WORKPLACE SMOKING CESSATION AND FRUIT AND VEGETABLE CONSUMPTION: SYNTHESIS AND RECOMMENDATIONS FOR THEORY- AND RESEARCH-BASED INTERVENTION PLANNING

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1 WORKPLACE SMOKING CESSATION AND FRUIT AND VEGETABLE CONSUMPTION: SYNTHESIS AND RECOMMENDATIONS FOR THEORY- AND RESEARCH-BASED INTERVENTION PLANNING Report to the Program Training and Consultation Centre, Cancer Care Ontario Kenneth R. Allison, Ph.D. and John J.M. Dwyer, Ph.D. KR Allison Research Consulting May, 2010 Theory- and Research-Based Interventions

2 Table of Contents Executive Summary 3 Introduction and Background 4 Methods 5 Summary of Literature Workplace Smoking Cessation Interventions 6 Summary of Literature Workplace Fruit and Vegetable Interventions 9 Logic Model Summary 11 Implications for Planning Workplace Interventions 16 Recommendations 19 Acknowledgements 20 References 21 Figures Tables Figure 1 Social Ecological Model of Behaviour Change 15 Table 1 Summary of Workplace Interventions for Smoking 30 Cessation Table 2 Summary of Workplace Interventions for Fruit and 67 Vegetable Consumption Table 3 Outcomes, Methods, and Examples of Strategies/ 110 Activities to Change Personal and Environmental Determinants of Smoking Cessation and Fruit and Vegetable Consumption (logic model) Theory-and Research-Based Interventions 2

3 Executive Summary This report provides a theory and research synthesis on workplace smoking cessation and fruit and vegetable consumption interventions, along with recommendations for further intervention planning by the Program Planning and Consultation Centre (PTCC) of Cancer Care Ontario. This synthesis project included five stages. In the first stage the search strategy for a literature review was developed and approved. In the second stage the literature search and review were conducted. The third stage involved the development of a logic model to examine the relevance of a number of theoretical frameworks and constructs to this topic. In the fourth stage, preliminary results of the synthesis were presented and discussed at a meeting of the LEARN collaborative group. The final step was development of this report. The review of 30 workplace smoking cessation intervention papers highlighted a number of studies highly relevant to the PTCC s initiative (Barbeau et al, 2006; Okechukwu et al., 2009; Prochaska et al., 2008; and Sorensen et al., 2002). Several studies were based on versions of Social-Ecological Theory, and included environmental components of the intervention, such as establishing workplace advisory committees and addressing workplace conditions. Other important components included: individual and group counseling, nicotine replacement theory (NRT), and the use of incentives to enhance recruitment and retention in smoking cessation interventions. A review of 34 workplace fruit and vegetable interventions published in peer-reviewed journals included two studies that are highlighted in this report (Campbell et al., 2008; French et al., 2010). These studies, along with several others, include the use of workplace advisory committees. The importance of such constructs as self-efficacy and knowledge as mediating factors related to intervention effectiveness are emphasized (Campbell et al., 2008) as well a the importance of changing the physical and social environments affecting wise food choices (French et al., 2010). Many of these studies were based on Social-Ecological Theory or the related Social-Contextual Model (Sorensen et al., 2005). The logic model summary included outcomes, methods, and examples of strategies to change personal and environmental determinants related to smoking cessation and fruit and vegetable consumption. Six constructs are highlighted in the report including: perceived barriers; self-efficacy; stages of change: organizational, policy, and community-level factors; empowerment; and organizational change factors. Several examples from the literature review are used to illustrate how various methods and strategies/activities have been used in intervention studies. Thus, the logic model is able to link theory- and research-based intervention approaches. Theory-and Research-Based Interventions 3

