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Review logic model
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Figure 1

Review logic model

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Study selection flow diagram.
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Figure 2

Study selection flow diagram.

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Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
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Figure 3

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
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Figure 4

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Forest plot of comparison: 1 Implementation strategy versus control, outcome: 1.1 Implementation score.
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Figure 5

Forest plot of comparison: 1 Implementation strategy versus control, outcome: 1.1 Implementation score.

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Comparison 1 Implementation strategy versus control, Outcome 1 Implementation score.
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Analysis 1.1

Comparison 1 Implementation strategy versus control, Outcome 1 Implementation score.

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Summary of findings for the main comparison. Summary of findings: strategies to improve the implementation of workplace‐based health promotion versus no implementation strategy

Strategies to improve the implementation of workplace‐based health promotion versus no implementation strategy: findings from randomised controlled trials

Patient or population: workplace employees

Settings: any work setting, of any employment sector and geographical location, staffed by employees

Intervention: any strategy (e.g. educational materials; educational meetings; audit and feedback; local opinion leaders; tailored intervention) with the intention of improving the implementation of health‐promoting policies or practices targeting diet, physical activity, obesity, tobacco use and alcohol use in the workplace setting

Comparison: no intervention e.g. wait‐list, usual practice or minimal support control (4 trials)

Summary of findings for the main comparison were based on included randomised trials only.

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

Number of participants
(trials)

Certainty of the evidence
(GRADE)

Comments

Risk with no intervention

Risk with implementation interventions

Implementation of workplace‐based policies or practices targeting diet, physical activity, obesity, tobacco use or alcohol use

The mean implementation score was 42.1a

The implementation score in the intervention group was 0.1 lower (3.8 lower to 3.5 higher)

Scores estimated using a standardised mean difference of −0.01 (−0.32 to 0.30) and a standard deviation of 11.8a

191

workplaces
(3 RCTs)

⊕⊕⊝⊝
Lowb,c

One RCT that compared a workplace cafeteria nutrition intervention to a wait‐list control could not be synthesised in the meta‐analysis (Bandoni 2010). The trial reported a significant improvement on the single primary measure of implementation included in the review.

One RCT reported additional dichotomous implementation outcomes that could not be synthesised in the meta‐analysis (Biener 1999). The trial reported a significant improvement on 1 out of 3 implementation outcomes included in the review.

Employee dietary intake

—

—

—

19,419 participants

(2 RCTs)

⊕⊝⊝⊝
Very lowb,d,e

Mixed results were reported for this outcome. One RCT found a workplace cafeteria nutrition intervention effective in increasing fruit and vegetable consumption (Bandoni 2010). The other RCT found a worksite cancer control intervention effective in decreasing dietary intake of fat and increasing fruit and vegetable intake; however, it was not effective in increasing fibre consumption (Biener 1999).

Employee tobacco use

—

—

—

18,205 participants

(1 RCT)

⊕⊕⊝⊝
lowb,c

One RCT which compared a worksite cancer control intervention to a minimal support control group reported no effect on smoking prevalence or the proportion of smokers who quit (Biener 1999).

Employee physical activity, weight status, and alcohol use

No RCTs reported these outcomes.

Cost or cost‐effectiveness

—

—

—

46 workplaces

(1 RCT)

⊕⊕⊝⊝
Lowc,f

One RCT reported an increase in employer costs in the implementation intervention group compared to the control group (Hannon 2012).

Unintended adverse effects

No RCTs reported this outcome.

GRADE Working Group grades of evidence
High certainty: further research is very unlikely to change our confidence in the estimate of effect.
Moderate certainty: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low certainty: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low certainty: we are very uncertain about the estimate.

aWe used the postintervention mean and standard deviation of the control group from Hannon 2012 for the risk with no intervention to re‐express the SMD in terms of a mean implementation score.
bDowngraded one level for risk of bias – most information comes from studies at unclear or high risk of bias for most criteria.
cDowngraded one level for imprecision – sample size < 400.
dDowngraded one level for inconsistency – results in both directions.
eDowngraded one level for imprecision – the confidence intervals contained the null value and upper CI crosses SMD of 0.5.
fDowngraded one level for high probability of publication bias – no other studies reported assessing cost‐effectiveness, selective reporting suspected.

