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PurposeA lifestyle front office (LFO) in the hospital is a not yet existing, novel concept that can refer patients under treatment in the hospital to community-based lifestyle interventions (CBLI). The aim of this study was to identify implementation barriers and facilitators regarding the implementation of an LFO in the hospital from the perspective of CBLI-professionals and to develop evidence-based implementation strategies to reduce these identified barriers.MethodsWe conducted semi-structured interviews until data saturation, with 23 lifestyle professionals working in the community. A semi-structured topic guide was used, inquiring about (1) community-based lifestyle interventions; (2) their views about referral from the LFO; and (3) their preferences, needs and recommendations for collaboration with the LFO in the hospital. The online interviews lasted on average 46 minutes, were audio-recorded and transcribed verbatim. A thematic content analysis was conducted. Found barriers and facilitators regarding the LFO where mapped using the consolidated framework for implementation research (CFIR) whereafter evidence based strategies were developed using the CFIR-Expert Recommendations for Implementing Change Strategy Matching Tool V.1.0 (CFIR-ERIC).ResultsBarriers and facilitators were divided into two main themes: 1) barriers and facilitators related to the referral from LFO to CBLI (i.e. financial, cultural, geographical, quality) and 2) barriers and facilitators related to the collaboration between LFO and CBLI (i.e. referral, communication platform and partnership). Thirty-seven implementation strategies concerning 15 barriers were developed and clustered into six overarching strategies: identify referral options, determine qualifications lifestyle professionals, develop support tools, build networks, facilitate learning collaboratives, and optimize workflow.ConclusionsIn this study, barriers and facilitators for the development of the LFO were found and matching implementation strategies were developed. Practical improvements, like identifying specific referral options or develop support tools, can be implemented immediately. The implementation of other strategies, like connecting care pathways in basic services, primary, secondary and tertiary care, will take more time and effort to come to full potential. Future research should evaluate all implemented strategies.

Abstract Background A randomised trial of European Fans in Training (EuroFIT), a 12-week healthy lifestyle program delivered in 15 professional football clubs in the Netherlands, Norway, Portugal, and the United Kingdom, successfully increased physical activity and improved diet but did not reduce sedentary time. To guide future implementation, this paper investigates how those effects were achieved. We ask: 1) how was EuroFIT implemented? 2) what were the processes through which outcomes were achieved? Methods We analysed qualitative data implementation notes, observations of 29 of 180 weekly EuroFIT deliveries, semi-structured interviews with 16 coaches and 15 club representatives, and 30 focus group discussions with participants (15 post-program and 15 after 12 months). We descriptively analysed quantitative data on recruitment, attendance at sessions and logs of use of the technologies and survey data on the views of participants at baseline, post program and after 12 months. We used a triangulation protocol to investigate agreement between data from difference sources, organised around meeting 15 objectives within the two research questions. Results We successfully recruited clubs, coaches and men to EuroFIT though the draw of the football club seemed stronger in the UK and Portugal. Advertising that emphasized getting fitter, club-based deliveries, and not ‘standing out’ worked and attendance and fidelity were good, so that coaches in all countries were able to deliver EuroFIT flexibly as intended. Coaches in all 15 clubs facilitated the use of behaviour change techniques and interaction between men, which together enhanced motivation. Participants found it harder to change sedentary time than physical activity and diet. Fitting changes into daily routines, planning for setbacks and recognising the personal benefit of behaviour change were important to maintain changes. Bespoke technologies were valued, but technological hitches frustrated participants. Conclusion EuroFIT was delivered as planned by trained club coaches working flexibly in all countries. It worked as expected to attract men and support initiation and maintenance of changes in physical activity and diet but the use of bespoke, unstable, technologies was frustrating. Future deliveries should eliminate the focus on sedentary time and should use only proven technologies to support self-monitoring and social interaction. Trial registration ISRCTN81935608, registered 16/06/2015.

Abstract Background A healthy lifestyle is indispensable for the prevention of noncommunicable diseases. However, lifestyle medicine is hampered by time constraints and competing priorities of treating physicians. A dedicated lifestyle front office (LFO) in secondary/tertiary care may provide an important contribution to optimize patient-centred lifestyle care and connect to lifestyle initiatives from the community. The LOFIT study aims to gain insight into the (cost-)effectiveness of the LFO. Methods Two parallel pragmatic randomized controlled trials will be conducted for (cardio)vascular disorders (i.e. (at risk of) (cardio)vascular disease, diabetes) and musculoskeletal disorders (i.e. osteoarthritis, hip or knee prosthesis). Patients from three outpatient clinics in the Netherlands will be invited to participate in the study. Inclusion criteria are body mass index (BMI) ≥25 (kg/m2) and/or smoking. Participants will be randomly allocated to either the intervention group or a usual care control group. In total, we aim to include 552 patients, 276 in each trial divided over both treatment arms. Patients allocated to the intervention group will participate in a face-to-face motivational interviewing (MI) coaching session with a so-called lifestyle broker. The patient will be supported and guided towards suitable community-based lifestyle initiatives. A network communication platform will be used to communicate between the lifestyle broker, patient, referred community-based lifestyle initiative and/or other relevant stakeholders (e.g. general practitioner). The primary outcome measure is the adapted Fuster-BEWAT, a composite health risk and lifestyle score consisting of resting systolic and diastolic blood pressure, objectively measured physical activity and sitting time, BMI, fruit and vegetable consumption and smoking behaviour. Secondary outcomes include cardiometabolic markers, anthropometrics, health behaviours, psychological factors, patient-reported outcome measures (PROMs), cost-effectiveness measures and a mixed-method process evaluation. Data collection will be conducted at baseline, 3, 6, 9 and 12 months follow-up. Discussion This study will gain insight into the (cost-)effectiveness of a novel care model in which patients under treatment in secondary or tertiary care are referred to community-based lifestyle initiatives to change their lifestyle. Trial registration ISRCTN ISRCTN13046877 . Registered 21 April 2022.