4 A number of implications for planning workplace interventions are discussed in the report, dealing with such issues as: the context of blue collar life; potential workplace issues affecting cooperation on intervention planning; adopting Social-Ecological Theory as the basis for the intervention; incorporating the inclusion of workplace advisory committees; issues of evaluation and sustainability; and the need to further refine the scope of the intervention planned. Several (16) recommendations to PTCC regarding further intervention planning are listed in the report. Introduction and Background The purpose of the current project is to provide the Program Training and Consultation Centre (PTCC) and its partners with theory- and research-based recommendations for an initiative currently being developed to promote smoking cessation and, potentially, fruit and vegetable consumption among young adult blue collar workers in Ontario. This report responds to the need for such information by providing a synthesis of relevant published literature, pertinent theoretical frameworks and constructs specific to this issue, along with discussion and recommendations as to how theory and research may converge to indicate appropriate intervention methods, strategies, and activities for this initiative. A number of developmental activities have already been conducted prior to this research and theory synthesis (synthesis), including the formation by PTCC of a collaborative team of researchers, policy-makers, and public health practitioners who are developing a pilot initiative for implementation in a number of workplaces in the province, a literature review on smoking cessation among young adults, and the development of a proposal submitted for pilot funding. In relation to the current synthesis, one of the key findings from the earlier literature review focusing on smoking cessation interventions for young adults was the tendency for young adult smokers to be interested in quitting but preferring to quit on their own rather than rely on external resources (Filsinger & McGrath, 2009). Another key point was that smoking cessation should be positioned as a positive step, coupled with the importance of quitting early. Some innovative technologies seen as promising included web-based programs, text messaging and quitlines. The authors also pointed out that the tobacco industry heavily targets young adults in their communication strategies though there is not concurrent emphasis on this age group on the part of tobacco control measures and approaches. Finally, the report emphasized the importance of taking into account the transitional nature of young adulthood in intervention planning and development (Filsinger & McGrath, 2009). The PTCC initiative is positioned within a Communities of Practice model Learning through Evidence, Action and Reflection Networks (LEARN). This initiative combines researchers and public health practitioners in collaboration on the development of context-relevant intervention knowledge and tobacco control interventions. In the initial stages of the PTCC initiative there was widespread agreement that the highest priority was for an evidence-informed workplace smoking cessation intervention aimed at young adult blue collar workers. For purposes of the current synthesis project, the focus of this Theory-and Research-Based Interventions 4

5 intervention priority was subsequently expanded to consider chronic disease prevention, specifically fruit and vegetable consumption as well. As many health intervention planners have recognized, there are a number of important steps needed in order to systematically develop, implement, and evaluate health interventions (Green & Kreuter, 2005; Bartholomew et. al., 2006). PTCC has emphasized the importance of using systematic intervention planning specifically the Intervention Mapping approach (Bartholomew et al., 2006). This approach has been shown to be a useful method of planning health promotion interventions, though frequently requiring considerable time for developing and implementing its several stages (McEachan et al., 2008). The present synthesis contributes to the Intervention Mapping process. Thus, our aim is to provide information and recommendations to further the process of planning the pilot intervention initiative. A further consideration as part of the context of the current synthesis is that LEARN is interested in the development and maintenance of core theory-based elements of an intervention, though other components of the program can be more flexible tailored to the specific organizational needs and characteristics of individual workplaces and their employees. The scope of the present synthesis has been expanded slightly in that we refer to the development of theory- and research-based interventions guidelines as opposed to just theory-based intervention guidelines. That expansion allows us to examine more thoroughly how theory and research may converge to inform further intervention planning. It is important to keep in mind some of the limitations of this synthesis. Our summary of the intervention literature represents a narrative, rather than a systematic review, a critical review or a meta-analysis. A narrative review summarizes the scientific literature but does not limit the scope of the review to particular types of design, such as RCTs, nor does it offer a critical analysis of the features or qualities of particular studies. Thus, our assessment of the literature and of the theoretical and research basis of particular interventions and approaches, though extensive, is subject to this limitation. A further limitation of our project is that the review of scientific literature and theory does not include unpublished reports. However, we have been able to review a relatively large number of intervention studies published in peer-reviewed journals. Few workplace smoking cessation or fruit and vegetable consumption interventions specifically targeting young adults are reported in the literature, so it was necessary to expand our search and review to include workplace interventions for other adult age groups as well. Methods There were five stages involved in the current synthesis. The first stage involved development and subsequent approval (by PTCC) of the search strategy for the literature review. In the second step, a search and narrative review of the literature was conducted. The third stage consisted of developing a logic model to examine theoretical frameworks and constructs relevant to this issue. A presentation and discussion of the findings and recommendations to PTCC and the LEARN collaborative group represented the fourth Theory-and Research-Based Interventions 5

6 step, and a synthesis of the findings and recommendations in this final report consisted of the final stage. A search and narrative review of published literature was conducted to inform the synthesis. Inclusion criteria for the search included the following: - primary focus on young adults ages workplace interventions as the setting - blue collar workers as the primary target group - interventions dealing with smoking cessation (primary importance) and fruit and vegetable consumption (secondary importance) The selection of search terms and Medical Search Headings (MeSH) were developed by a professional librarian, who conducted the search. Since there were few published articles dealing specifically with young blue collar workers, the search and subsequent review were expanded to include all workplace interventions dealing with smoking cessation and fruit or vegetable consumption, as well as all adult age groups. The rationale for this decision was that some of the intervention approaches reviewed may have relevance to the specific groups of interest to this synthesis. Peer-reviewed articles assessed as being promising were screened for further consideration. Those papers retained for the review were subsequently summarized in tabular form by a member of the synthesis team. The template for summarizing these articles included: author/date/journal; sample; research method; theory; intervention; and relevant results. The last two categories (intervention and relevant results) were described in detail to provide a source of information for future intervention planning in the PTCC initiative. In the next stage of the project, a program logic model was developed, drawing on relevant theoretical frameworks as well as pertinent scientific literature from the review of workplace smoking cessation and fruit and vegetable interventions. The template for the logic model included: constructs/determinants; theoretical framework; outcomes, methods, and strategies/activities. Information obtained from these two stages provided the basis for recommendations for a theory- and research-based intervention as the planned PTCC initiative. However, more detailed intervention methods, strategies and activities will need to be subsequently developed as further decisions are made by PTCC and the collaborative group regarding the more specific focus of the intervention. In this regard, the detailed literature review summary tables and the logic model table will provide important sources of documented information to assist in selecting evidence-based intervention methods, strategies and activities. Summary of Literature Workplace Smoking Cessation Interventions The review included 30 papers focusing on smoking cessation intervention studies reported in the peer-reviewed literature of which 17 (57%) were located in blue collar worksites settings and 13 in general worksite settings. The majority (63%) of these papers were published between Also, as few studies were based directly on young blue collar workers, the review examined the broader pool of workplace smoking cessation interventions. Most of the interventions were based on experimental or quasi- Theory-and Research-Based Interventions 6

