCUSSION This review found that onsite workplace HEPA programmes do not benefit worker absenteeism and there is inconsistent evidence of benefit for worker self-reported presenteeism outcomes. These findings echo the conflicting evidence among recent literature for the impact of workplace HEPA programmes. While there are many clear benefits from workplace HEPA programmes on clinical outcomes, for example, physical fitness, PA behaviours and health profiles such as diabetes risk and lipid levels,18 the situation regarding productivity outcomes is not as apparent. Proper et al36 concluded that there is limited evidence on absenteeism, however, a study published in 200918 found that workplace HEPA interventions had low levels of benefit on absenteeism. This conflict also exists when productivity was measured with presenteeism outcomes.27 36 The strength of this review is the comprehensiveness of productivity outcomes considered. Nevertheless, there was some variability in the productivity measures used with most (5 of 8) studies using the WAI or WLQ. These questionnaires were extrapolated from studies with disease populations.33 The WLQ55 has demonstrated validity and reliability as a measure of work productivity losses in chronic disease populations such as asthma and psychiatric disorders, while the WAI has been used to document changes in work abilities of an older working population.53 It may be possible that these questionnaires are less sensitive to changes in a healthy working population, accounting for the lack of clear benefit. Studies that reported baseline values of productivity42 43 49 demonstrated that workers were close to the best possible productivity levels at baseline (table 3). The population groups in these studies did not demonstrate low levels of productivity that could benefit from an intervention or the measurement tools had a ceiling effect.42 49 Hence the measurement tools utilised may not have been able to capture improvements due to the intervention. The lack of consistency in the measurement tool used may be due to lack of a single valid gold standard for presenteeism measure for the working population across occupations and age groups. Given the great variety of occupations and the varying nature of work as new technologies, systems and processes are introduced, qualitative studies of working adults, in various occupational groups, should be considered in order to investigate the factors that constitute workplace productivity. Future research regarding the validity and reliability of potential measurement tools in a reasonably healthy, working population needs to be conducted to guide researchers in the selection of appropriate presenteeim measures, a recommendation echoed by authors in a related review.27 Another important consideration for the lack of clear benefit is the choice of participants recruited. The inclusion of all participants rather than those at risk, such as those with high sick leave, physically demanding work or past ill-health, may explain the inconsistent evidence for benefit of onsite workplace HEPA. Interestingly, workers involved in studies showing benefit43 47 had occupations requiring higher physical demands when compared with sedentary jobs. It is possible that as a result of the intervention, the discrepancy between physical abilities and job demands was reduced,22 and hence these studies were able to demonstrate benefits of onsite workplace HEPA programmes. Future studies of onsite workplace HEPA programmes may consider selecting participant populations based on identified needs. Matching interventions with identified needs of the workers is not new. Recently, a group of researchers have suggested using occupation-specific training by customising interventions to ensure a balance between the individual’s physical capacity and the occupation-related physical demands.56 Tailoring of 410
interventions was undertaken more in successful workplace health promotion programmes on presenteeism outcomes compared with unsuccessful ones.27 Hence, these principles can be applied to onsite workplace HEPA interventions to enhance worker productivity, and these studies should be targeted in participant selection and be individualised to specific job requirements. There were several possible reasons for the inconsistent evidence for productivity outcomes. First, many of the high-quality studies may have not been adequately powered to detect a difference in productivity. We found most studies (5 of 8) examined health outcomes such as PA levels or physical capacity as the primary outcome.42 44–46 48 49 However, these outcomes may not be of interest to the employer, especially in a working population which is assumed to be reasonably healthy. Thus, more high-quality primary studies of onsite workplace HEPA programmes designed to be sufficiently powered to detect a difference in productivity outcomes from the employer’s perspective are needed. Second, all studies in this review used different forms of onsite workplace HEPA interventions, including body regionspecific strengthening, general cardiovascular exercise, combination exercises and therapeutic yoga. All of these forms of onsite workplace HEPA programmes were delivered to different populations ranging from sedentary