Non-communicable diseases (NCDs), including coronary heart disease, stroke, hypertension, type 2 diabetes, dementia, depression and cancers, are on the rise worldwide and are often associated with a lack of physical activity (PA). Globally, the levels of PA among individuals are below WHO recommendations. A lack of PA can increase morbidity and mortality, worsen the quality of life and increase the economic burden on individuals and society. In response to this trend, numerous organisations came together under one umbrella in Hamburg, Germany, in April 2021 and signed the ‘Hamburg Declaration’. This represented an international commitment to take all necessary actions to increase PA and improve the health of individuals to entire communities. Individuals and organisations are working together as the ‘Global Alliance for the Promotion of Physical Activity’ to drive long-term individual and population-wide behaviour change by collaborating with all stakeholders in the community: active hospitals, physical activity specialists, community services and healthcare providers, all achieving sustainable health goals for their patients/clients. The ‘Hamburg Declaration’ calls on national and international policymakers to take concrete action to promote daily PA and exercise at a population level and in healthcare settings.

OBJECTIVES: Emerging evidence suggests contrasting health effects for leisure-time and occupational physical activity. In this systematic review, we synthesized and described the epidemiological evidence regarding the association between occupational physical activity and cardiovascular disease (CVD) mortality. METHODS: A literature search was performed in PubMed, Embase, CINAHL, PsycINFO and Evidence-Based Medicine Reviews, from database inception to 17 April 2020. Articles were included if they described original observational prospective research, assessing the association between occupational physical activity and CVD mortality among adult workers. Reviews were included if they controlled for age and gender and at least one other relevant variable. We performed meta-analyses on the associations between occupational physical activity and CVD mortality. RESULTS: We screened 3345 unique articles, and 31 articles (from 23 studies) were described in this review. In the meta-analysis, occupational physical activity showed no significant association with overall CVD mortality for both males [hazard ratio (HR) 1.00, 95% confidence interval (CI) 0.87–1.15] and females (HR 0.95, 95% CI 0.82–1.09). Additional analysis showed that higher levels of occupational physical activity were non-significantly associated with a 15% increase in studies reporting on the outcome ischemic heart disease mortality (HR 1.15, 95% CI 0.88–1.49). CONCLUSIONS: While the beneficial association between leisure-time physical activity and CVD mortality has been widely documented, occupational physical activity was not found to have a beneficial association with CVD mortality. This observation may have implications for our appreciation of the association between physical activity and health for workers in physically demanding jobs, as occupational physical activity may not be health enhancing.

Abstract Background Increased physical activity (PA), reduced time spent sedentary (SED), healthier diet and reduced body weight may all have a positive impact on cardiometabolic risk. The relative importance of change in each of these variables on cardiometabolic risk, however, is unclear. We therefore sought to investigate the relative contributions of changes in PA, SED, diet and body weight on cardiometabolic risk. Methods This is a secondary analysis of data collected from the EuroFIT randomised controlled trial, which was a 12-week group-based lifestyle intervention for overweight middle-aged men delivered by coaches in football club stadia aiming to improve PA, SED, diet, and body weight. PA and SED were assessed by accelerometry, diet using the Dietary Instrument for Nutrition Education (DINE). An overall cardiometabolic risk score was derived from combining z-scores for glucose, HbA1c, insulin, lipids and blood pressure. In total, 707 men (from the overall cohort of 1113) with complete data for these variables at baseline and 12-month follow-up were included in the multivariable linear regression analyses. Results In multivariable analyses, change in number of steps (explaining 5.1% of R2) and dietary factors (less alcohol, fatty and sugary food, and more fruit and vegetables) (together explaining 4.5% of R2), but not changes in standing time or SED, were significantly associated with change in body weight. Changes in number of steps (R2 = 1.7%), fatty food score (R2 = 2.4%), and sugary food score (R2 = 0.4%) were significantly associated with change in cardiometabolic risk score in univariable models. However, in multivariable models which included changes in weight as well as changes in steps and dietary variables, change in weight explained a substantially larger proportion of the change in cardiometabolic risk score, explaining 14.1% of R2 (out of an overall model R2 of 19.0%). When baseline (as well as change) values were also included in the model, 38.8% of R2 for change in cardiometabolic risk score was explained overall, with 14.1% of R2 still explained by change in weight. Conclusion Change in body weight, together with baseline cardiometabolic risk explained most of the change in cardiometabolic risk. Thus, the benefits of increasing physical activity and improving diet on cardiometabolic risk appear to act largely via an effect on changes in body weight. Trial registration International Standard Randomised Controlled Trials, ISRCTN-81935608. Registered 06052015. https://www.isrctn.com/ISRCTN81935608?q=&filters=recruitmentCountry:Portugal&sort=&offset=7&totalResults=92&page=1&pageSize=10&searchType=basic-search