7 experimental designs and some form of randomization was used to assign participants, or sites, to the intervention or control condition in 60% of the studies reviewed. Interestingly, less than half of the papers reviewed made explicit reference to an underlying theoretical framework for the interventions. The most frequently cited theoretical frameworks included: Transtheoretical Model/Stages of Change, Social Contextual/Social Ecological Model, and Community Activation/Organization Theory. A number of interventions and relevant results are described in detail in Table 1. Here we will highlight a few of what we consider to be key studies/findings from those reviewed. Barbeau et al. s (2006) study of 337 iron apprentices in the Boston area, called MassBuilt, is highly relevant as a study of young (mean age 30) blue collar workers. Based on the Social-Contextual framework, this intervention included an educational module, a tobacco cessation group consisting of 8 sessions, nicotine replacement therapy (NRT), information (posters, newsletters) and a self-help quit kit. Although there was no control or comparison group in this study, the findings indicated several significant positive changes in quit rates, intention, and self-efficacy to quit between baseline and both 30 days and 6 months post-intervention. This study is important as a model for the PTCC initiative in that it combines a number of approaches within the intervention including examining occupational health risks as well as group and individual approaches to assist and support employees (in this case, apprentices) more directly in smoking cessation. Obechukwu et al. (2009) conducted a randomized controlled trial (RCT) of the MassBuilt intervention consisting of 10 apprenticeship training sites within the Massachusetts Building Trades Council. Mean age of the 1044 intervention group participants was 28, while the mean age of the control group was 29. Based on the Social-Contextual Model, occupational and health issues were seen as mediators of smoking cessation. The intervention condition was similar to that of the earlier study (Barbeau et al., 2006). However, state-certified tobacco treatment specialists trained in Motivational Interviewing were used for the group-based behavioural counseling sessions. Findings of the study indicated that there were significantly higher quit rates in the intervention group compared to the control group after 30 days, although the significant differences were not maintained after a period of 6 months. This study demonstrated a stronger research design than the initial MassBuilt study as well as more theory-based intervention methods using Motivational Interviewing. Thus, it should also be examined in-depth as a potential model for the PTCC initiative. Another relevant study is reported in a paper by Prochaska et al. (2008). Although the 1400 employees participating in this study were from a large medical university (not blue collar workers) with a mean age of 42 (not young adults), the study included an interesting combination of the Transtheoretical Model with Motivational Interviewing as the basis for the intervention approach. Three groups were compared: group 1 received only the health risk intervention (HRI); group 2 received the HRI plus Motivational Interviewing delivered by telephone; group 3 received the HRI and tailored feedback from an assessment of their stage of change (TTM). After 6 month follow-up, there was Theory-and Research-Based Interventions 7

