Lessons learned about online engagement and implementation of an intuitive eating programme for university employees.

Background: Intuitive eating (IE) principles present an evidence-based strategy for improving one's relationship with food while reducing the incidence of weight cycling and health risks associated with chronic dieting and weight regain. Offering online programming provides improved access to education while reducing barriers to programme enrollment but is also associated with high rates of attrition. Aim: To examine the process of programme implementation and identify barriers and facilitators of engagement for an online IE programme for employees at a large Midwestern university. Methods: The web-based programme Finding Peace with Food: An Intuitive Eating Approach consisted of an online community with discussion prompts, 10 weekly modules containing videos, activities, and counsellor interviews and was developed using recognized health behaviour theory and evidence-based practices. Participants were university employees (n = 20). Qualitative data were assessed using a phenomenological approach to discern the themes of barriers and facilitators of programme participation. Participation rates were assessed using descriptive statistics. Results: All participants were Caucasian, 85% were female, and their ages ranged from 26-64. The module-based structure was well received. The primary barriers to participation were time constraints, overwhelming amount of information, and aversion to Flipgrid platform use. The quality and usefulness of the programme information were identified as facilitators of participation. Conclusion: Program participation was influenced by the time frame available to complete the programme modules and participants' ease of use of platform applications.

Development and Evaluation of an Online Toolkit for Managers of 9-1-1 Emergency Communications Centers to Reduce Occupational Stress.

This article describes the development and evaluation of an online workplace stress reduction toolkit for use by managers of 9-1-1 emergency communication centers (ECCs). A three-step process for development and testing of digital learning resources was used: (1) establishing need and focus through ECC manager stakeholder engagement, (2) pretesting of the toolkit with the target ECC manager audience, and (3) toolkit utilization and evaluation. The toolkit was developed in close partnership with stakeholders throughout the entire process. Toolkit usage was documented via registration data. The evaluation utilized an online survey that included closed and open-ended questions, which were analyzed using descriptive statistics and qualitative thematic analysis. Over a 20-month period, 274 people registered for the toolkit and, of those, 184 (67%) accessed the content. Respondents to the evaluation survey (N = 156) scored the toolkit highly on satisfaction, self-efficacy, and perceived utility measures. Survey respondents reported intent to apply toolkit content through the following: providing organizational resources to help workers take better care of themselves (41%); creating a lower stress worksite environment (35%) and sharing resources with staff to (1) reduce stress (19%), (2) support conflict resolution (21%), and (3) prevent and/or stop bullying (17%). In delivering actionable content to ECC managers, the toolkit shows promise in addressing and mitigating occupational stress in ECCs. Further research needs to determine the relationship of this strategy for reducing ECC stress.

Exploring Successful Implementation of Organizational Supports at the Worksite Environment: A Mixed Methods Approach.

While there is evidence that organizational supports may lead to better employee health, research on implementing such organizational supports is lacking. This research sought to understand organizational supports and implementation of those supports using an Explanatory Sequential Mixed Methods design approach. Employee survey responses (n = 202) were used to classify organizations into "high" and "low" categories for employee-reported health behavior improvement, agreement, and readiness for implementing change. For the qualitative phase of research (organization-level), semi-structured interviews were conducted with organization leads, and data were analyzed through constant comparative analysis procedure. Analyses sought to identify differences between "high" versus "low" organizations. In addition, the researcher used the "high" and "low" classifications to further review themes that emerged, to determine where there may be differences in organizations classified as "high" versus "low." Study results found the following nine themes to explain how organizations can improve implementing organizational supports: provide a contracted wellness program, formalized programming, and wellness incentives; create a culture of wellness in the organization; provide consistency in the supports offered; provide clear communication to employees; utilize leadership role modeling to show support; focus on leadership support that ensures organizational supports are implemented and sustained; and work to combat employee hesitation of organizational supports. The results of this study show that organizations have the opportunity to improve implementation of their organizational supports by applying the nine themes found.

Maximizing the Potential of Mini-Grants to Promote Policy, Systems, and Environmental Changes: Outcomes and Challenges.

