By the Seat of Our Pants: the Experience of Small Businesses in the COVID-19 Pandemic, Washington State, March-October 2020.

INTRODUCTION: Most US businesses are small, yet they employ almost half of the nation's workforce. Literature is limited about how small employers (those with 20-250 employees) have made decisions about operating their businesses during the COVID-19 pandemic. We sought to learn how employers made these decisions, what information sources they used, what information they wanted, and to what extent they worked with or used information from their local health department. METHODS: We conducted qualitative, semistructured interviews with 26 employers in Washington State, from August through October 2020. Employers were recruited from 7 counties (4 urban and 3 rural) that were experiencing either higher or lower COVID-19 case rates than Washington State overall. RESULTS: Employers relied heavily on national government resources to make decisions about how to operate their businesses during the COVID-19 pandemic. Few employers had relationships with or turned to their local health departments for information or support. Employers wanted information about COVID-19 safety that was specific to their business operations and industry. Employers also described the emotional toll of COVID-19 and the challenge of trying to make high-stakes decisions with rapidly evolving information. CONCLUSION: Small employers showed little awareness of their local health departments and the information and assistance they could provide. Local health departments could increase their visibility and build relationships with small employers by partnering with them on value-added services such as workplace health promotion. Establishing these relationships could support more rapid collaboration between local health departments and small employers during future public health crises.

Local Health Jurisdiction Staff Deliver Health Promotion to Small Worksites, Washington.

CONTEXT: Worksites can serve as community sites for local health jurisdictions (LHJs) to assist with implementation of evidence-based interventions (EBIs) to prevent and control chronic diseases. OBJECTIVE: To assess the feasibility and effectiveness of using LHJ staff to disseminate Connect to Wellness (CtW), an effective dissemination package for increasing implementation of EBIs for chronic disease control by small worksites. DESIGN: Single-arm, multisite intervention trial, with measurement at baseline, after 6 months of intervention, and after a maintenance period of 6 months. SETTING: Six geographically dispersed counties in Washington State. Target worksites had 20 to 250 employees. PARTICIPANTS: Nine staff members from 6 LHJs delivered CtW to 35 worksites. INTERVENTION: Connect to Wellness seeks to increase worksites' implementation of 14 EBIs classified as communication, policy, or program approaches to increasing 4 behaviors: cancer screening, healthy eating, physical activity, and tobacco cessation. MAIN OUTCOME MEASURE: Evidence-based intervention implementation measured on a scale from 0% to 100%. RESULTS: Participating worksites showed a significant increase (P < .001, t test) in total mean implementation scores from baseline (33%) to 6-month follow-up (47%). Increases in implementation for communications, policy, healthy eating, and tobacco EBIs were statistically significant at 6 months and maintained at 12 months. Increased implementation at 6 months of a group physical activity program was not sustained after the program became unavailable, and total implementation scores at 12 months (38%) showed little change from baseline. CONCLUSIONS: Local health jurisdiction-delivered CtW increased worksites' implementation of EBIs at 6 months, and increased implementation in communication, policy, healthy eating, and tobacco was maintained at 12 months. This package, delivered by LHJ staff working part-time on CtW, was nearly as successful as prior delivery by staff working full-time on CtW.

Disseminating Evidence-Based Interventions in Small, Low-Wage Worksites: A Randomized Controlled Trial in King County, Washington (2014-2017).

Objectives. To determine whether (1) participating in HealthLinks, and (2) adding wellness committees to HealthLinks increases worksites' evidence-based intervention (EBI) implementation.Methods. We developed HealthLinks to disseminate EBIs to small, low-wage worksites. From 2014 to 2017, we conducted a site-randomized trial in King County, Washington, with 68 small worksites (20-200 employees). We assigned worksites to 1 of 3 arms: HealthLinks, HealthLinks plus wellness committee (HealthLinks+), or delayed control. At baseline, 15 months, and 24 months, we assessed worksites' EBI implementation on a 0% to 100% scale and employees' perceived support for their health behaviors.Results. Postintervention EBI scores in both intervention arms (HealthLinks and HealthLinks+) were significantly higher than in the control arm at 15 months (51%, 51%, and 23%, respectively) and at 24 months (33%, 37%, and 24%, respectively; P < .001). Employees in the intervention arms perceived greater support for their health at 15 and 24 months than did employees in control worksites.Conclusions. HealthLinks is an effective strategy for disseminating EBIs to small worksites in low-wage industries.Public Health Implications. Future research should focus on scaling up HealthLinks, improving EBI maintenance, and measuring impact of these on health behavior.