Abstract Objectives Increasing physical activity reduces the risk of chronic illness including Type 2 diabetes, cardiovascular disease and certain types of cancer. Lifestyle interventions can increase physical activity but few successfully engage men. This study aims to investigate the 5 year cost-effectiveness of EuroFIT, a program to improve physical activity tailored specifically for male football (soccer) fans compared to a no intervention comparison group. Methods We developed a Markov cohort model in which the impact of improving physical activity on five chronic health conditions (colorectal cancer, Type 2 diabetes, coronary heart disease, stroke and depression) and mortality was modelled. We estimated costs from a societal perspective and expressed benefits as quality adjusted life years (QALYs). We obtained data from a 4-country (England, Netherlands, Portugal and Norway) pragmatic randomised controlled trial evaluating EuroFIT, epidemiological and cohort studies, and meta-analyses. We performed deterministic and probabilistic sensitivity analyses to assess the impact of uncertainty in the model’s parameter values on the cost-effectiveness results. We used Monte Carlo simulations to estimate uncertainty and presented this using cost-effectiveness acceptability curves (CEACs). We tested the robustness of the base case analysis using five scenario analyses. Results Average costs over 5 years per person receiving EuroFIT were €14,663 and per person receiving no intervention €14,598. Mean QALYs over 5 years were 4.05 per person for EuroFIT and 4.04 for no intervention. Thus, the average incremental cost per person receiving EuroFIT was €65 compared to no intervention, while the average QALY gain was 0.01. This resulted in an ICER of €5206 per QALY gained. CEACs show that the probability of EuroFIT being cost-effective compared to no intervention is 0.53, 0.56 and 0.58 at thresholds of €10,000, €22,000 and €34,000 per QALY gained, respectively. When using a time horizon of 10 years, the results suggest that EuroFIT is more effective and less expensive compared to (i.e. dominant over) no intervention with a probability of cost-effectiveness of 0.63 at a threshold of €22,000 per QALY gained. Conclusions We conclude the EuroFIT intervention is not cost-effective compared to no intervention over a period of 5 years from a societal perspective, but is more effective and less expensive (i.e. dominant) after 10 years. We thus suggest that EuroFIT can potentially improve public health in a cost-effective manner in the long term.

Objectives Despite the many proven advantages of a physically active lifestyle in patient populations, prescription of exercise is currently not widely implemented in routine clinical practice. The aims of this study were twofold: (1) to assess perceptions of clinicians on the current practice of exercise is medicine (E=M) prescription in two Dutch university medical centres and (2) to determine their perceived barriers and facilitators for the implementation of E=M in routine clinical care in Dutch university medical centres.Design A mixed methodologies study, using both online questionnaires and semi-structured interviews.Setting Dutch university medical centres.Participants Clinicians working within the departments of medical oncology, orthopaedics and rehabilitation medicine of two university medical centres.Results Forty-five clinicians (response rate of 51%) completed the questionnaire, and 19 clinicians were interviewed. The results showed that even though clinicians had a positive attitude towards prescribing E=M, only a few reported to regularly prescribe E=M to their patients. The 52 identified facilitators and barriers for implementation of E=M were categorised into four main themes: (1) beliefs toward the implementation of E=M (eg, clinicians knowledge and skills, and social support), (2) factors related to the patient perspective (eg, patient priorities or motivation), (3) factors related to the referral options (eg, knowledge of and trust in local referral options) and (4) practical considerations when implementing E=M (eg, time constraints).Conclusions Our study showed that even though many clinicians have a positive attitude toward an active lifestyle, many are not prescribing E=M on a regular basis. In order for clinicians to effectively implement E=M, strategies should focus on increasing clinicians E=M referral skills, improving clinicians knowledge of E=M referral options and develop a support system to ensure that E=M is high on the priority list of clinicians.

Background: The extent to which eligible individuals in a target population are willing to participate in interventions is important when evaluating the efficacy of public health interventions.Objectives: As part of a process evaluation of an ongoing randomized controlled trial, this study aimed to identify the proportion of risky drinkers who were willing to participate in an alcohol prevention intervention in an occupational health setting, and correlates for such willingness.Methods: Risky drinking employees from 22 companies in Norway were identified through an alcohol screening survey. Risky drinkers' (N = 779) willingness to complete a health examination and to be randomized into an alcohol prevention intervention (digital or face-to-face intervention, or control) was recorded by personnel from occupational health services. The proportion of employees who were willing to participate was assessed on 31 potential correlates (sociodemographic, alcohol-related, work-related, and lifestyle/daily activity). Adjusted (multiple logistic regression) analyses were utilized to explore associations between potential correlates and willingness to participate.Results: Altogether, 38.1% of employees were willing to participate in prevention interventions. In the adjusted analysis, only 5 out of 31 potential correlates were significantly associated with willingness to participate. Managers were more than twice as willing to participate than workers (OR = 2.17, p < 0.01). Willing employees had less workplace decision latitude (perceived control over workplace decisions and less possibility of utilizing personal skills in the job) (OR = 0.62, p < 0.05), and were more overcommitted with exorbitant work ambition and need for approval (OR = 1.49, p < 0.05). Willing employees had to some extent less alcohol-related impaired work performance (presenteeism, OR = 0.78, p < 0.05), and they spent less time on care activities (OR = 0.84, p < 0.05).Conclusions: Reaching four out of ten with risky drinking habits for prevention interventions strengthens the rationale for targeting this public health problem in occupational health care settings. In particular, this study suggests the importance of ensuring secure commitment among workers, who were less willing til participate than managers. Nevertheless, tailoring recruitment and implementation strategies based on easily identifiable correlates may be onerous.

OBJECTIVES: Work-related musculoskeletal disorders (MSD) are highly prevalent and put a large burden on (working) society. Primary prevention of work-related MSD focuses often on physical risk factors (such as manual lifting and awkward postures) but has not been too successful in reducing the MSD burden. This may partly be caused by insufficient knowledge of etiological mechanisms and/or a lack of adequately feasible interventions (theory failure and program failure, respectively), possibly due to limited integration of research disciplines. A research framework could link research disciplines thereby strengthening the development and implementation of preventive interventions. Our objective was to define and describe such a framework for multi-disciplinary research on work-related MSD prevention. METHODS: We described a framework for MSD prevention research, partly based on frameworks from other research fields (ie, sports injury prevention and public health). RESULTS: The framework is composed of a repeated sequence of six steps comprising the assessment of (i) incidence and severity of MSD, (ii) risk factors for MSD, and (iii) underlying mechanisms; and the (iv) development, (v) evaluation, and (vi) implementation of preventive intervention(s). CONCLUSIONS: In the present framework for optimal work-related MSD prevention, research disciplines are linked. This framework can thereby help to improve theories and strengthen the development and implementation of prevention strategies for work-related MSD.