PURPOSE AND OBJECTIVES: This article describes the implementation and evaluation of a chronic disease mini-grant initiative, coordinated by a state health department in collaboration with multiple stakeholders. Braided funding from federal and state sources was used to build and implement the initiative. INTERVENTION APPROACH: Mini-grants, facilitated by five different facilitating organizations, were funded to promote implementation of policy, systems, and environmental (PSE) changes at the local level. Grant recipients represented a variety of sectors, including education, government, and nonprofit organizations. EVALUATION METHODS: Primary (surveys) and secondary (final reports) data documented achievement of PSE changes. RESULTS: A total of $196,369 was dispersed to 65 organizations; 126 PSE changes in the areas of physical activity, nutrition, and tobacco were reported. Challenges in implementing and evaluating mini-grants were identified, including the heterogeneity of the sectors/settings involved and associated variability of proposed activities, time lines, measurement, and evaluation activities. COVID-19 (coronavirus disease 2019) also disrupted the plans for many projects. IMPLICATIONS FOR PUBLIC HEALTH: The success of this initiative can be attributed to four main elements: (1) the use of intermediary organizations to facilitate the mini-grants; (2) a participatory evaluation process, combined with early and ongoing communication among all stakeholders; (3) a braided funding strategy; and (4) a multisector approach that engaged both traditional and nontraditional public health organizations. The processes and outcomes, including challenges, can inform other state health departments' efforts in braiding funding and engaging intermediary organizations to expand the reach of PSE changes at the local level.

Using CDC's Worksite Health ScoreCard to Evaluate Nutrition and Physical Activity Interventions in Priority Communities in New York State, 2015-2020.

The aim of our study was to evaluate a statewide obesity prevention program, designed to improve two social determinants of health (access to healthy foods and opportunities for physical activity) by changing worksite policies, systems, and environments. We used data on social determinants of health to identify priority communities and funded 25 contractors to recruit and engage worksites in those communities. We employed a pre/post quasi-experimental design and used the Centers for Disease Control and Prevention's Worksite Health ScoreCard to assess implementation of nutrition and physical activity strategies. Contractors collaborated with partners to conduct pre- and postassessments at 313 worksites. Worksites were successful at implementing all except one strategy; implementation doubled for eight strategies and tripled for three. We used weighted scores to incorporate strength of the evidence-base and level of impact into our analysis; increases in strategy implementation were statistically significant in worksites that provided places to purchase food and beverages and in those that did not. Our study revealed several important recommendations for practice. Use available data to prioritize communities experiencing health disparities and identify PSE change strategies to increase access to nutritious foods and physical activity opportunities. Engage with reputable community-based partners from different sectors when designing and implementing programs. Use standardized tools, such as the Worksite Health ScoreCard, to evaluate public health initiatives.

Creating a Workplace Culture of Preventive Health: Process and Outcomes of the Colon Cancer-Free Zone at Virginia Cooperative Extension.

Colorectal cancer is the third leading cause of cancer death in the USA, yet is highly preventable and detectable at an early stage through screening. Virginia Cooperative Extension (VCE) implemented a worksite colon cancer awareness program to increase colorectal cancer screening rates and preventive lifestyle behaviors among its employees. The Colon Cancer-Free Zone program is designed using best practice principles of worksite health programs and includes information sessions covering the topics of colorectal cancer, screening guidelines, insurance coverage, and preventive lifestyle behaviors. It is conducted in a campaign format that includes a strategic communication strategy targeting relevant screening barriers and facilitators, peer champions, and incentives. The program was implemented with VCE employees statewide utilizing a web-based system for the information sessions, and resulted in broad participation, a significant increase in screening self-efficacy (4.15 ± 0.64 vs 3.81 ± 0.76, ρ = 0.006), changes in diet and physical activity (50% and 40% of participants, respectively), and a 20.6% increase in the employee colorectal cancer screening rate. A Colon Cancer-Free Zone toolkit was developed for use by Extension Agents to implement the program at worksites in their service communities.