office workers to female nurses, female laundry workers and female cleaners. The latter three groups of workers would be considered to perform physically demanding tasks as part of their usual workday. Given the variation in populations and regimes, it is difficult to recommend one over another. The most ideal form of onsite workplace HEPA to improve productivity might involve more than one specific exercise type or be multidimensional in nature. This is based on the evidence gathered in this review, as a highquality study showed that 1 h/week of cardiovascular, strengthening and stretching exercises is beneficial for female laundry workers.43 Thus, firm conclusions regarding which aspect of the combination programme was effective in improving productivity levels cannot be drawn. However, recently published HEPA guidelines in Australia recommend combining two times a week strengthening exercises with at least 75 min of vigorous or 150 min of moderate levels of HEPA.57 Hence a combination approach to onsite workplace HEPA may be necessary to elicit changes in worker productivity. Perhaps worker productivity requires a multimodal approach that can tap into the processes underpinning behavioural change to effectively institute and maintain these changes compared to a single-component exercise intervention that does not. As above, in the high-quality study by Nurminen et al,43 individualised exercise prescription and counselling was integrated with HEPA to positively impact on productivity. This result is similar to findings from another review that demonstrated the importance of combining cognitive strategies to effect change on work-related outcomes.58 Hence, multimodal interventions, incorporating cognitive strategies or improving work procedures, can be considered in order to better target worker productivity. Third, low attendance was a factor in all studies not reporting benefit of onsite workplace HEPA on productivity. Thus, it would be premature to conclude that onsite workplace HEPA programmes are ineffective in productivity outcomes when these interventions were not received in the intended dose to effect change. Importantly, most of the participants were given time away from work duties during work hours to participate. A closer scrutiny in future research of possible reasons why included participants were so poorly compliant, in spite of these
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Review programmes being delivered onsite, is pertinent to guide future trials. Authors reported participants’ attendance in a variety of ways (table 3). Three studies did not report exact attendance data and primary authors were either uncontactable or did not have data available anymore. There is a need to consider standardised reporting of attendance for each cohort of participants in the future. Recording the mean amount of attendance (in minutes) of all available interventions each week would ease comparison to available PA guidelines and enhance generalisability of results. This is significant as the amount of HEPA delivered is an important factor. The minimum amount of HEPA recommended per week is 75 min of vigorous activity or 150 min of moderate activity to maintain physical health and mental well-being.57 Attendance for more than 6 months in a regime is also recommended to achieve health benefits.5 It is worthy to note that in the studies included in this review, the weekly amount of HEPA in those showing benefit on presenteeism ranged from 60 to 90 min (mean 75 min). In comparison, the weekly amounts of HEPA in studies not showing benefit on presenteeism ranged from 5 min51 (latter 9 months of programme) to approximately 75 min48 (mean 51 min). The amounts in the latter group of studies fall short of the recommended amounts of HEPA, and especially so if the participants did not reach a vigorous level of exertion. Considering the dose-dependent relationship of exercise and quality of life improvements,59 this could explain the lack of effect of onsite workplace HEPA programmes on worker productivity. While all the above factors need to be considered in future studies, building infrastructure and associated conduciveness for onsite workplace HEPA, and the workplace culture, such as management support, have been cited as vital to the successful implementation of any worksite programme.60
programmes to better understand the actual effects of these programmes, and to achieve larger beneficial changes to levels of worker productivity. Correction notice This paper has been amended since it was published Online First. In the section titled “Sickness absences outcomes” the third sentence has been amended. Acknowledgements The authors thank Ms Julie Anne Hansen from the University of Queensland Library for her assistance with searching the literature and Dr Shaun Patrick O’Leary for reviewing the final manuscript. Contributors MJP, TAC and VJ formulated the research questions and outlined the research design. MJP reviewed the existing literature, performed the computerised database search and drafted the manuscript. MJP and BKC screened all citations and analysed all the included studies. BKC, TAC and VJ revised the manuscript. All authors read and approved the final manuscript. Funding Funding sources that supported this review include the Australian Postgraduate Award and the National Health and Medical Research Council. NHMRC grant number: APP1042508. Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1