Abstract Background Mental disorders are associated with high costs for productivity loss, sickness absence and unemployment. A participatory supportive return to work (RTW) program was developed in order to improve RTW among workers without an employment contract, sick-listed due to a common mental disorder. The program contained a participatory approach, integrated care and direct placement in a competitive job. The aim of this study was to evaluate the cost-effectiveness and cost-utility of this new program, compared to usual care. In addition, its return on investment was evaluated. Methods An economic evaluation was conducted alongside a 12-month randomized controlled trial. A total of 186 participants was randomly allocated to the new program (n = 94) or to usual care (n = 92). Effect measures were the duration until sustainable RTW in competitive employment and quality-adjusted life years (QALYs) gained. Costs included intervention costs, medical costs and absenteeism costs. Registered data of the Dutch Social Security Agency were used to assess the duration until sustainable RTW, intervention costs and absenteeism costs. QALYs and medical costs were assessed using three- or six-monthly questionnaires. Missing data were imputed using multiple imputations. Cost-effectiveness analysis and cost-utility analysis were conducted from the societal perspective. A return on investment analysis was conducted from the social insurer’s perspective. Various sensitivity analyses were performed to assess the robustness of the results. Results The new program had no significant effect on the duration until sustainable RTW and QALYs gained. Intervention costs and medical costs were significantly higher in the intervention group. From the societal perspective, the maximum probability of cost-effectiveness for duration until sustainable RTW was 0.64 at a willingness to pay of about €10 000/day, and 0.27 for QALYs gained, regardless of the willingness to pay. From the social insurer’s perspective, the probability of financial return was 0.18. Conclusions From the societal perspective, the new program was neither cost-effective in improving sustainable RTW nor in gaining QALYs. From the social insurer’s perspective, the program did not result in a positive financial return. Therefore, the present study provided no evidence to support its implementation. Trial registration The trial was listed at the Dutch Trial Register (NTR) under NTR3563 on August 7, 2012.

Objective We undertook this qualitative study within an international circus company—Cirque du Soleil—to explore the narrative of artists and the artistic team in regards to injuries and their prevention and to describe the prevention of injuries from a systems thinking lens.Methods Focus groups (FG) with artists and semistructured individual interviews with the artistic team were conducted in six selected shows. The structure of the interviews and FGs concerned the themes: ‘injury’, ‘injury-related factors’ and ‘injury prevention’. Data were analysed through comparative data analysis based on Grounded Theory. Concept mapping and systems thinking approaches were used to design a map of participants’ views on how to prevent injuries.Results Injury was mainly described based on performance limitation. The factors mostly mentioned to be related to injury occurrence were physical load factors. Many of these factors were said to be connected and to influence each other. Injury prevention was mapped as a multilevel system, composed by artist-related factors (eg, technique and life style) and extrinsic factors (eg, touring conditions and equipment) that integrate different strategies and stakeholders.Conclusion Our study reinforces the importance of multilevel injury prevention approaches with shared responsibility and open communication among stakeholders.

Objectives The aim of this review was to explore the notion of alcohol-related presenteeism; that is, whether evidence in the research literature supports an association between employee alcohol consumption and impaired work performance.Design Systematic review of observational studies.Data sources MEDLINE, Web of Science, PsycINFO, CINAHL, AMED, Embase and Swemed+ were searched through October 2018. Reference lists in included studies were hand searched for potential relevant studies.Eligibility criteria We included observational studies, published 1990 or later as full-text empirical articles in peer-reviewed journals in English or a Scandinavian language, containing one or more statistical tests regarding a relationship between a measure of alcohol consumption and a measure of work performance.Data extraction and synthesis Two independent reviewers extracted data. Tested associations between alcohol consumption and work performance within the included studies were quality assessed and analysed with frequency tables, cross-tabulations and χ2 tests of independence.Results Twenty-six studies were included, containing 132 tested associations. The vast majority of associations (77%) indicated that higher levels of alcohol consumption were associated with higher levels of impaired work performance, and these positive associations were considerably more likely than negative associations to be statistically significant (OR=14.00, phi=0.37, p

[This corrects the article DOI: 10.1371/journal.pmed.1002736.].

BackgroundReducing sitting time as well as increasing physical activity in inactive people is beneficial for their health. This paper investigates the effectiveness of the European Fans in Training (EuroFIT) programme to improve physical activity and sedentary time in male football fans, delivered through the professional football setting.Methods and findingsA total of 1,113 men aged 30-65 with self-reported body mass index (BMI) ≥27 kg/m2 took part in a randomised controlled trial in 15 professional football clubs in England, the Netherlands, Norway, and Portugal. Recruitment was between September 19, 2015, and February 2, 2016. Participants consented to study procedures and provided usable activity monitor baseline data. They were randomised, stratified by club, to either the EuroFIT intervention or a 12-month waiting list comparison group. Follow-up measurement was post-programme and 12 months after baseline. EuroFIT is a 12-week, group-based programme delivered by coaches in football club stadia in 12 weekly 90-minute sessions. Weekly sessions aimed to improve physical activity, sedentary time, and diet and maintain changes long term. A pocket-worn device (SitFIT) allowed self-monitoring of sedentary time and daily steps, and a game-based app (MatchFIT) encouraged between-session social support. Primary outcome (objectively measured sedentary time and physical activity) measurements were obtained for 83% and 85% of intervention and comparison participants. Intention-to-treat analyses showed a baseline-adjusted mean difference in sedentary time at 12 months of -1.6 minutes/day (97.5% confidence interval [CI], -14.3-11.0; p = 0.77) and in step counts of 678 steps/day (97.5% CI, 309-1.048; p < 0.001) in favor of the intervention. There were significant improvements in diet, weight, well-being, self-esteem, vitality, and biomarkers of cardiometabolic health in favor of the intervention group, but not in quality of life. There was a 0.95 probability of EuroFIT being cost-effective compared with the comparison group if society is willing to pay £1.50 per extra step/day, a maximum probability of 0.61 if society is willing to pay £1,800 per minute less sedentary time/day, and 0.13 probability if society is willing to pay £30,000 per quality-adjusted life-year (QALY). It was not possible to blind participants to group allocation. Men attracted to the programme already had quite high levels of physical activity at baseline (8,372 steps/day), which may have limited room for improvement. Although participants came from across the socioeconomic spectrum, a majority were well educated and in paid work. There was an increase in recent injuries and in upper and lower joint pain scores post-programme. In addition, although the five-level EuroQoL questionnaire (EQ-5D-5L) is now the preferred measure for cost-effectiveness analyses across Europe, baseline scores were high (0.93), suggesting a ceiling effect for QALYs.ConclusionParticipation in EuroFIT led to improvements in physical activity, diet, body weight, and biomarkers of cardiometabolic health, but not in sedentary time at 12 months. Within-trial analysis suggests it is not cost-effective in the short term for QALYs due to a ceiling effect in quality of life. Nevertheless, decision-makers may consider the incremental cost for increase in steps worth the investment.Trial registrationInternational Standard Randomised Controlled Trials, ISRCTN-81935608.