"Working on Wellness:" protocol for a worksite health promotion capacity-building program for employers.

BACKGROUND: In the United States, worksite wellness programs are more often offered by larger employers. The Massachusetts Working on Wellness (WoW) program is an innovative, statewide capacity-building model designed to increase the number of smaller employers (200 or fewer workers) adopting health promotion initiatives. This article describes the WoW program design and approaches to recruitment, implementation, and evaluation. METHODS/DESIGN: WoW provides employer training, technical assistance and seed funding, utilizing a Wellness Program Development framework based on recognized good practices. For-profit employers with 200 employees or fewer are eligible for and encouraged to apply for a Massachusetts Small Business Wellness Tax Credit. During the phase described in this paper, employer organizations applied to the program and committed to designating a champion responsible for program implementation. Interventions were to include policy and environmental supports, as well as those targeting individual behavior change through raising awareness and education. Supports provided to employers included seed grants for qualifying activities (up to $10,000 with matching required), community linkages, data collection and organization-specific feedback tools, an on-line curriculum supplemented with technical assistance, and an expert webinar series. Data collection at multiple time points, from the initial application through program completion, provides information for evaluation of recruitment, planned and completed activities. DISCUSSION: This model is grounded in literature on good practices as well as in local knowledge about Massachusetts employers. It does not directly address the influence of working conditions, which can affect both worker participation and health behaviors. Implementation may be less successful with some organizations, such as those with many workers who are part-time or geographically distributed rather than in a centralized physical location. Program evaluation will assess the extent to which WoW achieves its goals. The data are expected to increase understanding of the needs of smaller employers and industries not traditionally implementing employee wellness programs.

Association of work-related and leisure-time physical activity with workplace food purchases, dietary quality, and health of hospital employees.

BACKGROUND: While leisure-time physical activity (PA) has been associated with reduced risk of cardiometabolic disease, less is known about the relationship between work-related PA and health. Work-related PA is often not a chosen behavior and may be associated with lower socioeconomic status and less control over job-related activities. This study examined whether high work-related PA and leisure-time PA reported by hospital employees were associated with healthier dietary intake and reductions in cardiometabolic risk. METHODS: This was a cross-sectional analysis of 602 hospital employees who used workplace cafeterias and completed the baseline visit for a health promotion study in 2016-2018. Participants completed the International Physical Activity Questionnaire and clinical measures of weight, blood pressure, HbA1c, and lipids. Healthy Eating Index (HEI) scores were calculated from two 24-h dietary recalls, and a Healthy Purchasing Score was calculated based on healthfulness of workplace food/beverage purchases. Regression analyses examined Healthy Purchasing Score, HEI, and obesity, hypertension, hyperlipidemia, and diabetes/prediabetes by quartile of work-related PA, leisure-time PA, and sedentary time. RESULTS: Participants' mean age was 43.6 years (SD = 12.2), 79.4% were female, and 81.1% were white. In total, 30.3% had obesity, 20.6% had hypertension, 26.6% had prediabetes/diabetes, and 32.1% had hyperlipidemia. Median leisure-time PA was 12.0 (IQR: 3.3, 28.0) and median work-related PA was 14.0 (IQR: 0.0, 51.1) MET-hours/week. Higher leisure-time PA was associated with higher workplace Healthy Purchasing Score and HEI (p's < 0.01) and lower prevalence of obesity, diabetes/prediabetes, and hyperlipidemia (p's < 0.05). Work-related PA was not associated with Healthy Purchasing Score, HEI, or cardiometabolic risk factors. Increased sedentary time was associated with lower HEI (p = 0.02) but was not associated with the workplace Healthy Purchasing Score. CONCLUSIONS: Employees with high work-related PA did not have associated reductions in cardiometabolic risk or have healthier dietary intake as did employees reporting high leisure-time PA. Workplace wellness programs should promote leisure-time PA and healthy food choices for all employees, but programs may need to be customized and made more accessible to meet the unique needs of employees who are physically active at work. TRIAL REGISTRATION: This trial was prospectively registered with clinicaltrials.gov (Identifier: NCT02660086) on January 21, 2016. The first participant was enrolled on September 16, 2016.