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Summary of findings for the main comparison. Summary of findings: strategies to improve the implementation of workplace‐based health promotion versus no implementation strategy
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Table 1. Summary of workplace settings, interventions, outcomes and effects for included trials: implementation strategies versus no intervention

Trial (study design)

Workplace setting

Intervention and comparison (sample sizes)

Implementation outcomes and effects

Secondary outcomes and effects

Bandoni 2010

(RCT)

Workplaces predominantly from industrial sector

Region: Brazil

Educational meetings and educational materials (15 workplaces; 630 employees)

vs

Wait‐list control (14 workplaces; 584 employees)

Quantity fruits and vegetables in lunch meals (g/meal), measured via food service manager self‐reported survey (validity NR). Greater increase in intervention (adjusted MD 49.05 g, 95% CI 8.38 to 89.71)

Employee fruit and vegetable consumption (g/day), measured via self‐reported survey (validity NR). Slightly greater increase in intervention (adjusted effect estimate 11.75 g, 95% CI 2.73 to 20.77)

Beresford 2010

(RCT)

Small‐ to medium‐sized workplaces in manufacturing, transportation and utilities, and personal and household services industries

Region: USA

Tailored intervention; local opinion leaders; local consensus process and educational materials (17 workplaces; n employees NR)

vs

Wait‐list control (17 workplaces; n employees NR)

Implementation of 11 practices supportive of healthy eating, physical activity and weight control, measured via scores derived from environmental assessment checklist (validity NR). NS difference 9/11 practices. Higher scores in intervention for notices encouraging physical activity (adjusted effect estimate 0.33, 95% CI 0.00 to 0.85) and healthy eating (0.40, 95% CI 0.00 to 1.46)

NR

Biener 1999

(RCT)

Workplaces from manufacturing, communications, public service and utilities sectors

Region: USA

Local opinion leaders; local consensus process; educational meetings; and educational outreach visits (55 workplaces; 8914 employees)

vs

Minimal support control comprising printed health promotion materials (56 workplaces; 9291 employees)

Workplace tobacco control policy restrictiveness and compliance, measured via scores derived from employee self‐reported survey (validity NR). NS difference restrictiveness: adjusted difference 0.01 (SE 0.09) or compliance: 0.03 (SE 0.07)

% workplaces reporting improvement in cafeteria and vending machine nutrition labelling and healthy catering policy, measured via organisational informant interview (validity NR). NS difference cafeteria labelling (MD 13.4%, P = 0.72) or catering policy (MD 10.9%, P = 0.30). Greater improvement in intervention vending machine labelling (MD 39.6%, P < 0.01)

Employee smoking prevalence and % of quitters, measured via self‐reported survey (validity NR). NS difference in prevalence (difference −0.66%, 95% CI −3.0 to 1.2) or quit rate (1.53%, 95% CI −1.0 to 3.7)

% dietary energy from fat, % increase in fibre (g/1000 kcal, and % increase in fruit and vegetables (servings/day), measured via Block FFQ (validated). Greater increase in intervention fruit and vegetables (adjusted increase 5.6%, SE 1.3, P < 0.001) and % dietary fat lower (adjusted difference −0.35%, SE 0.16, P < 0.05). NS difference fibre (adjusted increase 1.7%, SE 0.87, P > 0.05)

Hannon 2012

(RCT)

Low‐wage, mid‐sized workplaces predominantly from education, health, manufacturing and retail sectors

Region: USA

Audit and feedback; clinical practice guidelines; local consensus process; educational materials; educational outreach; and tailored intervention (23 workplaces; n employees NR)

vs

Wait‐list control (23 workplaces; n employees NR)

Implementation of 16 best practices for health promotion recommended by CPSTF Community Guide; measured via score derived from workplace self‐reported survey (validity NR). NS difference in total score mean (SD): intervention baseline 31.5 (8.3), follow‐up 39.2 (11.2) vs control baseline 36.8 (11.7), follow‐up 42.1 (11.8), P = 0.33

Workplace costs (per worker) for health promotion, measured via workplace self‐reported survey (validity NR). Costs increased slightly more in intervention, mean total costs (range): intervention baseline USD 8.30 (0.00 to 35.00), follow‐up USD 10.10 (0.00 to 53.00) vs control baseline USD 11.00 (0.00 to 53.00), follow‐up USD 11.80 (1.00 to 43.00)

Parker 2010

(non‐randomised, controlled trial)

Manufacturing, research and development and administrative facilities from a large science and technology company

Region: USA

Moderate‐intensity intervention: tailored intervention; local opinion leaders; educational meetings

(4 workplaces; 382 employees)

or

High‐intensity intervention: moderate strategies + local consensus process; audit and feedback; monitoring of performance; and other (5 workplaces; 1520 employees)

vs

Wait‐list control (3 workplaces; 529 employees)

Implementation of policies and practices promoting healthy eating, physical activity and weight control, measured via scores derived from EAT (validated tool). Relative to control, greater increase in total EAT score for moderate intensity intervention (contrast estimate 9.68, SE 3.48, P = 0.009) and high intensity intervention (16.99, SE 3.37, P < 0.001)