Abstract Background Lifestyle interventions targeting physical activity, sedentary time and dietary behaviours have the potential to initiate and support behavioural change and result in public health gain. Although men have often been reluctant to engage in such lifestyle programs, many are at high risk of several chronic conditions. We have developed an evidence and theory-based, gender sensitised, health and lifestyle program (European Fans in Training (EuroFIT)), which is designed to attract men through the loyalty they feel to the football club they support. This paper describes the study protocol to evaluate the effectiveness and cost-effectiveness of the EuroFIT program in supporting men to improve their level of physical activity and reduce sedentary behaviour over 12 months. Methods The EuroFIT study is a pragmatic, two-arm, randomised controlled trial conducted in 15 football clubs in the Netherlands, Norway, Portugal and the UK (England). One-thousand men, aged 30 to 65 years, with a self-reported Body Mass Index (BMI) ≥27 kg/m2 will be recruited and individually randomised. The primary outcomes are objectively-assessed changes in total physical activity (steps per day) and total sedentary time (minutes per day) at 12 months after baseline assessment. Secondary outcomes are weight, BMI, waist circumference, resting systolic and diastolic blood pressure, cardio-metabolic blood biomarkers, food intake, self-reported physical activity and sedentary time, wellbeing, self-esteem, vitality and quality of life. Cost-effectiveness will be assessed and a process evaluation conducted. The EuroFIT program will be delivered over 12 weekly, 90-minute sessions that combine classroom discussion with graded physical activity in the setting of the football club. Classroom sessions provide participants with a toolbox of behaviour change techniques to initiate and sustain long-term lifestyle changes. The coaches will receive two days of training to enable them to create a positive social environment that supports men in engaging in sustained behaviour change. Discussion The EuroFIT trial will provide evidence on the effectiveness and cost-effectiveness of the EuroFIT program delivered by football clubs to their male fans, and will offer insight into factors associated with success in making sustained changes to physical activity, sedentary behaviour, and secondary outcomes, such as diet. Trial registration ISRCTN: 81935608 . Registered 16 June 2015.

OBJECTIVES: Both the presence of mental health problems and the absence of an employment contract have been related to long-term sickness absence and unemployment, indicating a need for return-to-work (RTW) interventions. Our aim was to study the effectiveness of a new participatory, supportive RTW program for workers without an employment contract, sick-listed 2–14 weeks due to a common mental disorder, in comparison with usual care. METHODS: A participatory approach, integrated care and direct placement in a competitive job were part of the new program. The primary outcome measure was duration until first sustainable RTW in competitive employment. Cox regression analysis was applied to study this outcome. Secondary outcome measures were average working hours, duration until any type of employment, sickness benefit duration, and perceived health and functioning. RESULTS: In total, 186 participants were included in the study and randomly allocated to an intervention group (N=94), or control group (N= 92). A hazard ratio (HR) of 1.15 (95% CI 0.61–2.16) for duration until first sustainable RTW indicated no significant effect of allocation to the new program, compared to usual care. Furthermore, no significant differences were found in favor of the intervention group on any secondary outcome. CONCLUSIONS: Compared to usual care, the new program did not result in a significant shorter duration until first sustainable RTW. However, due to low protocol adherence, it remains unclear what the results would have been if the program had been executed according to protocol.

Abstract Background A process evaluation of a participatory supportive return to work program, aimed at workers without a (permanent) employment contract who are sick-listed due to a common mental disorder, revealed that this program was executed less successfully than similar programs evaluated in earlier studies. The program consisted of a participatory approach, integrated care and direct placement in competitive employment. Aim of this study was to get a better understanding of the execution of the program by evaluating stakeholders’ perceptions. In the absence of an employer, the program was applied by the Dutch Social Security Agency, in collaboration with vocational rehabilitation agencies. Together with the sick-listed workers, these were the main stakeholders. Our research questions involved stakeholders’ perceptions of the function(s) of the program, and their perceptions of barriers and facilitators for a successful execution of the program within the Dutch social security sector. Methods Semi-structured interviews were held with five sick-listed workers, eight professionals of the Social Security Agency, and two case managers of vocational rehabilitation agencies. Interview topics were related to experiences with different components of the program. Selection of respondents was based on purposive sampling and continued until data saturation was reached. Content analysis was applied to identify patterns in the data. Two researchers developed a coding system, based on predefined topics and themes emerging from the data. Results Although perceived functions of some components of the program were as intended, all stakeholders stressed that the program often had not resulted in return to work. Perceived barriers for a successful execution were related to a poor collaboration between the Dutch Social Security Agency, vocational rehabilitation agencies and healthcare providers, the type of experienced (health) problems, time constraints, and limited job opportunities. Conclusions For future implementation of the program, it will be important to consider how a better integration of services by the Dutch Social Security Agency, vocational rehabilitation agencies and the mental healthcare sector can be improved in order to address treatment and vocational needs simultaneously, and to better match the sick-listed worker with the limited opportunities in the Dutch labor market. Trial registration NTR3563