Work, worksites, and wellbeing among North American Indian women: a qualitative study.

The purpose of this study was to understand what factors influenced work-family balance and related health behaviors among a sample of rural North American Indian women. We interviewed 89 women through both in-depth interviews and focus groups across four tribal communities in the American Southwest and Upper Midwest between July 2010 and August 2011. Interviews were transcribed, coded, and analyzed for emerging themes related to work- family demands placed on women and resources available to cope with those demands. Three prominent themes emerged: structural characteristics (the context of rural reservation life), role stressors (women's multiple and conflicting roles) and the influence of social support (communal nature of care in the family and institutional support in the workplace). We found that women in participating rural reservation communities often acted as primary caregivers for both immediate and extended family, and often placed the needs of others before themselves. The context of rural reservations, with high rates of unemployment, poverty, and chronic illnesses associated with the collective trauma of colonization, placed high demands on female caregivers. Social support from within the workplace, family, and cultural traditions helped some female caregivers balance the demands of home and work. Tribal worksites could be a resource for promoting health and work-life balance by being responsive to the particular demands placed on women that often interfere with engaging in positive health behaviors in general and tribal wellness programs in particular.

The Healthy Health Care Workplace: a Competitive Advantage.

PURPOSE OF REVIEW: This review provides an evidence-based approach to improve health, reduce excessive medical costs, and optimize productivity for health care employees and their families. What opportunities and challenges are unique or specific to health care organizations particularly as aligned with value and competitive advantage in achieving the Quadruple Aim? RECENT FINDINGS: An integrated approach to improving health and performance is essential. The strategy includes the employer "environment" (broadly defined), health and medical care behaviors, care delivery modalities, benefits alignment, and a supportive, total health and productivity integrated data analytic capability. Epigenetics and lifestyle medicine represent a promising direction in accelerating the prevention, treatment, and reversal of common chronic disease. An integrated health and productivity approach, emerging science, and practices can accelerate health care systems' goal to improve employee health and organizational competitiveness. Additional published examples of health care specific employer experience will further advance refinement of existing models and tailoring to the medical care setting.

Health risk factors as predictors of workers' compensation claim occurrence and cost.

OBJECTIVE: The objective of this study was to examine the predictive relationships between employee health risk factors (HRFs) and workers' compensation (WC) claim occurrence and costs. METHODS: Logistic regression and generalised linear models were used to estimate the predictive association between HRFs and claim occurrence and cost among a cohort of 16 926 employees from 314 large, medium and small businesses across multiple industries. First, unadjusted (HRFs only) models were estimated, and second, adjusted (HRFs plus demographic and work organisation variables) were estimated. RESULTS: Unadjusted models demonstrated that several HRFs were predictive of WC claim occurrence and cost. After adjusting for demographic and work organisation differences between employees, many of the relationships previously established did not achieve statistical significance. Stress was the only HRF to display a consistent relationship with claim occurrence, though the type of stress mattered. Stress at work was marginally predictive of a higher odds of incurring a WC claim (p<0.10). Stress at home and stress over finances were predictive of higher and lower costs of claims, respectively (p<0.05). CONCLUSIONS: The unadjusted model results indicate that HRFs are predictive of future WC claims. However, the disparate findings between unadjusted and adjusted models indicate that future research is needed to examine the multilevel relationship between employee demographics, organisational factors, HRFs and WC claims.

Effect of the Emory Healthy Kitchen Collaborative on Employee Health Habits and Body Weight: A 12-Month Workplace Wellness Trial.

