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Meta-Analysis of Workplace Physical Activity Interventions

      Context

      Most adults do not achieve adequate physical activity levels. Despite the potential benefits of worksite health promotion, no previous comprehensive meta-analysis has summarized health and physical activity behavior outcomes from such programs. This comprehensive meta-analysis integrated the extant wide range of worksite physical activity intervention research.

      Evidence acquisition

      Extensive searching located published and unpublished intervention studies reported from 1969 through 2007. Results were coded from primary studies. Random-effects meta-analytic procedures, including moderator analyses, were completed in 2008.

      Evidence synthesis

      Effects on most variables were substantially heterogeneous because diverse studies were included. Standardized mean difference (d) effect sizes were synthesized across approximately 38,231 subjects. Significantly positive effects were observed for physical activity behavior (0.21); fitness (0.57); lipids (0.13); anthropometric measures (0.08); work attendance (0.19); and job stress (0.33). The significant effect size for diabetes risk (0.98) is less robust given small sample sizes. The mean effect size for fitness corresponds to a difference between treatment minus control subjects' means on VO2max of 3.5 mL/kg/min; for lipids, −0.2 on the ratio of total cholesterol to high-density lipoprotein; and for diabetes risk, −12.6 mg/dL on fasting glucose.

      Conclusions

      These findings document that some workplace physical activity interventions can improve both health and important worksite outcomes. Effects were variable for most outcomes, reflecting the diversity of primary studies. Future primary research should compare interventions to confirm causal relationships and further explore heterogeneity.

      Introduction

      Although strong evidence shows that exercisers are healthier than non-exercisers, most adults do not perform enough physical activity to achieve health and well-being benefits.
      • Troiano R.P.
      • Berrigan D.
      • Dodd K.W.
      • et al.
      Physical activity in the United States measured by accelerometer.
      Workplaces may implement physical programs in hopes of keeping workers healthy and reducing healthcare costs.
      • Golaszewski T.
      The limitations and promise of health education in managed care.
      Because employed adults spend about half of their workday waking hours at workplaces, offering physical activity programs at work may be an efficient strategy to increase physical actvity.
      • Dishman R.K.
      • Oldenburg B.
      • O'Neal H.
      • Shephard R.J.
      Worksite physical activity interventions.
      • Engbers L.H.
      • van Poppel M.N.
      • Paw M.J.
      • van Mechelen W.
      Worksite health promotion programs with environmental changes: a systematic review.
      • Proper K.I.
      • Koning M.
      • van der Beek A.J.
      • Hildebrandt V.H.
      • Bosscher R.J.
      • van Mechelen W.
      The effectiveness of worksite physical activity programs on physical activity, physical fitness, and health.
      Convenience, group support, existing patterns of formal and informal communication among employees in a worksite, and possible corporate behavior norms are potential advantages of worksite programs over other approaches.
      • Marcus B.H.
      • Forsyth L.H.
      How are we doing with physical activity?.
      • Shephard R.
      Worksite fitness and exercise programs: a review of methodology and health impact.
      • Pratt C.A.
      Findings from the 2007 Active Living Research conference implications for future research.
      Workplace programs may be especially important because the imbalance between physical activity and energy intake at work may contribute to the obesity epidemic.
      • Engbers L.H.
      • van Poppel M.N.
      • Paw M.J.
      • van Mechelen W.
      Worksite health promotion programs with environmental changes: a systematic review.
      This meta-analysis addresses the need to quantitatively synthesize the rapidly growing literature reporting workplace physical activity programs.
      Despite the potential health and economic benefits of worksite health promotion,
      • Golaszewski T.
      The limitations and promise of health education in managed care.
      no previous comprehensive meta-analysis has summarized health and physical activity behavior outcomes from these programs. Several previous narrative reviews were limited in scope and unable to address either the magnitude of outcomes or potential workplace moderators of outcomes.
      • Engbers L.H.
      • van Poppel M.N.
      • Paw M.J.
      • van Mechelen W.
      Worksite health promotion programs with environmental changes: a systematic review.
      • Proper K.I.
      • Koning M.
      • van der Beek A.J.
      • Hildebrandt V.H.
      • Bosscher R.J.
      • van Mechelen W.
      The effectiveness of worksite physical activity programs on physical activity, physical fitness, and health.
      • Janer G.
      • Sala M.
      • Kogevinas M.
      Health promotion traits at worksites and risk factors for cancer.
      • Matson–Koffman D.M.
      • Brownstein J.N.
      • Neiner J.A.
      • Greaney M.L.
      A site-specific literature review of policy and environmental interventions that promote physical activity and nutrition for cardiovascular health: what works?.
      The broadest narrative review was conducted using studies published before 1995.
      • Shephard R.J.
      Worksite fitness and exercise programs: a review of methodology and health impact.
      Two previous meta-analyses addressed physical activity behavior outcomes across some studies included in this project. One 1998 meta-analysis of 26 studies reported an effect size consistent with a standardized mean difference of 0.22, which was not significantly different from zero. The authors noted that their attempted moderator analyses suffered from inadequate statistical power.
      • Dishman R.K.
      • Oldenburg B.
      • O'Neal H.
      • Shephard R.J.
      Worksite physical activity interventions.
      A 1996 meta-analysis synthesized data for diverse adults and reported a workplace effect size consistent with a standardized mean difference of 0.35.
      • Dishman R.K.
      • Buckworth J.
      Increasing physical activity: a quantitative synthesis.
      This meta-analysis moves beyond the previous reported quantitative syntheses by greatly expanding the search strategies to ensure a more comprehensive synthesis, addressing both physical activity behavior and health outcomes, examining work-related outcomes, and conducting exploratory moderator analyses. The research questions were as follows: (1) What are the overall effects of interventions to increase physical activity on physical activity behavior; health (fitness, lipids, anthropometric measures, diabetes risk); well-being (quality of life, mood); and work-related outcomes (work attendance, healthcare utilization, job stress, and job satisfaction)? (2) Do interventions' effects on outcomes vary depending on workplace characteristics? (3) What are the effects of interventions on outcomes among studies comparing treatment subjects before versus after interventions?

      Methods

      Standard strategies for quantitative systematic reviews were used to locate and secure potential primary studies, determine eligibility, extract data from research reports, meta-analyze primary study results, and interpret findings.

      Search Strategies to Locate Primary Reports

      A comprehensive search was completed using multiple strategies to move beyond previous reviews and limit bias.
      • Conn V.S.
      • Isaramalai S.
      • Rath S.
      • Jantarakupt P.
      • Wadhawan R.
      • Dash Y.
      Beyond MEDLINE for literature searches.
      An experienced health sciences reference librarian used broad search terms in 11 computerized databases (e.g., MEDLINE, PsychINFO, EMBASE, Cochrane Controlled Trials Register, Dissertation Abstracts International). Multiple research registers were examined, including NIH Computer Retrieval of Information on Scientific Projects; Australian/New Zealand Clinical Trials Registry; and mRCT, which has 14 active registers and 16 archived registers. Computerized database searches on principal investigators of funded studies and on the first three authors of eligible primary studies were completed. Hand searches were conducted in 114 journals. Ancestry searches were completed on previous reviews and eligible studies. These comprehensive search strategies yielded 7251 papers, reports, and reviews that were examined to locate eligible primary studies.

      Inclusion Criteria

      Primary studies of interventions to increase physical activity that were reported in English between 1969 and late 2007 were included. Reports with adequate data to calculate an effect size for at least three subjects were included. Studies that focused on chronically ill workers were excluded. Published and unpublished studies were eligible because syntheses using only published studies may overestimate the effect size.
      • Conn V.S.
      • Valentine J.C.
      • Cooper H.M.
      • Rantz M.J.
      Grey literature in meta-analyses.
      Small-sample studies, which often lack statistical power to detect treatment effects, were included because they may report on novel interventions or may include difficult-to-recruit subjects.
      • Conn V.S.
      • Valentine J.C.
      • Cooper H.M.
      • Rantz M.J.
      Grey literature in meta-analyses.
      Studies with varied designs were included. RCTs may be especially difficult to implement at worksites because of employee resistance to randomization and potential contamination among workers with extensive contact.
      • Shephard R.J.
      Worksite fitness and exercise programs: a review of methodology and health impact.
      Some pre-experimental studies compare programs developed at workplaces. Some investigators find it unethical to withhold treatment when interventions are thought to be beneficial.
      • Brown S.A.
      • Upchurch S.
      • Anding R.
      • Winter M.
      • Ramirez G.
      Promoting weight loss in type II diabetes.
      Separate analyses were conducted for single-group and two-group comparisons. A richer variety of interventions and samples were included by using unpublished reports, small-sample studies, and pre-experimental research.

      Data Coding and Analysis

      A coding frame to record primary study characteristics and results was developed, pilot tested, and refined. Company size, profit versus nonprofit status, and whether multiple companies were included in the study, were coded. The extent of worksite involvement in the intervention was coded in two ways: whether the interventionist was a workplace employee and if the worksite designed the intervention. Other coded data included whether interventions were delivered during employees' paid time, whether data were collected at the workplace, whether interventions included fitness facilities at worksites, and whether some form of organizational policy change occurred in association with interventions. Interventions could include motivational or educational sessions or supervised exercise sessions.
      A priori lists of outcome measures were used to select from among multiple possible measures reported in primary studies, as a way of avoiding coder or author bias. For example, if studies presented both objective ergometer (step-counter) measures and self-reports of physical activity, the ergometer values were coded. Physical activity behavior was recorded only if the study clearly measured physical activity behavior separate from any interventionist-supervised exercise. Fitness was coded as oxygen consumption (VO2max). Lipid measures included total cholesterol, high-density lipoproteins, or the ratio of total cholesterol to high-density lipoproteins. BMI, weight, abdominal girth, and percent body fat were coded for anthropometric measures. Both quality of life and mood (e.g., depression, anxiety) were assessed with self-report measures. Diabetes risk was measured as fasting glucose or insulin levels. Work attendance and health services utilization measures were derived from company records. Job satisfaction and stress were coded from self-report instruments. The data that were reported most distally from completion of the intervention were recorded, because persistence of intervention effects is most important for long-term benefits to health. To ensure analysis of only independent samples, author lists were cross-checked to locate reports that might contain overlapping samples. When possible, multiple papers describing the same study were used to code comprehensive data. Coding was not masked because evidence indicates it does not decrease bias.
      • Berlin J.A.
      Does blinding of readers affect the results of meta-analyses? University of Pennsylvania Meta-analysis Blinding Study Group.
      Data calculations were handled by standard meta-analytic approaches using standardized mean difference (d) effect size weighted by inverse of variance. Exploratory moderator analyses were conducted among two-group post-intervention comparisons. Many potential moderators could not be analyzed because too few studies reported the necessary information (e.g., company focus, such as manufacturing). Analysis details are available from the authors.