Feasibility of Workplace Health Promotion for Restaurant Workers, Seattle, 2012.

INTRODUCTION: Restaurant workers are a large population at high risk for tobacco use, physical inactivity, and influenza. They are difficult to reach with health care interventions and may be more accessible through workplaces, yet few studies have explored the feasibility of workplace health promotion in this population. This study sought to identify barriers and facilitators to promotion of tobacco cessation, physical activity, and influenza vaccination in restaurants. METHODS: Moderators conducted 7 focus groups, 3 with restaurant owners and managers, 2 with English-speaking workers, and 2 with Spanish-speaking workers. All groups were recorded, and recordings were transcribed and uploaded to qualitative-analysis software. Two researchers coded each transcript independently and analyzed codes and quotations for common themes. RESULTS: Seventy people from the restaurant industry participated. Barriers to workplace health promotion included smoking-break customs, little interest in physical activity outside of work, and misinformation about influenza vaccinations. Facilitators included creating and enforcing equitable break policies and offering free, on-site influenza vaccinations. Spanish-speakers were particularly amenable to vaccination, despite their perceptions of low levels of management support for health promotion overall. Owners required a strong business case to consider investing in long-term prevention for their employees. CONCLUSION: Tobacco cessation and influenza vaccinations are opportunities for health promotion among restaurant workers, whereas physical activity interventions face greater challenges. Promotion of equitable breaks, limited smoking-break policies, and free, on-site influenza vaccinations could improve health for restaurant workers, who often do not have health insurance. Workplace interventions may be particularly important for Hispanic workers who have additional access barriers.

Promoting Employee Health Through an American Cancer Society Program, The CEOs Challenge, Washington State, 2013-2015.

INTRODUCTION: Evidence-based practices in the workplace can increase levels of healthy eating, cancer screening, physical activity, and tobacco cessation but are underused, even in large workplaces. This report summarizes an evaluation of the first year of The CEOs Challenge, a program developed by the American Cancer Society to promote implementation and maintenance of health-promoting, evidence-based workplace practices by large companies. METHODS: Use of 17 evidence-based practices by 17 companies in the Washington State Chapter of the American Cancer Society's CEOs Against Cancer network was assessed via survey and scored from 0 to 100. Companies received a written report of their baseline performance, followed by at least quarterly consultations with American Cancer Society staff members trained to assist in implementation of these practices. Follow-up performance was measured at 1 year. RESULTS: At baseline, implementation scores were 54.8 for cancer screening, 46.5 for healthy eating, 59.8 for physical activity, and 68.2 for tobacco cessation. At follow-up, scores increased by 19.6 for cancer screening, 19.4 for healthy eating, 16.0 for physical activity, and 9.4 points for tobacco cessation. CONCLUSION: The CEOs Challenge is a promising approach to chronic disease prevention via the workplace. It brings together one of the nation's largest health-promoting voluntary agencies with the nation's largest employers to promote evidence-based practices targeted at the most common causes of disease and death. The program increased the adoption of these practices and was well-accepted.

Influenza vaccination status and attitudes among restaurant employees.