INTRODUCTION: Teaching kitchens are being used to facilitate lifestyle changes with a focus on culinary and nutrition programs to improve health behaviors. Less is known regarding their use as a worksite wellness program and their influence on employees' quality of life, body weight, and adoption of healthy behaviors. We evaluated changes in self-reported healthy behaviors, overall health, and weight during a one-year multidisciplinary teaching kitchen program. METHODS: Thirty-eight benefits-eligible employees were recruited, screened based on a priori eligibility criteria that prioritized elevated body mass index (BMI), co-morbid conditions, and high levels of motivation to make lifestyle changes, and consented to participate in The Emory Healthy Kitchen Collaborative. This 12-month program included a 10-week didactic and experiential curriculum followed by continued support and access to health coaching implemented in an academic health system university hospital workplace between 2019 and 2020. Comparative statistics, paired t-test, Mcnemar's tests, and Wilcoxon signed-rank tests were used to assess changes at four time points. RESULTS: Participants improved diet quality (p ≤ 0.0001), increased confidence in tasting new foods (p = 0.03), and increased mindful eating habits (p = 0.00002). Significant changes were seen in physical activity levels; aerobic activities (p = 0.007), strength resistance activities (p = 0.02), and participation in yoga (p = 0.002). Most participants weighed within 5 lbs. of their starting weight at 3 months (p = 0.57). CONCLUSIONS: A teaching kitchen intervention is an innovative model for improving employee health behaviors and general health self-perception.

Rationale for participation in university worksite wellness programs.

Objective: To understand the wellness needs of university employees to design more effective and inclusive worksite wellness programs (WWP) for health promotion. Methods: Cross-sectional assessment of university employees' wellness needs (online survey, n = 639). Results: Employees were most interested in physical activity (PA), nutrition, and lifestyle WWP. Principal barriers to participation were time, scheduling, location, motivation, and confidentiality concerns. Significant correlations exist between having a diagnosed health condition and the likelihood of participating in related programs. 67.1% of past participation was predicted by (1) health status today versus last year, (2) use of university recreational facilities, (3) gender, (4) general health status, (5) PA in the past month, (6) faculty/staff, and (7) age. Conclusions: Our findings contribute to building a road map of how-to better design university WWP based on understanding participation predictors, barriers/facilitators, and the influence of health status/conditions on topics of interest/participation. Tailoring WWP to meet employees' needs may increase reach, engagement and promote a health culture.

Cost Analysis of Developing, Implementing, and Evaluating a Multi-Disciplinary Teaching Kitchen.

INTRODUCTION: Teaching kitchens have emerged as strategies to deliver lifestyle medicine principles and practices. However, a better understanding of their implementation, delivery cost, and potential benefits are needed. This article provides a comprehensive analysis of the costs associated with the development, deployment, and evaluation of the Emory Healthy Kitchen Collaborative (EHKC) teaching kitchen clinical trial. METHODS: The actual number of hours spent and costs incurred to develop and deploy the EHKC teaching kitchen were recorded and broadly categorized into 1 of 4 areas: program development, course delivery, research, and optional enhancements. Costs of each item were assigned as fixed or variable, enabling calculation of the marginal per participant program cost. RESULTS: Total costs were US$123,898, with 3/4 incurred for program development, research, and optional enhancements. Delivery of the course alone (not including program development costs, research, or any optional enhancements) cost US$30,194. The total cost per participant for the course was US$755, with a marginal participant cost of US$141. CONCLUSION: Teaching kitchens represent viable options to deliver lifestyle medicine interventions. However, more research and cost analyses are needed to better understand the value teaching kitchens provide to determine if they are an effective and economical way to deliver lifestyle medicine.

Do Faith Friendly Workplaces Increase Well-Being?

Many will draw distinctions between finding your purpose and tapping into spirituality. And many more are quick to point out that they are spiritual but not religious. This predictable definitional dynamic makes me doubtful that adoption of purpose finding strategies will be the gateway to unlocking the ambivalence and stigma related to sharing one's faith in company settings. Drawing from tenets that drive social epidemics, wellness professionals and faith leaders travel in 'closed circles' and it will take 'connectors' with ties in both circles to spread the idea that workplace wellness and faith traditions can have positive synergies. Healthy People 2030 defines health and well-being as "how people think, feel, and function-at a personal and social level-and how they evaluate their lives as a whole." This editorial describes components of faith friendly organizations and argues that employee resource groups and trends in diversity, equity and inclusion initiatives could be a catalyst for greater openness to including people's faith traditions as a part of bringing their whole selves to work.