Background: Recovery from fatigue is important in maintaining night workers' health. This study compared the course of self-reported recovery after 2-week 12-hour schedules consisting of either night shifts or swing shifts (i.e., 7 night shifts followed by 7 day shifts) to such schedules consisting of only day work. Methods: Sixty-one male offshore employees—20 night workers, 16 swing shift workers, and 25 day workers—rated six questions on fatigue (sleep quality, feeling rested, physical and mental fatigue, and energy levels; scale 1–11) for 14 days after an offshore tour. After the two night-work schedules, differences on the 1st day (main effects) and differences during the follow-up (interaction effects) were compared to day work with generalized estimating equations analysis. Results: After adjustment for confounders, significant main effects were found for sleep quality for night workers (1.41, 95% confidence interval 1.05–1.89) and swing shift workers (1.42, 95% confidence interval 1.03–1.94) when compared to day workers; their interaction terms were not statistically significant. For the remaining fatigue outcomes, no statistically significant main or interaction effects were found. Conclusion: After 2-week 12-hour night and swing shifts, only the course for sleep quality differed from that of day work. Sleep quality was poorer for night and swing shift workers on the 1st day off and remained poorer for the 14-day follow-up. This showed that while working at night had no effect on feeling rested, tiredness, and energy levels, it had a relatively long-lasting effect on sleep quality.

Depressive disorders are highly prevalent in the working population and lead to excessive costs. Online interventions have shown to be effective treatments for depression but are not often applied in the work setting, despite the importance of work related aspects in the development and perpetuation of depression. We developed a worker-directed web-based intervention for employees with depressive symptoms named Happy@Work. A process evaluation was conducted alongside a randomized controlled trial to assess the feasibility of the intervention and to explore barriers and facilitators for further implementation of the intervention. Employees from different companies in the Netherlands who experienced elevated depressive symptoms and were not on sick leave were eligible to take part in this study. Happy@Work contains six lessons and every lesson has several assignments. When completed, a coach provides feedback to assignments via the website. Process measures investigated were: reach, dose delivered, dose received, and fidelity. Recruitment methods and participant satisfaction with the intervention were described and analyzed as well. Data was collected at baseline and 8 weeks later via online questionnaires and data registrations on the website. The implementation score of the intervention was sufficient, but reach of the target population was low. The dose delivered was high, with 93.1% of participants who used the intervention components that were offered to them. However, adherence to the intervention was low; the dose received was 57.8%. The fidelity of the implementation of the intervention was satisfactory. Recruitment of companies and participants was difficult. Participants were satisfied with the different aspects of the intervention, especially with the feedback from the coach. The results of this process evaluation showed that the intervention was conducted according to protocol and seems feasible for further implementation. Potential barriers to further implementation of the intervention include the reach of the target population, intervention adherence and the quality of the feedback. Based on the results of the effectiveness of the intervention, we do not recommend further implementation of the intervention in its current form.

OBJECTIVE: This study aims to evaluate the effectiveness of a draft occupational health guideline, aimed at preventing weight gain, on employees’ body weight-related outcomes, cardiovascular disease (CVD) risk factors, and quality of life. METHODS: In a cluster randomized controlled trial including 16 occupational physicians (OP) and 523 employees, guideline-based care was compared to usual care by OP between 2009–2011 in the Netherlands. Guideline-based care consisted of (i) providing advice to employers on how to assess and intervene on the obesogenic work environment, (ii) conducting five face-to-face behavioral change counseling sessions with employees to improve their lifestyles, and (iii) evaluating the outcome and maintaining sections i and ii. Data were collected at baseline and 6, 12, and 18-months follow-up. To evaluate the effects of the intervention, multilevel analyses were performed. RESULTS: No significant differences were found between the intervention and control group on waist circumference [β 1.2 cm, 95% confidence interval (95% CI) -0.6–2.9], body weight (β 0.3 kg, 95% CI -1.0–1.6), body mass index (β 0.1 kg/m^2, 95% CI -0.3–0.5), systolic blood pressure (β 1.7 mmHG, 95% CI -2.4–5.8), diastolic blood pressure (β 0.3 mmHG, 95% CI -1.0–0.6), cholesterol (β 0 mmol/l, 95% CI -0.2–0.2), or quality of life indicators after 18-months follow-up. Stratified analyses showed an increase in waist circumference among men (β 2.5 cm, 95% CI 0.5–4.5) and obese intervention participants (β 2.7 cm, 95% CI 0.6–4.7) compared to control participants. CONCLUSION: The draft occupational health guideline was not more effective than usual care. Therefore, the guideline in its current form cannot be recommended for implementation.

OBJECTIVES: The aim of the study was to evaluate the cost-effectiveness, -utility, and -benefit of a newly developed participatory return-to-work (RTW) program for temporary agency and unemployed workers, sick-listed due to musculoskeletal disorders. METHODS: An economic evaluation was conducted alongside a randomized controlled trial with a 12-month follow-up. Temporary agency and unemployed workers, sick-listed for 2–8 weeks due to musculoskeletal disorders, were randomized to the participatory RTW program (N=79) or usual care group (N=84). The new RTW program was aimed at making a consensus-based RTW action plan with the possibility of a temporary (therapeutic) workplace. Effect outcomes were sustainable RTW and quality-adjusted life years (QALY). Healthcare utilization was measured from the social insurer’s perspective and societal perspective. RESULTS: Total healthcare costs in the participatory RTW program group [10 189 (standard deviation [SD] 7055) euros] were statistically significantly higher compared to care-as-usual [7862 (SD 7394) euros]. The cost-effectiveness analyses showed that the new intervention was more effective but also more costly than usual care (ie, to gain RTW one day earlier in the participatory RTW program group approximately 80 euros needed to be invested). The net societal benefit of the participatory RTW program compared to care-as-usual was 2073 euros per worker. CONCLUSIONS: The newly developed participatory RTW program was more effective but also more costly than usual care. The program enhanced work resumption and generated a net socioeconomic benefit. Hence, implementation of the participatory RTW program may have potential to achieve a sustainable contribution of vulnerable workers to the labor force.