CONTEXT: Restaurant employees represent a substantial portion of the US workforce, interact closely with the public, and are at risk for contracting influenza, yet their influenza vaccination rates and attitudes are unknown. OBJECTIVE: Assess influenza vaccination rates and attitudes among Seattle restaurant employees, to identify factors that could enhance the success of a restaurant-based vaccination program. DESIGN: In 2012, we invited employees of Seattle restaurants to complete an anonymous paper survey assessing participant demographics, previous influenza vaccination status, and personal attitudes toward influenza vaccination (using a 5-point scale). SETTING: Sit-down, full service restaurants in or near Seattle, Washington, were eligible if they had no previous history of offering worksite influenza vaccinations and had more than 20 employees who were older than 18 years and spoke either English or Spanish. PARTICIPANTS: We invited staff in all restaurant positions (servers, bussers, kitchen staff, chefs, managers, etc) to complete the survey, which was available in English and Spanish. RESULTS: Of 428 restaurant employees surveyed, 26% reported receiving the seasonal influenza vaccine in 2011-2012 (response rate = 74%). Across 8 attitude statements, participants were most likely to agree that the vaccine is not too expensive (89%), and least likely to agree that it is relevant for their age group (25%), or normative at their workplace (13%). Vaccinated participants reported significantly more positive attitudes than unvaccinated participants, and Hispanics reported significantly more positive attitudes than non-Hispanic whites. CONCLUSIONS: Increasing influenza vaccination rates among restaurant employees could protect a substantial portion of the US workforce, and the public, from influenza. Seattle restaurant employees have low vaccination rates against seasonal influenza. Interventions aimed at increasing vaccination among restaurant employees should highlight the vaccine's relevance and effectiveness for working-age adults.

Opportunities for improving cancer prevention at federally qualified health centers.

As the Affordable Care Act unfolds, federally qualified health centers (FQHCs) will likely experience an influx of newly insured, low-income patients at disparate risk for cancer. Cancer-focused organizations are seeking to collaborate with FQHCs and the Primary Care Associations (PCAs) that serve them, to prevent cancer and reduce disparities. To guide this collaboration, we conducted 21 interviews with representatives from PCAs and FQHCs across four western states. We asked about: FQHC priorities, barriers and facilitators to cancer prevention, the PCA-FQHC relationship, and collaboration opportunities for external organizations. FQHC priorities include medical home transformation, electronic health records, and clinical care; prevention efforts must integrate with these. Barriers to cancer prevention include competing priorities, inadequate patient insurance, and lack of reimbursement, while facilitators are the presence of patient navigators and cancer-related performance measures. Collaboration opportunities for external organizations include dissemination of culturally appropriate educational materials and support for patient navigators.

Understanding older adults' motivators and barriers to participating in organized programs supporting exercise behaviors.

Little is known about older adults' perceptions of organized programs that support exercise behavior. We conducted semi-structured interviews with 39 older adults residing in King County, Washington, who either declined to join, joined and participated, or joined and then quit a physical activity-oriented program. We sought to explore motivators and barriers to physical activity program participation and to elicit suggestions for marketing strategies to optimize participation. Two programs supporting exercise behavior and targeting older persons were the source of study participants: Enhance(®)Fitness and Physical Activity for a Lifetime of Success. We analyzed interview data using standard qualitative methods. We examined variations in themes by category of program participant (joiner, decliner, quitter) as well as by program and by race. Interview participants were mostly females in their early 70s. Approximately half were non-White, and about half had graduated from college. The most frequently cited personal factors motivating program participation were enjoying being with others while exercising and desiring a routine that promoted accountability. The most frequent environmental motivators were marketing materials, encouragement from a trusted person, lack of program fees, and the location of the program. The most common barriers to participation were already getting enough exercise, not being motivated or ready, and having poor health. Marketing messages focused on both personal benefits (feeling better, social opportunity, enjoyability) and desirable program features (tailored to individual needs), and marketing mechanisms ranged from traditional written materials to highly personalized approaches. These results suggest that organized programs tend to appeal to those who are more socially inclined and seek accountability. Certain program features also influence participation. Thoughtful marketing that involves a variety of messages and mechanisms is essential to successful program recruitment and continued attendance.

Exploring the Impact of the COVID-19 Pandemic on Employees' Workplace Health Promotion Preferences.