Employee Participation in Workplace Vaccination Campaigns: A Systematic Review and Meta-Analysis.

To reduce vaccine-preventable diseases in workers, workplace vaccination campaigns can be implemented on-site. The aim of this systematic review was to evaluate adherence to workplace vaccination campaigns. Three databases, PubMed, ISI Web of Science, and Scopus, were screened systematically for articles in English or Italian addressing participation in an on-site vaccination program by employees. The following data was extracted: authors, year, country, type of vaccine, type of workplace, sample size, vaccination rate. Data on the prevalence of flu vaccination were calculated and pooled using a random-effects model. Thirteen articles were included in the review, ten in the meta-analysis. Most studies were conducted in the USA (30.7%) and most vaccination campaigns were against influenza (69.2%), with a pooled estimate of 42% (95% CI: 0.25-0.60%); participation rate was highly variable, ranging from 88.9% for an influenza vaccination campaign to 5.7% for a Lyme disease vaccination campaign. Offering free on-site vaccination can be a successful tool to ensure adherence to vaccination campaigns and administration of all required doses according to the vaccine administration scheme. The occupational physician can play a key role in implementing workplace campaigns for employee mandatory vaccinations.

Completing a worksite health risk assessment correlates with continuing employment, lower health care costs and utilization.

OBJECTIVES: Companies that understand the collective health risks of their employees, as well as worker productivity as it relates to health risks can provide more effective and necessary interventions. Health Risk Assessments (HRAs) are an important source of information for understanding overall health risks of a company's employees. However, HRA data tend to represent only a subset of employees, thereby providing employers an incomplete picture of employee health risks. The current study identifies the representativeness of those completing a worksite HRA by selected demographics, health care costs, and health risks in a large US company. MATERIAL AND METHODS: A retrospective analysis of employees in a large US company during 2017-2019, with statistically significant results reported, adjusted for sex, age, and year. RESULTS: The percentage of employees completing the HRA increased from 23.9% in 2017 to 28.4% in 2018 to 32.3% in 2019. These employees were more likely women, middle aged, have lower health care costs, remain employed from year to year, and have better health behaviors and biometric scores. If all employees looked like employees completing the HRA, total medical costs would be 17% lower. If all employees looked like employees completing the HRA who had a health perception rating (1-10 [excellent]) of 7-8 (57.4%) or 9-10 (25.2%) vs. 1-6, total medical costs would be 21.9% and 25.6% lower, respectively. CONCLUSIONS: A minority of employees completed the worksite HRA. Basing overall employee health risks on the HRA underestimates health risks and can result in a poorly representative health intervention program. Int J Occup Med Environ Health. 2022;35(4):449-57.

Latin American Agricultural Workers' Job Demands and Resources and the Association With Health Behaviors at Work and Overall Health.

In the present study, we describe the job demands and job resources (JD-R) experienced by agricultural workers in three Latin American countries and their relationship to proactive health behaviors at work and overall health. Following previous research on the JD-R model, we hypothesized that job demands (H1) would be negatively related to agricultural workers' self-reported overall health. On the other hand, we hypothesized that job resources (H2) would be positively related to agricultural workers' overall health. Furthermore, we hypothesized (H3) that workers' engagement in jobsite health promotion practices via their proactive health behaviors at work would partially mediate the relationship between workers' job resources and job demands and overall health. We also had a research question (R1) about whether there were differences by type of job held. The sample of workers who participated in this study (N = 1,861) worked in Mexico, Guatemala, and Nicaragua for one large agribusiness that produces sugar cane. They worked in two distinct areas: company administration and agricultural operations. We administered employee health and safety culture surveys using survey methods tailored to meet the needs of both types of workers. Stratified path analysis models were used to test study hypotheses. In general, we found support for hypotheses 1 and 2. For example, operations workers reported more physically demanding jobs and administrative workers reported more work-related stress. Regardless, the existence of high job demands was associated with poorer overall health amongst both types of workers. We found that workers in more health-supportive work environments perform more proactive health behaviors at work, regardless of their role within the organization. However, hypothesis 3 was not supported as proactive health behaviors at work was not associated with overall health. We discuss future research needs in terms of evaluating these hypotheses amongst workers employed by small- and medium-sized agribusinesses as well as those in the informal economy in Latin America. We also discuss important implications for agribusinesses seeking to develop health promotion programs that meet the needs of all workers.