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CONCLUSIONS There is no benefit of onsite workplace HEPA programmes on worker absenteeism measures. There is inconsistent evidence regarding the effect of onsite workplace HEPA programmes on self-reported worker productivity measured with presenteeism measurement tools. One high-quality study of a combination programme incorporating cardiovascular, strengthening and flexibility exercises increased proportions of women laundry workers with more favourable WAI scores and a moderatequality study of a Tai Chi programme improved mean score on the WLQ in a population of older female nurses. Two highquality studies, one that compared strengthening and aerobic programmes and the other investigating the effects of a holistic health intervention that included a combination of aerobic, strengthening and flexibility exercises, did not show any benefit on productivity outcomes. Four moderate-quality studies of physical training exercise, walking or yoga programmes, did not show any benefit on productivity outcomes either. While there were no benefits on absenteeism, and inconsistent effects on presenteeism, no studies reported negative effects on productivity. The understanding of the concept of workplace productivity is still growing. Validity and reliability of various qualitative productivity outcomes need to be established. Primary studies of onsite workplace HEPA programmes of high quality and designed around appropriate participant populations and productivity outcomes are needed. Multimodal programmes that are occupation-specific in nature, and of sufficient intensity and duration, including HEPA, are worthwhile considerations. Thoughtful programme design keeping the perspective of the worker and employer in mind could aid researchers to enhance attendance rates, with improved recording of workplace
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Dumith SC, Hallal PC, Reis RS, III, et al. Worldwide prevalence of physical inactivity and its association with human development index in 76 countries. Prev Med 2011;53:24–8. Mukamal KJ, Ding EL, Djousse L. Alcohol consumption, physical activity, and chronic disease risk factors: a population-based cross-sectional survey. BMC Public Health 2006;6:118. Woolf K, Schmidt JL, Gilliatt-Wimberly MA, et al. Habitual physical activity reduces chronic disease risk factors in midlife and older women. Med Sci Sports Exerc 2003;35(5 Suppl 1):169. Haskell WL, Lee IM, Pate RR, et al. Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc 2007;39:1423–34. Fletcher GF, Balady G, Blair SN, et al. Statement on exercise: benefits and recommendations for physical activity programs for all Americans. Circulation 1996;94:340–4. Ng SW, Popkin BM. Time use and physical activity: a shift away from movement across the globe. Obes Rev 2012;13:659–80. Booth ML, Bauman A, Owen N, et al. Physical activity preferences, preferred sources of assistance, and perceived barriers to increased activity among physically inactive Australians. Prev Med 1997;26:131–7. Myers RS, Roth DL. Perceived benefits of and barriers to exercise and stage of exercise adoption in young adults. Am Psychol Assoc 1997;16:277–83. Reed JA, Phillips DA. Relationships between physical activity and the proximity of exercise facilities and home exercise equipment used by undergraduate university students. J Am Coll Health 2005;53:285–90. McCormack GR, Giles-Corti B, Bulsara M. The relationship between destination proximity, destination mix and physical activity behaviors. Prev Med 2008;46:33–40. Zimring C, Joseph A, Nicoll GL, et al. Influences of building design and site design on physical activity: research and intervention opportunities. Am J Prev Med 2005;28(2 Suppl 2):186–93. Watts AW, Masses LC. Is access to workplace amenities associated with leisure-time physical activity among Canadian adults? Can J Public Health 2012;104:e87–91. Kahn EB, Ramsey LT, Brownson RC, et al. The effectiveness of interventions to increase physical activity. A systematic review. Am J Prev Med 2002;22(4 Suppl):73–107. Penedo FJ, Dahn JR. Exercise and well-being: a review of mental and physical health benefits associated with physical activity. Curr Opin Psychiatry 2005;18:189–93. Boles M, Pelletier B, Lynch W. The relationship between health risks and work productivity. J Occup Environ Med 2004;46:737–45. Lamers LM. The relationship between productivity and health-related quality of life: an empirical exploration in persons with low back pain. Qual Life Res 2005;14:805–13. Martin BW, Kahlmeier S, Racioppi F, et al. Evidence-based physical activity promotion—HEPA Europe, the European Network for the promotion of health-enhancing physical activity. J Public Health 2006;14:53–7. Conn VS, Hafdahl AR, Cooper PS, et al. Meta-analysis of workplace physical activity interventions. Am J Prev Med 2009;37:330–9. Fonseca VR, Nobre MR, Pronk NP, et al. The association between physical activity, productivity, and health care utilization among employees in Brazil. J Occup Environ Med 2010;52:706–12.