PURPOSE: The COVID-19 pandemic has led to profound changes in the workplace as well as increases in stress, missed preventive care, and other health concerns. There is limited research since the onset of the pandemic on employees' primary health concerns and their willingness to engage with workplace health promotion (WHP) programs to address these needs. We conducted this survey about employees' current health priorities as a first step to exploring whether WHP programs need to evolve to be responsive to employees' needs at this stage of the pandemic. DESIGN: National cross-sectional survey. SETTING: United States, April 29-May 5, 2022. SUBJECTS: 2053 Americans employed part or full time. MEASURES: 17-item online survey assessing demographics, health priorities, and impact of the pandemic on health. ANALYSIS: Descriptive statistics, SPSS Version 19. RESULTS: Employees' most common health concerns included work/life balance and stress (each cited by 55%). Nearly half (46%) said their health or well-being was affected by the pandemic; within this group, the most common concerns were stress (66%), anxiety (61%), sleep (49%), and depression (48%). Almost all (94%) indicated they would be open to receiving support from their employers. CONCLUSION: This research is a first step in learning about employees' current health priorities and how they may have changed. WHP researchers and practitioners can determine how their programs align with current priorities. Our future research will explore employees' preferences, heath behaviors, and their current workplace environments in more depth.

Evaluation of a telephone-based physical activity promotion program for disadvantaged older adults.

BACKGROUND: Lack of adequate physical activity among older adults has been widely documented. Although interventions aimed at increasing physical activity that are based on behavioral strategies and theories have been shown to increase activity levels among older adults, little is known about responses to these interventions in different population segments. COMMUNITY CONTEXT: The Physical Activity for a Lifetime of Success (PALS) program attempted to translate a telephone-based, motivational support program for physical activity, Active Choices, for use by a low-income, ethnically diverse population of older adults living in southeast Seattle. This article describes the evaluation of PALS at the end of the 5-year program. METHODS: Evaluation data included a data set of participant physical activity assessments; internal study documents; and interviews with key PALS stakeholders, participants, volunteers, and people eligible for PALS who declined to enroll when invited. OUTCOME: PALS demonstrated improved physical activity levels among the sedentary older adults who participated in the program, but the PALS model did not appeal widely to a diverse, low-income target population. Extensive recruitment efforts resulted in a low number of participants, and attempts to recruit peer volunteers were largely unsuccessful. INTERPRETATION: Considering the resources required to engage both participants and volunteers, PALS does not appear to be a sustainable model for delivering support for physical activity to community-dwelling minority and low-income older adults.

Partnerships to expand worksite wellness programs - A qualitative analysis of state and local health department perspectives.

Chronic diseases such as heart disease, cancer, and diabetes are the leading causes of death and disability in the U. S. Because the central mission of state and local health departments (HDs) is to protect, promote, and improve population health, these agencies are well-positioned to address risk behaviors for chronic disease. HD-employer partnerships could enhance worksite wellness programming, but few studies have explored this topic. Building upon previously published findings, the purpose of this qualitative study was to describe the context and environment for HDs' delivery of worksite wellness programs, including interest, barriers, facilitators, and decision-making processes. We conducted 12 interviews with directors of state chronic disease programs, 21 interviews with local directors, and three focus groups with local staff. We performed a thematic analysis of the data. Key themes include the following: (1) worksite wellness programs delivered by HDs were diverse in topic and scope and delivered both internally (at the HD for their agency) and externally (for other employers); (2) decisions made about chronic disease prevention were largely driven by funding priorities, with federal, state, and local entities playing roles in the decision-making process; and (3) HDs expressed potential interest in worksite wellness program delivery, dependent upon staff capacity, available funding, and employer buy-in. Our results suggest that funding should be increased for and reallocated towards chronic disease prevention, including worksite wellness. To overcome HD barriers to program delivery, key funders and stakeholders should prioritize and communicate the importance of worksite wellness.

Pathways to Employee Outcomes in a Workplace Health Promotion Program.