OBJECTIVES: A worksite lifestyle intervention aiming to improve lifestyle behaviors could be an effective tool to keep older workers vital, and thereby prolong their labor participation. Therefore, this study evaluates the effectiveness of such an intervention on vitality, work engagement, productivity and sick leave. METHODS: In a randomized controlled trial design, 367 workers (control group: N=363) received a 6-month intervention, which included two weekly guided group sessions: one yoga and one workout, as well as one weekly session of aerobic exercising, without face-to-face instruction, and three individual coach visits aimed at changing workers’ lifestyle behavior by goal setting, feedback, and problem-solving strategies. Furthermore, free fruit was provided at the guided sessions. Data on work-related vitality (UWES vitality scale), general vitality (RAND-36 vitality scale), work engagement (UWES), productivity (single item scoring 0–10), and sick leave (yes/no past 3 months) were collected using questionnaires at baseline (N=730), and at 6- (N=575) and 12-months (N=500) follow-up. Effects were analyzed according to the intention-to-treat principle with complete cases (N=500) and imputed data (N=730). RESULTS: There were no significant differences in vitality, work engagement, productivity, and sick leave between the intervention and control group workers after either 6- and 12-months follow-up. Yoga and workout subgroup analyses showed a 12-month favorable effect on work-related vitality [β=0.14, 95% confidence interval (95% CI) 0.04–0.28] and general vitality (β=2.9, 95% CI 0.02–5.9) among high yoga compliers. For high workout compliers, this positive trend was also seen, but it was not statistically significant. CONCLUSIONS: Implementation of worksite yoga facilities could be a useful strategy to promote vitality-related work outcomes, but only if high compliance can be maximized. Therefore, impeding factors for participation should be investigated in more detail in future research.

OBJECTIVE: The aim of this study was to appraise and summarize the evidence on the cost-effectiveness of worksite physical activity and/or nutrition programs. METHODS: We searched EMBASE, MEDLINE, SportDiscus, PsycInfo, NIOSHTIC-2, NHSEED, HTA, and Econlit for studies published up to 14 January 2011. Additionally, we searched for articles by reviewing references, searching authors’ databases, and contacting authors of included studies. Two researchers independently selected articles. Articles had to include a cost-effectiveness and/or cost-utility analysis comparing a worksite physical activity and/or nutrition program to usual care or an abridged version of the program. Data were extracted on study characteristics and results. Two researchers independently assessed the risk of bias using the Consensus on Health Economic Criteria list (CHEC-list). RESULTS: Ten studies (18 programs) were included. More than 50% of the studies fulfilled 11 (58%) of the 19 CHEC-list items. From various perspectives, worksite nutrition and worksite physical activity and nutrition programs (N=6) were more costly and more effective in reducing body weight than usual care. When only intervention costs were considered, most worksite nutrition (N=4/5) and worksite physical activity and nutrition programs (N=5/6) were more costly and more effective in reducing cholesterol level and cardiovascular disease risks, respectively. CONCLUSIONS: The cost-effectiveness of more costly and more effective programs depends on the “willingness to pay” for their effects. It is unknown how much decision-makers are willing to pay for reductions in body weight, cholesterol level, and cardiovascular disease risks. Therefore, conclusions about the cost-effectiveness of worksite physical activity and/or nutrition programs cannot be made. There is substantial need for improvement of the methodological quality of studies and particular emphasis should be placed on the handling of uncertainty.

OBJECTIVE: The aim of this study was to examine the adherence of occupational physicians (OP) to the Dutch guideline on the management of common mental health problems and its effect on return to work as part of the process evaluation of a trial comparing adherence to the guideline to care as usual. The first hypothesis was that guideline adherence among the “guideline group” will be higher compared to the “usual care group”. The second hypothesis was that better guideline adherence by the occupational physician will be associated with earlier return to work. METHODS: In a randomized controlled trial, five participating OP had to provide care based on the Dutch guideline to 240 police workers with common mental health problems (the “guideline group”). The same OP had to provide usual care to the participants in the control group (the “usual care” group), including minimal involvement and easy access to a psychologist. In evaluating the process, we assessed guideline adherence via an audit of medical files, using 20 guideline-based performance indicators. Mean rates of guideline adherence were related to the duration until first and full return to work, using a Cox proportional hazards model. RESULTS: The mean rate of the sum score of guideline adherence was 10 in a range of 0–20 [standard deviation (SD) 1.8] and did not significantly differ between the intervention and control group. Mean better guideline adherence showed a statistically significant association with a shorter time to first and full return to work [hazard ratio 1.1; 95% confidence interval (95% CI) 1.0–1.2], which was explained by keeping more regular contact with the worker and the work system and better monitoring of stagnation or return to work. CONCLUSIONS: No contrast in guideline adherence was found between guideline-based versus usual care. This can be explained by contamination between the guideline and usual care group. Even though guideline adherence was only average, better adherence predicted earlier return to work. Guidelines for management of common mental health problems and return to work should focus on regular contact with the worker and the work organisation.