411
Downloaded from http://oem.bmj.com/ on June 10, 2015 - Published by group.bmj.com
Review 20 21 22 23
24 25 26 27
28 29 30 31 32
33 34 35 36
37 38 39
40
41
412
Proper KI, van den Heuvel SG, De Vroome EM, et al. Dose-response relation between physical activity and sick leave. Br J Sports Med 2006;40:173–8. van den Heuvel SG, Boshuizen HC, Hildebrandt VH, et al. Effect of sporting activity on absenteeism in a working population. Br J Sports Med 2005;39:e15. Holtermann A, Hansen JV, Burr H, et al. The health paradox of occupational and leisure-time physical activity. Br J Sports Med 2012;46:291–5. Collins JJ, Baase CM, Sharda CE, et al. The assessment of chronic health conditions on work performance, absence, and total economic impact for employers. J Occup Environ Med 2005;47:547–57. Pronk NP, Kottke TE. Physical activity promotion as a strategic corporate priority to improve worker health and business performance. Prev Med 2009;49:316–21. Gontijo LA, Santana AMC. Measuring and enhancing productivity. Proc Hum Factors Ergon Soc Annu Meet 2000;44:6-249–52. Escorpizo R, Bombardier C, Boonen A, et al. Worker productivity outcome measures in arthritis. J Rheumatol 2007;34:1372–80. Cancelliere C, Cassidy JD, Ammendolia C, et al. Are workplace health promotion programs effective at improving presenteeism in workers? A systematic review and best evidence synthesis of the literature. BMC Public Health 2011;11:395. Aronsson G, Gustafsson K, Dallner M. Sick but yet at work. An empirical study of sickness presenteeism. J Epidemiol Community Health 2000;54:502–9. Goetzel RZ, Ozminkowski RJ. The health and cost benefits of work site health-promotion programs. Annu Rev Public Health 2008;29:303–23. Drummond M. Cost of illness studies. A major headache? Pharmacoeconomics 1992;2:1–4. Brown HE, Burton NW, Gilson ND, et al. Measuring presenteeism: which questionnaire to use in physical activity research? J Phys Act Health 2013;11:241–8. Lenneman J, Schwartz S, Giuseffi DL, et al. Productivity and health: an application of three perspectives to measuring productivity. J Occup Environ Med 2011;53:55–61. Beaton D, Bombardier C, Escorpizo R, et al. Measuring worker productivity: frameworks and measures. J Rheumatol 2009;36:2100–9. Mills PR, Kessler RC, Cooper J, et al. Impact of a health promotion program on employee health risks and work productivity. Am J Health Promot 2007;22:45–53. Parks KM, Steelman LA. Organizational wellness programs: a meta-analysis. J Occup Health Psychol 2008;13:58–68. Proper KI, Staal BJ, Hildebrandt VH, et al. Effectiveness of physical activity programs at worksites with respect to work-related outcomes. Scand J Work Environ Health 2002;28:75–84. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 2009;339:b2535. Lovato CY, Green LW. Maintaining employee participation in workplace health promotion programs. Health Educ Behav 1990;17:73–88. Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health 1998;52:377–84. MacLehose RR, Reeves BC, Harvey IM, et al. A systematic review of comparisons of effect sizes derived from randomised and non-randomised studies. Health Technol Assess 2000;3:1–154. Kemp JL, Collins NJ, Makdissi M, et al. Hip arthroscopy for intra-articular pathology: a systematic review of outcomes with and without femoral osteoplasty. Br J Sports Med 2012;46:632–43.