PURPOSE: This study examined the relationship between employee outcomes and employer implementation of evidence-based interventions (EBIs) for chronic disease prevention. DESIGN: Cross-sectional samples collected at 3 time points in a cluster-randomized, controlled trial of a workplace health promotion program to promote 12 EBIs. SETTING: King County, WA. SAMPLE: Employees of 63 small, low-wage workplaces. MEASURES: Employer EBI implementation; 3 types of employee outcomes: perceived implementation of EBIs; perceived employer support for health; and health-related behaviors, perceived stress, depression risk, and presenteeism. ANALYSIS: Intent-to-treat and correlation analyses using generalized estimating equations. We tested bivariate associations along potential paths from EBI implementation, through perceived EBI implementation and perceived support for health, to several employee health-related outcomes. RESULTS: The intent-to-treat analysis found similar employee health-related behaviors in intervention and control workplaces at 15 and 24 months. Workplaces implemented varying combinations of EBIs, however, and bivariate associations were significant for 4 of the 6 indicators of physical activity and healthy eating, as well as perceived stress, depression risk, and presenteeism. We did not find significant positive associations for cancer screening and tobacco cessation. CONCLUSION: Our findings support broader dissemination of EBIs for physical activity and healthy eating, as well as more focus on improving employer support for employee health. They also suggest we need better interventions for cancer screening and tobacco cessation.

Using a Social Capital Framework to Explore a Broker's Role in Small Employer Wellness Program Uptake and Implementation.

PURPOSE: Small employers, while motivated to implement wellness programs, often lack knowledge and resources to do so. As a result, these firms rely on external decision-making support from insurance brokers. The objective of this study was to analyze brokers' familiarity with wellness programs and to characterize their role and interactions with small employers. DESIGN: Using a newly developed common interview guide (20 questions), protocol and analysis plan, 20 interviews were conducted with health insurance brokers in Illinois, Minnesota, North Carolina and Washington in 2016 and 2017. In addition to exploring patterns of broker interactions and familiarity by segment, we propose a framework to conceptualize the broker-client relationship using social capital theory and the RE-AIM model. METHODS: Interviews were transcribed, summarized and a common codebook was established using DeDoose. Themes were identified following multi-rater coding and structured within the framework. RESULTS: Participating brokers reported having a high to moderate familiarity with wellness programs (65%) and a majority (80%) indicated that they have previously advised their small business clients on the availability and features of them. Further, we find that brokers may help eliminate barriers to resources and act as a connector to wellness opportunities within their professional network. CONCLUSION: New initiatives to promote small employer wellness programs can benefit from examining the influence of brokers on the decision-making process. When engaged and supported with resources, brokers may be effective champions for employer wellness programs.

Development and Pilot Test of an Online Training to Engage Managers to Support Workplace Wellness.

OBJECTIVE: To contribute to a broader understanding of effective implementation strategies to help managers engage employees in workplace wellness. METHODS: We beta-tested an online training at four Washington state agencies (two test, two control). We administered a post-training evaluation, re-administered an online manager survey and conducted additional interviews with wellness leads. RESULTS: Training participation rate was high. The two test agencies experienced a significant increase in the percentage of managers who: agreed that they received training on employee wellness; agreed their agency's culture supports employee wellness; and encouraged their employees to participate in wellness activities. Approximately 80% of managers who received the training agreed they could apply information learned to support employee wellness. CONCLUSIONS: If proven effective, the training could be administered at a low cost and disseminated to improve employee health.

Development of a Wellness Committee Implementation Index for Workplace Health Promotion Programs in Small Businesses.