      Results

      Approximately 38,231 subjects participated in the studies included in the meta-analysis (k=206 comparisons, s=138 reports).
      Research Group of the Rome Project of Coronary Heart Disease Prevention
      Eight-year follow-up results from the Rome Project of Coronary Heart Disease Prevention.
      • Adams T.D.
      • Yanowitz F.G.
      • Chandler S.
      • et al.
      A study to evaluate and promote total fitness among fire fighters.
      • Aittasalo M.
      • Miilunpalo S.
      • Suni J.
      The effectiveness of physical activity counseling in a work-site setting A randomized, controlled trial.
      • Aldana S.
      • Barlow M.
      • Smith R.
      • et al.
      A worksite diabetes prevention program: two-year impact on employee health.
      • Aldana S.G.
      • Jacobson B.H.
      • Harris C.J.
      • Kelley P.L.
      • Stone W.J.
      Influence of a mobile worksite health promotion program on health care costs.
      • Aldana S.G.
      • Jacobson B.H.
      • Kelley P.L.
      • Quirk M.
      The effectiveness of a mobile worksite health promotion program in lowering employee health risk.
      • Alexy B.
      Goal setting and health risk reduction.
      • Allen J.G.
      • Delistraty D.A.
      Influence of a hospital-based wellness program on employee fitness.
      • Altekruse E.B.
      • Wilmore J.H.
      Changes in blood chemistries following a controlled exercise program.
      • Anderson R.C.
      • Anderson K.E.
      Positive changes and worksite health education.
      • Angotti C.M.
      • Chan W.T.
      • Sample C.J.
      • Levine M.S.
      Combined dietary and exercise intervention for control of serum cholesterol in the workplace.
      • Atlantis E.
      • Chow C.M.
      • Kirby A.
      • Singh M.F.
      An effective exercise-based intervention for improving mental health and quality of life measures: a randomized controlled trial.
      • Baer J.T.
      Improved plasma cholesterol levels in men after a nutrition education program at the worksite.
      • Barfield B.R.
      Evaluation of the effects of health risk appraisals and health promotion teaching on lifestyle behaviors.
      • Bassey E.J.
      • Patrick J.M.
      • Irving J.M.
      • Blecher A.
      • Fentem P.H.
      An unsupervised “aerobics” physical training programme in middle-aged factory workers: feasibility, validation and response.
      • Bauer R.L.
      • Heller R.F.
      • Challah S.
      United Kingdom heart disease prevention project: 12-year follow-up of risk factors.
      • Bennett B.
      • Schlichting C.
      • Bondi K.
      Cardiorespiratory fitness and cognitive performance before and after confinement in a nuclear submarine.
      • Bjurstrom L.A.
      • Alexiou N.G.
      A program of heart disease intervention for public employees A five year report.
      • Blair S.N.
      • Smith M.
      • Collingwood T.R.
      • Reynolds R.
      • Prentice M.C.
      • Sterling C.L.
      Health promotion for educators: impact on absenteeism.
      • Blissmer B.
      • McAuley E.
      Testing the requirements of stages of physical activity among adults: the comparative effectiveness of stage-matched, mismatched, standard care, and control interventions.
      • Boudreau F.
      • Godin G.
      • Pineau R.
      • Bradet R.
      Health risk appraisal in an occupational setting and its impact on exercise behavior.
      • Bowne D.
      • Russell M.
      • Morgan J.
      • Optenberg S.
      • Clarke A.
      Reduced disability and health care costs in an industrial fitness program.
      • Brand R.
      • Schlicht W.
      • Grossmann K.
      • Duhnsen R.
      Effects of a physical exercise intervention on employees' perceptions of quality of life: a randomized controlled trial.
      • Brownell K.D.
      • Bachorik P.S.
      • Ayerle R.S.
      Changes in plasma lipid and lipoprotein levels in men and women after a program of moderate exercise.
      • Brox J.I.
      • Froystein O.
      Health-related quality of life and sickness absence in community nursing home employees: randomized controlled trial of physical exercise.
      • Bruno R.
      • Arnold C.
      • Jacobson L.
      • Winick M.
      • Wynder E.
      Randomized controlled trial of a nonpharmacologic cholesterol reduction program at the worksite.
      • Campbell M.K.
      • Tessaro I.
      • DeVellis B.
      • et al.
      Effects of a tailored health promotion program for female blue-collar workers: health works for women.
      • Cardinal B.J.
      • Sachs M.L.
      Effects of mail-mediated, stage-matched exercise behavior change strategies on female adults' leisure-time exercise behavior.
      • Cash T.L.
      Effects of different exercise promotion strategies and stage of exercise on reported physical activity, self-motivation, and stages of exercise in worksite employees.
      • Chaney C.
      Effects of an employee fitness and lifestyle modification program upon health care costs, absenteeism, and job satisfaction.
      • Cohen R.Y.
      • Stunkard A.J.
      • Felix M.R.
      Comparison of three worksite weight-loss competitions.
      • Coleman K.J.
      • Raynor H.R.
      • Mueller D.M.
      • Cerny F.J.
      • Dorn J.M.
      • Epstein L.H.
      Providing sedentary adults with choices for meeting their walking goals.
      • Cook C.
      • Simmons G.
      • Swinburn B.
      • Stewart J.
      Changing risk behaviours for non-communicable disease in New Zealand working men—is workplace intervention effective?.
      • Cook R.F.
      • Back A.S.
      • Trudeau J.
      • McPherson T.
      Integrating substance abuse prevention into health promotion programs in the workplace: a social cognitive intervention targeting the mainstream user.
      • Cook R.F.
      • Billings D.W.
      • Hersch R.K.
      • Back A.S.
      • Hendrickson A.
      A field test of a web-based workplace health promotion program to improve dietary practices, reduce stress, and increase physical activity: randomized controlled trial.
      • Croteau K.A.
      A preliminary study on the impact of a pedometer-based intervention on daily steps.
      • Croteau K.A.
      • Young C.J.
      Effectiveness of a Navy remedial exercise intervention.
      • Dennis K.E.
      • Pane K.W.Adams
      • Qi B.B.
      The impact of a shipboard weight control program.
      • Eddy J.M.
      • Eynon D.
      • Nagy S.
      • Paradossi P.J.
      Impact of a physical fitness program in a blue-collar workforce.
      • Elliot D.L.
      • Goldberg L.
      • Duncan T.E.
      • et al.
      The PHLAME firefighters' study: feasibility and findings.
      • Fardy P.
      • Ilmarinem J.
      Evaluating the effects and feasibility of an at work stairclimbing intervention program for men.
      • Fukahori M.
      • Aono H.
      • Saito I.
      • Ikebe T.
      • Ozawa H.
      Program of exercise training as total health promotion plan and its evaluation.
      • Furukawa F.
      • Kazuma K.
      • Kawa M.
      • et al.
      Effects of an off-site walking program on energy expenditure, serum lipids, and glucose metabolism in middle-aged women.
      • Furuki K.
      • Honda S.
      • Jahng D.
      • Ikeda M.
      • Okubo T.
      The effects of a health promotion program on body mass index.
      • Geise J.M.
      The relation of a health promotion program to the cardiovascular health of fire fighters.
      • Gerdle B.
      • Brulin C.
      • Elert J.
      • Eliasson P.
      • Granlund B.
      Effect of a general fitness program on musculoskeletal symptoms, clinical status, physiological capacity, and perceived work environment among home care service personnel.
      • Gettman L.
      • Pollock M.
      • Ward A.
      Adherence to unsupervised exercise.
      • Goetzel R.
      • Sepulveda M.
      • Knight K.
      • et al.
      Association of IBM's “A Plan for Life” health promotion program with changes in employees' health risk status.
      • Gold D.B.
      • Anderson D.R.
      • Serxner S.A.
      Impact of a telephone-based intervention on the reduction of health risks.
      • Gomez-Merino D.
      • Chennaoui M.
      • Drogou C.
      • Bonneau D.
      • Guezennec C.Y.
      Decrease in serum leptin after prolonged physical activity in men.
      • Grandjean P.W.
      • Oden G.L.
      • Crouse S.F.
      • Brown J.A.
      • Green J.S.
      Lipid and lipoprotein changes in women following 6 months of exercise training in a worksite fitness program.
      • Griffin C.S.
      Evaluation of social cognitive versus motivationally-tailored self-help physical activity interventions.
      • Gronningsaeter H.
      • Hytten K.
      • Skauli G.
      • et al.
      Improved health and coping by physical exercise or cognitive behavioral stress management training in a work environment.
      • Hager R.L.
      • Hardy A.
      • Aldana S.G.
      • George J.D.
      Evaluation of an Internet, stage-based physical activity intervention.
      • Hallam J.S.
      • Petosa R.
      The long-term impact of a four-session work-site intervention on selected social cognitive theory variables linked to adult exercise adherence.
      • Halvorsen I, D.K.
      The effects of power circuit exercise training and health education on fitness and health status, and on risk factors for cardiovascular disease in a worksite health promotion program for men and women in the exercise deficient state.
      • Hanlon P.
      • McEwen J.
      • Carey L.
      • et al.
      Health checks and coronary risk: further evidence from a randomised controlled trial.
      • Hannah T.E.
      • Kozma A.
      • Stones M.
      • Mosher D.
      • Vardy L.
      Effects on mood of a life-styles program for the rehabilitation of injured workers.
      • Harma M.
      • Ilmarinen J.
      • Knauth P.
      • et al.
      Physical training intervention in female shift workers: I. The effects of intervention of fitness, fatigue, sleep, and psychosomatic symptoms.
      • Harrell J.S.
      • Griggs T.R.
      • Roskin E.W.
      • Meibohm A.R.
      • Williams O.D.
      Impact of a 12-week aerobic exercise and weight program for law enforcement trainees.
      • Harvey H.L.
      An evaluation of RMH Health Club.
      • Heath G.W.
      • Broadhurst C.B.
      Effects of exercise training and dietary behavior modification on weight reduction and lipoprotein lipids in female hospital employees.
      • Hendriksen I.J.M.
      • Zuiderveld B.
      • Kemper H.C.G.
      • Bezemer P.D.
      Effect of commuter cycling on physical performance of male and female employees.
      • Henritze J.
      • Brammell H.L.
      • McGloin J.
      LIFECHECK: a successful, low touch, low tech, in-plant, cardiovascular disease risk identification and modification program.
      • Horowitz S.M.
      Effects of a worksite wellness program on absenteeism and health care costs in a small federal agency.
      • Horowitz S.M.
      • Kissam T.
      • Riegel M.
      • Laflin M.T.
      • Sonne L.
      Results of a pilot health promotion program on non-facility based sales personnel.
      • Hubball
      Development and evaluation of a worksite health promotion rpgram: application of critical self-directed learning for exercise behavior change.
      • Ilmarinen J.
      • Ilmarinen R.
      • Koskela A.
      • et al.
      Training effects of stair-climbing during office hours on female employees.
      • Jette M.
      • Bishop D.
      • Baron R.
      Effects of Project Health on the lifestyle of senior government officials.
      • Jette M.
      • Sidney K.
      The benefits and challenges of a fitness and lifestyle enhancement program for correctional officers.
      • Kerr J.H.
      • Vos M.C.
      Employee fitness programmes, absenteeism and general well-being.
      • Kerr N.A.
      • Yore M.M.
      • Ham S.A.
      • Dietz W.H.
      Increasing stair use in a worksite through environmental changes.
      • King A.C.
      • Talyor C.B.
      • Haskell W.L.
      • DeBusk R.F.
      Influence of regular aerobic exercise on psychological health: a randomized, controlled trial of healthy middle-aged adults.
      • Knapik J.
      • Hauret K.G.
      • Arnold S.
      • et al.
      Injury and fitness outcomes during implementation of physical readiness training.
      • Knapik J.J.
      The influence of physical fitness training on the manual material handling capability of women.
      • Kneip J.K.
      • Fox H.M.
      • Fruehling J.K.
      A weight-control program for bank employees.
      • Kraemer W.J.
      • Vescovi J.D.
      • Volek J.S.
      • et al.
      Effects of concurrent resistance and aerobic training on load-bearing performance and the Army physical fitness test.
      • Lampman R.M.
      • Santinga J.T.
      • Savage P.J.
      • et al.
      Effect of exercise training on glucose tolerance, in vivo insulin sensitivity, lipid and lipoprotein concentrations in middle-aged men with mild hypertriglyceridemia.
      • Lane A.
      • Mills M.
      • Terry P.
      Mood regulation among corporate workers: effects of exercise on mood.
      • Leaf D.A.
      • Parker D.L.
      • Schaad D.
      Changes in VO2max, physical activity, and body fat with chronic exercise: effects on plasma lipids.
      • Li C.L.
      • Tseng H.M.
      • Tseng R.F.
      • Lee S.J.
      The effectiveness of an aerobic exercise intervention on worksite health-related physical fitness—a case in a high-tech company.
      • Loughlan C.
      • Mutrie N.
      An evaluation of the effectiveness of three interventions in promoting physical activity in a sedentary population.
      • Love M.
      • Morphis L.
      • Page P.
      Model for an employee wellness project.
      • Maes S.