8 a positive trend for use of HRI plus MI, or HRI plus TTM, in comparison to the HRI only group, though the differences were not significant. This study is important as an in-depth description of theoretically-based interventions relevant to the PTCC initiative. Sorensen et al. s (2002) study of several thousand workers in 15 manufacturing worksites in Massachusetts focused on the WellWorks-2 intervention. A RCT design, with the worksite as the unit of randomization, was used. The intervention was based on a participatory model incorporating principles of community organization theory, and the Social-Contextual Model. Intervention components included establishing a joint workermanagement advisory board. Two interventions were compared a Health Promotion (HP) only program and a Health Promotion plus Occupational Health and Safety (HP/OHS) program. Findings of the study indicated that hourly workers (blue collar) had significantly different outcomes compared to the salaried workers (white collar). The former group exhibited higher smoking cessation rates than the latter in interventions combining HP and HP/OHS. This study is important as a model for the PTCC initiative, particularly in relation to its use of the employee-employer advisory board and its inclusion of the occupational health and safety component. A variety of intervention approaches were described in the studies reviewed. Both the MassBuilt (Barbeau et al., 2006) and various iterations of the WorkingWell and WellWorks interventions (Sorensen et al., 1990; Sorensen et al., 1996; Sorensen et al., 1998; Sorensen et al., 2002; Sorensen et al., 2007) include a number of components that acknowledge the importance of occupational health and safety issues and the importance attached to employer responsibility to address workplace hazards as a means to enhance the health of workers. In addition, the WorkingWell and WellWorks interventions emphasize the importance of establishing joint advisory committees in order to improve communication linkages between employees and employers. A number of interventions included either group-based counseling (Barbeau et al., 2006; Okechukwu et al., 2009) or individual-based counseling (Cruse et al., 2001; Sorensen et al., 2007). Specific components of these counseling modules are described in Table 1. Suffice to say, there are several topics/components included with potential application to the PTCC initiative. It is difficult to determine the effectiveness of counseling interventions, as they are frequently imbedded in a combination of intervention approaches in the present review. However, a Cochrane review of workplace smoking cessation interventions (which reviewed a number of studies based on experimental or quasi-experimental designs), indicated empirical support for both individual and group counseling approaches (Cahill et al., 2008). Motivational Interviewing (MI), a specific approach used in counseling, was reported in a number of studies in the present review (Okechukwu et al., 2009; Sorensen et al, 2007; Prochaska et al., 2008). While most interventions using MI conducted programs in workplace settings (on site), an alternative is to recruit intervention participants in the workplace but conduct individual counseling, using MI, by telephone outside of the workplace (Sorensen et al., 2007). As MI was a key intervention strategy in a number of the important studies highlighted here (MassBuilt, WellWorks), this approach has relevance to the PTCC initiative. Theory-and Research-Based Interventions 8

9 Use of nicotine replacement therapy (NRT) was included in a number of interventions (Cruse et al., 2001; Maramoto et al., 2010; Okechukwu et al., 2009; Burgess et al., 2009; Barbeau et al., 2006). As was the case with counseling approaches, NRTs were frequently included as one component of a larger intervention, thus making it difficult to ascertain their effectiveness. The Cochrane Review of workplace smoking cessation interventions indicated support for the effectiveness of NRT in smoking cessation (Cahill et al., 2008). Thus, coupled with its prominence as a component of several of the studies profiled in this review, NRT has relevance for consideration in the PTCC initiative. Incentives to participate in smoking cessation interventions were also included in some descriptions in the current review (Hennrikus et al., 2002; Volpp et al., 2009). In earlier studies, incentives were more likely to positively affect participation in smoking cessation programs rather than quit rates (Hennrikus et al., 2002). Moreover, the Cochrane Review of workplace smoking cessation interventions did not support the effectiveness of incentives (Cahill et al., 2008). However, a more recent RCT study, using a series of graduated financial incentives for longer periods of cessation, reported that participants in the incentive group had 3.2 times the longer term quit rate compared to those in the control group (Volpp et al., 2009). Summary of Literature Workplace Fruit and Vegetable Interventions A detailed summary of 34 studies focusing on workplace fruit and vegetable interventions appears in Table 2. Almost all of the studies reviewed (82%) were published between 2000 and As the literature search did not produce a large number of studies dealing specifically with fruit and vegetable interventions for blue collar workers, the search was expanded to include workplace fruit and vegetable interventions. Of the studies reviewed, 44% were conducted at blue-collar worksites, with the remaining conducted at general worksites. The vast majority of studies reviewed were based on an experimental or quasi-experimental design and 65% of the studies used some form of randomization to assign participants or groups to intervention or control conditions. Most intervention studies reviewed (74%) were based explicitly on one or more theoretical frameworks with the most frequently mentioned including: Social- Contextual/Social Ecological Theory; Social Cognitive Theory, and the Transtheoretical Model/Stages of Change. Highlighted below are a few intervention studies we consider to be highly relevant to the PTCC initiative. Campbell et al. (2008), building on an earlier study, described the 5 A Day for Better Health community health studies as consisting of five different interventions with five separate samples. Based on a number of theoretical frameworks, including SCT, TTM, and the Social-Ecological Model, worksites or churches were randomized into intervention or control groups. The intervention, described in detail by Beresford et al. (2001), included the formation of an employee advisory board whose role was to make decisions around tailoring of interventions to specific worksites. The Stages of Change framework was used to develop intervention messages specific to the employees levels of readiness. Campbell et al. s (2008) study involved examining the role of knowledge, self-efficacy, and autonomy/responsibility as potential mediating factors related to intervention effectiveness. Based on the results of the five interventions, fruit and Theory-and Research-Based Interventions 9