Pragmatic Evaluation of a Health System-Based Employee Weight Management Program.

Objective: We aimed to evaluate the fidelity and estimate the effectiveness of a novel health system employee weight-management program. Methods: Employees participating in a weight loss program consisting of self-monitoring, health coaching and meal replacements optionally enrolled in the 12-month study. Longitudinal, single-arm analyses were conducted evaluating change over time via survey, claims and programmatic data. Token participation incentives were offered for survey completion. Results: In total, 140 participants enrolled (51.2 ± 9.8 years; BMI = 33.2 ± 6.5 kg/m2; 89.3% female). During 1 year, participants attended 18.0 ± 12.2 coaching appointments and self-reported significant improvements in weight (-8.2 ± 10.5% body weight), BMI (-3.9 ± 6.5 kg/m2), fruit/vegetable intake, home food preparation, added sugar, sugar sweetened beverages and life satisfaction (all p < 0.05). No significant changes were reported in physical activity, weight-related social support, self-efficacy or healthcare utilization (all p > 0.05). Conclusions: The findings from this evaluation establish implementation fidelity. Clinically significant self-reported weight loss, coupled with improvements in many weight-related behaviors, suggest the program is an effective weight management tool when offered as an employee well-being program.

The Effect of a Web-Based Deep Breathing App on Stress of Direct Care Workers: Uncontrolled Intervention Study.

Objectives: Studies have demonstrated success in reducing stress levels in complex interventions including deep breathing components. Breathing exercise interventions, however, tend not to be studied in isolation. The aim of the study was to examine the impact of a breathing exercise using a web-based app on the stress levels of direct care workers (DCWs) who serve people with intellectual and developmental disabilities. Design: Uncontrolled one-group intervention. Settings/Location: DCWs were recruited from intellectual and developmental disability service providers in a US Midwestern state. Subjects: Sixty-four DCWs who used the breathing exercise app at least 2 times. Interventions: Breathing exercise using a web-based app for a month. Outcome measures: Five measures were obtained from the data recorded in the app: initial stress level before exercise, exercise duration in minutes, change in stress level between before and after each breathing exercise, and frequency and number of days the app was used during a month. Participants' self-report of the number of days of app use was collected in a 1-month follow-up survey. Results: The participants appear to have a moderate stress level indicated by the initial stress level 5 out of 10. After the breathing exercise, the stress level decreased by 1.2 points from 5.0 (standard deviation [SD] = 1.8) to 3.7 (SD = 1.6) on average (paired t-test, p < 0.00005). Cohen's d 0.72 indicates a large effect size. Among within-individual factors, a higher initial stress level and longer app use per occasion were significantly associated with stress reduction. Among between-individual factors, only race was associated with stress reduction. Although there was no effect of being an African American alone on stress level change (coefficient = 0.44, 95% confidence interval = -0.29 to 1.18, p > 0.05), there was an additional reduction among African Americans in relation to the initial stress level, controlling for exercise duration. The number of breathing exercise days recorded in the app was not correlated with that of self-report (Pearson's correlation r = 0.12, p > 0.05). Although the app was used for 4.4 (SD = 4.2) days, participants reported using it for 10.7 (SD = 8.2) days on average in the follow-up survey. Conclusions: The findings suggest the benefit of breathing exercises using an app for reducing DCWs' stress levels. Regular use of such apps may assist with stress management and bolster overall health and well-being among DCWs.