      • Verhoeven C.
      • Kittel F.
      • Scholten H.
      Effects of a Dutch work-site wellness-health program: the Brabantia Project.
      • Maloney J.P.
      • Cheney R.
      • Spring W.
      • Kanusky J.
      The physiologic and psychological effects of a 5-week and a 16-week physical fitness program.
      • Marshall A.L.
      • Leslie E.R.
      • Bauman A.E.
      • Marcus B.H.
      • Owen N.
      Print versus website physical activity programs: a randomized trial.
      • Mayo M.J.
      • Grantham J.R.
      • Balasekaran G.
      Exercise-induced weight loss preferentially reduces abdominal fat.
      • McKenzie P.F.
      Effects of a nutrition-based health promotion program on nutritional adequacy, planned physical activity, body composition, job performance, and absenteeism among female airline reservationists.
      • Murphy M.H.
      • Murtagh E.M.
      • Boreham C.A.G.
      • Hare L.G.
      • Nevill A.M.
      The effect of a worksite based walking programe on cardiovascular risk in previously sedentary civil servants.
      • Musich S.
      • Adams L.
      • DeWolf G.
      • Edington D.
      A case study of 10-year health risk appraisal participation patterns in a comprehensive health promotion program.
      • Muto T.
      • Yamauchi K.
      Evaluation of a multicomponent workplace health promotion program conducted in Japan for improving employees' cardiovascular disease risk factors.
      • Napolitano M.A.
      • Fotheringham M.
      • Tate D.
      • et al.
      Evaluation of an Internet-based physical activity intervention: a preliminary investigation.
      • Nilsson P.M.
      • Klasson E.-B.
      • Nyberg P.
      Life-style intervention at the worksite—reduction of cardiovascular risk factors in a randomized study.
      • Nisbeth O.
      • Klausen K.
      • Andersen L.B.
      Effectiveness of counselling over 1 year on changes in lifestyle and coronary heart disease risk factors.
      • Norris R.
      • Carroll D.
      • Cochrane R.
      The effects of aerobic and anaerobic training on fitness, blood pressure, and psychological stress and well-being.
      • Oden G.
      • Crouse S.F.
      • Reynolds C.
      Worker productivity, job satisfaction, and work-related stress: Influence of an employee fitness program.
      • Ohta M.
      • Okufuji T.
      • Matsushima Y.
      • Ikeda M.
      The effect of lifestyle modification on physical fitness and work ability in different workstyles.
      • Okada K.
      Effects of long-term corporate fitness program on employees' health.
      • O'Loughlin J.
      • Renaud L.
      • Paradis G.
      • Meshefedjian G.
      Screening school personnel for cardiovascular disease risk factors: short-term impact on behavior and perceived role as promoters of heart health.
      • Orr N.
      The effects of a university based employee health promotion program on cardiovascular risk profiles.
      • Osteras H.
      • Hammer S.
      The effectiveness of a pragmatic worksite physical activity program on maximal oxygen consumption and the physical activity level in healthy people.
      • Ostwald S.K.
      Changing employees' dietary and exercise practices: an experimental study in a small company.
      • Partonen T.
      • Leppamaki S.
      • Hurme J.
      • Lonnqvist J.
      Randomized trial of physical exercise alone or combined with bright light on mood and health–related quality of life.
      • Patton J.
      • Vogel J.
      • Bedynek J.
      • Alexander D.
      • Albright R.
      Response of age forty and over military personnel to an unsupervised, self-administered aerobic training program.
      • Pescatello L.S.
      • Murphy D.
      • Vollono J.
      • Lynch E.
      • Bernene J.
      • Costanzo D.
      The cardiovascular health impact of an incentive worksite health promotion program.
      • Peterson P.M.
      The relationship between wellness program participation, job satisfaction, health perceptions and physical symptoms of stress.
      • Peterson T.R.
      • Aldana S.G.
      Improving exercise behavior: an application of the stages of change model in a worksite setting.
      • Plotnikoff R.C.
      • McCargar L.J.
      • Wilson P.M.
      • Loucaides C.A.
      Efficacy of an e-mail intervention for the promotion of physical activity and nutrition behavior in the workplace context.
      • Pohjonen T.
      • Ranta R.
      Effects of a worksite physical exercise intervention on physical fitness, perceived health status, and work ability among home care workers: five-year follow-up.
      • Pritchard J.E.
      • Nowson C.A.
      • Billington T.
      • Wark J.D.
      Benefits of a year-long workplace weight loss program on cardiovascular risk factors.
      • Proper K.I.
      • Hildebrandt V.H.
      • Van der Beek A.J.
      • Twisk J.W.R.
      • Van Mechelen W.
      Effect of individual counseling on physical activity fitness and health: a randomized controlled trial in a workplace setting.
      • Purath J.
      • Miller A.M.
      • McCabe G.
      • Wilbur J.
      A brief intervention to increase physical activity in sedentary working women.
      • Puterbaugh J.S.
      • Lawyer C.H.
      Cardiovascular effects of an exercise program: a controlled study among firemen.
      • Rhodes E.C.
      • Dunwoody D.
      Physiological and attitudinal changes in those involved in an employee fitness program.
      • Roberts M.A.
      • O'Dea J.
      • Boyce A.
      • Mannix E.T.
      Fitness levels of firefighter recruits before and after a supervised exercise training program.
      • Robison J.I.
      • Rogers M.A.
      • Carlson J.J.
      • et al.
      Effects of a 6-month incentive-based exercise program on adherence and work capacity.
      • Rodnick J.E.
      Health behavior changes associated with health hazard appraisal counseling in an occupational setting.
      • Saltin B.
      • Hartley I.H.
      • Kilbom A.
      • Astrand I.
      Physical training in sedentary middle-aged and older men: II. Oxygen uptake, heart rate, and blood lactate concentration at submaximal and maximal exercise.
      • Schultz A.B.
      • Lu C.
      • Barnett T.E.
      • et al.
      Influence of participation in a worksite health-promotion program on disability days.
      • Sherman J.B.
      • Clark L.
      • McEwen M.M.
      Evaluation of a worksite wellness program: impact on exercise, weight, smoking, and stress.
      • Simmons D.
      • Fleming C.
      • Cameron M.
      • Leakehe L.
      A pilot diabetes awareness and exercise programme in a multiethnic workforce.
      • Spate-Douglas T.
      • Keyser R.E.
      Exercise intensity: its effect on the high-density lipoprotein profile.
      • Speck B.J.
      • Looney S.W.
      Effects of a minimal intervention to increase physical activity in women: daily activity records.
      • Stein R.A.
      • Michielli D.W.
      • Glantz M.D.
      • et al.
      Effects of different exercise training intensities on lipoprotein cholesterol fractions in healthy middle-aged men.
      • Stone W.J.
      • Rothstein D.E.
      • Shoenhair C.L.
      Coronary health disease risk factors and health related fitness in long-term exercising versus sedenatry corporate executives.
      • Stonecipher L.J.
      • Hyner G.C.
      The effects of a comprehensive health risk appraisal, basic screening, and interpretation session on employee health practices: differences between participants and nonparticipants.
      • Talvi A.I.
      • Jarvisalo J.O.
      • Knuts L.R.
      A health promotion programme for oil refinery employees: changes of health promotion needs observed at three years.
      • Tate D.F.
      • Wing R.R.
      • Winett R.A.
      Using Internet technology to deliver a behavioral weight loss program.
      • Van Rhenen W.
      • Blonk R.W.B.
      • van der Klink J.J.L.
      • van Dijk F.J.H.
      • Schaufeli W.B.
      The effect of a cognitive and a physical stress-reducing programme on psychological complaints.
      • Vazquez J.M.M.
      • Garcia Alcon J.L.
      • Campillo Alvarez J.E.
      Influence of diet and physical exercise on plasma lipid concentrations in an homogeneous sample of young Spanish Air Force pilots.
      • Von Schlumperger B.
      Formation and maintenance of an exercise habit: an exploratory study of a self-management approach.
      • Williams A.G.
      Effects of basic training in the British Army on regular and reserve army personnel.
      • Williams A.G.
      • Rayson M.P.
      • Jones D.A.
      Resistance training and the enhancement of the gains in material-handling ability and physical fitness of British Army recruits during basic training.
      • Wilson L.F.M.
      The effects of an exercise conditioning program on reducing the stress response in nurses.
      • Wittmann A.
      Body composition in an employee health improvement program.
      • Wood E.
      • Olmstead G.
      • Craig J.
      An evaluation of lifestyle risk factors and absenteeism after two years in a worksite health promotion program.
      • Yarvote P.M.
      • McDonagh T.J.
      • Goldman M.E.
      Organization and evaluation of a physical fitness program in industry.
      • Zandee G.L.
      • Oermann M.H.
      Effectiveness of contigency contracting: component of a worksite weight loss program.
      • Blair S.N.
      • Collingwood T.R.
      • Reynolds R.
      • Smith M.
      • Hagan R.D.
      • Sterling C.L.
      Health promotion for educators: impact on health behaviors, satisfaction, and general well-being.
      Independent two-group post-test effect sizes included data from 24,520 subjects (k=94, s=71); two-group pre–post effect sizes, from 14,630 subjects (k=80, s=59); and pre–post treatment group comparisons, from 22,413 subjects (k=192, s=125). Sample sizes varied dramatically from 12 to 5038 subjects.
      • Heath G.W.
      • Broadhurst C.B.
      Effects of exercise training and dietary behavior modification on weight reduction and lipoprotein lipids in female hospital employees.
      • Blair S.N.
      • Collingwood T.R.
      • Reynolds R.
      • Smith M.
      • Hagan R.D.
      • Sterling C.L.
      Health promotion for educators: impact on health behaviors, satisfaction, and general well-being.
      Multiple treatment groups were common: 34, ten, three, and one paper(s) reported on two, three, four, and six treatment groups, respectively. Twelve unpublished dissertations and one unpublished presentation paper were included. Many studies reported funding (s=59). One report was disseminated before 1970, five in the 1970s, 35 in the 1980s, 49 in the 1990s, and 48 were disseminated after 2000. The earliest study was reported in 1969 and the most recent study in 2007. Analyses were completed in 2008.
      Among the studies that reported details about worksites, 55 were for-profit and 50 were not-for-profit companies. Most papers did not report company size (s=80). Among the papers reporting this information, the vast majority were large companies (at least 750 employees), with only five described as small (fewer than 100 employees). Most studies were conducted in single companies at one location (s=87), 17 used multiple locations of one company, and 23 conducted studies at multiple companies. The most common types of companies were education or health services (s=37); government (s=32); and manufacturing (s=17). Few studies reported whether study data were collected at the worksite; among those providing this information, 51 collected data at the workplace and 14 did not. Interventions were more often delivered at the workplace (s=51) than in other locations (s=21). Nearly all of the studies recruited subjects at the worksite (s=121). Only 32 papers reported that interventions were delivered during employees' paid time. Most studies used interventionists employed by the research project (s=101) instead of workplace employees. Only six studies reported including an organizational-level policy change, such as providing free or reduced memberships to fitness centers not located at the worksite. Twenty-six studies involved workplace employees in designing interventions. Thirty-eight papers reported on interventions that included fitness facilities at the worksite. Supervised exercise was used in 27% of the studies while 80% used motivational or educational sessions. Further details about interventions are found in Table 1.
      Table 1Intervention characteristics
      VariableReports (s)MinQ1MedianQ3Max
      Minutes/session of supervised exercise447325060160
      Number of supervised exercise sessions4542836602028
      Frequency/week of supervised exercise47133314
      Minutes/session of motivational content3210306060240
      Number of motivational sessions1011149390
      Days over which intervention was delivered145142841834179
      Recommend frequency of unsupervised physical activity4723457
      Recommend minutes/session of unsupervised physical activity36530304590
      Note: Interventions could include supervised exercise or motivational and educational content to increase physical activity.
      s, reports; min, minimum; max, maximum; Q1, first quartile; Q3, third quartile
      Visual and statistical assessment of funnel-plot asymmetry, as an indicator of possible publication bias, suggested substantial evidence of asymmetry for physical activity, fitness, lipids, and diabetes risk, especially for single-group comparisons. Evidence of asymmetry was weaker but still notable for anthropometric measures and mood. Because of the relatively few effect sizes on quality of life, health services utilization, work attendance, job stress, and job satisfaction, evidence for or against funnel-plot asymmetry was inconclusive for these variables.