10 vegetable intake was reportedly increased in each group. Self-efficacy and knowledge were shown to be significant partial mediators of intervention effectiveness. This intervention is a useful model for the PTCC initiative in a number of respects, including its strong theoretical grounding, use of an employee advisory group, and assessment of the role of a number of potential mediators of intervention effectiveness, such as selfefficacy. Another key intervention among those reviewed is the Route H Intervention, described by French et al. (2010). Employees (n=1123 [mostly bus drivers]) of the Metropolitan Transit Council in Minneapolis were included in the study. Four bus garages were paired and randomly assigned to either intervention or control conditions. Though there was no explicit theoretical framework mentioned, the intervention was directed at changing the physical and social environment to promote wise food choices and increased physical activity. An important component of this intervention was the formation of garage advisory groups at each intervention worksite. Specific intervention components included changes to vending machine choices, enhancement of fitness facilities and equipment through incentive funds provided by the research team, various team competitions such as self-weighing, and special promotional events. This intervention is relevant to the PTCC initiative as it includes detailed descriptions of the strategies and activities used to promote change, as well as an employee-employer advisory committee. A wide variety of intervention approaches are described in detail in Table 2. Some of these have similarities to the smoking cessation review summarized above (and shown in detail in Table 1). For example, several studies contained an employee advisory board/committee whose role involved assistance in developing and implementing programs and enhancing communication within the worksite (Hunt et al., 2003; Lasson et al., 2004; Sorensen et al., 2005, 2008; Beresford et al., 2001; Campbell et al., 2008; French et al., 2010). Thus, the use of employee-employer boards/committees appears to be a key component in interventions, especially those that include a broader scope of activities. In addition, several interventions include a policy and/or environmental focus, such as changes to cafeteria food offerings (Lasson et al., 2004), or vending machine choices (Sorensen et al., 1998, 1999; French et al., 2010). Other interventions focus on awareness of hazardous workplace exposures (Hunt et al., 2003; Sorensen et al., 2005). These components are consistent with the emphasis on the Social-Ecological Model/Social-Contextual Model underlying the interventions. Thus, these findings have clear relevance to the PTCC initiative. On the level of intervention components directed to employees, several approaches are summarized in the literature (Table 2). Risk appraisal approaches, food frequency questionnaires, and dietary assessments are often incorporated with individualized feedback to employees (Kristal et al., 2000; Tilley et al., 1997; Robroek et al., 2007; Franklin et al., 2006; Simpson et al., 2000; Sorensen et al., 2007). Individual feedback may also be combined with educational materials sent home to employees (Sorensen et al., 2005) or in other forms of tailored feedback approaches (Tessaro et al., 2000; Beresford et al., 2001; Robroek et al., 2007). Individual counseling is the focus of some intervention components, including coaching and Motivational Interviewing (Sorensen et Theory-and Research-Based Interventions 10

11 al., 2005, 2007; Roebrok et al., 2007). These approaches have potential relevance to the PTCC initiative as well. Group educational/nutrition classes are the focus of some intervention components (Tessaro et al., 2000; Kristal, et al., 2000; Hunt et al., 2003). These are frequently part of broader ecological/contextual approaches that include other intervention components. As such, they may have relevance for the PTCC initiative. A number of innovative intervention components summarized include the use of webbased approaches, feedback, or computer-based educational material (Block et al., 2004; Perez et al., 2009; Robroek et al., 2007; Sternfeld et al., 2007). These approaches may also be relevant to the PTCC initiative in the event that an off-site intervention focus is adopted. More traditional approaches include the provision of information sheets or educational materials/packages in on-site workplace interventions (Sorensen et al., 1998, 1999; Engbergs et al., 2006). Related to these are the provision of promotional posters, brochures and newsletters as intervention components (Kristal et al., 2000; Lasson et al., 2004). Finally, some intervention approaches include the provision of special events, competitions, and incentives (Hammond et al., 2000; French et al., 2010). As is the case with many interventions based on several components, it is difficult to ascertain the effectiveness of these specific approaches. However, some may be considered relevant to the PTCC initiative. Logic Model Summary The detailed logic model (Table 3) includes outcomes, methods, and examples of strategies/activities to change personal and environmental determinants of smoking cessation and fruit and vegetable consumption. Here we will summarize some of the salient logic model findings and highlight six constructs/determinants we consider to be most relevant to further planning of the PTCC initiative. Three of the constructs/determinants summarized below can be considered to be intrapersonal determinants: perceived barriers; self-efficacy; and stages of change. The remaining three constructs/determinants are considered to be on the level of social and physical environment determinants: organizational, policy and community-level factors; empowerment; and organizational change factors. Perceived barriers refer to those obstacles that make change difficult to implement. These may or may not be based on objective conditions. This construct was derived originally from the Health Belief Model (Champion & Skinner, 2008), though it also relates to components of additional frameworks, such as Social Cognitive Theory (Bandura, 1997). In relation to the present initiative, desired intervention outcomes may target a reduction in perceived barriers to smoking cessation or increased fruit and vegetable intake. Methods used to address perceived barriers might include the provision of information, as well as tailoring change interventions to decrease perceived barriers. Examples of intervention strategies/activities include providing information about the barriers to quitting smoking and having higher fruit and vegetable consumption. Another Theory-and Research-Based Interventions 11