% employees classified high risk poor nutrition and poor physical activity, measured via self‐reported HRA survey. Relative to control, NS difference for poor nutrition: moderate (estimate −7.7%, P = 0.068), high (−4.6%, P = 0.16), or poor physical activity: moderate (−1.6%, P = 0.77) or high (−0.7%, P = 0.89)

Weight (kg), BMI (kg/m2) and % employees overweight or obese. Relative to control, greater reduction in weight for moderate (estimate −2.1, P = 0.033), high (−1.5, P = 0.015) and in BMI moderate (−0.3, P = 0.034), high (−0.2, P = 0.008). NS difference % obese: moderate (0.1%, P = 0.88), high (0.3%, P =0.95), or % overweight: moderate (4.4%, P = 0.47); high (5.5%, P = 0.22)

BMI: body mass index; CI: confidence interval; CPSTF: Community Preventive Services Task Force, US Department of Health and Human Services; EAT: environmental assessment tool;FFQ: food frequency questionnaire; HRA: health risk assessment; MD: mean difference; NR: not reported; NS: not significant; RCT: randomised controlled trial; SD: standard deviation; SE: standard error.

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Table 1. Summary of workplace settings, interventions, outcomes and effects for included trials: implementation strategies versus no intervention
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Table 2. Summary of workplace settings, interventions, outcomes and effects for included trials: implementation strategy versus another implementation strategy

Trial (study design)

Workplace setting

Intervention and comparison (sample sizes)

Implementation outcomes and effects

Secondary outcomes and effects

Jones 2015

(non‐randomised trial)

NHS trusts including ambulance, mental health and acute care

Region: UK

Cohort C1: clinical practice guidelines and audit and feedback (26 workplaces; n employees NR)

vs

Cohort B: clinical practice guidelines; audit and feedback; educational meetings; and tailored intervention (36 workplaces; n employees NR)

Implementation of 6 sets NICE guidance for workplace health promotion addressing: obesity, physical activity, smoking, long‐term sickness absence and mental health, measured via score on organisational audit self‐reported by staff (validity NR). Greater increase in score for cohort B (adjusted median total score difference: 22.17 vs 4.94, P < 0.001)

NR

Parker 2010

(non‐randomised controlled trial)

Manufacturing, research and development and administrative facilities from a large science and technology company

Region: USA

Moderate‐intensity intervention: tailored intervention; local opinion leaders; educational meetings

(4 workplaces; 382 employees)

or

High‐intensity intervention: moderate strategies + local consensus process; audit and feedback; monitoring of performance; and other (5 workplaces; 1520 employees)

Implementation of workplace policies and practices promoting healthy eating, physical activity and weight control, measured via scores derived from EAT (validated tool). Greater increase in total EAT score for high‐intensity intervention (contrast estimate 7.31, SE 3.10, P = 0.024)

NR

EAT: environmental assessment tool; NHS: National Health Service; NICE: National Institute of Clinical Excellence; NR: not reported; SE: standard error.

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Table 2. Summary of workplace settings, interventions, outcomes and effects for included trials: implementation strategy versus another implementation strategy
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Table 3. Definition of EPOC subcategories utilised in the review

EPOC subcategory

Definition

Audit and feedback

A summary of health workers' performance over a specified period of time, given to them in a written, electronic or verbal format. The summary may include recommendations for clinical action.

Clinical practice guidelines

Clinical guidelines are systematically developed statements to assist healthcare providers and patients to decide on appropriate health care for specific clinical circumstances (US Institute of Medicine).

Educational materials

Distribution to individuals, or groups, of educational materials to support clinical care, i.e. any intervention in which knowledge is distributed. For example this may be facilitated by the Internet, learning critical appraisal skills; skills for electronic retrieval of information, diagnostic formulation; question formulation

Educational meetings

Courses, workshops, conferences or other educational meetings

Educational outreach visits

Personal visits by a trained person to health workers in their own settings, to provide information with the aim of changing practice

Local consensus process

Formal or informal local consensus processes, for example agreeing a clinical protocol to manage a patient group, adapting a guideline for a local health system or promoting the implementation of guidelines

Local opinion leaders

The identification and use of identifiable local opinion leaders to promote good clinical practice

Monitoring the performance of the delivery of healthcare

Monitoring of health services by individuals or healthcare organisations, for example by comparing with an external standard

Tailored interventions

Interventions to change practice that are selected based on an assessment of barriers to change, for example through interviews or surveys.

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Table 3. Definition of EPOC subcategories utilised in the review
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Comparison 1. Implementation strategy versus control

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Implementation score Show forest plot

3

164

Std. Mean Difference (Random, 95% CI)

‐0.01 [‐0.32, 0.30]
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Comparison 1. Implementation strategy versus control
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