      Effects of Interventions on Physical Activity Behavior, Health, and Well-Being

      Table 2 presents the overall effects of interventions on physical activity, health, and well-being outcomes. The findings should be interpreted with caution given the small number of studies or subjects for some outcomes. For physical activity behavior, the mean overall effect at post-test comparison in two-group studies was 0.21. The two-group pre–post effect and treatment group pre–post comparisons were of comparable magnitude. The Common Language Effect Size (CLES) of 0.56 for the two-group post-test effect size indicates that 56% of the time a random treatment subject would have a higher physical activity score than a random control subject (all CLES values reported are based on a random-effects mean effect size for two-group post-test comparisons). To enhance interpretability, mean physical activity effect sizes were transformed to steps/day using means and SD from appropriate reference groups. For two-group post-test comparisons, the raw mean difference was 612, which corresponds to a final steps/day mean of 8869 for treatment subjects versus 8257 for control subjects. The homogeneity test and estimated between-studies SD (Q and σ̂δ in Table 2) demonstrated significant heterogeneity for all physical activity behavior comparison types. The I2 value (Table 2), the percentage of total variation among studies' observed effect sizes that is due to heterogeneity rather than sampling of participants, also documents significant heterogeneity.
      Table 2Random effects of health and well-being outcome estimates and tests
      Dependent variablekμ̂δ (M of true ESs; 95% CI)Q (heterogeneity)σ̂δ (SD of ESs)I2 (heterogeneity index)
      Physical activity
       Two-group post-test410.21
      p<0.001 (for Q and μδ)
       (0.11, 0.31)
      102.8
      p<0.001 (for Q and μδ)
      0.2060.61
       Two-group pre–post270.22
      p<0.001 (for Q and μδ)
       (0.14, 0.29)
      86.3
      p<0.001 (for Q and μδ)
      0.1460.70
       Treatment pre–post560.26
      p<0.001 (for Q and μδ)
       (0.20, 0.32)
      728.4
      p<0.001 (for Q and μδ)
      0.2060.92
      Fitness
       Two-group post-test350.57
      p<0.001 (for Q and μδ)
       (0.40, 0.73)
      75.3
      p<0.001 (for Q and μδ)
      0.3060.55
       Two-group pre–post350.51
      p<0.001 (for Q and μδ)
       (0.39, 0.63)
      77.6
      p<0.001 (for Q and μδ)
      0.2580.56
       Treatment pre–post850.47
      p<0.001 (for Q and μδ)
       (0.38, 0.56)
      1656.8
      p<0.001 (for Q and μδ)
      0.3670.95
      Diabetes risk
       Two-group post-test60.98
      p<0.05,
       (0.06, 1.90)
      84.0
      p<0.001 (for Q and μδ)
      1.1000.94
       Two-group pre–post60.90
      p<0.01,
       (0.27, 1.53)
      76.0
      p<0.001 (for Q and μδ)
      0.7480.93
       Treatment pre–post190.31
      p<0.001 (for Q and μδ)
       (0.16, 0.47)
      223.2
      p<0.001 (for Q and μδ)
      0.3010.92
      Lipids
       Two-group post-test270.13
      p<0.05,
       (0.02, 0.24)
      51.3
      p<0.01,
      0.1640.49
       Two-group pre–post260.17
      p<0.05,
       (0.01, 0.33)
      299.2
      p<0.001 (for Q and μδ)
      0.3580.92
       Treatment pre–post690.12
      p<0.001 (for Q and μδ)
       (0.08, 0.17)
      623.9
      p<0.001 (for Q and μδ)
      0.1580.89
      Anthropometric
       Two-group post-test440.08
      p<0.05,
       (0.02, 0.15)
      59.3
      p<0.05,
      0.0860.27
       Two-group pre–post410.07
      p<0.001 (for Q and μδ)
       (0.03, 0.11)
      42.10.0300.05
       Treatment pre–post1260.13
      p<0.001 (for Q and μδ)
       (0.10, 0.17)
      708.8
      p<0.001 (for Q and μδ)
      0.1430.82
      Quality of life
       Two-group post-test70.23 (−0.09, 0.56)19.8
      p<0.01,
      0.3400.70
       Two-group pre–post60.35
      p<0.10,
       (−0.03, 0.73)
      39.9
      p<0.001 (for Q and μδ)
      0.4460.87
       Treatment pre–post100.24
      p<0.001 (for Q and μδ)
       (0.15, 0.32)
      18.7
      p<0.05,
      0.0870.52
      Mood
       Two-group post-test120.13 (−0.05, 0.31)14.90.1460.26
       Two-group pre–post70.21
      p<0.01,
       (0.07, 0.36)
      7.90.0960.24
       Treatment pre–post210.31
      p<0.001 (for Q and μδ)
       (0.22, 0.40)
      123.6
      p<0.001 (for Q and μδ)
      0.1690.84
      Note: Under homogeneity (H0: δi=δ for all studies), Q is distributed approximately as χ2 with df=k−1, where k is the number of observed effect sizes; this test also applies to the between-studies variance component, σδ2 (H0: σδ2=0). Treatment group pre–post and two-group pre–post effects assume ρ12=0.8. Boldface indicates significance.
      ES, effect size
      p<0.10,
      low asterisk p<0.05,
      low asterisklow asterisk p<0.01,
      low asterisklow asterisklow asterisk p<0.001 (for Q and μδ)
      Fitness outcomes also were significantly better among treatment than control subjects, and better at post-test when treatment subjects' pre- and post-intervention scores were compared. Mean effect sizes ranged from 0.47 to 0.57 (CLES=0.66). As with steps/day for physical activity, the mean effect size on fitness was transformed to maximal oxygen consumption (VO2max). For two-group comparisons, the raw mean difference was 3.5, which corresponds to, for example, a final VO2max mean of 37.7 mL/kg/min for treatment subjects versus 34.2 mL/kg/min for control subjects. Fitness effect sizes were significantly heterogeneous, which indicates that some studies found significantly better fitness outcomes than other studies.
      Diabetes risk was significantly reduced by interventions. Mean effect sizes for the two-group comparisons were 0.90 to 0.98 (CLES=0.76). For two-group studies, the calculated raw mean difference was −12.6, corresponding to a post-intervention fasting glucose mean of 81.0 mg/dL for treatment subjects versus 93.6 mg/dL for control subjects. Both mean values are within the range considered normal fasting glucose levels. Diabetes risk effect sizes exhibited significant substantial heterogeneity. Diabetes risk findings should be considered tentative given the small number of studies that reported this variable (k=6).
      Lipid and anthropometric effect sizes were more modest but positive, indicating better scores following interventions among treatment subjects. Lipids mean effect sizes ranged from 0.12 to 0.17 (CLES=0.54). In terms of the ratio of total cholesterol to high-density lipoprotein, the raw mean difference was −0.2, such as from a mean post-intervention ratio of 4.6 for treatment versus 4.8 for control. All of the lipids effect sizes were significantly heterogeneous. Anthropometric mean effect sizes for treatment subjects varied from 0.07 to 0.13 (CLES=0.52). For the two-group comparison in terms of BMI, the raw mean difference was −0.3, which would occur if the post-intervention BMI mean were 25.0 for treatment versus 25.3 for control. Anthropometric effect sizes were significantly heterogeneous, except the two-group pre–post comparisons.
      Mean effect sizes for both quality of life (0.23) and mood (0.13) two-group comparisons were positive, indicating better outcomes among treatment subjects, but these did not reach significance. Effect sizes for two-group pre–post and pre–post effects were significant, with improved quality-of-life and mood scores following interventions. Most of the quality-of-life and mood effect sizes exhibited significant heterogeneity.