12 approach would be to provide opportunities for individuals to identify obstacles to quitting or having higher fruit and vegetable intake and to develop tailored strategies to overcome these obstacles. As the illustrations from intervention research show (Table 3), a number of concrete strategies/activities lend themselves well to addressing perceived barriers. For example, individual counseling using Motivational Interviewing is a welldeveloped approach for addressing both environmental and individual barriers to change, based on understanding the context of the problem/issue and using non-judgmental approaches to meet these challenges. Since the PTCC initiative is drawn to the Social- Ecological/Social Contextual Model as the basis for the intervention, the inclusion of perceived barriers fits well as it is concerned with both environmentally and individuallybased factors/obstacles to change. The construct self-efficacy is also a central consideration for the development of theory and research-based interventions. Derived primarily as a key construct of Bandura s Social Cognitive Theory, self-efficacy is also a construct related to additional frameworks such as the Health Belief Model (Champion & Skinner, 2008), the Theory of Planned Behavior (Montano et al., 1997), and the Transtheoretical Model (Prochaska, et al., 2008b). In the present context, self-efficacy refers to the development of increased selfconfidence to be able to quit smoking or eat fruit and vegetables, and to overcome barriers to these behaviours. As described in detail in Table 3, there are several approaches Bandura suggests as potential mechanisms/factors affecting changes in selfefficacy: mastery experience, social modeling, incentive motivation, social persuasion, improving physical and emotional states, self-regulation, and facilitation. Examples of these mechanisms, along with illustrations from intervention research, were summarized in the recent presentation to PTCC and the LEARN collaborative (Allison & Dwyer, 2010). Self-efficacy appears to be a relevant construct to the PTCC initiative for a number of reasons. It is based on a reciprocal relationship with behaviour change, such that increased self-efficacy could lead to positive behaviour change, or it may be that behaviour affects beliefs in self-efficacy success leads to further attempts (perseverance) whereas failure may lead to giving up. Thus, the concept of self-efficacy as applied to smoking cessation or fruit and vegetable interventions can be used to support individual attempts to be successful in changing their behaviour. Self-efficacy also relates to the PTCC initiative in that it fits well with other potential components of the interventions, such as counseling and addressing perceived barriers and environmental factors affecting change. Finally, self-efficacy is considered to be the most powerful construct within SCT and can be used potentially as a component of a more comprehensive framework underlying the intervention. Stages of change is the central construct of the Transtheoretical Model (Prochaska et al., 2008a, 2008b). Within the present context stages of change refers to the outcome of making progress through the stages of pre-contemplation, contemplation, preparation, action, and maintenance. Potential methods applicable to this construct include classification of intervention participants and providing tailored processes of change. Table 3 provides detailed examples of strategies/activities that can be used in smoking Theory-and Research-Based Interventions 12

13 cessation and fruit and vegetable interventions. In addition, several illustrations are provided to show concrete examples of how the stages of change construct has been used in applied research in the field. Discussion in the presentation/consultation meeting concerning this framework emphasized its potential role in classifying participants on the basis of readiness to change rather than considering it as an integrated theory of change or as a means of tailoring interventions to these stages. Thus, this construct has potential relevance to the PTCC initiative. Organizational, policy, and community-level factors represent determinants at the level of the social and physical environment. These factors are based on ecological models of health and social behaviour. In relation to the current initiative, an outcome of this construct would be increased organizational, policy, and community support for quitting smoking and eating healthy foods. Methods used in interventions directed at organizational, policy, and community level factors include environmental changes. At the level of strategies and activities that could be utilized in this type of intervention, a number of examples, along with illustrations from research studies, are shown in detail in Table 3. To summarize a few of these, interventions could include: ensuring that fruits and vegetables are available and more accessible at the worksite cafeteria and vending machines (Simpson et al., 2000; Beresford et al., 2007); providing subsidized or co-paid NRTs to alleviate withdrawal symptoms as part of a smoking cessation program (Barbeau et al., 2006); and offering intervention activities during work hours to make them more accessible to employees (Sorensen et al., 2005). These examples clearly demonstrate the relevance of this construct/determinant to the PTCC initiative. Highly related to the Social Ecological/Social-Contextual framework, the methods, strategies, and activities fit well as approaches that address environmental sources of smoking and unhealthy eating through organizational, policy, and community-level change. Empowerment is based on models of community organization and community building. In relation to the current initiative, a desired outcome would be increased stakeholder participation in smoking cessation and fruit and vegetable interventions. The major method attached to empowerment is stakeholder engagement and a detailed summary of examples of strategies and activities to accomplish this, along with several illustrations from research studies, appears in Table 3. An example is the formation of employee advisory boards (EABs), including workers, managers, and representatives from the health and safety department of the organization, in an intervention to enhance healthrelated behaviours. These EABs were used to assist in planning and implementing the intervention (Sorensen et al., 2005). In another study, as part of an intervention to increase fruit and vegetable intake, cafeteria managers and staff were asked to jointly set goals for increasing fruit and vegetable consumption (Lasson et al., 2004). It is clear that the construct, empowerment, as related to the present context, is highly relevant to the PTCC initiative, providing theoretical and research support for the emphasis on employee advisory committees and other positive employee-employer relationships to enhance smoking cessation and fruit and vegetable interventions. Theory-and Research-Based Interventions 13