OBJECTIVE: Using a standardized quality criteria list, we appraised the methodological quality of economic evaluations of occupational safety and health (OSH) interventions conducted from a corporate perspective. METHODS: The primary literature search was conducted in Medline and Embase. Supplemental searches were conducted in the Cochrane NHS Economic Evaluation Database, the National Institute for Occupational Safety and Health (NIOSH) database, the Ryerson International Labour, Occupational Safety and Health Index, scans of reference lists, and researchers’ own literature database. Independently, two researchers selected articles based on title, keywords, and abstract, and if needed, fulltext. Disagreements were resolved by a consensus procedure. Articles were selected based on seven criteria addressing study population, type of intervention, comparative intervention, outcome, costs, language, and perspective. Two reviewers independently judged methodological quality using the Consensus on Health Economic Criteria (CHEC-list), a 19-item standardized quality criteria list. Disagreements in judgment were also resolved by consensus. Data were analyzed descriptively. RESULTS: A total of 34 studies were included. Of these, only 44% of the studies met more than 50% of the quality criteria. Of the 19 quality criteria, 8 were met by 50% or more of the studies. The 11 least fulfilled criteria related to (i) performance of a sensitivity analysis, (ii) selection of perspective, (iii) description of study population, (iv) discussion of generalizability, (v) description of competing alternatives, (vi) presentation of the research question, (vii) measurement of outcomes, (viii) measurement of costs, (ix) valuation of costs, (x) declaration of researchers’ independence, and (xi) discussion of ethical and distributional issues. CONCLUSIONS: Apart from a few exceptions, the overall methodological quality of the economic evaluations of OSH interventions from a corporate perspective was poor. As such, there is a risk of biased results. The quality of future evaluations needs to be improved to increase the validity of their conclusions and recommendations.

OBJECTIVE: The goal of this review was to summarize the evidence for an effect of lifestyle-targeted interventions at the workplace on the main biological risk factors for cardiovascular disease (CVD). METHODS: We performed an extensive systematic literature search for randomized controlled trials (RCT) that met the following inclusion criteria: (i) targeted at workers; (ii) aimed at increasing physical activity and/or improving diet; and (iii) measured body weight, body fat, blood pressure, blood lipids and/or blood glucose. We used a nine-item methodological quality list to determine the quality of each study. A best-evidence system was applied, taking into account study quality and consistency of effects. RESULTS: Our review included 31 RCT, describing a diversity of interventions (eg counseling, group education, or exercise). Of these studies, 18 were of high quality. Strong evidence was found for a positive effect on body fat, one of the strongest predictors of CVD risk. Among populations “at risk”, there was strong evidence for a positive effect on body weight. Due to inconsistencies in results between studies, there was no evidence for the effectiveness of interventions on the remaining outcomes. CONCLUSIONS: We found strong evidence for the effectiveness of workplace lifestyle-based interventions on body fat and, in populations at risk for CVD, body weight. Populations with an elevated risk of CVD seemed to benefit most from lifestyle interventions; supervised exercise interventions appeared the least effective intervention strategy. To gain better insight into the mechanisms that led to the intervention effects, the participants’ compliance with the intervention and the lifestyle changes achieved should be reported in future studies.

ObjectiveTo investigate the effectiveness of a worksite social and physical environment intervention on need for recovery (i.e., early symptoms of work-related mental and physical fatigue), physical activity and relaxation. Also, the effectiveness of the separate interventions was investigated.MethodsIn this 2 × 2 factorial design study, 412 office employees from a financial service provider participated. Participants were allocated to the combined social and physical intervention, to the social intervention only, to the physical intervention only or to the control group. The primary outcome measure was need for recovery. Secondary outcomes were work-related stress (i.e., exhaustion, detachment and relaxation), small breaks, physical activity (i.e., stair climbing, active commuting, sport activities, light/moderate/vigorous physical activity) and sedentary behavior. Outcomes were measured by questionnaires at baseline, 6 and 12 months follow-up. Multilevel analyses were performed to investigate the effects of the three interventions.ResultsIn all intervention groups, a non-significant reduction was found in need for recovery. In the combined intervention (n = 92), exhaustion and vigorous physical activities decreased significantly, and small breaks at work and active commuting increased significantly compared to the control group. The social intervention (n = 118) showed a significant reduction in exhaustion, sedentary behavior at work and a significant increase in small breaks at work and leisure activities. In the physical intervention (n = 96), stair climbing at work and active commuting significantly increased, and sedentary behavior at work decreased significantly compared to the control group.ConclusionNone of the interventions was effective in improving the need for recovery. It is recommended to implement the social and physical intervention among a population with higher baseline values of need for recovery. Furthermore, the intervention itself could be improved by increasing the intensity of the intervention (for example weekly GMI-sessions), providing physical activity opportunities and exercise schemes, and by more drastic environment interventions (restructuring entire department floor).Trial registrationNederlands Trial Register NTR2553.

School-based intervention studies promoting a healthy lifestyle have shown favorable immediate health effects. However, there is a striking paucity on long-term follow-ups. The aim of this study was therefore to assess the 3 yr-follow-up of a cluster-randomized controlled school-based physical activity program over nine month with beneficial immediate effects on body fat, aerobic fitness and physical activity.Initially, 28 classes from 15 elementary schools in Switzerland were grouped into an intervention (16 classes from 9 schools, n = 297 children) and a control arm (12 classes from 6 schools, n = 205 children) after stratification for grade (1st and 5th graders). Three years after the end of the multi-component physical activity program of nine months including daily physical education (i.e. two additional lessons per week on top of three regular lessons), short physical activity breaks during academic lessons, and daily physical activity homework, 289 (58%) participated in the follow-up. Primary outcome measures included body fat (sum of four skinfolds), aerobic fitness (shuttle run test), physical activity (accelerometry), and quality of life (questionnaires). After adjustment for grade, gender, baseline value and clustering within classes, children in the intervention arm compared with controls had a significantly higher average level of aerobic fitness at follow-up (0.373 z-score units [95%-CI: 0.157 to 0.59, p = 0.001] corresponding to a shift from the 50th to the 65th percentile between baseline and follow-up), while the immediate beneficial effects on the other primary outcomes were not sustained.Apart from aerobic fitness, beneficial effects seen after one year were not maintained when the intervention was stopped. A continuous intervention seems necessary to maintain overall beneficial health effects as reached at the end of the intervention.ControlledTrials.com ISRCTN15360785.