      Effects of Physical Activity Interventions on Work-Related Variables

      Estimates and tests for work-related outcomes are reported in Table 3. The two-group post-test comparison of work attendance documented that, on average, treatment subjects had lower mean absenteeism than control subjects (effect size=0.19, CLES=0.55). Although the direction of the effect was similar, mean effect sizes were smaller for both two-group pre–post effects and treatment group pre–post comparisons. Job stress was significantly lower at follow-up among treatment subjects than control subjects (effect size=0.33, CLES=0.59). Job stress effect sizes were positive for other comparisons but were not significant. Job satisfaction was significantly greater following interventions among treatment subjects than controls in the two-group pre–post effect analysis (effect size=0.20, CLES=0.54), but similar findings did not achieve significance for the two-group post-test analysis. Effect sizes for most comparison types on most outcomes were significantly heterogeneous, as documented by Q, estimated between-studies SDs, and I2 values.
      Table 3Random effects work-related outcome estimates and tests
      Dependent variablekμ̂δ (mean of true ESs; 95% CI)Q (heterogeneity)σ̂δ (SD of ESs)I2 (heterogeneity index)
      Work attendance
       Two-group post-test120.19
      p<0.001 (for Q and μδ)
       (0.11, 0.27)
      7.300.00
       Two-group pre–post90.05 (−0.19, 0.29)74.1
      p<0.001 (for Q and μδ)
      0.3280.89
       Treatment pre–post100.02 (−0.08, 0.13)34.8
      p<0.001 (for Q and μδ)
      0.1350.74
      Job stress
       Two-group post-test30.33
      p<0.10,
       (−0.06, 0.73)
      3.40.2240.41
       Two-group pre–post30.53 (−0.15, 1.22)21.1
      p<0.001 (for Q and μδ)
      0.5750.91
       Treatment pre–post50.14 (−0.07, 0.34)20.7
      p<0.001 (for Q and μδ)
      0.2040.81
      Job satisfaction
       Two-group post-test60.15 (−0.10, 0.40)9.00.2020.44
       Two-group pre–post50.20
      p<0.01,
       (0.06, 0.35)
      3.300.00
       Treatment pre–post60.08 (−0.09, 0.25)26.3
      p<0.001 (for Q and μδ)
      0.1810.81
      Healthcare utilization
       Two-group post-test5−0.17
      p<0.01,
       (−0.29, −0.06)
      0.200.00
       Two-group pre–post3−0.18 (−0.54, 0.17)7.9
      p<0.05,
      0.2640.75
       Treatment pre–post3−0.04 (−0.11, 0.02)0.900.00
      Note: Under homogeneity (H0: δi=δ for all studies), Q is distributed approximately as χ2 with df=k−1, where k is the number of (possibly dependent) observed effect sizes; this test also applies to the between-studies variance component, σδ2 (H0: σδ2=0). Treatment group pre–post and two-group pre–post effects all assume ρ12=0.8.
      ES, effect size
      p<0.10,
      low asterisk p<0.05,
      low asterisklow asterisk p<0.01,
      low asterisklow asterisklow asterisk p<0.001 (for Q and μδ)
      Healthcare utilization two-group post-test analyses revealed significantly higher healthcare utilization among treatment subjects than among control subjects (effect size=−0.17, CLES=0.45). The two-group pre–post effect estimate was of similar magnitude (−0.18) but not significant. The pre–post comparison for treatment subjects revealed no utilization differences. Healthcare effect sizes were more homogeneous than most other variables in the project. Findings regarding job stress, job satisfaction, and healthcare utilization should be viewed as tentative given the small numbers of studies that reported these variables (k in Table 3).

      Moderator Analyses

      Analyses of potential workplace moderators were conducted for variables with sufficient cases: physical activity behavior, fitness, lipids, and anthropometric variables. Dichotomous moderator results are presented in Table 4. Profit versus nonprofit company status was not significantly linked with mean effect size for any variable (QB in Table 4). Neither company size nor whether multiple companies were included in the study were significant moderators of mean effect sizes on physical activity behavior, fitness, lipids, or anthropometric outcomes. Three-level moderator analyses were conducted for numbers of companies and locations (results available from first author): The only significant effect was for anthropometric effect size, with significantly higher mean effect size for interventions conducted in one multi-location company (0.22) than in other combinations of numbers of companies and locations (both 0.04).
      Table 4Independent-group comparison mixed-effects analysis on four major variables
      Moderatork0k1μ̂δ0 (mean of true ES)μ̂δ1 (mean of true ES)QBetween groups (heterogeneity)QWithin groups (heterogeniety)σ̂δ (SD of ESs)I2 (heterogeneity index)
      Physical activity
       Profit status16160.120.220.989.2
      p<0.001 (for QB and QW)
      0.2230.66
       Large company4150.290.220.241.6
      p<0.001 (for QB and QW)
      0.2280.58
       Multiple companies24130.250.151.1109.5
      p<0.001 (for QB and QW)
      0.2220.68
       Data collected at WP5110.270.180.338.9
      p<0.001 (for QB and QW)
      0.2460.63
       Intervention delivered at WP19220.220.170.4113.6
      p<0.001 (for QB and QW)
      0.2170.65
       Paid during intervention3740.210.011.3112.2
      p<0.001 (for QB and QW)
      0.2090.65
       Employee interventionist3370.190.130.3106.7
      p<0.001 (for QB and QW)
      0.2110.64
       WP-designed intervention3830.180.290.5105.9
      p<0.001 (for QB and QW)
      0.2050.63
       Fitness facility onsite3290.190.220.1113.2
      p<0.001 (for QB and QW)
      0.2110.65
      Fitness
       Profit status1790.680.660.053.9
      p<0.001 (for QB and QW)
      0.4010.55
       Large company550.580.660.113.9
      p<0.10,
      0.2720.38
       Multiple companies2150.540.610.148.0
      p<0.01,
      0.3380.49
       Data collected at WP3100.470.520.011.90.1040.00
       Intervention delivered at WP19160.560.610.165.5
      p<0.001 (for QB and QW)
      0.3310.49
       Recruitment at WP5300.500.590.265.5
      p<0.001 (for QB and QW)
      0.3320.49
       Paid during intervention2780.490.925.4
      p<0.05,
      53.9
      p<0.05,
      0.2670.38
       Employee interventionist2750.501.036.4
      p<0.05,
      49.4
      p<0.05,
      0.2650.38
       WP-designed intervention2840.491.1810.5
      p<0.01,
      45.1
      p<0.05,
      0.2350.32
       Fitness facility onsite23120.530.680.862.8
      p<0.01,
      0.3180.47
      Lipids
       Profit status11130.200.110.546.4
      p<0.01,
      0.1650.52
       Large company37−0.040.190.928.7
      p<0.001 (for QB and QW)
      0.1810.71
       Multiple companies1740.100.120.029.9
      p<0.10,
      0.1420.34
       Intervention delivered at WP11160.100.170.348.8
      p<0.01,
      0.1640.48
       Recruitment at WP3240.030.150.744.6
      p<0.01,
      0.1480.43
       Paid during intervention2160.090.251.650.4
      p<0.01,
      0.1700.49
       Employee interventionist2030.090.596.6
      p<0.05,
      42.6
      p<0.01,
      0.1520.50
       Organizational policy change2430.110.220.750.0
      p<0.01,
      0.1680.49
       WP-designed intervention2030.110.291.243.9
      p<0.01,
      0.1760.51
       Fitness facility onsite16110.070.323.8
      p<0.10,
      48.3
      p<0.01,
      0.1550.47
      Anthropometric outcome
       Profit status18190.180.091.044.30.0860.19
       Large company3120.070.080.024.9
      p<0.05,
      0.1160.46
       Multiple companies2290.040.050.035.30.0690.15
       Intervention delivered at WP24200.050.173.1
      p<0.10,
      48.90.0630.12
       Recruitment at WP7370.100.090.055.1
      p<0.10,
      0.0890.22
       Paid during intervention32120.020.228.1
      p<0.01,
      44.50.0380.03
       Employee interventionist3460.050.326.1
      p<0.05,
      45.10.0640.14
       Organizational policy change4040.030.246.5
      p<0.05,
      45.90.0470.06
       WP-designed intervention3370.060.223.9
      p<0.05,
      45.90.0730.15
       Fitness facility onsite31130.050.243.9
      p<0.05,
      49.10.0630.13
      Note: kj=number of (possibly dependent) ES estimates in group coded j. Moderator levels: 0=no, 1=yes. Heterogeneity statistics: QB=between groups (distributed as χ2 on df=1 under H0: μδ0=μδ1); QW=combined within groups (distributed as χ2 on df=k0+k1−2 under H0: σδ02=σδ12=0). Weighted method of moments used to estimate between-studies variance component σδ2. Analysis reported if k0≥3 and k1≥3.
      ES, effect size; WP, workplace
      p<0.10,
      low asterisk p<0.05,
      low asterisklow asterisk p<0.01,
      low asterisklow asterisklow asterisk p<0.001 (for QB and QW)
      Intervention delivery at the worksite or elsewhere was significant only for anthropometric effect sizes, such that interventions delivered at workplaces yielded a larger mean effect size (0.17) than in those delivered elsewhere (0.05). Whether employees received interventions on company paid time was significant for two of the four outcomes: Studies with employees paid during intervention reported larger mean effect sizes than those with employees receiving interventions outside company paid time on both fitness (0.92 vs 0.49) and anthropometric measures (0.22 vs 0.02). Interventions with employee interventionists were more effective than those with others as interventionists for fitness (1.03 vs 0.50); lipids (0.59 vs 0.09); and anthropometric measures (0.32 vs 0.05). Workplace participation in designing the interventions, as compared to interventions designed by people not employed by the worksite, was significant for fitness (1.18 vs 0.49) and anthropometric outcomes (0.22 vs 0.06) but not for lipids or physical activity behavior. Neither recruitment nor data collection location (workplace versus elsewhere) was related to variables with adequate data for moderator analyses.
      The presence of a fitness facility onsite in the workplace did not affect mean effect sizes on fitness or physical activity behavior. Studies with onsite fitness facilities reported larger mean effect sizes on lipids (0.32) than studies without such facilities (0.07). Anthropometric outcomes also yielded larger mean effect sizes among studies with onsite facilities (0.24) than in those without facilities (0.05). Organizational policy change could be analyzed for lipids and anthropometric outcomes only. Lipid effect sizes were unrelated to policy changes while anthropometric outcomes yielded significantly larger mean effect sizes in studies with policy changes (0.24) than in those without policy changes (0.03). Whereas for physical activity behavior, fitness, and lipids, nearly all moderators left significant residual heterogeneity (QW in Table 4), all but two moderators left nonsignificant residual heterogeneity for anthropometric outcomes. Results of exploratory multiple moderator analyses are available from the corresponding author.

      Discussion

      These findings document that some interventions improve physical activity in some subjects, and these changes may in turn improve selected health outcomes, work culture, and job stress. However, significant heterogeneity requires cautious interpretation of findings.
      The physical activity mean effect size of 0.21 is similar to that reported in 26 worksite studies (r=0.11, d=0.22)
      • Dishman R.K.
      • Oldenburg B.
      • O'Neal H.
      • Shephard R.J.
      Worksite physical activity interventions.
      and smaller than the effect size reported of 33 workplace studies (r=0.17, d=0.35).
      • Dishman R.K.
      • Buckworth J.
      Increasing physical activity: a quantitative synthesis.
      This might reflect more comprehensive searching that could have located more studies with small effect sizes. Previous workplace quantitative syntheses have not addressed health, well-being, or work-related outcomes of improved physical activity; the present study therefore constitutes the first published report of the impact of physical activity interventions on these variables. This meta-analysis moved beyond previously reported syntheses by comprehensively searching to obtain far more studies, separating effect sizes for one- and two-group designs, and conducting moderator analyses on two-group studies.
      • Dishman R.K.
      • Oldenburg B.
      • O'Neal H.
      • Shephard R.J.
      Worksite physical activity interventions.
      The results of single-moderator analyses should be interpreted cautiously given the potential for confounding of moderators.
      Improvement in fitness was documented with an effect size of 0.57. The magnitude of physical activity, fitness, and health benefits appears modest, and it is unclear if the physical activity dose was sufficient to improve health to meet public health goals.
      • Proper K.I.
      • Koning M.
      • van der Beek A.J.
      • Hildebrandt V.H.
      • Bosscher R.J.
      • van Mechelen W.
      The effectiveness of worksite physical activity programs on physical activity, physical fitness, and health.
      This meta-analysis was limited by the number of studies located with sufficient data to calculate effect sizes and substantial heterogeneity among studies. Physical activity interventions varied widely, as did methods for assessing some variables. For example, physical activity was rarely objectively measured, leading to difficulties in comparisons across interventions.
      Although findings on improved work attendance, job satisfaction, and job stress were mixed, this study suggests that some physical activity programs are effective beyond direct health benefits. Even modest reductions in absenteeism may result in substantial fiscal savings when multiplied by many employees. The findings regarding health utilization should be interpreted cautiously given the very small sample size and the inadequate time between interventions and utilization measurement among these studies. Some programs may have conducted health screening prior to encouraging subjects to begin exercising, which might have prompted needed health care.
      • Musich S.
      • Adams L.
      • DeWolf G.
      • Edington D.
      A case study of 10-year health risk appraisal participation patterns in a comprehensive health promotion program.
      Longer follow-up studies could determine the enduring economic impact of programs.