42
43
44
45 46
47 48
49
50 51
52
53 54
55 56
57 58
59 60
Blangsted AK, Sogaard K, Hansen EA, et al. One-year randomized controlled trial with different physical-activity programs to reduce musculoskeletal symptoms in the neck and shoulders among office workers. Scand J Work Environ Health 2008;34:55–65. Nurminen E, Malmivaara A, Ilmarinen J, et al. Effectiveness of a worksite exercise program with respect to perceived work ability and sick leaves among women with physical work. Scand J Work Environ Health 2002;28:85–93. Pedersen MT, Blangsted AK, Andersen LL, et al. The effect of worksite physical activity intervention on physical capacity, health, and productivity: a 1-year randomized controlled trial. J Occup Environ Med 2009;51:759–70. Tveito TH, Eriksen HR. Integrated health programme: a workplace randomized controlled trial. J Adv Nurs 2009;65:110–19. Brox JI, Frooystein O. Health-related quality of life and sickness absence in community nursing home employees: randomized controlled trial of physical exercise. Occup Med 2005;55:558–63. Palumbo MV, Wu G, Shaner-McRae H, et al. Tai Chi for older nurses: a workplace wellness pilot study. Appl Nurs Res 2012;25:54–9. Puig-Ribera A, McKenna J, Gilson N, et al. Change in work day step counts, wellbeing and job performance in Catalan university employees: a randomised controlled trial. Promot Educ 2008;15:11–16. Wolever RQ, Bobinet KJ, McCabe K, et al. Effective and viable mind-body stress reduction in the workplace: a randomized controlled trial. J Occup Health Psychol 2012;17:246–58. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977;33:159–74. Jorgensen MB, Faber A, Hansen JV, et al. Effects on musculoskeletal pain, work ability and sickness absence in a 1-year randomised controlled trial among cleaners. BMC Public Health 2011;11:840. van Poppel MNM, de Vet HCW, Koes BW, et al. Measuring sick leave: a comparison of self-reported data on sick leave and data from company records. Occup Med 2002;52:485–90. Ilmarinen J, Tuomi K, Klockars M. Changes in the work ability of active employees over an 11-year period. J Work Environ Health 1997;23(Suppl 1):49–57. van Tulder M, Furlan A, Bombardier C, et al., Group tEBotCCBR. Updated method guidelines for systematic reviews in the Cochrane collaboration back review group. Spine 2003;28:1290–9. Lerner D, Amick BC III, Rogers WH, et al. The work limitations questionnaire. Med Care 2001;29:72–85. Holtermann A, Jorgensen MB, Gram B, et al. Worksite interventions for preventing physical deterioration among employees in job-groups with high physical work demands: background, design and conceptual model of FINALE. BMC Public Health 2010;10:120. Health AGDo. Australia’s physical activity and sedentary behaviour guidelines. 2014. Schonstein E, Kenny DT, Keating JL, et al. Work conditioning, work hardening and functional restoration for workers with back and neck pain. Cochrane Database Syst Rev 2009;(1):CD001822. Martin CK, Church TS, Thompson AM, et al. Exercise dose and quality of life. A randomized controlled trial. Arch Intern Med 2009;169:269–78. Hopkins JM, Glenn BA, Cole BL, et al. Implementing organizational physical activity and healthy eating strategies on paid time: process evaluation of the UCLA WORKING pilot study. Health Educ Res 2012;27:385–98.
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The impact of onsite workplace health-enhancing physical activity interventions on worker productivity: a systematic review Michelle Jessica Pereira, Brooke Kaye Coombes, Tracy Anne Comans and Venerina Johnston Occup Environ Med 2015 72: 401-412 originally published online March 16, 2015
doi: 10.1136/oemed-2014-102678 Updated information and services can be found at: http://oem.bmj.com/content/72/6/401
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