14 Organizational Change factors are based on organizational change theories. In relation to the current context, a desired outcome would be that support is provided to organizations at each stage of change within the organization and the primary method suggested is tailoring. For example, tailoring might include involving management and staff in identifying the health issue and developing the intervention (awareness stage), providing resources and support to initiate (adoption stage) and implement the intervention. Institutionalization of the intervention would involve identifying a champion and overcoming obstacles, and attempting to integrate the intervention within the organization (Butterfoss et al., 2008). Further illustrations of this approach, some of which were provided in the presentation (Allison & Dwyer, 2010), are shown in Table 3. Organizational change factors overlap conceptually with both organizational, policy, and community-level factors and empowerment, and these three environmental level constructs are highly related to the PTCC initiative. They provide both theoretical and research support for intervention approaches that include: recognition and understanding of environmental-level determinants of health-related behaviours; interest in, and commitment to, the principles of employee-employer joint participation in intervention planning and implementation; and recognition that smoking cessation and fruit and vegetable interventions can be enhanced by approaches that include occupational health and safety and addressing workplace hazards. It is important to acknowledge that, in addition to the six constructs/determinants highlighted above, the logic model (Table 3) includes a great deal of additional information that may prove useful in intervention planning for the PTCC initiative. Additional constructs/determinants potentially related to smoking cessation and fruit and vegetable interventions include: knowledge, skills, perceived susceptibility, perceived severity, perceived benefits, outcome expectation, attitudes, perceived norms, perceived behavioral control, behavioral intentions, interpersonal factors, and diffusion of the intervention. These constructs can be categorized in a Social-Ecological framework in order to show their relationship to behaviour change (Figure 1). Depending on the subsequent refinement of the PTCC initiative, some of the detailed information dealing with methods, strategies/activities, and research illustrations related to these additional constructs, may also prove to be both relevant and useful in further intervention planning and implementation. Theory-and Research-Based Interventions 14

15 Figure 1 Ecological Model of Behavioral Change Intrapersonal Factors knowledge; skills; perceived susceptibility; perceived severity; perceived benefits; perceived barriers; selfefficacy; outcome expectations; attitudes; perceived behavioral control; behavioral intentions; stages of change. Interpersonal Factors perceived norms; diffusion of intervention. Behavior Change - Smoking Cessation - Fruit & Vegetable Consumption Environmental Factors organizational, policy, and community-level factors; empowerment; organizational change factors. Theory-and Research-Based Interventions 15

16 Implications for Planning Workplace Interventions As mentioned earlier, our central purpose in this synthesis project is to provide a summary of theory- and research-based interventions, with recommendations for PTCC s initiatives to increase smoking cessation and fruit and vegetable consumption among young blue-collar workers. Our extensive search and review of literature, combined with development of the logic model, has helped to achieve our purpose. As a final step in this process we now consider how this synthesis of theory and research converges to indicate possible directions for further intervention development and planning. This synthesis has provided a theory- and research-based rationale for selecting several core components of an intervention. It also has produced insight as to the potential suitability of several approaches, theoretical frameworks, constructs, methods, and strategies/activities that can be incorporated into the intervention. The project has not, however, produced detailed menu-driven guidelines for implementing an intervention in the field. That step would need to follow decisions by PTCC and LEARN as to what the core and optional components of the intervention will contain. Thus, our goal here is to contribute to informing those decisions. On the basis of this synthesis, the key findings suggest a number of implications for further planning of a workplace intervention: 1. The literature is relatively sparse in regards to interventions targeted specifically to young blue collar workers. Because of this, it was necessary to examine the larger pool of workplace interventions. Thus it is not clear how generalizable the findings of some studies are to this more specific group. Of the interventions highlighted in this report only the MassBuilt studies (Barbeau et al., 2006; Okechukwu et al., 2009) focus specifically on young (apprentice) blue collar workers. So the implication is, for each approach highlighted here, an issue to be addressed should be can this be applied/extended to young blue collar workers? 2. While both blue collar workers and white collar workers share an interest in trying to quit, it is generally recognized that blue collar workers have lower levels of success in smoking cessation interventions (Green & Johnson, 1990; Barbeau et al., 2004; Honjo et al., 2006). Thus, there are particular challenges to smoking cessation interventions for this group. It is important to consider possible reasons for this phenomenon and to think creatively about what can be done to address this challenge of greater relapse among this group. One explanation for this is that the life situations and life conditions of blue collar workers differ considerably from white collar workers. Much of blue collar work is characterized by low job control, repetition, and high demand, resulting in job strain (Albertsen et al., 2006). Moreover, it is possible that such phenomena as work alienation may spillover into family life and leisure time, making it less likely that they will feel motivated to change their behaviour. Thus, it likely will be more challenging to reach these individuals with traditional health promotion programs emphasizing wellbeing and disease prevention in general, or smoking cessation and fruit and vegetable consumption in particular. Theory-and Research-Based Interventions 16