      Conclusion

      Well-designed studies evaluating worksite physical activity promotion programs are needed. Direct comparisons between programs that allow employees to participate on paid work time versus those that do not should be investigated. Also necessary are direct comparisons of programs with and without worksite fitness facilities to determine whether the cost of providing onsite facilities is justified by improvements in employee health and productivity. Investigations targeting at-risk subjects would determine whether interventions need to be tailored to specific subgroups of employees. Investigations should also examine the impact of interventions on important worksite-related outcomes that influence worker productivity, including absenteeism, stress levels, and job satisfaction.
      Financial support was provided by a grant from the NIH (R01NR009656) to Vicki Conn, principal investigator. The content is solely the responsibility of the authors and does not necessarily represent the official views of NIH.
      No financial disclosures were reported by the authors of this paper.

      References

        • Troiano R.P.
        • Berrigan D.
        • Dodd K.W.
        • et al.
        Physical activity in the United States measured by accelerometer.
        Med Sci Sports Exerc. 2008; 40: 181-188
        • Golaszewski T.
        The limitations and promise of health education in managed care.
        Health Educ Behav. 2000; 27: 402-416
        • Dishman R.K.
        • Oldenburg B.
        • O'Neal H.
        • Shephard R.J.
        Worksite physical activity interventions.
        Am J Prev Med. 1998; 15: 344-361
        • Engbers L.H.
        • van Poppel M.N.
        • Paw M.J.
        • van Mechelen W.
        Worksite health promotion programs with environmental changes: a systematic review.
        Am J Prev Med. 2005; 29: 61-70
        • Proper K.I.
        • Koning M.
        • van der Beek A.J.
        • Hildebrandt V.H.
        • Bosscher R.J.
        • van Mechelen W.
        The effectiveness of worksite physical activity programs on physical activity, physical fitness, and health.
        Clin J Sport Med. 2003; 13: 106-117
        • Marcus B.H.
        • Forsyth L.H.
        How are we doing with physical activity?.
        Am J Health Promot. 1999; 14: 118-124
        • Shephard R.
        Worksite fitness and exercise programs: a review of methodology and health impact.
        Am J Health Promot. 1996; 10: 436-452
        • Pratt C.A.
        Findings from the 2007 Active Living Research conference implications for future research.
        Am J Prev Med. 2008; 34: 366-368
        • Janer G.
        • Sala M.
        • Kogevinas M.
        Health promotion traits at worksites and risk factors for cancer.
        Scand J Work Environ Health. 2002; 28: 141-157
        • Matson–Koffman D.M.
        • Brownstein J.N.
        • Neiner J.A.
        • Greaney M.L.
        A site-specific literature review of policy and environmental interventions that promote physical activity and nutrition for cardiovascular health: what works?.
        Am J Health Promot. 2005; 19: 167-193
        • Shephard R.J.
        Worksite fitness and exercise programs: a review of methodology and health impact.
        Am J Health Promot. 1996; 10: 436-452
        • Dishman R.K.
        • Buckworth J.
        Increasing physical activity: a quantitative synthesis.
        Med Sci Sports Exerc. 1996; 28: 706-719
        • Conn V.S.
        • Isaramalai S.
        • Rath S.
        • Jantarakupt P.
        • Wadhawan R.
        • Dash Y.
        Beyond MEDLINE for literature searches.
        J Nurs Scholarsh. 2003; 35: 177-182
        • Conn V.S.
        • Valentine J.C.
        • Cooper H.M.
        • Rantz M.J.
        Grey literature in meta-analyses.
        Nurs Res. 2003; 52: 256-261
        • Brown S.A.
        • Upchurch S.
        • Anding R.
        • Winter M.
        • Ramirez G.
        Promoting weight loss in type II diabetes.
        Diabetes Care. 1996; 19: 613-624
        • Berlin J.A.
        Does blinding of readers affect the results of meta-analyses?.
        Lancet. 1997; 350 ([see comment]): 185-186
        • Research Group of the Rome Project of Coronary Heart Disease Prevention
        Eight-year follow-up results from the Rome Project of Coronary Heart Disease Prevention.
        Prev Med. 1986; 15: 176-191
        • Adams T.D.
        • Yanowitz F.G.
        • Chandler S.
        • et al.
        A study to evaluate and promote total fitness among fire fighters.
        J Sports Med Phys Fitness. 1986; 26: 337-345
        • Aittasalo M.
        • Miilunpalo S.
        • Suni J.
        The effectiveness of physical activity counseling in a work-site setting.
        Patient Educ Couns. 2004; 55: 193-202
        • Aldana S.
        • Barlow M.
        • Smith R.
        • et al.
        A worksite diabetes prevention program: two-year impact on employee health.
        AAOHN J. 2006; 54: 389-395
        • Aldana S.G.
        • Jacobson B.H.
        • Harris C.J.
        • Kelley P.L.
        • Stone W.J.
        Influence of a mobile worksite health promotion program on health care costs.
        Am J Prev Med. 1993; 9: 378-383
        • Aldana S.G.
        • Jacobson B.H.
        • Kelley P.L.
        • Quirk M.
        The effectiveness of a mobile worksite health promotion program in lowering employee health risk.
        Am J Health Promot. 1994; 8: 254-256
        • Alexy B.
        Goal setting and health risk reduction.
        Nurs Res. 1985; 34: 283-288
        • Allen J.G.
        • Delistraty D.A.
        Influence of a hospital-based wellness program on employee fitness.
        Health Values. 1987; 11: 11-14
        • Altekruse E.B.
        • Wilmore J.H.
        Changes in blood chemistries following a controlled exercise program.
        J Occup Med. 1973; 15: 110-113
        • Anderson R.C.
        • Anderson K.E.
        Positive changes and worksite health education.
        Psychol Rep. 1994; 74: 607-610
        • Angotti C.M.
        • Chan W.T.
        • Sample C.J.
        • Levine M.S.
        Combined dietary and exercise intervention for control of serum cholesterol in the workplace.
        Am J Health Promot. 2000; 15: 9-16
        • Atlantis E.
        • Chow C.M.
        • Kirby A.
        • Singh M.F.
        An effective exercise-based intervention for improving mental health and quality of life measures: a randomized controlled trial.
        Prev Med. 2004; 39: 424-434
        • Baer J.T.
        Improved plasma cholesterol levels in men after a nutrition education program at the worksite.
        J Am Diet Assoc. 1993; 93 ([see comment]): 658-663
        • Barfield B.R.
        Evaluation of the effects of health risk appraisals and health promotion teaching on lifestyle behaviors.
        ([dissertation]) University of Alabama, Birmingham AL1992
        • Bassey E.J.
        • Patrick J.M.
        • Irving J.M.
        • Blecher A.
        • Fentem P.H.
        An unsupervised “aerobics” physical training programme in middle-aged factory workers: feasibility, validation and response.
        Eur J Appl Physiol. 1983; 52: 120-125
        • Bauer R.L.
        • Heller R.F.
        • Challah S.
        United Kingdom heart disease prevention project: 12-year follow-up of risk factors.
        Am J Epidemiol. 1985; 121: 563-569
        • Bennett B.
        • Schlichting C.
        • Bondi K.
        Cardiorespiratory fitness and cognitive performance before and after confinement in a nuclear submarine.
        Aviat Space Environ Med. 1985; 56: 1085-1091
        • Bjurstrom L.A.
        • Alexiou N.G.
        A program of heart disease intervention for public employees.
        J Occup Med. 1978; 20: 521-531
        • Blair S.N.
        • Smith M.
        • Collingwood T.R.
        • Reynolds R.
        • Prentice M.C.
        • Sterling C.L.
        Health promotion for educators: impact on absenteeism.
        Prev Med. 1986; 15: 166-175
        • Blissmer B.
        • McAuley E.
        Testing the requirements of stages of physical activity among adults: the comparative effectiveness of stage-matched, mismatched, standard care, and control interventions.
        Ann Behav Med. 2002; 24: 181-189
        • Boudreau F.
        • Godin G.
        • Pineau R.
        • Bradet R.
        Health risk appraisal in an occupational setting and its impact on exercise behavior.
        J Occup Environ Med. 1995; 37: 1145-1150
        • Bowne D.
        • Russell M.
        • Morgan J.
        • Optenberg S.
        • Clarke A.
        Reduced disability and health care costs in an industrial fitness program.
        J Occup Med. 1984; 26: 809-816
        • Brand R.
        • Schlicht W.
        • Grossmann K.
        • Duhnsen R.
        Effects of a physical exercise intervention on employees' perceptions of quality of life: a randomized controlled trial.
        Soz Praventivmed. 2006; 51: 14-23
        • Brownell K.D.
        • Bachorik P.S.
        • Ayerle R.S.
        Changes in plasma lipid and lipoprotein levels in men and women after a program of moderate exercise.
        Circulation. 1982; 65: 477-484
        • Brox J.I.
        • Froystein O.
        Health-related quality of life and sickness absence in community nursing home employees: randomized controlled trial of physical exercise.
        Occup Med (Lond). 2005; 55: 558-563
        • Bruno R.
        • Arnold C.
        • Jacobson L.
        • Winick M.
        • Wynder E.
        Randomized controlled trial of a nonpharmacologic cholesterol reduction program at the worksite.
        Prev Med. 1983; 12: 523-532
        • Campbell M.K.
        • Tessaro I.
        • DeVellis B.
        • et al.
        Effects of a tailored health promotion program for female blue-collar workers: health works for women.
        Prev Med. 2002; 34: 313-323
        • Cardinal B.J.
        • Sachs M.L.
        Effects of mail-mediated, stage-matched exercise behavior change strategies on female adults' leisure-time exercise behavior.
        J Sports Med Phys Fitness. 1996; 36: 100-107
        • Cash T.L.
        Effects of different exercise promotion strategies and stage of exercise on reported physical activity, self-motivation, and stages of exercise in worksite employees.
        Temple University, 1997
        • Chaney C.
        Effects of an employee fitness and lifestyle modification program upon health care costs, absenteeism, and job satisfaction.
        University of Utah, 1988
        • Cohen R.Y.
        • Stunkard A.J.
        • Felix M.R.
        Comparison of three worksite weight-loss competitions.
        J Behav Med. 1987; 10: 467-479
        • Coleman K.J.
        • Raynor H.R.
        • Mueller D.M.
        • Cerny F.J.
        • Dorn J.M.
        • Epstein L.H.
        Providing sedentary adults with choices for meeting their walking goals.
        Prev Med. 1999; 28: 510-519
        • Cook C.
        • Simmons G.
        • Swinburn B.
        • Stewart J.
        Changing risk behaviours for non-communicable disease in New Zealand working men—is workplace intervention effective?.
        N Z Med J. 2001; 114: 175-178
        • Cook R.F.
        • Back A.S.
        • Trudeau J.
        • McPherson T.
        Integrating substance abuse prevention into health promotion programs in the workplace: a social cognitive intervention targeting the mainstream user.
        in: Bennett J.B. Lehman W.E.K. Preventing workplace substance abuse: beyond drug testing to wellness. American Psychological Association, Washington DC2003: 97-133
        • Cook R.F.
        • Billings D.W.