PURPOSE: To construct a wellness committee (WC) implementation index and determine whether this index was associated with evidence-based intervention implementation in a workplace health promotion program. DESIGN: Secondary data analysis of the HealthLinks randomized controlled trial. SETTING: Small businesses assigned to the HealthLinks plus WC study arm. SAMPLE: Small businesses (20-200 employees, n = 23) from 6 low-wage industries in King County, Washington. MEASURES: Wellness committee implementation index (0%-100%) and evidence-based intervention implementation (0%-100%). ANALYSIS: We used descriptive and bivariate statistics to describe worksites' organizational characteristics. For the primary analyses, we used generalized estimating equations with robust standard errors to assess the association between WC implementation index and evidence-based intervention implementation over time. RESULTS: Average WC implementation index scores were 60% at 15 months and 38% at 24 months. Evidence-based intervention scores among worksites with WCs were 27% points higher at 15 months (64% vs 37%, P < .001) and 36% points higher at 24 months (55% vs 18%, P < .001). Higher WC implementation index scores were positively associated with evidence-based intervention implementation scores over time (P < .001). CONCLUSION: Wellness committees may play an essential role in supporting evidence-based intervention implementation among small businesses. Furthermore, the degree to which these WCs are engaged and have leadership support, a set plan or goals, and multilevel participation may influence evidence-based intervention implementation and maintenance over time.

The Role of Managers in Employee Wellness Programs: A Mixed-Methods Study.

PURPOSE: The purpose of this study is to evaluate managers' barriers and facilitators to supporting employee participation in the Washington State Wellness program. DESIGN: Exploratory sequential mixed methods. SETTING: Four Washington State agencies located in Olympia and Tumwater, Washington. PARTICIPANTS: State employees in management positions (executive, middle, and line), whose job includes supervision of subordinates and responsibility for the performance and conduct of a subunit or group. METHODS: We interviewed 23 managers and then used the results to create a survey that was fielded to all managers at the 4 agencies. The survey response rate was 65% (n = 607/935). ANALYSIS: We used qualitative coding techniques to analyze interview transcripts and descriptive statistics to summarize survey data. We used the Total Worker Health framework to organize our findings and conclusions. RESULTS: Managers support the wellness program, but they also face challenges with accommodating employees' participation due to workload, scheduling inflexibility, and self-efficacy to discuss wellness with direct reports. About half the managers receive support from the manager above them, and most have not received training on the wellness program. CONCLUSION: Our findings point to several strategies that can strengthen managers' role in supporting the wellness program: the provision of training, targeted messages, formal expectations, and encouragement (from the manager above) to support employees' participation.

Comparing Strategies for Recruiting Small, Low-Wage Worksites for Community-Based Health Promotion Research.

BACKGROUND: HealthLinks is a workplace health promotion program developed in partnership with the American Cancer Society. It delivers a package of evidence-based interventions and implementation support to small worksites in low-wage industries. As part of a randomized, controlled trial of HealthLinks, we studied approaches to recruiting these worksites. AIMS: This study aims to guide future recruitment for community-based worksite health promotion interventions by comparing three approaches, including leveraging relationships with community partners. METHOD: We recruited 78 small, low-wage worksites in King County, Washington, to participate in the trial via three approaches: phone calls to companies on a purchased list ("cold"), phone calls to a list of eligible companies provided by a health insurer ("lukewarm"), and personal referrals from local health insurers and brokers ("warm"). Eligible and interested worksites received an in-person visit from researchers and completed additional steps to enroll. RESULTS: Of the worksites screened and deemed eligible, 32% of the "cold" worksites enrolled in HealthLinks, as did 48% and 60%, respectively, of the "lukewarm" and "warm" worksites. Compared with "warm" worksites, "cold" worksites were twice as likely to be ineligible. DISCUSSION: Two distinct factors help explain why "warmer" worksites were more likely to enroll in HealthLinks. First, eligibility was significantly higher among warmer referrals. Second, most of the warm-referred worksites eligible for the study agreed to meet in person with the project team to hear more about the project. CONCLUSIONS: "Warmer" recruitment approaches yielded higher recruitment. Leveraging relationships with community partners can help researchers identify and successfully recruit small, low-wage worksites.

Managers' Support for Employee Wellness Programs: An Integrative Review.