17 Compounding this picture of relatively poor working conditions among blue collar workers is the likelihood of heightened workplace conflict between employers and employees in terms of both quantitative and qualitative indicators such as compensation, benefits, work conditions, workplace safety, and job security (Albertsen et al., 2006). There is an inherent tension between these parties that can create discord and labour unrest or, at best, provide an environment of cautious negotiation. The context of blue collar work presents challenges to the development and implementation of workplace health programs. This needs to be acknowledged in considering how best to proceed. In the case of a related group, service workers, these challenges may not be as pronounced, though the work conditions of these employees appear to be increasingly more similar to blue collar, as opposed to white collar work. As well, young adults are in a stage of life course transition (Clausen, 1986), in between older adolescence and full adulthood. Some young adults believe that they do not require help in smoking cessation rather they may believe they can quit on their own (Filsinger & McGrath, 2009). This presents unique challenges for program planners to develop interventions that will be compatible with their life stage and appropriate to their normative attitudes and beliefs. 3. This project has provided PTCC and LEARN with the theoretical and research basis for development, implementation, and evaluation of an intervention for young blue collar workers. Based on discussion following the presentation (Allison & Dwyer, 2010), the primary focus remains on smoking cessation, with additional interest in other chronic disease prevention measures. This suggests that decisions need to be made to further refine the scope of the initiative. On that basis, the findings from the current project can be selectively used to suggest more specific methods, strategies/activities most suitable for the intervention. It appears that existing interventions, such as MassBuilt (Barbeau et al., 2006; Okechukwu et al., 2009) and WellWorks (Sorensen et al., 2002), will serve as useful model programs on which to base some components of the PTCC intervention. Those research teams in other settings responsible for developing the model interventions likely will need to be contacted further regarding permission and use of program approaches and materials for which intellectual property issues may apply. 4. Social Ecological/Social-Contextual Theory is seen as the most appropriate overall framework for the PTCC initiative. Discussion following the presentation of findings (Allison & Dwyer, 2010) indicates endorsement of our recommendation to this effect, and the collaborative group shares an existing interest in establishing this framework. This framework is considered to be sufficiently broad to incorporate intrapersonal, interpersonal, and environmental factors, and can be augmented by components/constructs of additional theoretical frameworks to operationalize it. Theory-and Research-Based Interventions 17

18 5. The literature review summary tables and the logic model table contain a great deal of useful information for intervention planning purposes. In this report, we have provided several examples and illustrations of how this information can be used. With further refinement of the scope of the intervention, program planners can selectively draw on these tables to help develop intervention components, including methods and strategies/activities. At that stage, it may be possible to create a systematic step-by step set of guidelines for field personnel responsible for more detailed organization and implementation of the intervention. The development of that detailed guideline document would also benefit from prior consultation with both field staff and potential workplace program participants regarding their resource and program needs and issues of feasibility and logistics. The importance of this stage is emphasized by Bartholomew et al., 2006) in discussing step 3 of the Intervention Mapping approach. 6. Establishing an employee-employer advisory committee has been consistently seen as a useful and democratic way of facilitating communication, cooperation, and interest in a workplace intervention. The topic of exactly how to go about establishing these committees goes beyond the scope of the present project. However, those studies that deployed these committees/boards contain fairly detailed descriptions of their purpose and operation. While there may be some variability and flexibility in the process of development, depending on unique features of a specific workplace, it would appear prudent to establish a core set of principles pertaining to how these groups are formed and how they will operate. Thus, further implication of the findings is that this will be an important next step in planning. 7. Process evaluation will also be an important means of assessing the Pilot intervention. Detailed documentation of the context of each workplace, the participants, and the salient factors (barriers and other issues) that make change difficult for them, will be useful information for further development of the intervention. 8. Though it goes beyond the scope of the current project, an additional issue of importance to PTCC is the potential sustainability of the intervention. This issue will need to be taken into account as the intervention undergoes further refinement and planning. Theory-and Research-Based Interventions 18