        • Hersch R.K.
        • Back A.S.
        • Hendrickson A.
        A field test of a web-based workplace health promotion program to improve dietary practices, reduce stress, and increase physical activity: randomized controlled trial.
        J Med Internet Res. 2007; 9: e17
        • Croteau K.A.
        A preliminary study on the impact of a pedometer-based intervention on daily steps.
        Am J Health Promot. 2004; 18: 217-220
        • Croteau K.A.
        • Young C.J.
        Effectiveness of a Navy remedial exercise intervention.
        Mil Med. 2000; 165: 786-790
        • Dennis K.E.
        • Pane K.W.Adams
        • Qi B.B.
        The impact of a shipboard weight control program.
        Obes Res. 1999; 7: 60-67
        • Eddy J.M.
        • Eynon D.
        • Nagy S.
        • Paradossi P.J.
        Impact of a physical fitness program in a blue-collar workforce.
        Health Values. 1990; 14: 14-23
        • Elliot D.L.
        • Goldberg L.
        • Duncan T.E.
        • et al.
        The PHLAME firefighters' study: feasibility and findings.
        Am J Health Behav. 2004; 28: 13-23
        • Fardy P.
        • Ilmarinem J.
        Evaluating the effects and feasibility of an at work stairclimbing intervention program for men.
        Med Sci Sports. 1975; 7: 91-93
        • Fukahori M.
        • Aono H.
        • Saito I.
        • Ikebe T.
        • Ozawa H.
        Program of exercise training as total health promotion plan and its evaluation.
        J Occup Health. 1999; 41: 76-82
        • Furukawa F.
        • Kazuma K.
        • Kawa M.
        • et al.
        Effects of an off-site walking program on energy expenditure, serum lipids, and glucose metabolism in middle-aged women.
        Biol Res Nurs. 2003; 4: 181-192
        • Furuki K.
        • Honda S.
        • Jahng D.
        • Ikeda M.
        • Okubo T.
        The effects of a health promotion program on body mass index.
        J Occup Health. 1999; 41: 19-26
        • Geise J.M.
        The relation of a health promotion program to the cardiovascular health of fire fighters.
        University Of California–Los Angeles, Los Angeles1995
        • Gerdle B.
        • Brulin C.
        • Elert J.
        • Eliasson P.
        • Granlund B.
        Effect of a general fitness program on musculoskeletal symptoms, clinical status, physiological capacity, and perceived work environment among home care service personnel.
        J Occup Rehabil. 1995; 5: 1-16
        • Gettman L.
        • Pollock M.
        • Ward A.
        Adherence to unsupervised exercise.
        Phys Sportsmed. 1983; 11: 56-64
        • Goetzel R.
        • Sepulveda M.
        • Knight K.
        • et al.
        Association of IBM's “A Plan for Life” health promotion program with changes in employees' health risk status.
        J Occup Med. 1994; 36: 1005-1009
        • Gold D.B.
        • Anderson D.R.
        • Serxner S.A.
        Impact of a telephone-based intervention on the reduction of health risks.
        Am J Health Promot. 2000; 15: 97-106
        • Gomez-Merino D.
        • Chennaoui M.
        • Drogou C.
        • Bonneau D.
        • Guezennec C.Y.
        Decrease in serum leptin after prolonged physical activity in men.
        Med Sci Sports Exerc. 2002; 34: 1594-1599
        • Grandjean P.W.
        • Oden G.L.
        • Crouse S.F.
        • Brown J.A.
        • Green J.S.
        Lipid and lipoprotein changes in women following 6 months of exercise training in a worksite fitness program.
        J Sports Med Phys Fitness. 1996; 36: 54-59
        • Griffin C.S.
        Evaluation of social cognitive versus motivationally-tailored self-help physical activity interventions.
        ([dissertation]) University of Georgia, Athens GA2001
        • Gronningsaeter H.
        • Hytten K.
        • Skauli G.
        • et al.
        Improved health and coping by physical exercise or cognitive behavioral stress management training in a work environment.
        Psychol Health. 1992; 7: 147-163
        • Hager R.L.
        • Hardy A.
        • Aldana S.G.
        • George J.D.
        Evaluation of an Internet, stage-based physical activity intervention.
        Am J Health Educ. 2002; 33: 328-335
        • Hallam J.S.
        • Petosa R.
        The long-term impact of a four-session work-site intervention on selected social cognitive theory variables linked to adult exercise adherence.
        Health Educ Behav. 2004; 31: 88-100
        • Halvorsen I, D.K.
        The effects of power circuit exercise training and health education on fitness and health status, and on risk factors for cardiovascular disease in a worksite health promotion program for men and women in the exercise deficient state.
        ([dissertation]) University of Minnesota, Minneapolis MN1996
        • Hanlon P.
        • McEwen J.
        • Carey L.
        • et al.
        Health checks and coronary risk: further evidence from a randomised controlled trial.
        Br Med J. 1995; 311 ([see comment]): 1609-1613
        • Hannah T.E.
        • Kozma A.
        • Stones M.
        • Mosher D.
        • Vardy L.
        Effects on mood of a life-styles program for the rehabilitation of injured workers.
        J Occup Med. 1989; 31: 454-457
        • Harma M.
        • Ilmarinen J.
        • Knauth P.
        • et al.
        Physical training intervention in female shift workers: I. The effects of intervention of fitness, fatigue, sleep, and psychosomatic symptoms.
        Ergonomics. 1988; 31: 39-50
        • Harrell J.S.
        • Griggs T.R.
        • Roskin E.W.
        • Meibohm A.R.
        • Williams O.D.
        Impact of a 12-week aerobic exercise and weight program for law enforcement trainees.
        Am J Health Promot. 1993; 7: 410-412
        • Harvey H.L.
        An evaluation of RMH Health Club.
        Worksite Wellness, 1999
        • Heath G.W.
        • Broadhurst C.B.
        Effects of exercise training and dietary behavior modification on weight reduction and lipoprotein lipids in female hospital employees.
        Health values. 1984; 8: 3-9
        • Hendriksen I.J.M.
        • Zuiderveld B.
        • Kemper H.C.G.
        • Bezemer P.D.
        Effect of commuter cycling on physical performance of male and female employees.
        Med Sci Sports Exerc. 2000; 32: 504-510
        • Henritze J.
        • Brammell H.L.
        • McGloin J.
        LIFECHECK: a successful, low touch, low tech, in-plant, cardiovascular disease risk identification and modification program.
        Am J Health Promot. 1992; 7: 129-136
        • Horowitz S.M.
        Effects of a worksite wellness program on absenteeism and health care costs in a small federal agency.
        Fit Bus. 1987; : 167-172
        • Horowitz S.M.
        • Kissam T.
        • Riegel M.
        • Laflin M.T.
        • Sonne L.
        Results of a pilot health promotion program on non-facility based sales personnel.
        J Health Educ. 1998; 29: 282-288
        • Hubball
        Development and evaluation of a worksite health promotion rpgram: application of critical self-directed learning for exercise behavior change.
        ([dissertation]) University of British Columbia, Vancouver, British Columbia, Canada1996
        • Ilmarinen J.
        • Ilmarinen R.
        • Koskela A.
        • et al.
        Training effects of stair-climbing during office hours on female employees.
        Ergonomics. 1979; 22: 507-516
        • Jette M.
        • Bishop D.
        • Baron R.
        Effects of Project Health on the lifestyle of senior government officials.
        Can J Public Health. 1981; 72: 97-99
        • Jette M.
        • Sidney K.
        The benefits and challenges of a fitness and lifestyle enhancement program for correctional officers.
        Can J Public Health. 1991; 82: 46-51
        • Kerr J.H.
        • Vos M.C.
        Employee fitness programmes, absenteeism and general well-being.
        Work Stress. 1993; 7: 179-190
        • Kerr N.A.
        • Yore M.M.
        • Ham S.A.
        • Dietz W.H.
        Increasing stair use in a worksite through environmental changes.
        Am J Health Promot. 2004; 18: 312-315
        • King A.C.
        • Talyor C.B.
        • Haskell W.L.
        • DeBusk R.F.
        Influence of regular aerobic exercise on psychological health: a randomized, controlled trial of healthy middle-aged adults.
        Health Psychol. 1989; 8: 305-324
        • Knapik J.
        • Hauret K.G.
        • Arnold S.
        • et al.
        Injury and fitness outcomes during implementation of physical readiness training.
        Int J Sports Med. 2003; 24: 372-381
        • Knapik J.J.
        The influence of physical fitness training on the manual material handling capability of women.
        Appl Ergon. 1997; 28: 339-345
        • Kneip J.K.
        • Fox H.M.
        • Fruehling J.K.
        A weight-control program for bank employees.
        J Am Diet Assoc. 1985; 85: 1489-1491
        • Kraemer W.J.
        • Vescovi J.D.
        • Volek J.S.
        • et al.
        Effects of concurrent resistance and aerobic training on load-bearing performance and the Army physical fitness test.
        Mil Med. 2004; 169: 994-999
        • Lampman R.M.
        • Santinga J.T.
        • Savage P.J.
        • et al.
        Effect of exercise training on glucose tolerance, in vivo insulin sensitivity, lipid and lipoprotein concentrations in middle-aged men with mild hypertriglyceridemia.
        Metabolism. 1985; 34: 205-211
        • Lane A.
        • Mills M.
        • Terry P.
        Mood regulation among corporate workers: effects of exercise on mood.
        J Sports Sci. 1998; 16: 87
        • Leaf D.A.
        • Parker D.L.
        • Schaad D.
        Changes in VO2max, physical activity, and body fat with chronic exercise: effects on plasma lipids.
        Med Sci Sports Exerc. 1997; 29: 1152-1159
        • Li C.L.
        • Tseng H.M.
        • Tseng R.F.
        • Lee S.J.
        The effectiveness of an aerobic exercise intervention on worksite health-related physical fitness—a case in a high-tech company.
        Chang Gung Med J. 2006; 29: 100-106
        • Loughlan C.
        • Mutrie N.
        An evaluation of the effectiveness of three interventions in promoting physical activity in a sedentary population.
        Health Educ J. 1997; 56: 154-165
        • Love M.
        • Morphis L.
        • Page P.
        Model for an employee wellness project.
        J Am Coll Health Assoc. 1981; 29: 171-173
        • Maes S.
        • Verhoeven C.
        • Kittel F.
        • Scholten H.
        Effects of a Dutch work-site wellness-health program: the Brabantia Project.
        Am J Public Health. 1998; 88: 1037-1041
        • Maloney J.P.
        • Cheney R.
        • Spring W.
        • Kanusky J.
        The physiologic and psychological effects of a 5-week and a 16-week physical fitness program.
        Mil Med. 1986; 151: 426-433
        • Marshall A.L.
        • Leslie E.R.
        • Bauman A.E.
        • Marcus B.H.
        • Owen N.
        Print versus website physical activity programs: a randomized trial.
        Am J Prev Med. 2003; 25: 88-94
        • Mayo M.J.
        • Grantham J.R.
        • Balasekaran G.
        Exercise-induced weight loss preferentially reduces abdominal fat.
        Med Sci Sports Exerc. 2003; 35: 207-213
        • McKenzie P.F.
        Effects of a nutrition-based health promotion program on nutritional adequacy, planned physical activity, body composition, job performance, and absenteeism among female airline reservationists.
        Dissertation Abstracts International. 1988; 48: 2610B-2611B