OBJECTIVE: The aim of this integrative literature review is to synthesize the existing evidence regarding managers' support for employee wellness programs. DATA SOURCE: The search utilized multiple electronic databases and libraries. STUDY INCLUSION AND EXCLUSION CRITERIA: Inclusion criteria comprised peer-reviewed research published in English, between 1990 and 2016, and examining managers' support in the context of a worksite intervention. The final sample included 21 articles for analysis. DATA EXTRACTION: Two researchers extracted and described results from each of the included articles using a content analysis. DATA SYNTHESIS: Two researchers independently rated the quality of the included articles. Researchers synthesized data into a summary table by study design, sample, data collected, key findings, and quality rating. RESULTS: Factors that may influence managers' support include their organization's management structure, senior leadership support, their expected roles, training on health topics, and their beliefs and attitudes toward wellness programs and employee health. Managers' support may influence the organizational culture, employees' perception of support, and employees' behaviors. CONCLUSIONS: When designing interventions, health promotion practitioners and researchers should consider strategies that target senior, middle, and line managers' support. Interventions need to include explicit measures of managers' support as part of the evaluation plan.

Supporting the Health of Low Socioeconomic Status Employees: Qualitative Perspectives From Employees and Large Companies.

OBJECTIVE: The aim of this study was to identify alignments between wellness offerings low socioeconomic status (SES) employees need and those large companies can provide. METHODS: Focus groups (employees); telephone interviews (large companies). Employees were low-SES, insured through their employers, and employed by large Washington State companies. Focus groups covered perceived barriers to healthy behaviors at work and potential support from companies. Interviews focused on priorities for employee health and challenges reaching low-SES employees. RESULTS: Seventy-seven employees participated in eight focus groups; 12 companies completed interviews. Employees identified facilitators and barriers to healthier work environments; companies expressed care for employees, concerns about employee obesity, and reluctance to discuss SES. CONCLUSION: Our findings combine low-SES employee and large company perspectives and indicate three ways workplaces could most effectively support low-SES employee health: create healthier workplace food environments; prioritize onsite physical activity facilities; use clearer health communications.

Readiness to Change Over Time: Change Commitment and Change Efficacy in a Workplace Health-Promotion Trial.

INTRODUCTION: Organizational readiness to change may be a key determinant of implementation success and a mediator of the effectiveness of implementation interventions. If organizational readiness can be reliably and validly assessed at the outset of a change initiative, it could be used to assess the effectiveness of implementation-support activities by measuring changes in readiness factors over time. METHODS: We analyzed two waves of readiness-to-change survey data collected as part of a three-arm, randomized controlled trial to implement evidence-based health promotion practices in small worksites in low-wage industries. We measured five readiness factors: context (favorable broader conditions); change valence (valuing health promotion); information assessment (demands and resources to implement health promotion); change commitment (an intention to implement health promotion); and change efficacy (a belief in shared ability to implement health promotion). We expected commitment and efficacy to increase at intervention sites along with their self-reported effort to implement health promotion practices, termed wellness-program effort. We compared means between baseline and 15 months, and between intervention and control sites. We used linear regression to test whether intervention and control sites differed in their change-readiness scores over time. RESULTS: Only context and change commitment met reliability thresholds. Change commitment declined significantly for both control (-0.39) and interventions sites (-0.29) from baseline to 15 months, while context did not change for either. Only wellness program effort at 15 months, but not at baseline, differed significantly between control and intervention sites (1.20 controls, 2.02 intervention). Regression analyses resulted in two significant differences between intervention and control sites in changes from baseline to 15 months: (1) intervention sites exhibited significantly smaller change in context scores relative to control sites over time and (2) intervention sites exhibited significantly higher changes in wellness program effort relative to control sites. DISCUSSION: Contrary to our hypothesis, change commitment declined significantly at both Healthlinks and control sites, even as wellness-program effort increased significantly at HealthLinks sites. Regression to the mean may explain the decline in change commitment. Future research needs to assess whether baseline commitment is an independent predictor of wellness-program effort or an effect modifier of the HealthLinks intervention.