        • Murphy M.H.
        • Murtagh E.M.
        • Boreham C.A.G.
        • Hare L.G.
        • Nevill A.M.
        The effect of a worksite based walking programe on cardiovascular risk in previously sedentary civil servants.
        BMC Public Health. 2006; 6: 136-143
        • Musich S.
        • Adams L.
        • DeWolf G.
        • Edington D.
        A case study of 10-year health risk appraisal participation patterns in a comprehensive health promotion program.
        Am J Health Promot. 2001; 15: 237-240
        • Muto T.
        • Yamauchi K.
        Evaluation of a multicomponent workplace health promotion program conducted in Japan for improving employees' cardiovascular disease risk factors.
        Prev Med. 2001; 33: 571-577
        • Napolitano M.A.
        • Fotheringham M.
        • Tate D.
        • et al.
        Evaluation of an Internet-based physical activity intervention: a preliminary investigation.
        Ann Behav Med. 2003; 25: 92-99
        • Nilsson P.M.
        • Klasson E.-B.
        • Nyberg P.
        Life-style intervention at the worksite—reduction of cardiovascular risk factors in a randomized study.
        Scand J Work Environ Health. 2001; 27: 57-62
        • Nisbeth O.
        • Klausen K.
        • Andersen L.B.
        Effectiveness of counselling over 1 year on changes in lifestyle and coronary heart disease risk factors.
        Patient Educ Couns. 2000; 40: 121-131
        • Norris R.
        • Carroll D.
        • Cochrane R.
        The effects of aerobic and anaerobic training on fitness, blood pressure, and psychological stress and well-being.
        J Psychosom Res. 1990; 34: 367-375
        • Oden G.
        • Crouse S.F.
        • Reynolds C.
        Worker productivity, job satisfaction, and work-related stress: Influence of an employee fitness program.
        Fit Bus. 1989; 3: 198-204
        • Ohta M.
        • Okufuji T.
        • Matsushima Y.
        • Ikeda M.
        The effect of lifestyle modification on physical fitness and work ability in different workstyles.
        J UOEH. 2004; 26: 411-421
        • Okada K.
        Effects of long-term corporate fitness program on employees' health.
        J Nutr Sci Vitaminol (Tokyo). 1991; 37S: S131-S138
        • O'Loughlin J.
        • Renaud L.
        • Paradis G.
        • Meshefedjian G.
        Screening school personnel for cardiovascular disease risk factors: short-term impact on behavior and perceived role as promoters of heart health.
        Prev Med. 1996; 25: 660-667
        • Orr N.
        The effects of a university based employee health promotion program on cardiovascular risk profiles.
        ([exercise]) University of Pittsburgh, Pittsburgh PA1997
        • Osteras H.
        • Hammer S.
        The effectiveness of a pragmatic worksite physical activity program on maximal oxygen consumption and the physical activity level in healthy people.
        J Bodyw Mov Ther. 2006; 10: 51-57
        • Ostwald S.K.
        Changing employees' dietary and exercise practices: an experimental study in a small company.
        J Occup Med. 1989; 31: 90-97
        • Partonen T.
        • Leppamaki S.
        • Hurme J.
        • Lonnqvist J.
        Randomized trial of physical exercise alone or combined with bright light on mood and health–related quality of life.
        Psychol Med. 1998; 28: 1359-1364
        • Patton J.
        • Vogel J.
        • Bedynek J.
        • Alexander D.
        • Albright R.
        Response of age forty and over military personnel to an unsupervised, self-administered aerobic training program.
        Aviat Space Environ Med. 1983; 54: 138-143
        • Pescatello L.S.
        • Murphy D.
        • Vollono J.
        • Lynch E.
        • Bernene J.
        • Costanzo D.
        The cardiovascular health impact of an incentive worksite health promotion program.
        Am J Health Promot. 2001; 16: 16-20
        • Peterson P.M.
        The relationship between wellness program participation, job satisfaction, health perceptions and physical symptoms of stress.
        University of Kentucky, Lexington KY1993
        • Peterson T.R.
        • Aldana S.G.
        Improving exercise behavior: an application of the stages of change model in a worksite setting.
        Am J Health Promot. 1999; 13: 229-232
        • Plotnikoff R.C.
        • McCargar L.J.
        • Wilson P.M.
        • Loucaides C.A.
        Efficacy of an e-mail intervention for the promotion of physical activity and nutrition behavior in the workplace context.
        Am J Health Promot. 2005; 19: 422-429
        • Pohjonen T.
        • Ranta R.
        Effects of a worksite physical exercise intervention on physical fitness, perceived health status, and work ability among home care workers: five-year follow-up.
        Prev Med. 2001; 32: 465-475
        • Pritchard J.E.
        • Nowson C.A.
        • Billington T.
        • Wark J.D.
        Benefits of a year-long workplace weight loss program on cardiovascular risk factors.
        Nutr Diet: J Diet Assoc Austr. 2002; 59: 87-96
        • Proper K.I.
        • Hildebrandt V.H.
        • Van der Beek A.J.
        • Twisk J.W.R.
        • Van Mechelen W.
        Effect of individual counseling on physical activity fitness and health: a randomized controlled trial in a workplace setting.
        Am J Prev Med. 2003; 24: 218-226
        • Purath J.
        • Miller A.M.
        • McCabe G.
        • Wilbur J.
        A brief intervention to increase physical activity in sedentary working women.
        Can J Nurs Res. 2004; 36: 76-91
        • Puterbaugh J.S.
        • Lawyer C.H.
        Cardiovascular effects of an exercise program: a controlled study among firemen.
        J Occup Med. 1983; 25: 581-586
        • Rhodes E.C.
        • Dunwoody D.
        Physiological and attitudinal changes in those involved in an employee fitness program.
        Can J Public Health. 1980; 71: 331-336
        • Roberts M.A.
        • O'Dea J.
        • Boyce A.
        • Mannix E.T.
        Fitness levels of firefighter recruits before and after a supervised exercise training program.
        J Strength Cond Res. 2002; 16: 271-277
        • Robison J.I.
        • Rogers M.A.
        • Carlson J.J.
        • et al.
        Effects of a 6-month incentive-based exercise program on adherence and work capacity.
        Med Sci Sports Exerc. 1992; 24: 85-93
        • Rodnick J.E.
        Health behavior changes associated with health hazard appraisal counseling in an occupational setting.
        Prev Med. 1982; 11: 583-594
        • Saltin B.
        • Hartley I.H.
        • Kilbom A.
        • Astrand I.
        Physical training in sedentary middle-aged and older men: II. Oxygen uptake, heart rate, and blood lactate concentration at submaximal and maximal exercise.
        Scand J Clin Lab Invest. 1969; 24: 323-334
        • Schultz A.B.
        • Lu C.
        • Barnett T.E.
        • et al.
        Influence of participation in a worksite health-promotion program on disability days.
        J Occup Environ Med. 2002; 44: 776-780
        • Sherman J.B.
        • Clark L.
        • McEwen M.M.
        Evaluation of a worksite wellness program: impact on exercise, weight, smoking, and stress.
        Public Health Nurs. 1989; 6: 114-119
        • Simmons D.
        • Fleming C.
        • Cameron M.
        • Leakehe L.
        A pilot diabetes awareness and exercise programme in a multiethnic workforce.
        N Z Med J. 1996; 109: 373-376
        • Spate-Douglas T.
        • Keyser R.E.
        Exercise intensity: its effect on the high-density lipoprotein profile.
        Arch Phys Med Rehabil. 1999; 80: 691-695
        • Speck B.J.
        • Looney S.W.
        Effects of a minimal intervention to increase physical activity in women: daily activity records.
        Nurs Res. 2001; 50: 374-378
        • Stein R.A.
        • Michielli D.W.
        • Glantz M.D.
        • et al.
        Effects of different exercise training intensities on lipoprotein cholesterol fractions in healthy middle-aged men.
        Am Heart J. 1990; 119: 277-283
        • Stone W.J.
        • Rothstein D.E.
        • Shoenhair C.L.
        Coronary health disease risk factors and health related fitness in long-term exercising versus sedenatry corporate executives.
        Am J Health Promot. 1991; 5: 169-175
        • Stonecipher L.J.
        • Hyner G.C.
        The effects of a comprehensive health risk appraisal, basic screening, and interpretation session on employee health practices: differences between participants and nonparticipants.
        Am J Health Promot. 1993; 7: 167-169
        • Talvi A.I.
        • Jarvisalo J.O.
        • Knuts L.R.
        A health promotion programme for oil refinery employees: changes of health promotion needs observed at three years.
        Occup Med (Lond). 1999; 49: 93-101
        • Tate D.F.
        • Wing R.R.
        • Winett R.A.
        Using Internet technology to deliver a behavioral weight loss program.
        JAMA. 2001; 285: 1172-1177
        • Van Rhenen W.
        • Blonk R.W.B.
        • van der Klink J.J.L.
        • van Dijk F.J.H.
        • Schaufeli W.B.
        The effect of a cognitive and a physical stress-reducing programme on psychological complaints.
        Int Arch Occup Environ Health. 2005; 78: 139-148
        • Vazquez J.M.M.
        • Garcia Alcon J.L.
        • Campillo Alvarez J.E.
        Influence of diet and physical exercise on plasma lipid concentrations in an homogeneous sample of young Spanish Air Force pilots.
        Eur J Appl Physiol Occup Physiol. 1994; 69: 75-80
        • Von Schlumperger B.
        Formation and maintenance of an exercise habit: an exploratory study of a self-management approach.
        ([dissertation]) University of Oregon, Eugene OR1985
        • Williams A.G.
        Effects of basic training in the British Army on regular and reserve army personnel.
        J Strength Cond Res. 2005; 19: 254-259
        • Williams A.G.
        • Rayson M.P.
        • Jones D.A.
        Resistance training and the enhancement of the gains in material-handling ability and physical fitness of British Army recruits during basic training.
        Ergonomics. 2002; 45: 267-279
        • Wilson L.F.M.
        The effects of an exercise conditioning program on reducing the stress response in nurses.
        ([dissertation]) Wayne State University, Detroit1985
        • Wittmann A.
        Body composition in an employee health improvement program.
        Coll Anthropol. 1998; 22: 447-450
        • Wood E.
        • Olmstead G.
        • Craig J.
        An evaluation of lifestyle risk factors and absenteeism after two years in a worksite health promotion program.
        Am J Health Promot. 1989; 4: 128-133
        • Yarvote P.M.
        • McDonagh T.J.
        • Goldman M.E.
        Organization and evaluation of a physical fitness program in industry.
        J Occup Med. 1974; 16: 589-598
        • Zandee G.L.
        • Oermann M.H.
        Effectiveness of contigency contracting: component of a worksite weight loss program.
        AAOHN J. 1996; 44: 183-188
        • Blair S.N.
        • Collingwood T.R.
        • Reynolds R.
        • Smith M.
        • Hagan R.D.
        • Sterling C.L.
        Health promotion for educators: impact on health behaviors, satisfaction, and general well-being.
        Am J Public Health. 1984; 74: 147-149
        • Musich S.
        • Adams L.
        • DeWolf G.
        • Edington D.
        A case study of 10-year health risk appraisal participation patterns in a comprehensive health promotion program.
        Am J Health Promot. 2001; 15: 237-240